International Journal of Otorhinolaryngology and Head and Neck Surgery

Gowda CGBV et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Nov;6(11):2119-2122

http://www.ijorl.com

pISSN 2454-5929 | eISSN 2454-5937

Case Report

DOI: https://dx.doi.org/10.18203/issn.2454-5929.ijohns20204642

A rare case of acrochordon of external auditory canal

Chandre Gowda Bendiganahalli Venkate Gowda, Rakshita R. Kamath*

Department of ENT, MVJ Medical College and Research Hospital, Hoskote, Karnataka, India

Received: 13 August 2020

Accepted: 02 October 2020

*Correspondence:

Dr. Rakshita R. Kamath,

E-mail: dr.rakshitakamath@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Independently arising acrochordon of the external auditory canal is a rare entity with only one reported case in literature. We present here the second such case. A 54-yr old lady presented to our outpatient department with complains of aural fullness and reduced hearing in right ear for 2 weeks. Clinical examination showed a pedunculated polypoidal growth in the external auditory canal. Excisional biopsy and histopathology revealed an acrochordon. Following the procedure, patient was free of symptoms and all structures of the right ear were normal. In the head and neck region, acrochordons have only but once been reported in the external auditory canal and hence should be considered as a differential diagnosis in the masses of this region. Resection must be done for confirmation of diagnosis, differentiation from neoplasia and alleviation of symptoms when associated.

Keywords: Fibroepthelial polyp, Acrochordon, Aural polyp

INTRODUCTION

Acrochordon also known as fibroma or fibroepithelial polyp is a benign cutaneous lesion of mesothelial origin. It is generally an incidental finding on the skin of the neck, trunk, or face representing a nonspecific and indolent polypoid growth pattern of both epidermis and dermal fibrovascular tissue. They are usually solitary, and reports of multiple, bilateral polyps are extremely rare.1 They may be skin colored or hyperpigmented and appear as surface nodules or papilloma on healthy skin. They have been reported in the ureteropelvic system, genitals and bronchus.2-5 They are benign outgrowths with extremely low incidence of malignant potential.6

Of the two case reports related to this entity presenting as fibroepithelial polyp of external auditory canal (EAC) in literature, the first case was found to be an EAC Osteoma with overlying reactive fibro- epithelioid changes and not a true fibroepithelial polyp per say. There has been only one case reported of an independent polyp of the posterior bony EAC with a papilloma-like appearance. Here we present this rare entity arising independently in the anterior EAC with the appearance of a pedunculated polyp.

CASE REPORT

A 54-year old female presented to the outpatient clinic with complains of right aural fullness and reduced hearing for 2 weeks. She reported ‘something occluding her ear canal’ when she probed with her finger.

Figure 1: Clinical examination image under bulls’ eye lamp showing the right pinna with an aural polyp mass completely occluding the canal.
Figure 1: Clinical examination image under bulls’ eye lamp showing the right pinna with an aural polyp mass completely occluding the canal.

She had no prior history of ear disease or any other comorbidities. On clinical examination, a pedunculated skin covered polypoidal mass was seen arising from the posterosuperior wall of the anterior EAC of the right pinna almost completely occluding the lumen (Figure 1) other ENT examinations were normal. Blood tests were within normal limits. After obtaining necessary consents from the patient, an excisional biopsy of the mass was done using microscopy under local anesthesia. Following excision, the remaining canal appeared normal and tympanic membrane was intact. No signs of any growth or debris were found. Upon histopathological examination of the excised mass (Figure 2) of 1*0.5*0.5 cm firm grey white soft excised tissue, the mass was revealed to have polypoidal tissue lined by stratified squamous epithelium as shown in (Figure 3).

Figure 2: Gross image showing 1*0.5*0.5 cm firm grey white soft tissue excised mass.
Figure 2: Gross image showing 1*0.5*0.5 cm firm grey white soft tissue excised mass.
Figure 3: Low power microscopy image of aural polyp mass showing polypoidal tissue lined by stratified squamous epithelium with fibro collagenous tissue.
Figure 3: Low power microscopy image of aural polyp mass showing polypoidal tissue lined by stratified squamous epithelium with fibro collagenous tissue.

In (Figure 4), the high-power microscopy image of said mass showed polypoidal tissue lined by Stratified Squamous epithelium. Sub-epithelium showed fibro collagenous tissue admixed with few adnexal structures and blood vessels surrounded by mild chronic inflammatory cell infiltrates composed of lymphocytes. There was no evidence of dysplasia/atypical cells. Post-operative period was uneventful and at 1-week post op follow up as shown in (Figure 5) revealed a well epithelizing EAC with no clinical abnormalities.

Figure 4: High power microscopy 200X image denoting stratified squamous epithelium with subepithelial fibro collagenous tissue.
Figure 4: High power microscopy 200X image denoting stratified squamous epithelium with subepithelial fibro collagenous tissue.
Figure 5: Two weeks post-operative follow up showing well healed right EAC.
Figure 5: Two weeks post-operative follow up showing well healed right EAC.

DISCUSSION

Fibroepithelial polyp is regarded as a pseudotumor caused by inflammation or hyperplasia secondary to local lesions. It is a benign mass with an extremely low incidence of malignancy, and its etiology remains largely unknown.7 In addition to the skin, these polyps can occur anywhere on mucosa, most commonly on tongue, lips and cheek along the occlusal line.8 Polyps arising in oral cavity represent a reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma.9

Since the year 2000, there have been various rare presentations of fibroepithelial polyp that have been reported from sites such as ureter, renal pelvis, genitals and bronchus. Head and neck region showed these lesions at oropharynx, tongue and inferior nasal turbinate.10-12 That said, EAC as a site resounded in the world of such fibromas in two cases reported in the past denoted in (Table 1). The first case reported by Toma AG et al was an EAC mass which on excision and evaluation was in fact a reactive fibroepithelial change in the skin overlying an osteoma.15 Their patient had prior history of an aural polypectomy more than 12 years earlier, which was reported on histopathology as an “aural inflammatory polyp covered by stratified squamous epithelium”. Therefore, it is undeniable that this fibroepithelial polyp, unlike our case, had appeared secondarily, not independently, or in association with an initial inflammatory polyp. Among true acrochordons for this rare site, only one other case has been reported by Tanaka et al in 2013 which was also an independent mass of the EAC which primarily arose from the posterior EAC with a papilloma /wart like appearance.15 In this case, however, the mass was smooth surfaced with a pedunculated large skin tag like appearance.13 There was no age/sex related predilection and all cases had undergone in toto excision surgically either under GA/LA, which completely relieved the presenting complaints of the patients, as was the outcome in this patient.

Table 1: Review of literature of Acrochordons reported exclusively in the EAC.
Table reproduced from source PDF page 3

Many a times masses that present in such fashion are considered tumor-like lesions of the EAC, so-called “aural polyps,” which include exostosis, osteoma, fibrous dysplasia, granuloma, ceruminous gland tumor, epidermoid cholesteatoma, papilloma, and even malignancies. These Mass lesions that narrow or occlude the auditory canal can cause hearing loss, otitis externa with resultant otalgia and otorrhea, tinnitus, aural fullness, and vertigo.14 Only after ruling out malignancy with thorough investigations, should aural polyps be subjected to excision. Caution to associated complications linked to these lesions must be borne in mind. An association between “aural polyp” and cholesteatoma and an external auditory canal polyp accompanying squamous cell carcinoma have been reported previously and, in such cases, aggressive surgical resections may be necessary.16 In this regard, Acrochordons seldom undergoes malignant transformations. However, symptomatic acrochordons must be excised to establish diagnosis and alleviate symptoms completely. Surgical excision is the treatment of choice.

CONCLUSION

Fibroepithelial polyp, although a rare occurrence in the EAC, should be considered a differential diagnosis for polypoidal mass of this unusual site. They may arise as polypoidal outgrowths or papilloma like lesions from either anterior or posterolateral wall of the canal. It is recommended that such aural polyps should be excised for confirmation of diagnosis and complete resolution of symptoms such as reduced hearing, aural fullness and when in doubt, be subjected to biopsy to rule out malignancy associated with aural polyps.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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