Eur Arch Otorhinolaryngol (2012) 269:481–485
DOI 10.1007/s00405-011-1676-x
OTOLOGY
Dilute vinegar therapy for the management of spontaneous
external auditory canal cholesteatoma
Jiwon Chang · June Choi · Gi Jung Im · Hak Hyun Jung
Received: 3 March 2011 / Accepted: 8 June 2011 / Published online: 8 July 2011
© Springer-Verlag 2011
Abstract The purpose of this study is to evaluate the
eYciency of conservative dilute vinegar therapy in the
management of spontaneous external auditory canal choles-
teatoma (EACC). From 2000 to 2007, 19 patients presented
to our clinic with spontaneous EACC. EACC was divided
into four grades based on the temporal bone computed
tomography: grade I with Xattening of bony external canal,
grade II with partial destruction of inferior bony canal,
grade III with total destruction of inferior bony canal and
grade IV with bony destruction into the middle ear and
mastoid cavity. Clinical Wndings and treatment results were
recorded. Microscopic local cleansing and dilute vinegar
therapy was conducted in the ears with grades I, II and III.
Combined mastoid surgery and dilute vinegar therapy was
conducted in four ears with stage IV. There were no recur-
rences after average of 31 months follow-up. Spontaneous
EACC can be eVectively controlled with dilute vinegar
therapy after microscopic local cleansing. However, sur-
gery must be considered in the cases which have involved
the mastoid and middle ear. Dilute vinegar therapy in com-
bination with microscopic local cleansing was eVective in
the management of spontaneous EACC. Dilute vinegar
therapy is an easy, cost-eVective, and home-based cleans-
ing method to prevent EACC and promotes healing. How-
ever, long-term follow-up may reveal frequent recurrence
of cholesteatoma debris and involvement of middle ear or
mastoid cavity, and then meticulous debridement with skin
graft or surgical intervention should be considered.
J. Chang · J. Choi · G. J. Im · H. H. Jung (&)
Department of Otolaryngology, Head and Neck Surgery,
Korea University College of Medicine, 126-1,
Anam-dong-5 Ga, Seungbuk-Gu, Seoul 136-705, South Korea
e-mail: brune77@naver.com; ranccoon@naver.com
Keywords Ear canal · Cholesteatoma · Acetic acid
Introduction
External auditory canal cholesteatoma (EACC) is an
uncommon form of cholesteatoma originating in the exter-
nal auditory canal extending into surrounding structures,
including mastoid and middle ear. After Toynbee [1]
described a lesion of the external auditory canal with epi-
dermal scales as the Wrst report of EACC, its incidence has
been estimated at approximately 0.1% of new otologic
patients [2]. EACC has been classiWed into congenital,
posttraumatic, iatrogenic, postobstructive, postinXamma-
tory, and spontaneous types depending on the etiology [3].
Spontaneous EACC can be deWned as EACC of uncertain
cause with no history of previous ear disease, signiWcant
trauma, or surgery [3].
The treatment regimens of spontaneous EACC are
variable with inconsistent results, and to date no consen-
sus has been reached on a single eVective therapeutic
regimen [3, 4]. Small lesions of spontaneous EACC can
be usually controlled with regular microscopic oYce
debridements, while large and destructive lesions require
surgery including tympanomastoidectomy for the com-
plete eradication of the cholesteatoma matrix. However,
since, patients tend to present with otorrhea which is
believed to be linked to an associated localized infection
resulting in the loss of acidity in the ear canal, the resto-
ration of acidity in the ear canal could be a very eVective
therapy. In fact, there are many studies that demonstrate
the acidiWcation is a good way to treat external ear canal
diseases [5, 6].
In the present study, self-cleansing with dilute vinegar
solution was applied to the external auditory canal for the
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482 Eur Arch Otorhinolaryngol (2012) 269:481–485

management of spontaneous EACC and the therapeutic

eYcacy of this modality was observed.

Materials and methods

Between January 2000 and December 2007, 19 patients

with unilateral or bilateral spontaneous EACC who could
be followed up for more than 6 months were included in the
study. The age of the patients ranged from 17 to 87 years at
the time of diagnosis (average age 48, median age 40). 12
patients were female, and 7 were male. Both ears were
aVected in six patients. Average follow-up periods were
31 months ranging from 10 to 108 months. Patients with
prior trauma, otologic surgery, or diseases associated with
middle ear or mastoid were excluded. The Institutional
Review Board of Korea University Anam Hospital
approved this study (AN10198-002).
Spontaneous EACC was classiWed by temporal bone
computed tomography (TBCT) into four grades instead of
pathologic Wndings [7]: grade I with Xattening of bony
external canal, grade II with partial destruction of inferior
bony canal, grade III with total destruction of inferior bony
canal and grade IV with bony destruction and invasion into
middle ear and/or mastoid cavity (Fig. 1).
In patients with spontaneous EACC, polypoid granula-
tion with crust in EAC was removed with meticulous
debridement under microscopic control and then EAC was
packed with a half-inch strip of gauze soaked with antibi-
otic otic drops. The polypoid granulation was sent to the
pathologic department to conWrm the histopathologic diag-
nosis. The gauze strip was removed after 3 days by the doc-
tor and then self-cleansing with dilute vinegar therapy was Fig. 1 ClassiWcation spontaneous EACC according to TBCT.
a Grade I EACC on the right side. It reveals Xattening of right bony
started.
external auditory canal but no bony erosion. b Grade II EACC (right)
A suitable vinegar solution with pH 2.25 § 0.02 was with partial destruction of inferior bony canal. c Grade III EACC
commercially available. The manual for self-cleansing of (right) with total destruction of inferior bony canal. d Grade IV EACC
EAC with diluted vinegar solution was provided to (left) with total destruction of inferior bony canal and invasion into
mastoid cavity
patients, directed as follows: (1) dilute the vinegar with dis-
tilled water to 1:3 ratio (Wnal pH of the solution was
2.43 § 0.02), (2) warm the vinegar solution to 37–40°C, (3) appearance. In the case of recurrent otorrhea, dilute vinegar
instill 40 ml of diluted vinegar solution into each EAC treatment was tried again.
using a 10-ml syringe without needle, (4) allow the vinegar
solution to drain naturally, and then dry the EAC with a
hair-dryer for 1 min, and (5) perform this self-cleansing Results
once a day for 2–4 weeks. This treatment was continued
until the EAC became dry and no presence of otorrhea was Subjects
evident on microscopic examination. The patients were
reexamined regularly every other week for 8 weeks, and Six patients had bilateral spontaneous EACC, 10 had spon-
then all patients were scheduled for bimonthly follow-up taneous EACC on the right side, and 3 had on left side. Of
for a year, and twice a year after then. Recovery after ther- 25 ears from 19 patients, 7 ears were classiWed into grade I,
apy was deWned as cessation of ear discharge, absence of 5 ears into grade II, 9 into grade III, and 4 ears into grade
crust in the EAC, and the reversion of EAC skin to normal IV according to TBCT.

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Eur Arch Otorhinolaryngol (2012) 269:481–485 483

Fig. 2 Endoscopic Wndings of

EAC in grade I, II, and III after
treatment. a EAC Wnding of
grade I spontaneous EACC just
after removal of cholesteatoma
at the outpatient clinic. There is
remnant keratin material after
cleansing the canal. b EAC Wnd-
ing of grade II after 2 weeks of
dilute vinegar therapy. Partial
destruction of inferior wall is
identiWed. c EAC Wnding of
grade III after 2 weeks of dilute
vinegar therapy. There is a
destruction of inferior and pos-
terior canal wall with severe ca-
nal widening

Fig. 3 Endoscopic Wndings of

EAC in grade III, before and af-
ter treatment. a Endoscopic Wnd-
ing of the right external auditory
canal shows purulent otorrhea
and crust with widening of infe-
rior canal wall. b Debridement
and daily cleansing of external
canal with diluted vinegar solu-
tion resulted in a clear external
auditory canal at the fourth week

Microscope local cleansing and dilute vinegar treatment
In patients with spontaneous EACC of grades I, II or III,
crust in EAC was removed with meticulous debridement
under microscope after topical apply of anesthetic in the
outpatient clinic (Fig. 2). Among 21 ears with grades I, II or
III, 14 ears showed complete resolution of otorrhea when
observed at the end of second week with initial microscopic
debridement and self-cleansing of EAC with dilute vinegar
solution for 2 weeks, and 7 ears showed complete resolu-
tion of otorrhea at the end of fourth week (Fig. 3). During
follow-up, no recurrence was observed in these patients,
but three ears revealed occasional scanty wax in the canal.
No complication was observed.
In four ears which involved middle ear or mastoid
cavity (grade IV), intact bridge method mastoidectomy was

123
484
performed before the use of vinegar treatment, and the surgical
results were successful.
Discussion
The cause of EACC remains to be completely elucidated,
but it can be surmised by its pathophysiologic mechanism
or clinical process. The former suggests postsyphilitic
sequelae [8], lower migratory rate of epithelium in the infe-
rior ear canal [9], implantation of squamous epithelium
deep to the canal skin and ingrowths of squamous epithe-
lium into the defect [3, 10]. The latter, described by Holt
[11], classiWed EACC according to the division of the clini-
cal process of the disease into congenital ear canal stenosis,
ear canal obstruction, posttraumatic, postsurgical, and
spontaneous canal cholesteatoma. The cases in previous
study were mostly spontaneous EACC in an elderly popula-
tion and they suggested that spontaneous EACC might be
caused by an epithelial abnormality [12]. Vrabec and Chal-
jub [3] recently reported 12 cases of spontaneous EACC for
which the most common causes were hard cerumen, Q-tip
injury, and pressure from a hearing aid. They also added the
postinXammatory factor to Holt’s categories. Post-radiation
therapy can be considered as another cause [13]. In the
present study, all patients had no speciWc causes inducing
canal destruction except longstanding scanty otorrhea, sug-
gesting that external otitis can be the cause of spontaneous
EACC.
The treatment plan for spontaneous EACC can be vari-
able depending on the extent of bone destruction, but some
simple oYce procedures like meticulous debridement under
the microscope, topical antibiotic drops, and the use of min-
eral oil can be considered in cases of EACC with mild bone
erosion. These can be applied in isolation or in combina-
tion. Most cases of spontaneous EACC have been satisfac-
torily managed with local dressing, even in the presence of
signiWcant bone destruction [3].
In our study, we used self-cleansing of EAC with dilute
vinegar solution for the maintenance of EAC acidiWcation.
Because chronic infection of EAC may lead pH of EAC to
alkaliWcation that may delay healing of external otitis or
osteitis, the acidiWcation may be important in the manage-
ment of chronic external otitis. Self-cleansing with dilute
vinegar solution may help in recovering and maintaining
the acidiWcation of EAC and this acidiWcation may prevent
the progression of spontaneous EACC and reduce symp-
toms. Although our cases also showed variable clinical
Wndings from mild ear canal widening to total destruction
of the inferior canal wall, no treatment beyond local dress-
ing was required in any of the cases. In this aspect, dilute
vinegar treatment may represent the Wrst choice in the man-
agement of spontaneous EACC. Previously, such dilute
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Eur Arch Otorhinolaryngol (2012) 269:481–485
vinegar treatment has proven eVective in the management
of granular myringitis [5]. However, in cases of grade IV
(middle ear or mastoid involvement), vinegar treatment
alone was not eVective because permanent changes in tem-
poral bone are resistant to therapy and these cases needed
surgical intervention.
Because this disease shows slow progression, a continu-
ous and meticulous management of the EAC was helpful in
our experiences. The short-term prognosis of spontaneous
EACC may be so good that only oYce debridement is nec-
essary to control SCC over the short term. In the long term,
however, the prognosis is poor and recurrence is also com-
mon. When compared with the application of topical antibi-
otics, self-irrigation of dilute vinegar solution has several
advantages: (1) cost-eVectiveness, (2) more frequent clean-
ing eVect of EAC, (3) fewer visits to hospital, (4) promo-
tion of natural healing. However, because recurrent
otorrhea in spontaneous EACC occasionally occurs even
after self-cleansing of the ear canal with diluted vinegar
solution, a long term and intermittent management may be
necessary to maintain the dry canal.
Local canal widening does not seem to show spontane-
ous regression and tends to become more aggressive in
older patients. Therefore, the dilemma remains in the long-
lasting treatment of spontaneous EACC. Although self-irri-
gation using dilute vinegar solution with intermittent oYce-
based dressing enables the long-term management of spon-
taneous EACC without assistance from physicians, surgical
resection may still be required in the case of frequent recur-
rences. Spontaneous EACC may progress to advanced cho-
lesteatoma and deeper pockets into the mastoid that cannot
easily be managed with diluted vinegar treatment. Cana-
loplasty may be needed, with or without tympanomastoi-
dectomy, and previously, authors also performed intact
bridge method mastoidectomy in the management of spon-
taneous EACC extending into mastoid cavity with severe
bony destruction before the use of vinegar treatment and
the surgical result was successful. Some spontaneous
EACC with extensive mastoid involvement or complicated
cases, including facial nerve paralysis, ossicular chain ero-
sion, and labyrinthine Wstula may require surgical interven-
tion [14–17].
Conclusion
In summary, dilute vinegar therapy in combination with
microscopic local cleansing was eVective in the manage-
ment of spontaneous EACC. Dilute vinegar therapy is an
easy, cost-eVective, and home-based cleansing method to
prevent EACC and promotes healing. However, long-term
follow-up may reveal frequent recurrence of cholesteatoma
debris and involvement of middle ear or mastoid cavity,
Eur Arch Otorhinolaryngol (2012) 269:481–485
and then meticulous debridement with skin graft or surgical
intervention should be considered.
Acknowledgments This work was supported by the Brain Korea 21
Project.
ConXict of interest None.
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