Spontaneous hemotympanum associated with chronic middle ear effusion.

Idiopathic or spontaneous hemotympanum (SH) is an uncommon disorder characterized by a black-blue tympanic membrane discoloration as a result of recurrent hemorrhage in the middle ear or mastoid in the presence of eustachian tube obstruction. Initial evaluation of a blue middle ear mass includes an audiogram and computed tomography (CT) scan with intravenous contrast. CT may identify congenital vascular malformation or bone erosion due to chronic otitis media or tumors. A magnetic resonance imaging (MRI) scan is useful in distinguishing hemotympanum from a vascular tumor and avoiding angiography, which is associated with significant morbidity. Evidence suggests that secretory otitis media and SH are different phases of the same disease process.     

Tympanometry in the evaluation of vascular lesions of the middle ear and tinnitus of vascular origin.

The occurrence of vascular perturbations in the tympanogram in association with glomus tumors has previously been noted in the literature. We have broadened the scope of this method of diagnosis in the study of 3 glomus tympanicum and 3 glomus jugulare tumors, 1 dehiscent high jugular bulb, 1 aberrant carotid artery in the middle ear and 2 cases of pulsatile tinnitus of vascular origin. Analysis of illustrative tympanograms at standard and at increased sensitivity (x 20) obtained in these cases are presented. The following factors as they relate to the mechanism of recording the vascular perturbations are presented: air pressure and/or presence of fluid in the middle ear; compliance of the tympanic membrane and ossicular chain as affected by the mass, size and degree of vascularity of the mass and presence of extraneous sounds. A new method of recording the vascular perturbations utilizing a time-base generator affixed to an X-Y plotter is described. It is the purpose of this study to demonstrate the utility of obtaining tympanograms at standard and at increased sensitivity in the evaluation of vascular middle ear lesions and tinnitus of vascular origin.     

Cholesterol cyst manifesting as a middle ear vascular tumor

A localized, cystic, "blue ear drum" (idiopathic hymotympanum) mimicking a middle ear vascular tumor occurred in a 12-year-old boy. This lesion must be included in the differential diagnosis of suspected vascular mass of the middle ear. A history of eustachian tube dysfunction should be sought. Physical examination is usually not diagnostic, and a full radiologic evaluation is essential in order to rule out a high jugular bulb, an ectopic carotid artery, or a glomus tumor.     

The effects of the vacuum on vascular permeability of the middle ear

Following local application of various degrees of negative pressure to the middle ear, the authors observed changes in vascular permeability in guinea pigs, using Majno's vascular labelling technique. Increased permeability and effusions were seen in all experimental middle ears. Any pressure below -5 mm of mercury induced middle ear effusions. Accordingly, a decrease in pressure developed in the middle ear cavity may cause transdation of serum drawn from the submucosal vessels, resulting in fluids in the middle ear of aero-otitis. In such a circumstance, mast cells which are easily influenced by atmospheric pressure may be involved in increasing vascular permeability.     

Pressure-dependent variation in volume of mucosal lining of the middle ear.

A method is described for studying pressure-dependent variation in the volume of the mucosa of the middle ear. Studies were performed at different pressures in the middle ear as well as at different ambient pressures. It was found that the pressure-dependent volumetric changes of the mucosa were the same whether the pressure in the middle ear was changed directly by altering the intratympanic or indirectly by altering the ambient pressure. With the method described it is also possible to determine the middle ear volume without artefacts due to the middle ear mucosa. The volume-pressure relationship of the middle ear mucosa varied from 0.6 to 1.7 mul/cm H2O and linearly with the volume of the middle ear. Comparisons between determinations of the middle ear volume with and without consideration of the mucosal compliance showed differences, especially in small middle ears. The effect on the volume of the mucosa caused by variation of posture was also studied. The physiological middle ear pressure depends on the functional state of the Eustachian tube, the middle ear volume, the tympanic membrane and the middle ear mucosa. Thus, knowledge of the mucosa compliance is important for calculating middle ear pressure as well as for determining the volume of the air-filled middle ear space. The method might also prove a useful tool in the elucidation of the vascular bed both in health and in disease as well as the reaction of the mucosal vessels to drugs.     

The chorda tympani degenerates during chronic otitis media: an electron microscopy study

Conclusion: Chorda tympani nerve specimens from ears with chronic inflammatory middle ear disease exhibit structural signs of degeneration. These correlate well with taste disturbance. Simultaneously, they exhibit signs of regeneration, which may explain the ability for taste recovery. Objectives: The chorda tympani, the major taste nerve, runs uncovered through the middle ear cavity. This situation exposes it to various forms of middle ear pathology. A difference has been noticed regarding taste symptoms pre- and postoperatively between inflammatory and non-inflammatory diseases. The present study aimed to investigate ultrastructural changes of chorda tympani in different forms of inflammatory middle ear disease, such as chronic suppurative otitis media and cholesteatoma, as compared with normal. Methods: Five chorda tympani specimens were collected from healthy middle ears of patients subjected to surgery for acoustic neuroma, to be used as normal controls, and five from middle ears with chronic otitis media or cholesteatoma, where the nerve could not be saved during the operation. Light and electron microscopy were performed. Results: For all five nerves from diseased ears, microscopy showed a higher percentage of axon and myelin sheath degeneration than in the normal controls. Furthermore, three of the five also exhibited sprouting.     

Effect of recombinant vascular endothelial growth factor on experimental otitis media with effusion

CONCLUSION: This study demonstrates that rVEGF in the middle ear cavity contributes significantly to the development of OME by increasing the vascular permeability of the middle ear mucosa. OBJECTIVE: Vascular endothelial growth factor (VEGF) has been detected in otitis media with effusion (OME). It has a very strong effect on increasing vascular permeability, and is much more potent than platelet-activating factor, arachidonic acid metabolites or histamine. The purpose of this study was to investigate whether recombinant VEGF (rVEGF) can increase vascular permeability in the middle ear mucosa of rats. MATERIAL AND METHODS: rVEGF was injected transtympanically at doses of 0.01, 0.1 and 1.0 microg in the experimental groups; normal saline was injected in the control group. Twenty-four h after the injection of rVEGF, middle ear fluid was aspirated and the vascular permeability of the middle ear mucosa was measured by means of the Evans Blue vital dye technique. RESULTS: Extravasation of Evans Blue dye was found in all specimens injected with rVEGF, and was quantified using a spectrophotometer. Middle ear fluid developed in all ears injected with 0.1 or 1.0 microg of rVEGF and histopathology of the middle ear mucosa revealed severe inflammatory cellular infiltration, subepithelial edema and vascular dilatation. Rats injected with 1.0 microg of rVEGF showed a significant increase in middle ear vascular permeability in comparison with the control group (p < 0.05).     

Facial paralysis: a presenting feature of rhabdomyosarcoma

The purpose of this paper is to present a child with embryonal rhabdomyosarcoma involving the left middle ear, who initially presented with unilateral facial paralysis. A 5-year-old boy presented with a 4-week history of left-sided facial weakness, associated with persistent otitis media on that side. Examination revealed complete left lower motor neuron facial weakness and hearing loss. A myringotomy revealed a soft tissue mass behind the tympanic membrane. Biopsy and oncologic assessment confirmed a stage II, group III left middle ear embryonal rhabdomyosarcoma. Despite debulking surgery, local irradiation and multiple chemotherapeutic courses the child deteriorated quickly. He developed carcinomatous meningitis and died 9 months after his initial presentation. In conclusion, middle ear tumors should be considered in the differential diagnosis of unresolving otitis media, particularly when associated with persistent ipsilateral facial paralysis. An ear mass, discharge, facial swelling, or systemic symptoms may be initially absent despite the presence of this aggressive malignancy. Careful examination of the middle ear is recommended in children with facial weakness. A myringotomy incision may be necessary including a complete assessment of the middle ear cavity, particularly when there is no fluid return.     

Nitric Oxide: A Mediator of Endotoxin-Induced Middle Ear Effusions

Using a rat model, the authors investigated the role of nitric oxide (NO) in endotoxin-induced middle ear effusion (MEE). After the eustachian tube was obstructed, the middle ear was transtympanically injected with 35μL of either 1 mg/mL lipopolysaccharide (LPS) or LPS and 1 mmol/L N-nitro-L-arginine methyl ester (L-NAME), a competitive inhibitor of NO synthase. Over the next 6 hours, the fluid within the middle ear was collected every 2 hours, and the quantity of albumin in the fluid, an index of vascular leakage, was determined using enzyme-linked immunosorbent assay. L-NAME significantly reduced LPS-induced vascular extravasation into the middle ear. Inoculation of the ear with L-arginine, the substrate for NO synthase, reversed the effects of L-NAME. These results indicate that NO is a mediator of LPS-induced MEE. Therefore, inhibition of NO synthase may represent a novel approach to the treatment of otitis media with effusion.     

Plasma cell granuloma of the middle ear and mastoid. Case report.

We present the case of a 37-year-old man with plasma cell granuloma affecting the middle ear and mastoid. At magnetic resonance imaging scan, the lesion appeared as a homogeneously enhancing mass of soft tissue replacing the majority of the mastoid bone and causing vascular compression. After surgical resection, microscopic examination showed predominantly plasmacytes, and histochemical studies confirmed a polyclonal origin consistent with nonneoplastic plasma cell granuloma. We believe this is the first case report of plasma cell granuloma affecting the middle ear and mastoid.     

Cholesterol granuloma of the middle ear: cause of idiopathic hemotympanum

We report a case of a 49-year-old man with a cholesterol granuloma of the middle ear in an only hearing ear. As it mimicked a vascular middle ear tumor, a contrast cranial computed tomography and a gadolinium-enhanced-magnetic resonance imaging with vascular reconstructions were performed, confirming that both carotid artery and jugular vein were near the lesion but not involved. This patient could be managed with a conservative hearing preserving approach. Differential diagnosis of vascular middle ear anomalies is reviewed, specially in relation to cholesterol granulomas as a cause of idiopathic hemotympanum.     

Effect of recombinant vascular endothelial growth factor on experimental otitis media with effusion

Conclusion This study demonstrates that rVEGF in the middle ear cavity contributes significantly to the development of OME by increasing the vascular permeability of the middle ear mucosa. Objective Vascular endothelial growth factor (VEGF) has been detected in otitis media with effusion (OME). It has a very strong effect on increasing vascular permeability, and is much more potent than platelet-activating factor, arachidonic acid metabolites or histamine. The purpose of this study was to investigate whether recombinant VEGF (rVEGF) can increase vascular permeability in the middle ear mucosa of rats. Material and methods rVEGF was injected transtympanically at doses of 0.01, 0.1 and 1.0 μg in the experimental groups; normal saline was injected in the control group. Twenty-four h after the injection of rVEGF, middle ear fluid was aspirated and the vascular permeability of the middle ear mucosa was measured by means of the Evans Blue vital dye technique. Results Extravasation of Evans Blue dye was found in all specimens injected with rVEGF, and was quantified using a spectrophotometer. Middle ear fluid developed in all ears injected with 0.1 or 1.0 μg of rVEGF and histopathology of the middle ear mucosa revealed severe inflammatory cellular infiltration, subepithelial edema and vascular dilatation. Rats injected with 1.0 μg of rVEGF showed a significant increase in middle ear vascular permeability in comparison with the control group (p<0.05).     

Middle ear schwannoma--case report

Schwannoma is one of the common benign middle ear space tumors. The tumors may present with facial nerve paresis or palsy, otologic symptoms and/or parotid mass middle ear schwannomas may originate from the nerves of the tympanic caviti or by extensions from outside the middle ear space. Schwannomas of the facial nerve can occur along any segment, but they frequently involve the geniculate ganglion and extend proximally or distally from there. MRI and CT imaging characteristics are similar to those of vestibular schwannomas. We present the clinical and radiologic features of a middle-space schwannoma originating from facial nerve. The patient underwent middle ear exploration and mastoidectomy. The tumor was of facial nerve origin and was separated from middle ear. The pathologic diagnosis was schwannoma.     

Pathophysiology of Streptococcus pneumoniae otitis media: kinetics of the middle ear biochemical and cytologic host responses.

Streptococcus pneumoniae is an important bacterial pathogen in the pathophysiology of otitis media. To elucidate the inflammatory responses that occur during pneumococcal otitis media, the kinetics of the biochemical and cytologic middle ear responses to heat-killed encapsulated and nonencapsulated pneumococci were studied in the chinchilla model. Inoculation of the middle ear cavity with at least 10(6) S pneumoniae cells induced an early, brief vascular response with leakage of small (albumin) followed by larger (alpha 2-macroglobulin) proteins, followed by sustained influx of acute inflammatory cells and lysozyme. The threshold for a sustained lysozyme response was 1,000 times lower for nonencapsulated than for encapsulated pneumococci. These results indicate that nonviable S pneumoniae organisms with an intact envelope initiate the middle ear inflammatory response. Therefore, interventions that enhance the clearance of pneumococcal cells from the middle ear may reduce the inflammatory response and prevent chronic middle ear inflammation.     

Aberrant internal carotid artery as a cause of objective pulsatile tinnitus

An aberrant internal carotid artery (ICA) is a rare vascular anomaly and causes to objective pulsatile tinnitus and retrotympanic mass. In the past, it was often diagnosed during ear surgery or biopsy, which may lead to massive bleeding. We present a case of 37-year-old woman complaining of pulsatile tinnitus. The tinnitus was objectively audible at the right ear through an otoscope. Previously, MRA plays a pivotal role in the evaluation of the aberrant ICA. But in this case, the resolution of magnetic resonance angiography (MRA) was not enough to portray the course of the ICA, because dephasing of the spins due to turbulence may cause loss of the signal intensity on MRA. Computed tomography (CT) of the temporal bone revealed aberrant internal carotid artery passing through the middle ear. It is important to diagnose approximately this anomaly using with combination of high-resolution CT, MRI, and MRA.     

Hemangioma of the middle ear

A 13-month-old child was seen and evaluated for persistent aural bleeding following the placement of a pressure equalizing tube. A vascular mass was identified in the middle ear space. The radiologic evaluation is discussed. The mass was surgically resected for both diagnostic and therapeutic reasons. Pathologic examination revealed a benign hemangioma. The significance of this diagnosis is discussed.     

Salivary gland choristoma of the middle ear: a case report

A choristoma is a nonneoplastic proliferation of histologically normal tissue that forms at an abnormal site. It is extremely uncommon in the middle ear space. It appears to be a developmental abnormality and may be associated with abnormalities of adjacent structures. It usually occurs with unilateral conductive hearing loss and requires a differential diagnosis from other mass lesions in the middle ear cavity. This article discusses a case of salivary gland choristoma of the middle ear that we believe to be the 24th case reported on this subject.     

Tympanic paraganglioma with extension into the Eustachian tube and nasopharynx: a case report

Tympanic paragangliomas usually present as a vascular middle ear mass, with the most common presenting symptoms being pulsatile tinnitus and hearing loss. We report an unusual case of a recurrent tympanic paraganglioma extending along the Eustachian tube and nasopharynx, presenting with recurrent epistaxis.     

Von Hippel-Lindau disease associated with an invasive choroid plexus tumour presenting as a middle ear mass.

Cerebellar haemangioblastomata and angiomata of the retina are the most common vascular tumours seen in von Hippel-Lindau disease. A definite association between this condition and choroid plexus tumour has not been described previously and its presentation as a middle ear mass is unique.     

Primary middle ear schwannoma

Schwannomas of the middle ear may originate from the nerves of the middle ear cavity or by extensions from neighboring structures. We present a case of a 51-year-old female patient with primary middle ear schwannoma believed to arise from Jacobson's nerve. The tumor was easily divided from the facial nerve and the chorda tympani nerve. Erosion of the promontory was noted, and the jugular foramen and posterior wall of the ear canal were preserved without destruction. The mass was successfully removed by a canal down mastoidectomy procedure, while preserving the hearing and facial nerve functions of the patient. To our knowledge, this is only the second reported case of a patient with Jacobson's nerve schwannoma.