Document Detail

A rare case of petrified ear.
Jump to Full Text
MedLine Citation:
PMID:  23259082     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Calcification or ossification of the auricle, also referred to as petrified ear, is a rare diagnosis in dermatology. In medical literature, it has most often been attributed to trauma, hypothermia and frostbite, or hypercalcemia secondary to a metabolic or endocrine disorder, such as Addison's disease. Here, we report the clinical and radiologic findings of a 79-year-old African American male whose unilateral petrified auricle was an incidental finding. He had a preceding history of hyperparathyroidism and subsequent hypercalcemia treated with a subtotal parathyroidectomy three years prior to presentation. In addition to laboratory analysis, a history and physical examination was performed which revealed no other signs of hypercalcemia. Radiologic studies demonstrated partial ossification of the external auricular cartilage on the left side. The patient was diagnosed with the rare occurrence of a petrified ear. In light of this case, we provide a discussion concerning the possible etiologies of this diagnosis including appropriate patient evaluation and possible treatment recommendations.
Authors:
Kathryn E Buikema; Erin G Adams
Publication Detail:
Type:  Journal Article     Date:  2012-10-15
Journal Detail:
Title:  Case reports in dermatological medicine     Volume:  2012     ISSN:  2090-6463     ISO Abbreviation:  Case Rep Dermatol Med     Publication Date:  2012  
Date Detail:
Created Date:  2012-12-21     Completed Date:  2012-12-24     Revised Date:  2013-03-14    
Medline Journal Info:
Nlm Unique ID:  101591808     Medline TA:  Case Rep Dermatol Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  410601     Citation Subset:  -    
Affiliation:
Kimbrough Ambulatory Care Center, Fort George G. Meade, MD 20755, USA.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Case Rep Dermatol Med
Journal ID (iso-abbrev): Case Rep Dermatol Med
Journal ID (publisher-id): CRIM.DM
ISSN: 2090-6463
ISSN: 2090-6471
Publisher: Hindawi Publishing Corporation
Article Information
Download PDF
Copyright © 2012 K. E. Buikema and E. G. Adams.
open-access:
Received Day: 31 Month: 8 Year: 2012
Accepted Day: 18 Month: 9 Year: 2012
Print publication date: Year: 2012
Electronic publication date: Day: 15 Month: 10 Year: 2012
Volume: 2012E-location ID: 410601
PubMed Id: 23259082
ID: 3505947
DOI: 10.1155/2012/410601

A Rare Case of Petrified Ear
Kathryn E. Buikema1
Erin G. Adams2*
1Kimbrough Ambulatory Care Center, Fort George G. Meade, MD 20755, USA
2Department of Dermatology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
Correspondence: *Erin G. Adams: erin.adams@med.navy.mil
[other] Academic Editors: S. Inui and A. A. Navarini

1. Introduction

Petrified ear, whether due to calcification or ossification, is a rare diagnosis. Generally patients are asymptomatic, and the diagnosis is made incidentally. These patients often have endocrine or metabolic disorders that lead to hypercalcemia and ectopic calcification or ossification. In other cases, patients recall trauma to the ear or an episode of frostbite. Greater awareness of this diagnosis would be beneficial for all practitioners, especially considering its association with potentially serious and life-threatening endocrinopathies, such as cortisol deficiency.


2. Case Report

We present a case of a 79-year-old African American male referred from his internist for evaluation of a rigid left ear. The patient reported increased difficulty in fitting his hearing aid in his left ear over the preceding year. He denied history of wrestling, boxing, headset use, frostbite, or other trauma to the ear. He denied other systemic symptoms. His medical history revealed persistent hypercalcemia five years prior to presentation which had been attributed to hyperparathyroidism. He was treated with a subtotal parathyroidectomy three years prior to our evaluation which resulted in normalization of his serum calcium and parathyroid hormone levels.

On physical examination, the left anterior helix was markedly rigid and could not be folded. The superior helix to the crus of the helix was hyperpigmented and seemed bound to the crura of the antihelix (Figure 1). Debris had collected within this space. The left earlobe was normal and easily mobile. His right ear was normal. Deep tendon reflexes were normal.

A noncontrast temporal bone computed tomography (CT) scan demonstrated partial ossification of the left external auricular cartilage (Figure 2). Ossification was favored in this case due to the presence of tiny radiolucent air spaces seen within the opacity. Laboratory testing to include complete metabolic panel, serum calcium and phosphorus, parathyroid hormone, serum morning cortisol, adrenocorticotropic hormone, rapid plasma reagin, uric acid, hemoglobin A1c, vitamin D, and thyroid function tests was within the normal range. Complete blood count revealed a mild microcytic anemia. Based on these clinical and radiographic findings, a rare case of a petrified left ear was diagnosed.


3. Discussion

Bochdalek first reported a case of petrified auricle in a cadaver in 1866 [1], while Wassmund first reported the X-ray findings of this condition in 1899 [2]. Since then, approximately 140 cases of petrified ear have been reported with evidence of either calcification or ossification of the elastic auricular cartilage by radiography and/or histopathologic examination [3].

Elastic cartilage is a component of the auricle, external ear canal, nose, and epiglottis of the head and neck and does not usually have a tendency to calcify or ossify. Elastic cartilage of the auricle is normally highly malleable and painless to manipulate. Upon calcification or ossification of the auricle, it becomes difficult to maneuver and rock hard or petrified. Petrification of the auricular cartilage has been attributed to dystrophic calcification, metastatic calcification, and ectopic ossification. The petrification process can be initiated by local injury, such as frostbite, physical trauma, or as a result of systemic or inflammatory conditions. The most common cause of auricular calcification and ossification is frostbite [4, 5].

Petrification is caused more often by calcification than ossification [6]. Dystrophic calcification occurs when a patient has normal serum calcium and phosphorous levels, but calcium is deposited in previously damaged tissue. The auricle of the ear is vulnerable to local trauma and frostbite which can damage the auricular cartilage, result in calcium deposition, and lead to stiffening of the auricle [4, 7]. Metastatic calcification is due to an imbalance in calcium metabolism and occurs secondary to hypercalcemia, milk-alkali syndrome, vitamin D intoxication, hyperparathyroidism, and sarcoidosis [4, 8]. Adrenal insufficiency, leading to hypercalcemia, is the most common etiology of metastatic calcification of the auricle [4]. Jarvis et al. reported a high incidence of rigid ears in Addisonian patients [9]. It is believed that cortisol deficiency may contribute to the development of hypercalcemia in not only Addison's disease, but also in hypopituitarism and adrenogenital syndrome [10, 11]. Other systemic diseases that have been associated with auricular calcification include hypertension, alkaptonuria, systemic chondromalacia, familial cold hypersensitivity, relapsing polychondritis, scleroderma, polyarteritis nodosa, acromegaly, diabetes mellitus, hypothyroidism, hyperthyroidism, hyperparathyroidism, and pseudohyperparathyroidism [1, 5, 1215].

Ectopic ossification occurs when new bone is formed in tissue that does not normally have a tendency to ossify. It can be classified as primary when it arises de novo, such as in rare syndromes, or as secondary if it occurs within an existing lesion and is often preceded by calcification [16]. True ossification of the auricle is a rare diagnosis, with less than 20 cases having been histopathologically documented [1, 3, 5, 1214, 1721]. It typically begins with the production of bone morphogenetic protein [6] which is necessary for the transformation of primitive cells to osteogenic precursor cells [3]. Besides frostbite, other local causes of ossification are recurrent cold exposure, mechanical trauma, repeated manipulation of the auricle, radiation therapy, acne scarring, and insect bites [21]. It has also been reported in association with inflammatory conditions such as chondritis, perichondritis, and syphilitic perichondritis [4, 7, 10]. Moreover, auricular ossification has been associated with benign melanocytic nevi, pilomatricomas, chondroid syringomas, and external auditory canal exostoses [13, 17] as well as with syndromes such as congenital plaque-like osteomatosis, Albright's hereditary osteodystrophy, fibrodysplasia ossificans progressiva, and osseous heteroplasia [13]. Collagen vascular diseases such as morphea, scleroderma, CREST, and childhood dermatomyositis can demonstrate areas of both calcification and ossification [12, 21].

The clinical presentation of petrified ear can vary, and there is no clinical difference between auricular calcification and ossification [22]. Most patients are asymptomatic, although some may experience discomfort with application of pressure, such as when sleeping on the affected ear. Bilateral involvement tends to be more frequent than unilaterality, and petrified ear seems to occur more commonly in men than in women [7]. On physical exam, the superior pinna is rigid and immobile. The ear lobule is spared. Rarely, patients have subjective and/or objective hearing loss which may be evaluated with an audiogram. External otalgia may be present if the process involves the ear canal.

Laboratory evaluation is helpful in detecting any underlying metabolic or endocrine disorder or other systemic disease. Laboratory analysis should include at a minimum a complete blood count, basic metabolic panel, thyroid function tests, parathyroid hormone levels, vitamin D, and serum calcium and phosphorus. If the fasting glucose is high, a hemoglobin A1c should be evaluated.

Further assessment should include radiography. A skull X-ray may demonstrate a hyperdense area, but a temporal bone CT can more specifically evaluate this finding. Calcification and ossification appear as hyperdense areas. Ossification is suspected by the presence of a trabecular bone pattern of minute radiolucent spaces within the dense opacities on CT [5, 19].

Histopathological examination is not mandatory but can confirm the diagnosis. It aids in the distinction between auricular calcification and ossification.

Because most patients are asymptomatic, no specific therapy is necessary. The condition can be progressive, extending into the external ear canal cartilage, but it always spares the ear lobule. Evaluating for and correcting or controlling any underlying metabolic, endocrine, or other systemic condition is essential as well as protecting the affected auricle from further trauma. There is no known treatment to reverse the calcification or ossification. Patients who are symptomatic have been reported to show improvement with wedge resection of the affected cartilage or conchal reduction surgery [5, 18, 23]. Most asymptomatic patients choose to forgo surgery, as in our patient's case.

Our patient declined auricular biopsy for histopathological confirmation as he understood the lack of available treatment for his mostly asymptomatic condition. He planned to follow up with audiology for adjustment of his hearing aid.

Petrified ear has been associated with serious, potentially life-threatening, endocrine, and metabolic disorders, such as cortisol deficiency [5, 10, 11]. Its diagnosis warrants an investigation for cause, thereby eliminating delays in diagnosis of an underlying systemic condition. Patient morbidity could be minimized by recognizing petrified ear and expeditiously diagnosing and treating any related disorders.


Conflict of Interests

The authors have no conflict of interests to declare.


Disclosure

The views expressed in this paper are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Army, Department of Defense, or the US Government.


Authors' Contribution

The authors certify that all individuals who qualify as authors have been listed; each has participated in the conception and design of this work, the analysis of data (when applicable), the writing of the paper, and the approval of the submission of this version; the paper represents valid work; that if they used information derived from another source, we obtained all necessary approvals to use it and made appropriate acknowledgements in the document; they each takes public responsibility for it.


References
1. Bochdalek V. Verknocherung der aureculaPrag VierteljahrschrYear: 1866893346
2. Wassmund L. Verkno cherung der ohrmuschel und roentgenographieDeutsche medizinische WochenschriftYear: 18994439440
3. Chang K,Kim D,Kim J,Park Y. Idiopathic acquired ectopic auricular ossification: a case report and review of the literatureEar, Nose and ThroatYear: 2011909427424
4. Gordon DL. Calcification of auricular cartilageArchives of Internal MedicineYear: 196411323272-s2.0-7554912160614067590
5. Manni JJ,Berénos-Riley LCM. Ossification of the external ear: a case report and review of the literatureEuropean Archives of Oto-Rhino-LaryngologyYear: 2005262129619642-s2.0-2914446764115965703
6. Carfrae MJ,Foyt D. Auricular ossification resulting in external auditory canal stenosisEar, Nose and Throat JournalYear: 20088732-s2.0-43549098789
7. Scherrer FW. Calcification and ossification of external earsAnnals of Otology, Rhinology and LaryngologyYear: 193241p. 867
8. Batson J. Calcification of the ear cartilage associated with the hypercalcemia of sarcoidosisThe New England Journal of MedicineYear: 196126587687713865767
9. Jarvis JL,Jenkins D,Sosman MC,Thorn GW. Roentgenologic observations in Addison’s patientsRadiologyYear: 195462p. 16
10. Barkan A,Glantz I. Calcification of auricular cartilages in patients with hypopituitarismJournal of Clinical Endocrinology and MetabolismYear: 19825523543572-s2.0-00203544677085858
11. Fuster MAA,Fornés MJA,Rodríguez AF,Martínez MJR,Biosca JDC,Martínez JMV. Calcification of auricular cartilages in adrenal insufficiencyActa Otorrinolaringologica EspanolaYear: 20075841671682-s2.0-3454786427117428414
12. Stites PC,Boyd AS,Zic J. Auricular ossificans (ectopic ossification of the auricle)Journal of the American Academy of DermatologyYear: 20034911421442-s2.0-003804716412833029
13. Yeatman JM,Varigos GA. Auricular ossificationAustralasian Journal of DermatologyYear: 19983942682702-s2.0-00317359329838729
14. Sterneberg-Vos H,Winnepenninckx V,Frank J,Kelleners-Smeets NW. Ossification of the auricleInternational Journal of DermatologyYear: 200746supplement 342442-s2.0-3564895410217973890
15. McKusick V,Goodman R. Pinnal calcificationJournal of the American Medical AssociationYear: 1962179230232
16. Fairley JA. Bolognia JL,Jorizzo JL,Rapini RP,et al.Calcifying and ossifying disorders of the skinDermatologyYear: 20082nd editionLondon, UKMosby653660
17. DiBartolomeo JR. The petrified auricle: comments on ossification, calcification and exostoses of the external earLaryngoscopeYear: 19859555665762-s2.0-00218763853990487
18. Lister GD. Ossification in the elastic cartilage of the ear.British Journal of SurgeryYear: 19695653994002-s2.0-00145082934976415
19. High WA,Larson MJ,Hoang MP. Idiopathic bilateral auricular ossificans: a case report and review of the literatureArchives of Pathology and Laboratory MedicineYear: 200412812143214342-s2.0-1034422111215578890
20. Machado A,Lopes M,Ferreira C. Petrified auricular cartilages pointing the diagnosis of post-partum hypopituitarism in an encephalopathic patientEuropean Archives of Oto-Rhino-LaryngologyYear: 200926623053072-s2.0-5764919574118369651
21. Mastronikolis NS,Zampakis P,Kalogeropoulou C,et al. Bilateral ossification of the auricles: an unusual entity and review of the literatureHead and Face MedicineYear: 200951p. 172-s2.0-70350023237
22. Laguna EV,Martinez AA,Burgos F. Petrified ear-a case of calcinosis cutisActa Dermato-VenereologicaYear: 20098955265272-s2.0-70350138662
23. Lari AA,Al-Rabah N,Dashti H. Acrobativ ears: a cause of petrified auriclesBritish Journal of Plastic SurgeryYear: 19894267197212-s2.0-00248546342513998

Article Categories:
  • Case Report


Previous Document:  Dramatic Clinical Response of Relapsed Metastatic Extramammary Paget's Disease to Trastuzumab Monoth...
Next Document:  Complex Decongestive Physiotherapy Treats Skin Changes like Hyperkeratosis Caused by Lymphedema.