Hearing Loss in the Petrified Ears

Petrified ear is a rare diagnosis caused by calcification or ossification of auricular cartilage, often associated with trauma, frostbite, inflammation, and endocrinopathies, such as adrenal insufficiency.1 The cases published focus on etiology and diagnostic workup rather than management of associated hearing loss (HL). Therefore, we present a case of petrified ears and discuss surgical intervention. The Penn State Human Subjects Committee determined this case to be exempt from Institutional Review Board Approval (STUDY00024605). A 79-year-old male presented with progressive bilateral HL (L>R), intermittent tinnitus, and firm pinnas that have been stable for decades. He endorsed a history of noise exposure but denied vestibular symptoms, otorrhea, otalgia, auricular swelling/trauma, otologic surgery or infections, and endocrinopathies. His medical history was unremarkable and blood work, including adrenal function testing, was normal. On exam, bilateral auricles appeared normal but were “stone-hard” with minimal cartilaginous flexibility. Otoscopy and binocular microscopy were limited due to auricular rigidity but demonstrated canal stenosis and inability to view the tympanic membranes (TM) due to cerumen, which was significantly worse on the left and extended to the bony-cartilaginous junction. Cerumen removal was not performed in-office due to limited visualization and instrumentation from canal stenosis and auricular rigidity. Computed tomography showed extensive calcification of the auricular cartilages with significant left external auditory canal (EAC) opacification consistent with cerumen impaction (Figure 1). Cochlear and ossicular anatomy was normal. Audiometry demonstrated moderate to profound mixed HL on the left with a 4-frequency (500, 1000, 2000, 4000 Hz) pure tone average air-bone gap of 40 decibels. The right ear showed moderate to severe high-frequency sensorineural HL (SNHL) (Figure 2). The sensorineural components were not thought to be related to auricular petrification. It was hypothesized that cerumen impaction caused the HL, so left otoplasty and endaural meatoplasty were offered. Placement of a bone conduction device was offered alternatively, but the patient declined. Due to poor intraoperative EAC visualization, otoplasty involving resection of the antitragus and anterior portion of the conchal cartilage was performed in addition to meatoplasty in which an anterior portion of the cartilaginous canal was removed. Tragal resection wasn't necessary for adequate visualization. Cartilaginous resection of the contralateral ear was unnecessary due to the smaller cerumen burden, which likely resulted from minute differences in tragal flexibility. Bilateral cerumen disimpaction revealed normal TMs. One month follow-up revealed increased patency and visualization of the left EAC without cerumen impaction. The patient reported significant hearing improvement, so repeat audiometry wasn't performed. The same procedure was offered for the contralateral side along with hearing aid evaluation for persistent SNHL, but he opted for regular cerumen removal. Petrified ear is a rare, irreversible, and often asymptomatic condition; however, some patients have conductive HL (CHL) and discomfort with ear compression, such as during sleep.2, 3 HL often occurs secondary to cerumen impaction, as auricular inflexibility prevents natural expulsion and manual extraction.2, 3 Most cases discuss workup and etiology, with only three reporting surgical management.3-5 Two patients received surgery to relieve discomfort,4, 5 and one underwent surgery to improve HL.3 Specifically, Manni et al. reported a patient who underwent resection of the lamina of the tragus followed by resection of the medial concha up to the antitragus and cartilaginous EAC 1.5 years later due to progressive stenosis. This improved otoscopy and cerumen removal, resolving the HL.3 Our unique report highlights treatment considerations for petrified ears and mixed HL. As in similar cases, cerumen removal should be considered first to address CHL. For severe disease, surgery is often needed due to otoscopy limitations and the high-risk of reaccumulation. Otoplasty alone can be considered since removal of the tragal, antitragal, and/or portions of the conchal cartilage improves access for disimpaction. However, meatoplasty appears necessary to address current or future canal stenosis and prevent cerumen reaccumulation. Combined, these procedures also facilitate hearing aid use to treat residual HL, which in our patient would have been limited by his altered anatomy. Placement of a bone conduction device may be considered in those unable to wear traditional hearing aids; however, this has not been reported. Petrified ears are rare, and the literature on treatment of HL is limited. Our case reinforces the need for otoplasty with meatoplasty to address cerumen impaction while introducing considerations for any persistent sensorineural component. We thank Caia Hypatia for their assistance with manuscript preparation and submission. All individuals who met authorship criteria are listed as authors. All authors certify that they have participated sufficiently in the work to take responsibility for its content. Bao Y. Sciscent, concept design, acquisition, analysis, and interpretation of data, writing the manuscript, presentation; Marc D. Polanik, concept design, acquisition, analysis, and interpretation of data, critical editing of the manuscript; Hanel W. Eberly, interpretation of data, critical editing of the manuscript; Mark E. Whitaker, supervision, concept design, interpretation of data, critical editing of the manuscript, final approval. None. None.