PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 1 January – June 2014
PhiliPPine Journal of otolaryngology-head and neck Surgery 35
UNDER THE MICROSCOPE
A 58-year-old Filipino man with a two-year history of a left external auditory canal mass
associated with ipsilateral hearing loss underwent polypectomy for a clinical impression of aural
polyp.
We received several cream tan, irregular tissue fragments with an aggregate diameter of
1.4 cm. Histopathologic examination shows clusters of tumor cells forming variably sized ducts
and glands some of which are cystically dilated; many of these structures have irregular lumina.
(Figure 1) Higher magnification shows a dual cell population: an outer layer of round to ovoid cells
with clear cytoplasm corresponding to basal myoepithelial cells; and an inner layer of cuboidal
to columnar cells that have eosinophilic and granular cytoplasm with decapitating apical
ends, corresponding to luminal epithelial cells with apocrine morphology. (Figure 2) Nuclear
pleomorphism is mild to moderate, nucleoli are not prominent and mitoses, perineural invasion
and necrosis are not seen. In some glands a yellow to golden brown, coarse pigment is seen at
the cytoplasm of the luminal cells. (Figure 3) The tumor does not involve the epidermis and there
is a variable amount of chronic inflammation. (Figure 4) Based on these features we diagnosed it
as ceruminous adenoma.
Ceruminous neoplasms are uncommon tumors found in the external auditory canal. Benign
ceruminous tumors include ceruminous adenoma, ceruminous pleomorphic adenoma and
ceruminous syringocystadenoma papilliferum.1 Most common among these is the ceruminous
adenoma; making up 88% in one thirty-year review of benign ceruminous neoplasms.1 These
tumors occur in a wide age range, most commonly in the sixth decade, and have no sex
Ceruminous Adenoma
Correspondence: Dr. Jose M. Carnate Jr.,
Department of Pathology
College of Medicine, University of the Philippines Manila
547 Pedro Gil St., Ermita, Manila 1000
Philippines
Phone (632) 526 4450
Telefax (632) 400 3638
Email: jmcjpath@yahoo.com
Reprints will not be available from the authors.
The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere, in full or in
part, in print or electronic media; that the manuscript has been
read and approved by the authors, that the requirements for
authorship have been met by the authors, and that the authors
believe that the manuscript represents honest work.
Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional affiliations
that might lead to a conflict of interest. Philipp J Otolaryngol Head Neck Surg 2014; 29 (1):35-36 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Albert Joseph B. Lupisan, MD1
Jose M. Carnate, Jr., MD2
1Department of Laboratories,
University of the Philippines
Philippine General Hospital
2Department of Pathology,
University of the Philippines College of Medicine
Philippine General Hospital
Figure 1. Hematoxylin and Eosin (100x) Neoplastic cells with a glandular and cystic
architecture.
(Hematoxylin and Eosin, 100x)
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 1 January – June 2014
UNDER THE MICROSCOPE
36 PhiliPPine Journal of otolaryngology-head and neck Surgery
REFERENCES
Thompson LDR, Nelson BL, Barnes EL. Ceruminous adenomas: a clinicopathologic study of 41 1.
cases with a review of literature. Am J Surg Pathol. 2004 Mar; 28(3):308-318.
Thompson LDR. In: Thompson LDR, editor. Foundations in Diagnostic Pathology. Head and 2.
Neck Pathology. Philadelphia, PA: Elsevier, Inc.; 2006. p.397-340.
Srivalli M, Qaiyum HA, Moorthy PNS, Srikanth K. Adenomatous neoplasia presenting as aural 3.
polyp. Indian J Otolaryngol Head Neck Surg. 2012 Jan-Mar; 64(1):87-89. DOI: 10.1007/s12070-
011-0128-7.
Michaels L, Thompson LDR. In: Barnes L, Eveson JW, Reichart P, Sidransky D, editors. World 4.
Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck
Tumours. 2005; Lyon: IARC Press. p.331.
Lassaletta L, Patron M, Oloriz J, Perez R, Gavilan J. Avoiding misdiagnosis in ceruminous gland 5.
tumours. Auris Nasus Larynx. 2003 Aug; 30(3):287-290. DOI: 10.1016/S0385-8146(03)00055-5.
Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck. 26. nd edition. Philadelphia, PA:
Saunders; 2009.
in our case. The main differential diagnosis of ceruminous adenoma
is a ceruminous adenocarcinoma.1,2,5,6 Marked pleomorphism, brisk
mitoses, necrosis, invasion (e.g. perineural), and loss of the two-cell
population favor a diagnosis of ceruminous adenocarcinoma but some
well-differentiated cases can be confused with an adenoma. In these
cases, sometimes the only clue of malignancy is invasion especially
at the surgical margins.6 Lassaletta et al.5 stressed the importance of
adequate tumor excision for a more accurate diagnosis. The presence
of a dual cell population and the absence of malignant features led us
to a diagnosis of ceruminous adenoma. Immunohistochemical staining
for cytokeratin (specifically CK7) which highlight the luminal cells and
for basal/myoepithelial cell markers like CK 5/6, S-100 and p63 may be
done to further demonstrate the dual cell population.2 Complete or
adequate local excision is the treatment of choice; however, residual
tumor often remains because of the difficulty of surgery at this location
leading to recurrence. Subsequent repeat surgery to completely remove
the tumor leads to cure.1,2,6
Figure 2. Hematoxylin and Eosin (400x) Glands and ducts have a dual cell population of
basal myoepithelial cells and luminal epithelial cells with apocrine features.
(Hematoxylin and Eosin, 400x)
Figure 4. Hematoxylin and Eosin (100x) Chronic inflammation is variably present, sometimes
peritumorally. The tumor does not involve the skin.
(Hematoxylin and Eosin, 1000x)
Figure 3. Hematoxylin and Eosin (1000x) Yellow to golden brown, granular “ceroid” material
present in cytoplasm of the luminal epithelial cells (marked by black arrows).
(Hematoxylin and Eosin, 100x)
predilection.2 They present as masses in the outer half of the external
auditory canal with hearing changes and pain.2 They can be mistaken
for aural polyps especially when there is associated chronic suppurative
otitis media.3
Ceruminous adenomas arise from ceruminous glands4 which are
modified sweat glands of the outer one half of the external auditory
canal.1 These are well-circumscribed tumors with glandular architecture
composed of two populations of cells with apocrine features as
described above. Two microscopic features reinforce the ceruminous
nature of the glands: the apocrine morphology and presence of
“ceroid” material which are lipofuscin-like pigment granules seen in
the cytoplasm of ceruminous gland luminal cells.1,2 Both are evident