Abstract
Hemangiomas of the external auditory canal are rare with only 16 cases reported in the literature. We report the case of a 62-year-old woman who presented with bleeding from the external auditory canal. Physical examination and imaging were consistent with a hemangioma. Initial diagnostic evaluation failed to reveal the full extent of the lesion resulting in recurrence after primary local excision. After recurrence, the hemangioma was managed successfully with embolization and a more extensive resection. In addition, we review the relevant literature with respect to epidemiology, presentation, evaluation, pathology, and management options for hemangiomas arising in the external auditory canal.
1
Introduction
Hemangiomas are the most common soft tissue neoplasm in children and have a characteristic clinical course. The classic growth pattern of hemangiomas consists of a proliferating phase followed by spontaneous involution. Nearly 2% of neonates have hemangiomas at birth and another 10% of children develop these lesions within the first few months of life . Hemangiomas rarely involve the external auditory canal. Epidemiology, presentation, pathology, and management differ substantially between hemangiomas of infancy and those affecting the external auditory canal. Including our case, there are 17 reported cases of external auditory canal hemangiomas. With adequate diagnostic evaluation and treatment, local recurrence can be avoided. In this article, we present a new case of a hemangioma of the external auditory canal and review the relevant literature.
2
Case presentation
A 62-year-old woman presented to the emergency department with episodic bleeding from the left external auditory canal and intermittent aural pressure. Her medical history was significant for hypertension, recurrent left otitis media, and eustachian tube dysfunction. A computed tomography (CT) of the temporal bones without contrast showed normal temporal bones and no boney dehiscence. The patient was discharged home with amoxicillin and ofloxacin otic drops for presumed otitis media.
Upon follow-up with otolaryngology, the patient continued to have intermittent bleeding from the left external auditory canal with jaw movement. Physical examination revealed a left myringostapediopexy with no attic retraction and a sessile lesion arising from the anteroinferior aspect of the boney external auditory canal. The lesion was compressible, nonpulsatile, and nonblanching with pneumatic otoscopy. Using a 512-Hz tuning fork, Weber did not lateralize and Rinne was positive bilaterally. The facial nerve was intact and flexible fiberoptic nasopharyngoscopy was unremarkable. An audiogram showed normal pure tone thresholds, Jerger type A tympanograms, and normal acoustic reflexes.
Local excision performed in the operating room revealed an anteriorly based and sessile lesion. After removal of the lesion, a small area of dehiscence was palpated in the anterior canal wall. A temporalis fascia graft was placed over the anterior canal wall. Pathology revealed keratinized stratified squamous epithelium with surface ulceration overlying large cavernous vascular spaces, consistent with a cavernous hemangioma.
On postoperative day 25, the patient returned to the office with a pulsatile lesion filling the entire external auditory canal. Magnetic resonance imaging (MRI) of the temporal bone with gadolinium showed dumbbell-shaped lesion extending from the temporal bone and temporomandibular joint to the boney external auditory canal ( Fig. 1 ). Because of bleeding encountered in the initial excision, angiography and embolization were completed preoperatively. Angiogram revealed a vascular blush in the area of the left external auditory canal. The occipital, middle meningeal, and internal maxillary arteries were embolized the day before the planned surgical excision. Using a transcanal approach, removal of the external auditory canal portion revealed a dehiscence in the anterior canal wall, which measured 8 × 15 mm. TMJ arthrotomy was performed to remove a 1.5 × 1-cm lesion anterior to the canal wall. The mass was adherent to TMJ capsule and partially eroded the zygoma. The anterior canal wall was reconstructed using tragal cartilage and temporalis fascia grafts.
The remaining postoperative course was uneventful. Pathology, again, was consistent with a cavernous hemangioma with reactive bony changes and granulation tissue. Because of symptoms of left-sided aural fullness 5 months postoperatively, an MRI was completed, which showed no evidence of recurrence.
2
Case presentation
A 62-year-old woman presented to the emergency department with episodic bleeding from the left external auditory canal and intermittent aural pressure. Her medical history was significant for hypertension, recurrent left otitis media, and eustachian tube dysfunction. A computed tomography (CT) of the temporal bones without contrast showed normal temporal bones and no boney dehiscence. The patient was discharged home with amoxicillin and ofloxacin otic drops for presumed otitis media.
Upon follow-up with otolaryngology, the patient continued to have intermittent bleeding from the left external auditory canal with jaw movement. Physical examination revealed a left myringostapediopexy with no attic retraction and a sessile lesion arising from the anteroinferior aspect of the boney external auditory canal. The lesion was compressible, nonpulsatile, and nonblanching with pneumatic otoscopy. Using a 512-Hz tuning fork, Weber did not lateralize and Rinne was positive bilaterally. The facial nerve was intact and flexible fiberoptic nasopharyngoscopy was unremarkable. An audiogram showed normal pure tone thresholds, Jerger type A tympanograms, and normal acoustic reflexes.
Local excision performed in the operating room revealed an anteriorly based and sessile lesion. After removal of the lesion, a small area of dehiscence was palpated in the anterior canal wall. A temporalis fascia graft was placed over the anterior canal wall. Pathology revealed keratinized stratified squamous epithelium with surface ulceration overlying large cavernous vascular spaces, consistent with a cavernous hemangioma.
On postoperative day 25, the patient returned to the office with a pulsatile lesion filling the entire external auditory canal. Magnetic resonance imaging (MRI) of the temporal bone with gadolinium showed dumbbell-shaped lesion extending from the temporal bone and temporomandibular joint to the boney external auditory canal ( Fig. 1 ). Because of bleeding encountered in the initial excision, angiography and embolization were completed preoperatively. Angiogram revealed a vascular blush in the area of the left external auditory canal. The occipital, middle meningeal, and internal maxillary arteries were embolized the day before the planned surgical excision. Using a transcanal approach, removal of the external auditory canal portion revealed a dehiscence in the anterior canal wall, which measured 8 × 15 mm. TMJ arthrotomy was performed to remove a 1.5 × 1-cm lesion anterior to the canal wall. The mass was adherent to TMJ capsule and partially eroded the zygoma. The anterior canal wall was reconstructed using tragal cartilage and temporalis fascia grafts.
