Abstract
Verruca vulgaris is a common skin disease caused by human papillomavirus (HPV) infection, but it rarely involves the tympanic membrane. The current treatments for verruca are usually destructive and irreversible, should not be performed universally; the most relevant therapy will be variable subject to disease location, severity, and the patient’s immune status. In this report, we demonstrated a case with verruca vulgaris of tympanic membrane, who had topical immunomodulatory agent treatment successfully with well-preserved hearing, and who has no any recurrence up to now for 3 years. In clinical, to cure verruca on the vulnerable tympanic membrane without hearing sequela is a dilemma, and there is no any treatment guideline due to its rarity. Topical immunomodulatory agent with high selectivity, showed great competence on this occasion and verified its practicability in treating verruca on unapproachable area, or where bearing vital functions; the convenient out-patient-based application also ensures good compliance. However, it does need longer duration and higher costs than the other routine treatment modalities.
1
Introduction
Verruca vulgaris is a common skin disease caused by human papillomavirus (HPV) that usually infects epithelial tissues and mucous membranes . It is a benign epidermal proliferation with infrequent malignant change . The clinical presentations of verruca are variable in accordance with the viral type and the anatomical site infected. Verruca in patients with intact cellular immunity may regress spontaneously , but it may recur subject to the host’s immune status. As a contagious disorder, it could be transmitted to other areas of body if left unattended. Compared to the more common affecting sites, such as hands, feet or face, the verruca involving tympanic membrane (TM) had never been reported in the English literature, therefore, there is no any standardized treating modality available. Several treatments including surgery, cryotherapy, electrocauterization, laser or topical agents all focus on eradicating the lesions; however, the most relevant treatments are variable depending on the disease location, severity, and the patient’s immune status. In this report, we demonstrate a case with verruca vulgaris of TM, who had topical immunomodulatory agent treatment successfully and who has no any recurrence for 3 years up to now. In contrast to the conventional treating modalities, the topical immunomodulatory agent has more benefits in this scenario, because it has advantages of the least traumatic but the most functioning preserving results, could be completed easily with good compliance by an out-patient-based application.
2
Case report
In March 2010, a 51-year-old female came to our clinic presented with right-sided otalgia and otorrhea developed for 2 weeks. She had visited local clinics where oral antibiotics had been used for presumed otitis media. However, aggravated otalgia, otorrhea and hearing impairment developed subsequently, so she was referred to us.
On physical examination, we found a reddish desquamatous mass lesion occupying the posterosuperior quadrant of the right tympanic membrane (TM), extending to the external ear canal with purulent discharge coating ( Fig. 1 A ). Pure tone audiometry (PTA) showed a 45-dB conductive hearing loss (mean of air conduction threshold at frequency 500, 1000, 2000 and 4000 Hz) ( Fig. 2 A ) with type As tympanogram on that day; the culture revealed strains of Staphylococcus aureus and Aspergillus niger . Computed tomography (CT) showed external auditory canal (EAC) swelling, mastoid air cells fluid accumulation and soft tissue density filled in middle ear cavity ( Fig. 3 A ). Biopsy was done under microscope subsequently; the pathology showed a feature of verruca vulgaris, in which squamous epithelium with acanthosis, papillomatosis, hyperkeratosis and interspersed parakeratosis were noted, and some keratinocytes of the upper epidermis have vacuolated cytoplasm and basophilic nuclei ( Fig. 4 A and B ).
Because the lesion was located on the part of the TM and EAC, in order to maintain the integrity of TM and the sound conduction structures, we chose the topical immunomodulatory agent, imiquimod (Aldara cream, 5%), applied once daily, 5 days a week, as treatment when the verruca vulgaris was confirmed. Meanwhile, we also incorporated oral antibiotic amoxicillin/clavulanate (Augmentin, 375 mg/tab), three times daily for the first 3 weeks due to superimposed bacterial infection. Otalgia and otorrhea subsided subsequently, while the mass lesion remained indolent in the first few weeks, then paled and shrank gradually under regular topical treatment. Three months later, the patient had a totally regressed lesion with intact tympanic membrane and recovered hearing ( Figs. 1 B and 2 B). The following CT scan 1 month after the treatment was finished showed intact ossicular chain, without any soft tissue density in either EAC or middle ear cavity ( Fig. 3 B). The patient then had regular follow-up at our clinic; there is no any sequela or recurrence through these 3 years.
2
Case report
In March 2010, a 51-year-old female came to our clinic presented with right-sided otalgia and otorrhea developed for 2 weeks. She had visited local clinics where oral antibiotics had been used for presumed otitis media. However, aggravated otalgia, otorrhea and hearing impairment developed subsequently, so she was referred to us.
On physical examination, we found a reddish desquamatous mass lesion occupying the posterosuperior quadrant of the right tympanic membrane (TM), extending to the external ear canal with purulent discharge coating ( Fig. 1 A ). Pure tone audiometry (PTA) showed a 45-dB conductive hearing loss (mean of air conduction threshold at frequency 500, 1000, 2000 and 4000 Hz) ( Fig. 2 A ) with type As tympanogram on that day; the culture revealed strains of Staphylococcus aureus and Aspergillus niger . Computed tomography (CT) showed external auditory canal (EAC) swelling, mastoid air cells fluid accumulation and soft tissue density filled in middle ear cavity ( Fig. 3 A ). Biopsy was done under microscope subsequently; the pathology showed a feature of verruca vulgaris, in which squamous epithelium with acanthosis, papillomatosis, hyperkeratosis and interspersed parakeratosis were noted, and some keratinocytes of the upper epidermis have vacuolated cytoplasm and basophilic nuclei ( Fig. 4 A and B ).
