Discussion
Otic LP is an extremely rare localisation of LP, with few cases reported
in the literature. Clinically, it is characterised by a conductive
hearing loss, running ear, pruritus, pain, bleeding from the EAC and
tinnitus. The otologic involvement is reported to be bilateral in 14
cases (58,3%) and monoliteral in 10 cases (41,6%).
The diagnosis is clinical, with a coexistence of mucosal LP and
conductive hearing loss associated with EAC
stenosis3-6. A bioptic
sampling of the EAC can confirm the diagnosis of lichen, showing
hyperacanthosis, hypergranulosis, dermal lymphocytic infiltrate, focal
exocytosis and damaged basal cell layer with colloid
bodies3.
In the few cases reported in the scientific literature, medical and
surgical therapies have been proposed for the otologic management.
Martin et al. in one case, proposed a surgical treatment with the
removal of the inflammatory tissue and the calibration of the external
auditory canal and, after the three months relapsing, a medical therapy
with oral acitretine (initially 25 mg/day and then 35 mg/day) followed
by oral prednisolone (1mg/Kg/day) with a temporary clinical improvement
of the otologic finding and the conductive hearing
loss3. Hopsu &
Pitkäranta reported three mild cases threated with otologic eardrops
with antiseptic and/or corticosteroids with a non-progression of the
otologic finding and the stabilization of the hearing
threshold5. In a review,
Sartori-Valinotti et al. reported seventeen patients undergone a topical
otologic therapy with tacrolimus and two patients that received topical
clobetasol propionate or a combination of otologic ciprofloxacin and
dexamethasone drops with a good rate of subjective and/or objective
improvement6. Systemic
therapy has been reserved for the patients with severe extra-otic LP; in
this case series are also reported some patients that were previously
unsuccessfully submitted to meatoplastic or tympanoplasty surgery,
before the diagnosis of
LP6. In a recent
article, Kosec et al. reported one case of unilateral otic LP treated
with a meatoplasty in general anaesthesia and, because a five years
later recurrence, with a canal wall down tympanoplasty after the fails
of the medical treatments with topical and oral
steroids4. Globally the
surgical treatment is reported to have controversial results, usually
with short term
benefit6.
The patient we report was treated with otologic drop achieving a good
control of the local symptoms after twelve months of medical therapy.
Regarding the hearing deficit associated with otic LP, a conductive or
mixed hearing loss, with a variable degree of presentation, but
frequently mild, is generally reported, due to the stenosis of the EAC
and in some cases of the tympanic cavity. Sartori-Valinotti et al.
reported the hearing loss to as the most frequent symptom in patients
with otic LP, both conductive or mixed; they also report that four
patients presenting a relevant hearing loss in their cohort received
bilateral hearing aids6.
Also Kosec et al. report a case of otic LP with mixed hearing loss, but
no strategies for hearing remediation are ever been
reported4. Moreover, in
the available literature some surgical approaches to settle the stenosis
of the ear canal are reported but results in terms of hearing
restorations are
limited3-6.
As we previously stated, some authors reported that patients may have
benefit from the use of traditional hearing
aids6; anyway, in some
cases, as in the patient herein reported, the EAC is severely stenotic
or occluded and an earmold cannot be fitted. Furthermore, it has to be
considered that, even with an adequate ventilation, a stenotic and
inflammatory EAC can difficult receive the earmold. Finally, the chronic
trauma by the earmold could precipitate a recurrence of the otologic
symptoms in patients that presented a remission of disease. For these
reasons, we believe that the implantation of a BAHD is an option to be
considered in these cases, and even if nowadays the BAHDs are commonly
used for the treatment of conductive or mixed hearing loss, to our
knowledge no other case of oticus LP implanted with a BAHD has been
reported in the literature. In the reported patient, indeed, the BAHD
allowed to achieve satisfactory hearing results, without affecting the
ear canal and without the need of a surgical treatment of the occlusion
of the ear canal.
In the present article we report a case with a rare otic localization of
LP. In our case also, as previously reported in the scientific
literature, topical therapies with antibiotics and corticosteroids
eardrops proved to be effective to control the local
symptoms3,5,6.
Further, this report attests the effectiveness and safety of BAHD
implantation for the treatment of the mixed or conductive hearing
impairment in cases oticus LP.