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guarded for many patients because recurrence of inflam mation and partial restenosis is common. Still, greater than 60% of patients have favorable long-term hearing outcomes. Patients need to be accurately informed dur ing the preoperative consultation of the expected short and long-term results, and the decision to pursue sur gery should strongly consider these expectations. Refine ments in surgical technique, attempts to identify perioperative factors that may help to stratify patients into recurrence risk categories, and advancements in medical approaches should continue to be studied in an effort to improve outcomes in patients treated for PIMCF. As in any patient with a large conductive hear ing loss, a conventional hearing aid or osseointegrated device should be considered as an alternative to surgery. BIBLIOGRAPHY 1. Dhooge I, D’Hoop M, Loose D, Acke F. Acquired atresia of the external auditory canal: long-term clinical and audiometric results after surgery. Otol Neurotol 2014; 35:1196–1200. 2. Cremers CWRJ, Smeets JHJM. Acquired atresia of the external auditory canal: Surgical treatment and results. Arch Otolaryngol Head Neck Surg 1993;119:162–164. 3. Birman CS, Fagan PA. Medial canal stenosis—chronic stenosing external otitis. Am J Otol 1996;17:2–6. 4. Adkins WY, Osguthorpe JD. Management of canal stenosis with a transpo sition flap. Laryngoscope 1981;91:1267–1269. 5. Herdman RC, Wright JL. Surgical treatment of obliterative otitis externa. Clin Otolaryngol Allied Sci 1990;15:11–14. 6. Selesnick S, Nguyen TP, Eisenman DJ. Surgical treatment of acquired external auditory canal atresia. Am J Otol 1998;19:123–130. 7. Magliulo G. Acquired atresia of the external auditory canal: recurrence and long-term results. Ann Otol Rhinol Laryngol 2009;118:345–349. 8. Tos M, Balle V. Postinflammatory acquired atresia of the external auditory canal: late results of surgery. Am J Otol 1986;7:365–370. 9. Bonding P, Tos M. Postinflammatory acquired atresia of the external audi tory canal. Acta Otolaryngol 1975;79:115–123. 10. Ghani A, Smith MC. Postinflammatory medial meatal fibrosis: early and late surgical outcomes. J Laryngol Otol 2013;127:1160–1168. 11. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Tri als 1986;7:177–188. 12. Freeman M, Tukey J. Transformations related to the angular and the square root. Ann Math Statist 1950;21:607–611. 13. Becker BC, Tos M. Postinflammatory acquired atresia of the external audi tory canal: treatment and results of surgery over 27 years. Laryngoscope 1998;108:903–907. 14. Katzke D, Pohl DV. Postinflammatory medial meatal fibrosis. A neglected entity? Arch Otolaryngol 1982;108:779–780. 15. Lin VY, Chee GH, David EA, Chen JM. Medial canal fibrosis: surgical technique, results, and a proposed grading system. Otol Neurotol 2005; 26:825–829. 16. Moser G, Emberger M, Toth M, Roesch S, Rasp G, Laimer M. Ectopic apo crine glands as a predisposing factor for postinflammatory medial mea tal fibrosis: a clinicopathologic study. Otol Neurotol 2015; 36:191–197. 17. Ribeiro A, Leonardo A, Rodrigues ERM, Lopes G. Split thickness skin grafts in four cases of medial meatal fibrosis of the external auditory canal. [Article in English, Spanish]. Acta Otorrinolaringol Esp 2015;66: 281–285. doi: 10.1016/j.otorri.2014.07.005 18. Slattery WH 3rd, Saadat P. Postinflammatory medial canal fibrosis. Am J Otol 1997;18:294–297. 19. Suzukawa K, Karino S, Yamasoba T. Surgical treatment of medial meatal fibrosis. Report of four cases. Auris Nasus Larynx 2007;34:365–368. 20. Tos M, Bonding P. Treatment of postinflammatory acquired atresia of the external auditory canal. ORL J Otorhinolaryngol Relat Spec 1979;41: 85–90. 21. McCary WS, Kryzer TC, Lambert PR. Application of split-thickness skin grafts for acquired diseases of the external auditory canal. Am J Otol 1995;16:801–805. 22. Soliman T, Fatt-Hi A, Abdel Kadir M. A simplified technique for the man agement of acquired stenosis of the external auditory canal. J Laryngol Otol 1980;94:549–552. 23. Cremers WR, Smeets JH. Acquired atresia of the external auditory canal. Surgical treatment and results. Arch Otolaryngol Head Neck Surg 1993; 119:162–164. 24. el-Sayed Y. Acquired medial canal fibrosis. J Laryngol Otol 1998;112: 145–149. 25. Keohane JD, Ruby RR, Janzen VD, MacRae DL, Parnes LS. Medial mea tal fibrosis: the University of Western Ontario experience. Am J Otol 1993;14:172–175.

restenosis was 64.3%, which was significantly higher than that observed at short-term follow-up (0%). Inter estingly, hearing outcomes were also significantly worse in those patients with partial restenosis versus those who healed normally. Given the substantial risk for par tial restenosis and significantly poorer hearing outcomes in these patients, we believe reporting cases of partial restenosis is critical. Patients need to be counseled of the possibility of any degree of disease recurrence and the need for ongoing medical management when partial stenosis/OE/CSOM recur. In general, there tends to be two primary reasons for restenosis: 1) Early restenoses likely occur from surgical failure, that is, in cases when the fibrotic plug was incom pletely cleared or denuded canal bone remained ungrafted. Our cohort did not have any cases of early restenoses that could have been attributed to surgical technique. 2) However, late recurrences are likely the result of ongoing inflammatory/infectious disease in the EAC, which appeared to be the case in all of our long-term partial/complete recurrences. In our single case of com plete canal restenosis, the patient experienced late recur rence of episodic OE and stenosis after approximately 9 years from initial surgery. The patient underwent revision canaloplasty but has continued to require ongoing ear toi let and frequent wick placement. This patient’s case was similar to all of our cases of late, partial restenosis for which recurrent OE/CSOM/otorrhea resulted in some degree of canal narrowing. Conservative management in these cases with ear wicks/topicals has maintained canal patency and acceptable hearing, avoiding further surgery. Unfortunately, it remains difficult to predict which patients are likely to recur versus those who, once their diseased canal skin is cleared and replaced with healthy skin during surgery, will remain disease-free. Limitations The primary study and meta-analysis presented here are not without limitations. Our cohort was small and underpowered for most statistical analyses being per formed. Furthermore, given the low incidence of PIMCF, even to achieve a cohort of only 21 ears, the study period spanned > 15 years. The surgical technique, however, did not change during this interval. The systematic review and meta-analysis performed included only retrospective, level IV studies. Ideally, higher level studies would have been available for a more meaningful systematic review. Anoth er limitation to the meta-analysis was the significant het erogeneity in outcomes reporting among the included articles. Not all articles reported ABGs, SRTs, restenosis rates, and so forth. Although a meta-analysis could still be performed, missing data certainly limited its power. CONCLUSION PIMCF is a rare disease entity that causes signifi cant hearing deficits secondary to complete obliteration of the medial EAC with fibrosis; surgery becomes the only treatment option in later stages of the disease. Although surgery seeks to restore patency of the EAC and a healthy canal environment, late outcomes are

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