1975, British Journal of Radiology, 48, 170-175

Tomography of the petrous bone in keratosis obturans

By S. B. Lagundoye, M.B.B.S. (London), D.M.R.D. (Edin.), F.M.C.R. (Nigeria),
F. D. Martinson, M.B.Ch.B. (Edin.), F.R.C.S. (Eng. and Edin.), F.I.C.S., and A. A. Fajemisin,
M.B.Ch.B. (Liverpool), F.R.C.S. (Edin.)
University College Hospital and University of Ibadan, Ibadan, Nigeria
(Received June, 1974)
ABSTRACT

CASE REPORTS

Three cases of keratosis obturans, which were studied by

tomography of the petrous temporal bone, are described.
The widening of the deep bony part of the external auditory canal by pressure erosion of an impacted benign slowlygrowing mass is the key radiological finding. Erosion was so
severe as to involve the facial nerve canal in one and the
temporo-mandibular joint in two cases. The theories of
causation are reviewed. Tomography using elliptical tube
movement was valuable in diagnosis, pre- and post-operative management.
Keratosis obturans is a condition characterized by
the gradual accumulation of a cholesteatoma-like
mass in the deep part of the bony external auditory
meatus which becomes progressively occluded and
later expanded by pressure erosion. The condition
was first described by Tonybee in 1860 (Biber,
1953) who called it "Molluscum contagiosum" but
it was Wreden (Biber, 1953) who, 100 years ago,
first named it keratosis obturans. Other synonyms
used by various authors include cholesteatoma (Altmann and Maltner, 1943), cholesteatosis, primary
cholesteatoma, cholesteatoma-like accumulation
(Green, 1933), keratosis obturans ottica and obstructive keratotic castall of the external auditory
meatus or canal.
The surface of the mass is glistening white in
colour, but may be darkened by admixture with
wax. Indeed, impaction of a plug of wax deep in the
external auditory canalthe so-called wax keratosis,
has been suggested as the precursor of keratosis
obturans (Black, 1967). A hollow cast of the external auditory canal may be formed by the accumulated material (Costello and Fried, 1953). The condition has been known to form a syndrome triad in
association with chronic sinusitis and bronchiectasis. The most frequent symptoms are pain, deafness, tinnitus, otorrhoea and bleeding.
The purpose of this report is to highlight the
usefulness of tomography of the petrous temporal
bone in the diagnosis and management of keratosis
obturans as exemplified by three cases seen at the
University College Hospital (U.C.H.) Ibadan,
Nigeria between 1969 and 1973. The tomographic
technique using elliptical movement of the Siemens
Multiplanigraph is as previously described (Lagundoye, 1971).

Casel
A.A., a 24-year-old male with five years history of persistent noise (tinnitus) in the left ear associated with dizziness.
On examination there was impacted wax deep in the left
external auditory meatus with some granulations in the
posterior wall at the junction of the bony and cartilaginous
portions of the meatus. There was some tenderness in the
pretragal and post-auricular regions on deep palpation.
Tuning-fork tests and audiometry showed no deafness on
the affected side. No facial or other cranial nerve lesions.
Plain X-ray of the mastoids showed a widened left external auditory canal. Elliptical tomograms of the petrous
bones revealed ballooning of the inner and bony part of the
left external auditory canal by a slow-growing long-standing
radiolucent expanding mass with fairly smooth margins and
a barrel-shape. The stylomastoid foramen and lower part of
the facial nerve canal were widened on the affected side
(Fig. 1).
After an unsuccessful attempt at removal of the wax in the
out-patient clinic, the patient was admitted for surgical
exploration under general anaesthesia. At operation, the
material was removed piecemeal, and the ballooning of the
meatus confirmed. The meatal lining was very thin and
friable. The tympanic membrane was intact. A tympanoplasty was done. Portions of the vertical portion of the
facial nerve and tympanic nerve were found to be exposed
due to pressure erosion of the overlying bone. The patient
had an uneventful post-operative period and was discharged to follow-up clinic. The tinnitus had gradually disappeared over a three-year period.
Case 2
A.A., a male 24 years, complained of pain in the right
jaw and ear for two months. The ear was syringed at an
outside hospital and slight bleeding ensued. He was therefore referred to U.C.H. where on examination there were
granulations in the anterior wall of the external auditory
canal associated with debris in the rest of the canal. Tomograms of the ear (Figs. 2, 3A and B) on admission showed a
widening of the deep bony portion of the right external
auditory canal in the antero-posterior (Fig. 2) and lateral
cuts (Fig. 3B). The latter showed a defect in the tympanic
bone anteriorly as a result of pressure erosion of the anterior
wall of the meatus.
He was admitted a month later when the right tympanic
membrane was seen to be pushed against the medial wall of
the middle ear by granulations and further debris which
were removed. After a year and again after three years there
was reaccumulation of debris, which was removed. A recent
audiogram was essentially normal.
Case 3
O.M., a 21-year-old male patient seen with intermittent
pains in the left jaw and ear and recurrent blood-stained
discharge from the ear. Examination was negative apart from
a little wax in the left external auditory meatus and a slightly
thickened right tympanic membrane. He was treated conservatively as a possible case of left recurrent otitis externa.
There was no recurrence of symptoms until 15 months later
when the right external auditory meatus was found to be

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Tomography of the petrous bone in keratosis obturans

The shaded area represents the External Auditory Canal ( E A C )

B

FIG. 1. Case 1.
(A) Antero-posterior tomograms show ballooning of the deep part of the left external auditory canal (EAC) by pressure erosion by a barrel-shaped radiolucent mass. Note the widened stylomastoid foramen and lower part of the facial nerve canal
(white arrow).
(B) Sketch of (A).

filled with dried, hard, waxy material. A diagnosis of keratosis obturans was made. Routine radiography of the mastoids showed a widened external auditory canal and elliptical tomography showed ballooning of the deep bony part
of the external auditory meatus in the antero-posterior cuts
(Fig. 4). The normal parallelism of the roof and floor of the
bony external auditory canal was replaced with a bi-concavity above and below. The drum crest remained intact,
although thinned and elevated with consequent upward
displacement of the ossicles. Tomographic cuts in the
lateral position revealed widening of the external auditory
canal in its vertical diameter with smooth excavation of its
floor and thinning of the tympanic bone anteriorly and
inferiorly (Fig. 5).

The material was removed without anaesthesia and the

ballooning of the external meatus was confirmed. The
patient has been followed up for 12 months with no recurrence.
DISCUSSION

In keratosis obturans, the cartilaginous part of the

external auditory canal is not involved, but the
junction of the bony and cartilaginous parts is often
the site of granulation tissue which has a tendency to
bleed and may thus raise the suspicion of possible

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48, No. 567

S. B. Lagundoye, F. D. Martinson, A. A. Fajemisin

The shaded area represents the External Auditory Canal

( E A C ).
B

FIG. 2. Case 2.
(A) Antero-posterior tomograms show widening of the deep, bony portion of the right external auditory canal (EAC). Note
the loss of parallelism of the roof and floor of the canal.
(B) Sketch of (A).

malignancy. Tomography of the petrous bone will

reveal the presence of a slowly expanding radiolucent mass producing extrinsic pressure on the
bony canal which results in the excavation and
thinning of its walls, the hall-mark of radiological
diagnosis in keratosis obturans. The uniform smooth
ness of the margins of the erosion is evidence of the
benignity of the mass. The increased radiolucency of
the widened canal is due to the cholesterol content of
the mass. The erosion of the deep part of the exter-

nal auditory canal may extend into the aditus-adantrum, with elevation of the ossicles as in our Case
3 or may involve the wall of the facial nerve canal as
in Case 1 which is similar to three such cases reported by Habermann (Biber, 1953). Sometimes
facial palsy may develop from the erosion of the
vertical portion of the facial nerve canal. Although
such erosion was noted on tomography, and confirmed at surgery in our Case 1, facial palsy was absent. The pain in the jaws on the affected side in

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Tomography of the petrous bone in keratosis obturans

The shaded area

represents the External

FIG. 3. Case 2.
(A) Lateral tomogram showing the normal left EAC.
(B) Lateral tomograms of the affected right EAC showing thinning of the tympanic bone with an erosive defect anteroinferiorly behind the neck of mandible.
(c) Sketch of (A) and (B).

Cases 2 and 3 can be explained by the erosion of the

anterior wall of the meatusa direct posterior relation of the temporomandibular jointwhich was
severe enough as to produce a defect in the bone in
Case 2.

Although not a feature of our three cases, an

association with bronchiectasis and sinusitis has been
observed and in unilateral keratosis obturans, the
bronchiectasis and sinusitis are on the same side
also. A reflex mechanism has been postulated,

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48, No. 567

S. B. Lagundoye, F. D. Martinson, A. A. Fajemisin

The shaded area represents the External Auditory Canal

(EAC)
B

FIG. 4. Case 3
(A) Antero-posterior tomograms show ballooning of the deep bony part of the external auditory canal. Note the biconcavity
(from pressure erosion of the impacted keratotic mass) of the roof and floor of the canal instead of the normal parallelism.
(B) Sketch of (A).

mediated via the vagus nerve whose auricular

branch is the secretomotor nerve to the ceruminous
glands (Biber, 1953; Morrison, 1956).
Tomography was of great value for showing the
extent of the bony involvement in all our three cases.
The antero-posterior tomograms gave useful information about involvement of the roof and floor of
the external auditory canal while the tomograms in
the lateral projection were valuable for assessing

involvement of all four walls, particularly the anterior and posterior walls. This knowledge of the involvement of the facial nerve canal, in the absence of
facial palsy in Case 1 would not have been possible
without tomography and in Cases 2 and 3 details of
the defects in the anterior wall of the canal were not
shown on conventional views. Such prior knowledge revealed by tomography was invaluable in
planning both management and follow-up.

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Tomography of the petrous bone in keratosis obturans

ACKNOWLEDGMENTS

Our gratitude goes to Mr. L. A. Anifalaje, Senior Medical

Artist, University of Ibadan for the sketches; Mr. J. O.
Abiola for the secretarial assistance and Messrs. J. A.
Adewole and R. A. Otukomaiya for the photography. This
work was in part supported by Senate Research grant of the
University of Ibadan.
REFERENCES
ALTMANN, F. and WALTNER, J. G., 1943. Cholesteatoma of

the external auditory meatus. Archives of Otolaryngologv,

38, 236-240.
BIBER, J. J., 1953. The so-called primary cholesteatoma of
the external auditory meatus. Journal of Laryngology and
Otology, 67,474-485.
BLACK, J. I. M., 1967. Wax keratosis. The Eve, Ear, Nose
and Throat Monthly, 46, 192-196.
COSTELLO, M. R. and FRIED, S., 1953. Keratosis obturans

ottica; (obstructive hollow keratotic cast of external

auditory canal). Archives of Dermatology, 67, 516-517.
GREEN, L. D., 1933. Cholesteatoma-like accumulations in
the external auditory meatus. Archives of Otolarvngologv,
15,161-167.
LAGUNDOYE, S. B., 1971. Elliptical petrous tomography in
congenital deafness in Nigerian children. African Journal
of Medical Sciences, 2, 121-126.
MORRISON, A. W., 1956. Keratosis obturans. Journal of
Laryngology and Otology, 70, 317321.

The shaded area represents the

External Auditory Canal ( E A C )
FIG. 5. {Case 3)
(A) The lateral tomograms showed a widening of the external auditory canal (EAC) in vertical and transverse
diameters more marked in the former. Note particularly
the smooth excavation of the floor and anterior walls.
(B) Sketch of (A).

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