Progressive soft tissue laxity due to aging often leads to sagging of the pinna relative to the bony external auditory canal. This causes an anteroinferior displacement of the conchal cartilage toward the tragus, with a resultant “fish-mouth” narrowing of the meatus. Simple posterosuperior distraction of the pinna allows examination and cleaning of the ear. Surgical correction is indicated when the deformity results in collapse of the meatus when trying to use the telephone, retention of cerumen, or difficulty in insertion of the ear mold of a hearing aid. A simple meatoplasty under local anesthesia is effective in correcting this condition.

Current understanding of keratosis obturans is based on the work of Piepergerdes et al. (1), who clearly differentiated this disorder from external auditory canal cholesteatoma. It presents clinically as hearing loss and usually acute, severe pain secondary to accumulation of large plugs of desquamated keratin in the ear canal. Cleaning may require repeated attempts with administration of topical antibiotics
and wax softeners or even general anesthesia. Removal of the keratin cast from the ear canal reveals circumferentially erythematous, scaly, canal skin and occasional granulation tissue. In long-standing cases there is diffuse dilation (“ballooning”) of the bony canal, presumably from the chronic pressure effect of the keratin plug. The condition typically occurs in children and young adults, is usually bilateral, and has been associated with a high incidence of bronchiectasis and sinusitis (2,3). The underlying pathophysiology is believed to be a desquamative reaction to chronic hyperemia (4, 5, 6). The majority of cases will respond to frequent cleaning in conjunction with topical steroids and emollients to reduce desquamation and inflammation. Surgery is indicated for those cases refractory to this conservative approach. Removal of all affected canal skin, a wide canalplasty, and split-thickness skin grafting is curative.

Tos and Balle (7) have reviewed the clinical presentation, pathophysiology, and management of fibrous obliteration of the medial ear canal resulting from chronic inflammation. They believe that recurrent external otitis and granular myringitis lead to fibrous proliferation of the soft tissue of the lateral surface of the tympanic membrane and bony external auditory canal. Patients present with a history of several years of recurrent external otitis and progressive conductive hearing loss. Treatment is surgical and consists of debridement of all abnormal tissue, including the tissue lateral to the lamina propria of the tympanic membrane, a wide bony canalplasty, and split-thickness skin grafting of all denuded areas.

Both postauricular and endaural surgical approaches to the middle ear and mastoid can lead to meatal or canal stenosis. This complication arises from proliferation of scar tissue along surgical planes where skin has been elevated from underlying tissues or where incisions have been made for a Koerner flap or endaural approach. A wide meatoplasty with excision of a crescent of conchal cartilage and adjacent soft tissue and a wide bony canalplasty greatly reduce the incidence of this problem. In the case of endaural incisions, a simple advancement of the pinna side of the incision relative to the facial side at the time of closure complements the meatoplasty/canalplasty to further reduce the likelihood of meatal stenosis. If a developing stenosis is detected in the early postoperative period, it is easily managed by serial dilation with Merocel sponge wicks cut to the largest size the stenotic segment will admit, kept moist with antibiotic drops, and replaced with a larger wick every 7 to 10 days. Very dense or persistent scar tissue will respond better to dilation with the addition of intradermal triamcinolone acetonide injections at the time of each wick change. Complete resolution is expected within 2 to 6 weeks. Surgical correction by meatoplasty is indicated when the problem is detected after meatal healing is complete (more than 3 or 4 months postoperatively) and there is inadequate meatal size for easy inspection, cleaning, or hearing aid insertion.

Exostosis is the most common bony abnormality of the external auditory canal, reported to occur in 6.3 of every 1,000 patients examined for otolaryngologic problems (8). It presents as a gradual narrowing of the bony canal by broad-based mounds of bone arising from both the anterior and posterior bony canal walls. Occasionally a smaller mound may arise posterosuperiorly as well. Histopathologic examination of the bone reveals a dense stratified arrangement of new bone that in time is remodeled, beginning around vascular channels into normal-appearing lamellar bone (Figs. 13.1 and 13.2). The bone deposition is believed to be secondary to a chronic periostitis due to cold temperature. The abnormality is most often seen in cold-water swimmers. It is usually bilateral and asymptomatic. Symptoms may arise, however, if the exostoses become so large as to occlude the ear canal or cause retention of cerumen or desquamated keratin and produce a conductive hearing loss or recurrent external otitis. In such symptomatic cases a wide bony canalplasty with split-thickness skin grafting of all denuded surfaces is indicated.