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.