although this technique is frequently performed , it is also commonly associated with diverse complications12 . the present case report describes an external auditory canal ( eac ) injury following extraction of the lower molar . the eac was torn in the same fashion that occurs in an anterior tympanic plate fracture . a 55-year - old female patient visited our department of oral and maxillofacial surgery ( oms ) with complaints of right ear discomfort , which began bleeding immediately following a dental extraction performed 30 minutes prior . an hour earlier , the right lower molar and premolar were removed in our oms department . the patient had a medical history of hypertension , diabetes , hyperlipidemia , and varicose veins . this patient had a dental history of an intermittent clicking sound on the right temporomandibular joint ( tmj ) with mouth opening . she first visited our department two weeks earlier with a chief complaint of a defect in the lower right , 3-unit gold bridge and a loose , upper right lateral incisor.(fig . 1 ) she received a simple extraction of the maxillary lateral incisor with external root resorption during the first visit . a second appointment was scheduled for extractions of the mandibular right molar and premolar two weeks later due to the risk of secondary dental caries . the patient did not report any discomfort during the waiting period after the inferior alveolar nerve block anesthesia . briefly , the lower right second molar was grasped with forceps and luxated in the lingual direction . the second premolar , which was the 3-unit gold bridge abutment , was removed simultaneously . the second molar roots were removed one at a time ; first the distal root followed by the mesial root with straight elevation . the patient was instructed to bite firmly on three sterile 22-inch gauze pads placed over the extraction socket area to stop the bleeding . the patient 's mouth was wide open during the entire extraction procedure and no abnormal signs were observed . the patient also reported that she did not experience any abnormal symptoms during the procedure . however , the patient reported that her right ear area began to itch immediately after the extraction and it started bleeding 30 minutes after the extraction . the right eac was bleeding when the patient returned to the hospital one hour after the extraction . the right ear was examined with an endoscope at the department of ear , nose , and throat surgery . a ) while clenching , a bump formed on the inside of the ear , within the anterior wall of the eac.(fig . c ) when the teeth were closed , a bump was not formed on the inside of the left ear . a computed tomography ( ct ) scan showed a fracture in the anterior tympanic plate.(fig . 3 ) based on the endoscopic and ct findings , the patient was diagnosed with a fracture in the anterior tympanic plate of the eac . the patient was instructed to be careful when chewing or closing the mouth and to return to the hospital immediately if any abnormal symptoms arose in the ear area . we checked for signs and symptoms of abnormal mouth function and we acquired a panoramic radiograph.(fig . 4 ) the patient did not exhibit any abnormal symptoms in the ear area when opening or closing the mouth or when chewing . we decided to proceed with dental treatment , because there were no symptoms in the ear area or in the tmj with lower jaw movements . several complications can accompany dental extractions . the present case describes a rare complication where the eac was injured after extracting the lower molar . we speculated that the anterior tympanic plate was damaged when the mouth was closed after remaining wide open for extraction , and that the damage was worsened by keeping the mouth closed for a sustained period after the extraction . after the anterior tympanic plate was fractured , the fractured bone segments most likely displaced , thereby tearing the soft tissues in the eac , which ultimately caused bleeding . bayram et al.3 previously reported a case of an eac injury following extraction of the lower third molar in a 22-year - old female patient . they reported that excess pressure during extraction or suddenly closing the mouth could affect the tmj , causing a minor fracture without displaced segments . in bayram 's case3 , the extraction procedure took about 30 minutes . that patient visited the emergency room with bleeding in the eac four hours after the extraction . in the present case injection of anesthesia for the inferior alveolar nerve block and the infiltration of anesthesia took about two minutes , and ten minutes were given to obtain a completely anesthetized state . several factors are thought to play a role in damaging the eac during dental extraction , including a steep slope of the glenoid fossa in the tmj and a narrow distance between the mandibular condyle and the anterior wall region of the eac . based on ct images taken 3 years ago to examine the maxillary sinus , our patient had a narrow space between the mandibular condyle and anterior tympanic plate of the eac in the tmj.(fig . 5 ) the panoramic radiograph that we acquired before the extraction did not clearly indicate whether this space was small . therefore , a separate ct image may be required to assess the space between the mandibular condyle and the tympanic plate . quickly closing the mouth after opening for an extended period of time may cause the mandibular condyle to stress the eac . wish - baratz et al.4 suggested that when the mouth remains open during molar extraction , blood flow to the retrodiscal pad tissue at the tmj increases and thereby enlarges the tissue . the tmj 's retrodiscal pad then functions to alleviate the posterior displacement of the mandibular condyle when closing the mouth . in the present case , when the patient was instructed to open her mouth wide , the retrodiscal pad of the tmj should have enlarged . we speculated that quickly closing the mouth when the retrodiscal pad of the tmj was not sufficiently enlarged may have increased the pressure on the anterior wall of the eac . at the same time , the condyle head may have caused increased stress on the anterior tympanic plate of the eac , due to the steep slope of the glenoid fossa . the past medical history of the patient including diabetes and hypertension may also be associated with impaired blood flow to the retrodiscal pad . in the case presented by bayram et al.3 , the left eac was damaged following the extraction of the lower left third molar . in the present case , therefore , the eac ipsilateral to the extraction site appeared more likely to be stressed and damaged than the contalateral eac . this type of eac injury is a rare complication of dental extraction because the retrodiscal pad of the tmj normally buffers posterior movement of the mandibular condyle4 . despite the fact that the extraction of the lower third molar requires the patient to maintain the mouth wide open for a long time , eac injuries are rare , particularly in young patients with good blood circulation to provide sufficient buffering capacity at the retrodiscal pad of the tmj . in the case presented by bayram et al.3 , the main cause of the complication was the long extraction time ( 30 minutes ) . in the present case , the injury was thought to have been aggravated by posterior and superior displacement of the mandibular condyle , due to a malocclusion of the molars after the extraction . these conclusions were based on the endoscopic finding that the eac was internally displaced when the molars were clenched tightly and the fact that bleeding occurred 40 minutes after extraction . when examining bayram 's case3 , we found that the panoramic radiograph taken after eac bleeding showed that the mandible had been displaced to the left . thus , the left eac may have been damaged when the mandible was displaced to the left . the slope of the glenoid fossa at the tmj and the space between the mandibular condyle and eac should be assessed with ct data when possible . in patients with a steep slope from the tmj to the glenoid fossa or a small space between the mandibular condyle and eac , dental extraction we advise the clinician to ensure that patients do not open their mouths excessively wide or close them too quickly during and immediately after extraction procedures . furthermore , caution should be taken when luxating teeth to avoid causing the mandibular condyle to exert excessive pressure on the eac . moreover , after the extraction , patients should be instructed to bite on a gauze padding of appropriate size , i.e. , when the gauze is placed in the extraction socket , the appropriate vertical dimension and anteroposterior position of the mandible should be maintained . finally , it is critical to observe the symptoms after an atraumatic extraction procedure . an eac injury following the extraction of the lower molar is a rare but real complication of this procedure .
the present case report describes an external auditory canal injury following extraction of the lower molar . 
 the external auditory canal was torn in the same fashion that occurs in an anterior tympanic plate fracture . 
 this case demonstrates one of the rare complications associated with dental extractions .