Abstract
Primary middle ear neoplasms are rare, and commonly cause conductive hearing loss. When aural masses result in sensorineural hearing loss, malignant etiologies are often suspected. Fibroepithelial polyps are benign lesions commonly found in the skin and genitourinary tract and are not commonly identified as primary lesions of the middle ear. Here, we present a case of a benign fibroepithelial polyp of the middle ear causing sensorineural hearing loss and describe its surgical management. Imaging and histologic characteristics are reviewed.
1
Introduction
Fibroepithelial polyps are benign lesions of mesodermal origin that are most commonly found in the genitourinary tract and skin . Their etiology is thought to be an underlying chronic inflammatory process, and theories for congenital, traumatic, and infectious origins have all been proposed . In the head and neck, fibroepithelial polyps are not commonly problematic. However, case reports exist in which lesions of the tonsil, tongue, inferior nasal turbinate, epiglottis, orbit, and external auditory canal (EAC) have become clinically relevant. Several reports have also described symptomatic fibroepithelial polyps of the aerodigestive tract, specifically the bronchus and trachea . Herein, we describe a case in which a patient’s presentation with a mass protruding through the external meatus and a profound unilateral sensorineural hearing loss aroused suspicion for a malignant process, but a benign fibroepithelial polyp was instead identified. The radiographic, and histologic characteristics of these lesions are described, as well as a recommended management strategy for a benign appearing external and middle ear tumor.
2
Case report
A 55 year-old female was referred to a tertiary care neurotology clinic for evaluation of longstanding left ear mass that completely occluded the external auditory canal. According to the patient’s report, the lesion had been present for approximately 15 years in the setting of recurrent otorrhea. Approximately 8 years prior to her presentation at our clinic, she experienced a sudden, profound hearing loss in the affected ear. She sought medical counsel at a different institution at that time, but was lost to follow-up. Subsequently, the patient experienced progressive growth of the mass, which protruded through her external meatus into the conchal bowl. Immediately prior to the current consultation, she was seen in an outside facility and had a biopsy of the mass, which revealed a benign elastotic nodule. At the time of her presentation to our clinic, she reported episodic otalgia and otorrhea from the affected ear, which had previously been treated with oral and topical antibiotics. She denied associated tinnitus, vertigo, and facial weakness. Her past medical history was significant for diabetes and hypertension, both of which were well controlled. Her family and social history was unremarkable.
On physical exam, the patient had an exophytic mass obliterating her left external auditory meatus, resulting in complete obstruction of the ear canal ( Fig. 1 A). No periauricular edema or erythema was identified, and the auricle was otherwise well formed. There was no associated cervical adenopathy, and her cranial nerve function was normal bilaterally. An audiogram showed profound sensorineural hearing loss in the affected ear. High-resolution, contrast-enhanced computed tomography (CT) identified complete opacification of the left middle ear, mastoid, and EAC. Of note, a central vascular channel was identified in the lesion, which arose suspicion for a fibrovascular polyp. Mass effect on the ossicular chain was noted, as were sclerotic changes of the mastoid bone ( Fig. 2 ). Contrast enhanced magnetic resonance imaging (MRI) showed a relatively homogeneous enhancing mass filling the EAC and middle ear, with extension anteromedially along the eustachian tube. The lesion did not appear to affect the cochlea or membranous labyrinth, which retained an appropriate fluid-intensity signal ( Fig. 3 ).
Surgical management was offered to the patient in the form of a tympanomastoidectomy. During examination under anesthesia, no clear site of origin for the tumor could be identified in the lateral external auditory canal. The mastoid was noted to be sclerotic, and the tumor was identified throughout the antrum. After debulking the tumor from the external auditory canal, the tumor was dissected from the ossicles, dehiscent facial nerve, eustachian tube, and sinus tympani. The site of origin of the tumor appeared to be the cochlear promontory, where a large vascular pedicle was encountered and controlled with bipolar electrocautery. During resection of the lesion from the stapes, obliterative ossification of the oval window niche was identified. Once the tumor was fully resected, the ear canal was overclosed. Intraoperative frozen section analysis revealed benign appearing pathology, and final analysis showed a fibroepithelial polyp with surface inflammatory and reactive changes ( Fig. 4 ). The patient awoke from surgery with normal facial nerve function and had an uncomplicated postoperative course. The surgical site was healing well at her three-month follow-up visit. There was no evidence of recurrent disease ( Fig. 1 B), facial nerve function remained intact, and the patient had no complaints of post-operative vertigo.
2
Case report
A 55 year-old female was referred to a tertiary care neurotology clinic for evaluation of longstanding left ear mass that completely occluded the external auditory canal. According to the patient’s report, the lesion had been present for approximately 15 years in the setting of recurrent otorrhea. Approximately 8 years prior to her presentation at our clinic, she experienced a sudden, profound hearing loss in the affected ear. She sought medical counsel at a different institution at that time, but was lost to follow-up. Subsequently, the patient experienced progressive growth of the mass, which protruded through her external meatus into the conchal bowl. Immediately prior to the current consultation, she was seen in an outside facility and had a biopsy of the mass, which revealed a benign elastotic nodule. At the time of her presentation to our clinic, she reported episodic otalgia and otorrhea from the affected ear, which had previously been treated with oral and topical antibiotics. She denied associated tinnitus, vertigo, and facial weakness. Her past medical history was significant for diabetes and hypertension, both of which were well controlled. Her family and social history was unremarkable.
On physical exam, the patient had an exophytic mass obliterating her left external auditory meatus, resulting in complete obstruction of the ear canal ( Fig. 1 A). No periauricular edema or erythema was identified, and the auricle was otherwise well formed. There was no associated cervical adenopathy, and her cranial nerve function was normal bilaterally. An audiogram showed profound sensorineural hearing loss in the affected ear. High-resolution, contrast-enhanced computed tomography (CT) identified complete opacification of the left middle ear, mastoid, and EAC. Of note, a central vascular channel was identified in the lesion, which arose suspicion for a fibrovascular polyp. Mass effect on the ossicular chain was noted, as were sclerotic changes of the mastoid bone ( Fig. 2 ). Contrast enhanced magnetic resonance imaging (MRI) showed a relatively homogeneous enhancing mass filling the EAC and middle ear, with extension anteromedially along the eustachian tube. The lesion did not appear to affect the cochlea or membranous labyrinth, which retained an appropriate fluid-intensity signal ( Fig. 3 ).
