Metastatic disease of the temporal bone

This paper discusses metastatic disease of the temporal bone, and illustrates its discussion with a case history. The incidence, signs, symptoms, and treatment generally recorded are discussed. The histopathology of such lesions, as well as a documentation of those organ systems most likely to provide temporal bone metastatic spread, is noted. As with primary neoplasias of the temporal bone, metastatic disease may coexist with or mimic chronic otitis media. It is the wary surgeon who carefully analyzes his patient, the history, the intensity of signs, particularly pain — and, therefore, is prepared for the exigencies of recognizing neoplasia with or without associated chronic otitis media.     

Chronic serous otitis media as a manifestation of temporal meningioma

Chronic serous otitis media is a common problem in the daily routine of the otorhinolaryngologist. In the majority of cases, the cause is related to dysfunction of the eustachian tube due to viral or bacterial rhinitis and occasionally to nasopharyngeal tumors. We report a case of a patient presenting with chronic serous otitis media that was resistant to conventional therapy. MRI with gadolinium finally revealed that the middle ear fluid was caused by leakage of cerebrospinal fluid (CSF) due to bone destruction by a temporal meningioma. The CSF leakage was closed by surgery. Histopathology confirmed meningioma in the temporal bone.     

Primary temporal bone secretory meningioma presenting as chronic otitis media

We report an extremely rare case of a secretory meningioma primarily involving the temporal bone. A 56-year old female patient presented to us with a history of a chronic otitis media and unilateral hearing loss. Diagnostic investigations revealed a tumor arising from the temporal bone without signs of intracranial involvement. Histopathological examination showed a meningioma of the secretory type. The tumor was partially resected and serial imaging at follow-up revealed no extension of the tumor. No new symptoms developed 1 year after surgery. Secretory meningioma is a rare meningioma subtype and extracranial presentation in the temporal bone is very unusual. We present the first case of a primary temporal bone secretory meningioma in the otorhinolaryngological literature. As radical as possible surgical excision with serial imaging at follow-up is recommended.     

慢性化脓性中耳炎及中耳胆脂瘤术前颞骨CT及耳内镜评估的意义

目的 探讨颞骨CT及耳内镜对慢性化脓性中耳炎静止期及中耳胆脂瘤术前评估的重要性。方法 回顾性分析慢性化脓性中耳炎静止期及中耳胆脂瘤患者42耳病历资料,从CT、耳内镜及术中发现进行分析。结果 ①根据CT结合术中所见,慢性化脓性中耳炎静止期CT分型分为单纯型、硬化灶型、肉芽型、硬化灶肉芽型。胆脂瘤型CT主要表现为听骨链消失或锤砧关节消失,乳突大部分呈硬化型,少部分为板障型,上鼓室鼓窦扩大,上鼓室、中鼓室甚至后鼓室乳突腔为软组织影占据,部分病例外半规管骨质破坏、面神经管水平段骨质破坏,部分病例外耳道后壁骨质破坏;单纯型CT示中耳鼓室乳突呈不完全气化型;硬化灶型CT示中耳鼓室乳突呈硬化型,病变局限于中鼓室,锤骨柄及镫骨周围有“类似骨质影”包裹;肉芽型、硬化灶肉芽型CT相似,示病变累及鼓室及乳突,听骨链基本完整,面神经管水平段骨质完整,但硬化灶型与肉芽型区别之处在于前者鼓室内听骨链周围有“类骨质”样散在高密度影。②耳内镜所见慢性化脓性中耳炎静止期鼓膜紧张部穿孔,鼓膜可有钙化斑;中耳胆脂瘤型则有上鼓室内陷或穿孔、后上象限穿孔、大穿孔、外耳道顶壁或后上壁下塌。结论 慢性化脓性中耳炎静止期及中耳胆脂瘤的术前CT及耳内镜评估,对病变性质、范围、程度及指导手术起重要作用。     

A case of an inflammatory myofibroblastic tumor of the mastoid presenting with chronic suppurative otitis media

Inflammatory myofibroblastic tumors, also known as inflammatory pseudotumors, include a diverse group of lesions characterized by inflammatory cell infiltration and variable fibrotic responses. Their occurrence in the temporal bone is unusual. We present a case of an inflammatory myofibroblastic tumor of the mastoid bone in a 55-year-old female who complained of repeated otorrhea and a hearing impairment. On an otoscopic exam, her tympanic membrane was perforated. The computed tomographic imaging revealed a soft-tissue density-filled middle ear and mastoid with sclerotic bony change. The initial clinical diagnosis was chronic suppurative otitis media and mastoiditis, and the patient underwent a canal-wall down tympanomastoidectomy through a retroauricular approach. A histopathologic examination showed the presence of myofibroblastic spindle cells with mixed inflammatory infiltrates, and the pathologic diagnosis was inflammatory myofibroblastic tumor.     

Histiocytosis X of the ear and temporal bone: review of 22 cases.

Histiocytosis X encompasses three syndromes characterized by the idiopathic proliferation of histiocytes: eosinophilic granuloma, Hand-Schuller-Christian syndrome, and Letterer-Siwe disease. At the Mayo Clinic between 1926 and 1978, 22 patients with histiocytosis X had involvement of the ear or temporal bone. These patients comprised 15% of all patients with histiocytosis X seen during that period. The ages at onset of the disease ranged from 2 months to 49 years. The most frequent otologic symptom was aural discharge (15 patients), followed in frequency by swelling in the temporal region (11 patients), vertigo (6 patients), and deafness (5 patients). Clinical findings included otitis media (13 patients), otitis externa with or without granulation tissue (10 patients), and osteolytic lesions of the temporal bone (9 patients). A high index of suspicion is required to recognize the otologic manifestations of histiocytosis X for two reasons: the systemic manifestations of the disease are often so dramatic that the ear findings are overlooked, and the otologic findings of histiocytosis X can mimic more common diseases, including simple otitis externa, aural polyps, acute mastoiditis, chronic otitis media, and metastatic lesions.     

中耳乳突炎性改变对人工耳蜗置入的影响

目的：探讨中耳乳突炎性改变对人工耳蜗置入术的影响。方法：9例行人工耳蜗置入术患者均伴有中耳乳突炎性改变。1例乳突根治术后Ⅱ期行人工耳蜗置入及应用耳廓软骨一软骨膜复合物重建并加强后鼓室外侧壁及外耳道后壁;1例慢性中耳炎伴鼓膜穿孔Ⅰ期行人工耳蜗置入及应用耳廓软骨一软骨膜复合物重建鼓膜;3例隐性中耳乳突炎,Ⅰ期行改良乳突开放术并人工耳蜗置入术;3例硬化型乳突伴鼓室粘连,Ⅰ期行鼓室探查并人工耳蜗置入术;1例慢性中耳乳突炎伴松弛部内陷袋形成,Ⅰ期行上鼓室开放及软骨一软骨膜复合物重建上鼓室外侧壁并人工耳蜗置入术。结果：术中所有的电极均顺利置入,并经术中检测电极完好,电阻测试效果满意。术后伤口均甲级愈合,1个月后均开机成功。随访无并发症。结论：对于慢性中耳乳突炎的患者,若欲行Ⅱ期人工耳蜗置入术,Ⅰ期中耳乳突手术应尽可能保留相关解剖结构。对于隐性中耳乳突炎的患者在确保鼓窦乳突、上鼓室、咽鼓管口三处引流均通畅的前提下可行Ⅰ期人工耳蜗置入。对于病变局限的上鼓室胆脂瘤,有经验的术者可以选择Ⅰ期手术,但一定要慎重。感染因素很可能在乳突汽化不良及不明原因先天性感音神经性聋的发病中起着重要的作用。对于乳突硬化、乙状窦前移严重的患者可选择经外耳道鼓岬开窗。对于人工耳蜗置入术时的鼓膜修补术,上鼓室外侧壁或外耳道后壁重建选择软骨一软骨膜复合物可以提高成功率,加固鼓膜避免内陷及电极脱出。     

Fibrous dysplasia of the temporal bone

A 38-year-old woman with fibrous dysplasia of the entire right half of the mandible and the right temporal bone is presented. She had a unilateral progressive conductive hearing loss and stenosis of the auditory canal complicated by a chronic external otitis, a hidden cholesteatoma, destruction of the ossicles and an impending facial palsy. Surgery was performed to create a new auditory canal, to eradicate the cholesteatoma and to decompress the facial nerve from the surrounding fibrous dysplasia.     

Fibrous dysplasia of the temporal bone presenting as an osteoma of the external auditory canal

The involvement of the temporal bones by fibrous dysplasia is uncommon. This disease is usually manifested by a conductive hearing loss. We describe a case of fibrous dysplasia misdiagnosed as an osteoma in a young man. This case emphasizes the need to suspect fibrous dysplasia of the temporal bone as the cause of bony lesions in the external auditory canal in young patients.     

Oval window canal and CT-diagnosis of peripheral pareses of the facial nerve

Computed tomography (CT) has examined 200 patients (400 temporal bones) at the age of 0-74 with unaffected facial nerve and 28 patients with symptoms of peripheral paresis or paralysis of the facial nerve of different genesis. Polyposition CT of the temporal bone is an intravital noninvasive method of the Fallopius' canal visualization. The canal is visualized on the tomograms in 100% cases irrespective of the patients' age. The following causes of n. facialis paresis were revealed: neurinoma of the facial nerve, sarcoma of the temporal bone, destruction of the tympanic canal wall in chronic otitis media, fractures of the temporal bone, malformations of the Fallopius' canal in malformations of the temporal bone, stenosis of the canal in fibrous dysplasia. The above alterations of n. facialis canal determine further therapeutic policy.     

Role of retraction pockets in cholesteatoma formation

Temporal bones were obtained from 100 routine cases at post mortem who died of causes other than otological. The tympanic membranes were examined under the operating microscope and retraction pockets were seen and photographed in 12 cases. Radiological examination of these 12 mastoid bones showed a sclerotic mastoid in 8 cases. On serial histopathological examination of the temporal bones there was evidence of old or recent chronic otitis media in each case. In 3 cases a sac with a narrow neck leading to the retraction pocket was seen. In 2 cases squamous epithelial ‘pearls' in close proximity to the retraction pockets were seen. The significance of these findings in the pathogenesis of retraction pockets and cholesteatoma is discussed.     

A study of inflammatory mediators in the human tympanosclerotic middle ear

OBJECTIVE: To analyze immunocompetent cells as well as 2 factors involved in inflammation and also thought to be involved in bone remodeling-interleukin 6 (IL-6) and inducible nitric oxide synthase in the human middle ear, including the tympanic membrane. DESIGN: Biopsy specimens were obtained from the human middle ear and tympanic membrane during surgery. Using an immunohistochemical technique, the expression of macrophages, T cells, B cells, IL-6, and inducible nitric oxide synthase were analyzed. MATERIALS: Nine biopsy specimens from tympanic membranes in children having a transtympanic ventilation tube inserted as a treatment for secretory otitis media and 11 biopsy specimens from tympanosclerotic plaques from patients with chronic otitis media and tympanosclerosis. RESULTS: More positively stained specimens showing macrophages, B cells, and IL-6 were seen in the biopsy specimens from children with secretory otitis media compared with the biopsy specimens from patients with chronic otitis media and tympanosclerosis. The biopsy specimens from patients with chronic otitis media and tympanosclerosis more often showed positive stainings for inducible nitric oxide synthase than the biopsy specimens from children with secretory otitis media. The presence of IL-6 and inducible nitric oxide synthase was shown by staining to be mostly in the surface cells, while macrophages and B cells were stained deeper in the tissues, in connective tissue, or around sclerotic lesions. CONCLUSIONS: The 2 patient groups differed in antigen presentation so that macrophages, B cells, and IL-6 were labeled more frequently in patients with secretory otitis media, that is, an early phase of the disease. Inducible nitric oxide synthase was seen more frequently in the patients with already established tympanosclerosis in a later phase of the disease.     

Osteopetrosis of temporal bone with blockage of the eustachian tube. A case report

Osteopetrosis is an inherited disorder characterized by bone sclerosis. One of the more predominant feature of the disease in the temporal bone is conductive hearing loss due to anomalous bone formation in the middle ear and to otitis media. A 55-year-old woman affected by the adult type of osteopetrosis was referred to our department with a long history of otitis media. CT study demonstrated a narrowing of Eustachian tube due to abnormal deposition of sclerotic bone; this condition was confirmed during surgery. Tubotomy was performed during tympanoplastic surgery and there were no relapse of otitis after 12 months of follow up. Timpanoplastic surgery should be considered in those cases where medical treatment has failed in dealing with otitis media. In our experience an enlargement of Eustachian tube shuld be performed in this kind of patients, thus helping the functional recovery and the potential well-being of the patient as we observed in our case.     

Actinomycosis of the temporal bone: a report of a case

Actinomycosis is a chronic suppurative infection of the cervicofacial region caused by Actinomyces species, which are anaerobic, gram-positive filamentous bacteria. Although actinomycosis has a propensity for involving the oral cavity, rare cases of actinomycosis involving the temporal bone have been published. We report the case of a 14-year-old girl who presented with clinical, audiometric, and radiologic findings consistent with right chronic suppurative otitis media that persisted despite tympanomastoidectomy. Findings on histologic evaluation of a specimen obtained during revision surgery were consistent with a diagnosis of actinomycosis. Although actinomycosis of the temporal bone is rare, it should be considered in the differential diagnosis of chronic suppurative temporal bone infections that are resistant to standard therapy.     

Computed tomography of the temporal bone in diagnosis of chronic exudative otitis media

Computed tomography (CT) of the temporal bone was made in 37 patients aged 2 to 55 years with chronic exudative otitis media (CEOM). In 21 of them the pathology was bilateral. The analysis of 58 CT images has identified CT signs of chronic exudative otitis media. They include partial (17 temporary bones) or complete (38 temporal bones) block of the bone opening of the auditory tube, pneumatic defects of the tympanic cavity (58 temporal bones), pneumatic defects of the mastoid process and antrum (47 temporal bones), pathologic retraction of the tympanic membrane. The examination of the temporal bone detected both CT-signs of CEOM and other causes of hearing disorders in 14 patients (26 temporal bones) with CEOM symptoms and inadequately high hypoacusis. Among these causes were malformation of the auditory ossicula (n=5), malformation of the labynthine window (n=2), malformation of the middle and internal ear (n=4), a wide aqueduct of the vestibule, labyrinthine anomaly of Mondini's type (n=1), cochlear hypoplasia (n=4), stenosis of the internal acoustic meatuses (n=2). Sclerotic fibrous dysplasia was suggested in 2 temporal bones (by CT data). CT was repeated after surgical treatment of 10 patients (14 temporal bones) and visual assessment of tympanostomy results was made.     

Serous otitis media revealing temporal en plaque meningioma.

OBJECTIVES: To present a series of temporal en plaque meningiomas involving the middle ear or mastoid, whose main symptoms suggested a serous otitis media. STUDY DESIGN AND SETTINGS: Multicentric retrospective study reviewing clinical records originating from eight tertiary referral centers. MATERIALS AND METHODS: The clinical records of 10 patients presenting with signs and symptoms suggesting serous otitis media and whose neuroimaging studies revealed a temporal en plaque meningioma involving the middle ear or mastoid are reported. RESULTS: All the patients were women, ranging from 49 to 71 years old. The delay between the onset of symptoms and the diagnosis of meningioma varied from 1 to 10 years. All the patients underwent various procedures usually applied for the treatment of serous otitis media, which failed in all the cases, particularly ventilating tube placement, which was followed by severe episodes of discharge. In all cases, the computed tomographic scans showed three imaging signs: soft tissue mass filling the middle ear or mastoid, hyperostosis of the petrous bone, and hairy aspect of the intracranial margins of the affected bone. This imaging triad must alert the otologist of the possibility of intracranial meningioma. Magnetic resonance imaging was the method of choice to assess the diagnosis of intracranial meningioma involving the middle ear or mastoid. When analyzing management options, it appeared that conventional middle ear procedures were inefficient. CONCLUSION: Temporal en plaque meningioma involving the middle ear or mastoid can mimic a serous otitis media. A computed tomographic scan is recommended for cases of atypical or prolonged unilateral serous otitis media to investigate indirect signs of a meningioma, which has to be confirmed with magnetic resonance imaging.     

胆脂瘤型中耳炎的CT表现特点

目的探讨和总结胆脂瘤中耳炎的CT表现特点。方法对80例耳手术证实为胆脂瘤型中耳炎的CT影像特点进行分类和归纳。结果胆脂瘤的CT影像主要表现为：盾板破坏；有软组织充填的扩大的上鼓室；软组织包裹的听小骨移位：有软组织充填的边缘清楚的扩大骨腔隙，充填的软组织可呈均匀型、网格型和周边间隙型；中耳结构骨组织的破坏及硬化型乳突等表现。结论盾板破坏，有软组织充填的边缘清晰的扩大骨腔隙，中耳腔结构骨组织的破坏．是胆脂瘤CT表现的基本特征。     

Endolymphatic hydrops and otitis media.

Clinical observation of patients with fluctuant sensorineural hearing loss following or occurring with chronic otitis media led to the hypothesis that endolymphatic hydrops can result from chronic otitis media. Illustrative case reports are described. This hypothesis resulted in a temporal bone study of 560 cases in which 109 temporal bones demonstrated the presence of hydrops and 194 evidenced otitis media. Seventy-five cases demonstrated both otitis media and hydrops, of which 20 cases were selected for more detailed histopathological study. An interesting finding was the presence of apical hydrops in every case of the latter group. Statistical interpretation of this data helped rule out a coincidental or chance occurrence. A discussion of this clinical relationship included the significance of subclinical (silent) otitis media as a possible cause of endolymphatic hydrops.     

Evaluation and management of temporal bone arachnoid granulations.

The diagnosis and evaluation of temporal bone arachnoid granulations (AGs) is based on characteristic bone defects in the posterior or middle fossa surfaces of the temporal bone in adult patients with persistent serous otitis media or septic meningitis following acute otitis media. The cerebrospinal communication caused by AGs should be repaired by a middle fossa craniotomy (middle fossa AGs) or an intact canal wall mastoidectomy (posterior fossa AGs) to preserve normal sound transmission. In adult patients with chronic mastoiditis, the dural defect of an AG may permit intracranial extension of the chronic inflammatory process. This rare extension of disease should be considered in patients who have chronic ear inflammation and severe pain or signs of intracranial disease.     

Chronic silent otitis media

Otitis media occurs along a continuum. For example, otitis media with effusion characterized by fluid pathology can lead to chronic otitis media plus chronic mastoiditis, characterized by the presence of intractable tissue pathology such as cholesteatoma, cholesterol granuloma or granulation tissue. The literature defines chronic otitis media as having a tympanic membrane perforation and otorrhea. Amongst many other sequelae, which can result from the continuum, an important common one is chronic silent otitis media. This overlooked entity which includes pathology beneath an intact tympanic membrane is commonly seen in our human temporal bone laboratory and in patients. The clinical pathological correlates of this important disease are discussed herein.