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Complication of dilute vinegar therapy forexternal auditory canal cholesteatoma

ARTICLE in ARCHIVES OF OTO-RHINO-LARYNGOLOGY MAY 2012Impact Factor: 1.61 DOI: 10.1007/s00405-012-2035-2 Source: PubMed

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Annabelle Leong

Khoo Teck Puat Hospital

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LETTER TO THE EDITOR

Complication of dilute vinegar therapy for externalauditory canal cholesteatoma

Annabelle C. Leong David A. Bowdler

Received: 1 April 2012 / Accepted: 20 April 2012/ Published online: 11 May 2012 Springer-Verlag 2012

Dear Editor,

We read with great interest the recent article by Changet al. [ 1] which advocated the use of repeat irrigation withdilute vinegar in conjunction with regular microscopiclocal cleansing to manage spontaneous external auditorycanal (EAC) cholesteatoma. In their series of 16 patients,they declared no complications resulting from this treat-ment regimen. However, we wish to report that when wetrialled the very same regimen on one of our patients, ourpatient suffered a perforated tympanic membrane withsubsequent worsened pain and otorrhoea, just 7 days afterstarting this treatment. Her external canal cholesteatoma

was classied as grade I according to Changs suggestedtemporal bone CT staging, i.e., with attening of the bonyexternal canal. She had surgical debridement and recon-struction of the EAC 6 months previously and was keen toexplore another treatment option apart from repeat surgicalintervention. She followed the self-cleansing instructionsexactly as described in Changs paper, using a 10-ml syr-inge to gently irrigate her ear canal with dilute vinegar,40 ml in total volume daily, aiming towards the posteriorcanal wall. When the tympanic membrane perforation wasdetected at her next clinic visit, she was instructed to stopthe vinegar washouts and to commence a course of quin-

olone ear drops, after which her otorrhoea improved. She iscurrently still attending our clinic regularly for repeatmicrosuctioning of her canal cholesteatoma. If her perfo-rated tympanic membrane fails to heal (and it has not done

so thus far after 5 weeks), then performing a tympano-plasty would be the next obvious option.Cadaveric studieshave found an association of ear irrigation with rupture of atrophic tympanic membranes with the lowest tensilestrength but not of normal tympanic membranes [ 2]. Ourpatients tympanic membrane was essentially normalbefore the perforation event and her cholesteatoma is solelyconned to the EAC, as conrmed on computed tomog-raphy scanning on two separate occasions. We would liketo politely enquire if the authors have experienced similarcomplications since publication of their paper or if theyhave any further insights into the vinegar regimen to sharewith us.

Thank you very much.Yours sincerely,Annabelle C. Leong, FRCS (ORL-HNS)David A. Bowdler, FRCS

References

1. Chang J, Choi C, Im GJ, Jung HH (2012) Dilute vinegar therapyfor the management of spontaneous external auditory canalcholesteatoma. Eur Arch Otolrhinolaryngol 269:481485

2. Sorensen VZ, Bonding P (1995) Can ear irrigation cause rupture of the tympanic membrane? An experimental study in man. J Laryn-gol Otol 109:10361040

A. C. Leong ( & ) D. A. BowdlerDepartment of Otolaryngology, University Hospital Lewisham,London SE13 6LH, UK e-mail: ackleong@gmail.com

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Eur Arch Otorhinolaryngol (2012) 269:2301DOI 10.1007/s00405-012-2035-2