Response from the Authors

Abstract

Dear Editor,

    We are sincerely grateful for the interest and valuable insights the writer has provided regarding the case that we presented. Prior to the patient’s consultation and admission to our institution, a number of general practitioners and ENT doctors who had seen the patient treated him with oral and topical antibiotics with a diagnosis of Chronic Otitis Media. Upon receiving the patient, we immediately thought of a different disease process present because of the unusual presentation. Diagnostics as well as surgical planning was mobilized. Intraoperatively, the tympanic membrane’s status was noted to be perforated because the mass that was seen obliterating the external ear canal was noted to have extended from the middle ear. About 40% of fibrous dysplasia presents with cholesteatoma and the majority of them are found in the external auditory canal.¹ However, in our case, the cholesteatoma was seen in the middle ear. A similar case by Jethanamest and Roehm showed an unusual presentation of cholesteatoma in the middle ear.² Another study by Ge et al. also observed middle ear cholesteatoma in their patient with fibrous dysplasia.³ There is a lack of literature identifying chronic otitis media in fibrous dysplasia. It has been pointed out that cholesteatoma in fibrous dysplasia is usually caused by the accumulation of keratin due to stenosis of the external auditory canal.⁴ Theoretically, cholesteatomas can further cause complications and can spread infection and products of inflammation like proteins, bacteria, and toxins.⁴ Their presence in the middle ear could cause infection and erosion of the ossicles. This is also seen in patients with cholesteatoma formed from the EAC stenosis of fibrous dysplasia. The similarity in effect could be diagnostically challenging for some otorhinolaryngologists.

    We completely agree with the important pointers and knowledge that the letter writer has imparted to us, and this is in line with the main purpose for writing the paper. We have highlighted that this case calls physicians, especially ENT physicians, to be vigilant of ear discharges. We have stressed that not all chronic ear discharges mean Chronic Otitis Media and that we have to be wary of other pathologies. The letter only shows that there is more to understand about this disease and that with the pointers, experience and expertise given by this letter and the previous article, the readers will understand the disease process better and will be able to identify and treat patients accordingly. This case was presented to share our experience on the diagnostic dilemma and outcome of the treatment done. We share the same sentiments that misdiagnosing would delay treatment, this is why we immediately took action when we received the referral. In the future, we are hoping that readers would be guided in planning for patients with fibrous dysplasia by the different literatures available and share their experiences of the outcomes.

    Thank you.