1
Introduction
A temporomandibular-external auditory canal (EAC) fistula is a permanently lined epithelial tract extending between the temporomandibular joint (TMJ) and the EAC. True fistulas occur rarely, and there are only a few cases reported in the literature. Previous case reports have described fistulae arising spontaneously from otitis externa and malignant otitis externa after iatrogenic trauma and a result of radiotherapy to the head and neck .
Traumatic communications may arise after fractures to the mandibular condyles and otologic and TMJ surgery. Most of these communications heal spontaneously and require no further treatment . True fistulas do not close and may lead to recurrent otitis externa, septic arthritis of the TMJ, otorrhea, and disturbing noises upon mastication. Currently, there is no consensus on how to manage temporomandibular-EAC fistulas. Conservative treatments as well as surgical techniques have been described in the management of this condition. This article reports 3 cases and aims to establish an algorithm to assist medical practitioners who may encounter this rare condition.
2
Case reports
2.1
Case 1
A 70-year-old retired general medical practitioner with no significant medical history underwent removal of a bony auditory canal exostosis by an ears, nose, and throat surgeon. Postoperative review revealed an ulceration of the anterior canal with passage of fluid on mastication. He was referred to the Maxillofacial Unit at the Royal Brisbane and Women’s Hospital, Brisbane, Australia, for further management. His symptoms were palliated with a mandibular advancement splint, and the patient refused any more intervention. Healing of the fistula was achieved; however, a significant bulging of the anterior wall of the EAC persisted.
2.2
Case 2
A 50-year-old man with no significant medical history underwent removal of a bony auditory canal exostosis by an ears, nose, and throat surgeon. At his postoperative review, the surgeon noticed a communication with the TMJ. The patient was referred to the Maxillofacial Unit service at the Royal Brisbane and Women’s Hospital for management. Treatment involved the wearing of a mandibular advancement splint for 3 months. After this, successful long-term healing of the fistula has resulted.
2.3
Case 3
A 47-year-old woman was referred to the Maxillofacial Unit at the Princess Alexandra Hospital, Brisbane, Australia, for investigation of aural discharge during mastication. Her medical history was significant for significant facial trauma, including bilateral mandibular condylar fractures after a motor vehicle accident 15 years prior. For the past 10 years, the patient has had recurrent episodes of otitis externa with tympanic membrane perforation. Multiple otologic procedures were performed to correct the otitis externa and tympanic membrane perforation. Otoscopy revealed a perforation with herniation and fluid leak in the anterior wall of the EAC. Sialography excluded a salivary fistula. Fine-cut computed tomographic scanning revealed a defect in the bony EAC with soft tissue herniation. Because of severe periodontal disease and tooth loss, conservative management with a mandibular advancement splint was not feasible. Surgical correction was undertaken with a vascularized temporalis muscle flap using a preauricular approach after ligation and inversion of the fistula tract. Her symptoms resolved with no recurrence of the fistula or otitis externa at 24 months.
2
Case reports
2.1
Case 1
A 70-year-old retired general medical practitioner with no significant medical history underwent removal of a bony auditory canal exostosis by an ears, nose, and throat surgeon. Postoperative review revealed an ulceration of the anterior canal with passage of fluid on mastication. He was referred to the Maxillofacial Unit at the Royal Brisbane and Women’s Hospital, Brisbane, Australia, for further management. His symptoms were palliated with a mandibular advancement splint, and the patient refused any more intervention. Healing of the fistula was achieved; however, a significant bulging of the anterior wall of the EAC persisted.
2.2
Case 2
A 50-year-old man with no significant medical history underwent removal of a bony auditory canal exostosis by an ears, nose, and throat surgeon. At his postoperative review, the surgeon noticed a communication with the TMJ. The patient was referred to the Maxillofacial Unit service at the Royal Brisbane and Women’s Hospital for management. Treatment involved the wearing of a mandibular advancement splint for 3 months. After this, successful long-term healing of the fistula has resulted.
2.3
Case 3
A 47-year-old woman was referred to the Maxillofacial Unit at the Princess Alexandra Hospital, Brisbane, Australia, for investigation of aural discharge during mastication. Her medical history was significant for significant facial trauma, including bilateral mandibular condylar fractures after a motor vehicle accident 15 years prior. For the past 10 years, the patient has had recurrent episodes of otitis externa with tympanic membrane perforation. Multiple otologic procedures were performed to correct the otitis externa and tympanic membrane perforation. Otoscopy revealed a perforation with herniation and fluid leak in the anterior wall of the EAC. Sialography excluded a salivary fistula. Fine-cut computed tomographic scanning revealed a defect in the bony EAC with soft tissue herniation. Because of severe periodontal disease and tooth loss, conservative management with a mandibular advancement splint was not feasible. Surgical correction was undertaken with a vascularized temporalis muscle flap using a preauricular approach after ligation and inversion of the fistula tract. Her symptoms resolved with no recurrence of the fistula or otitis externa at 24 months.
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