Keratosis obturans

DEFINITION

Keratosis obturans or obliterans is excessive growth of epithelial tissue of the outer ear canal. Keratosis obliturans rare. Usually by chance discovered by inspectors in otoskopi examination. Keratosis obliterans usually found on a bilateral basis and may be accompanied by bronchiectasis and chronic sinusitis. In keratosis obturans found clumps of the epidermis in the ear canal caused by excessive formation of epithelial cells that do not migrate toward the outer ear. Although it can be observed widening of the ear canal and hyperplasia and epithelial and subepithelial inflammation, but no bone erosion. This condition is thought to be caused by the production of stoppers squamous epithelium and excessive or incorrect epithelial migration. The recommended treatment is removal of the plug and the handling of inflammatory processes.

In 1850 Tonybee find early symptoms in the form of epithelial tissue buildup in the ear canal, which is described in the same with extra auditory canal cholesteatoma (EACC). In 1980 by Piepergedes et al stated that different EACC with keratosis obliterans. Patients with Keratosis obliterans comes usually with pain and hearing loss and can also be accompanied by symptoms such as metallic taste. Patients can come without interruption ears but only with impaired only metallic taste.

Keratosis obturans is the accumulation or buildup of keratin layer of the epidermis desquamation in the ear canal, pearly white, thus forming clots and cause a full flavor and less heard. The disease is not on the part kartilagenous external auditory meatus. Typically, these lesions confined to the meatus, without causing bone destruction. If not addressed properly will happen skin erosion and destruction of bone sections external auditory meatus.

keratosis obturans actually been introduced by Wreden in 1874 to distinguish it from cerumen impaction. The disease is also to be distinguished from primary cholesteatomas are characterized by the invasion of squamous tissue of the middle ear accompanied by erosion and bone destruction. Piepergerdes and colleagues in 1980 stated that keratosis obturans

produced by disease in the external auditory meatus skin whereas bone disease in external auditory meatus is the basis for cholesteatoma in external auditory meatus.

PREVALENCE

Keratosis obturans generally occurs in younger patients between the ages of 5-20 years and can attack one or both ears. Morrison reported that there were 50 cases of keratosis obturans in 1956 in which 20 patients aged 5-9 years, 15 patients between the ages of 9 ± 19, and 15 patients aged 20 ± 59 years. Black and Clayton reported the occurrence of keratosis obturans in children in 1958 with a 90% incidence occurs bilaterally.

Etiology

There is no exact cause. Although, it can be caused by chronic hyperemia increase desquamasi and formation of epidermal keratin debris. Another theory regarding the cause include broncheotracheosinusitis, which is a reflex sympathetic nerve system in cerumen glands causing hyperemia and keratin growing. Can also be a migration error auditory epithelium is responsible for the accumulation of debris accumulation. Abnormal migration is probably due to an inflammation that is triggered because of a virus.

Etiology keratosis obturans until now unknown. However, it may be because of eczema, seborrheic and furonkulosis. The disease is sometimes associated with bronchiectasis and chronic sinusitis

Pathophysiology

There are two different forms of the pathophysiology of keratosis obliturans or obliterans.

The first form there is a chronic inflammation in the subepithelial tissue, and this is responsible for epithelial hyperplasia and accumulation of keratin in the external canal ear canal.

The second form is no inflammation in the skin lining the ear canal external channels. The second form occurs bilaterally and may be linked to genetic or acquired in an enzyme (not yet identified) which is responsible for the separation of superficial keratin layer. It occurs when this layer out normally.

Keratosis obliterans associated with chronic inflammation, duct epithelium in the outer ear canal can be treated as keratin moved successfully treated and the underlying inflammation. However, patients with keratosis obliterans are not associated with inflammation of the skin line will require regular cleaning of the ears because it deals with the mechanism of the normal displacement of the epithelium. Treatment is done with regular mikrosuctin until the buildup of debris in canal outside telingta reduced. Required therapy faithfully repeated five to six months until the resulting metallic taste back.

Pathogenesis

Keratosis obturans occur because of abnormal migration of epithelial lining the ear canal skin. Normally, the surface epithelium of the tympanic membrane pars flaksida migrate down to the pars Tensa and then move past the inferior tympanic membrane. However, the movement of epithelial cells in this disease appears upside down. This migration failure or obstruction at the time of migration caused by keratin layer causes epithelial debris accumulation on the inside of the meatus. This is consistent with the study of normal skin on the outer ear is done by Alberti (1964) shows that there are normal epithelial migration from the tympanic membrane to the external auditory meatus

According Paparella and Shumrick, keratosis obturans can be caused by several factors, among others: the excessive production of epithelial cells, skin epithelial migration failure and inability of the self-cleaning mechanism by external auditory meatus. Self-cleaning mechanism by external auditory meatus is the result of coordinated maturation of keratin and cell migration to the outside. In keratosis obturans, this mechanism does not work.

Relationship with the incidence of bronchiectasis and sinusitis obturans keratosis (in frequency appears ipsilateral) have been reported previously associated with this discovery led to the emergence of the hypothesis that the presence of pus stimulate reflex sympathetic system of branches to stimulate reflex tracheobronchial secretions wax obstructing the formation of a plug of keratin and epidermal

CLINICAL SYMPTOMS

Clinical symptoms that can occur in this disease is mild-moderate conductive hearing loss, severe ear pain, ear canal wider, intact tympanic membrane but thicker and tinnitus as well as rare otorea. Hearing loss and severe ear pain caused by clots insistence keratinized epithelium in the ear canal. Keratosis obturans accompanied by bronchiectasis and chronic sinusitis and bilateral.

Symptoms are conventionally bilaterally (cases of childhood more Often, whereas unilateral disease occur more in adults)

- Regarding a young age, less than 40 years.

- Acute

- Kehilngan conductive hearing

- Sometimes otorrhea

- Thickening tympani because of the insistence of keratin

- The possibility of granulation

- Widening of the ear canal

- On histopathologic examination lamellar keratin shaped like a leaf.

Conditions associated with eczema, seborrheic dermatitis and / or furunculosis and is associated with inflammation of the mucous membranes and / or bronchiectasis

In Patients with keratosis obturans are:

?? Acute conductive deafness,

?? severe pain,

?? ear canal is wider (due to erosion of the bone so that the ear canal thoroughly look wider),

?? Thicker but intact tympanic membrane and

?? rarely found any ear secretions.

?? Hearing loss and severe pain the caused by the insistence of the keratinized epithelium clot in the ear canal.

DIAGNOSIS

history

Otology history should be Obtained in order to know the early symptoms of keratosis obturan. The most common symptom is hearing loss, otalgia great, otorea and bilateral tinnitus is accompanied by bronchiectasis and chronic sinusitis.

   physical examination

In addition to the head and neck examination, examination of particular concern Otology. General assessment to avoid missed on the assessment of fever, altered mental status and other assessments that may provide clues towards complications. On inspection, it appears visible obstructions along the tympanic membrane in the external auditory meatus by clumps of white keratin debris that contains brown wax in the middle. Clumps of keratin in the external auditory meatus increase of the pressure on the walls of the meatus, the resulting in bone remodeling. This led to the widening of the bones in the MAE is accompanied by inflammation of the epithelium. Rinne and Weber tests using a 512 Hz tuning fork is performed to Determine conduction deafness and Compared with the audiometric examination.



examination support

- Radiology:

In the temporal bone CT scans can show the erosion and dilation of the meatus.

- Pathology:

Obstruction of keratin on obturans keratosis looks like the geometric lines the external auditory meatus in that looks like a picture of onion skin. This pathology associated denagan existence under the epithelium hyperplasia and chronic inflammation in tissues subepitelium.



MANAGEMENT

Keratosis Treatment of desquamated squamous epithelium obturan Be removal. In addition, surgery can be performed with general anesthesia for surgical debridement, canal plasty and timpanomastoidektomi can be done to Prevent the continued erosion of bone. This disease can usually be controlled with periodic cleaning of the ear canal every 3 months, reduce the accumulation of debris. Provision of ear drops of glycerin in the mixture alkoholatau peroxide 3%, three times a week can help Often. In Patients WHO have undergone bone erosion ear canal, surgery is required to perform Often tissue under the skin grafts to Eliminate echo in the ear canal wall. The important thing is to make-the ear canal is shaped like a funnel, dry the ear canal so spontaneously guaranteed.

This disease can usually be controlled by cleaning the ear canal Periodically, Reviews such as every 3 months. Giving ear drops from a mixture of alcohol or glycerin in peroxide 3%, 3 times a week can help Often.

The most important thing is to make-the ear canal is shaped like a funnel so the ear canal dry spontaneously can be more Assured.


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