Abstract
Tinnitus is a common symptom caused by numerous diseases. The etiology is unknown in most cases; however, nasopharyngeal lesions may cause a certain tinnitus. We herein report a case of nasopharyngeal inverted papilloma which presents with rustling tinnitus as the sole initial symptom. The tympanic membrane was intact, and results of hearing test and impedance audiometry were normal. However, sonotubometry showed a complete blockage of the Eustachian tube. A large tumor was found that originated from the choana and occupied the nasopharynx which caused a rustling sound when she swallowed or spoke. Tinnitus totally subsided after removal of this tumor. To our knowledge, the tumor origin and presenting symptom of this case are very rare, and nasopharyngeal examination is required in the diagnosis of unknown hearing symptoms.
1
Introduction
Inverted papilloma (IP) is a locally aggressive, benign nasal lesion remarkable for its tendency for local recurrence and association with carcinoma. It accounts for 0.5%–4% of all neoplasms of the sinonasal tract . IP is associated with a sinonasal carcinoma in up to 5% of patients. Clinically, it is most commonly seen among male subjects age 50 to 60 years. Usually, this tumor originates from the lateral nasal wall, particularly in the osteomeatal complex of the middle meatus, and adjacent inferior and middle turbinates. Subsequently, it involves the contiguous paranasal sinuses with the maxillary sinus as the most frequent ly involved followed by the ethmoid sinus. We herein report a case of IP that arises from the choana and presents with episodic tinnitus.
2
Case reports
A 71-year-old female visited an ENT clinic due to tinnitus. She complained of a rustling sound on the ears with gradual exacerbation. Both tympanic membranes were normal on examination. However, nasopharyngeal endoscopy showed a large mass that occupied the right nasopharynx. Tumor biopsy revealed inverted papilloma. She was then referred to our hospital.
At the first visit, she still complained of rustling sound on her right ear, especially during swallowing and phonation. The audiogram showed normal hearing for her age, and impedance audiometry was also normal. On the contrary, sonotubometry revealed complete blockage of the right Eustachian tube even during swallowing; whereas, the left tube opened well. The acoustic rhinomanometry showed severe right-sided nasal obstruction even though she had never experienced nasal obstruction. A large pharyngeal mass almost fully occupied the nasopharynx and obstructed the right choana. The greater part of the tumor was behind the middle and inferior turbinates and could not be observed well. After thorough opening of the nasal cavity using an epinephrine-soaked gauze, a pedicle of the tumor was observed around the choana just anterior to the orifice of the sphenoid sinus ( Fig. 1 ). This mass was in contact with the orifice of the Eustachian tube and also protruded into the left side. It moved during phonation and swallowing, and the rustling tinnitus was generated by the movement of tumor near the tubal orifice. No adhesion was noted, except for the pedicle. On magnetic resonance (MR) imaging, the tumor showed high intensity at T2-weighted-image and was well enhanced after administration of gadolinium. This tumor was limited to the nasopharynx and did not show invasion to the sphenoid sinus or skull base. From these findings, endoscopic endonasal removal was planned.
Under general anesthesia, the lower part of the inferior turbinate was removed that allowed visualization of most part of the tumor. The middle turbinate was shifted laterally which showed the tumor pedicle. A periosteal incision was made 2 cm away from the pedicle. Then, the periostium was carefully dissected from the bone, the pedicle was totally excised, and a 5-cm-sized tumor was removed orally ( Fig. 2 ). The exposed bone was polished by a diamond bar and covered with a polyglycolic acid sheet. Histopathology revealed IP with a negative margin. Postoperative course was uneventful, and tinnitus totally subsided. Despite removal of the lower part of the inferior turbinate, no nasal symptom developed afterward. She was disease-free 1½ years later both on physical examination and on imaging study.
2
Case reports
A 71-year-old female visited an ENT clinic due to tinnitus. She complained of a rustling sound on the ears with gradual exacerbation. Both tympanic membranes were normal on examination. However, nasopharyngeal endoscopy showed a large mass that occupied the right nasopharynx. Tumor biopsy revealed inverted papilloma. She was then referred to our hospital.
At the first visit, she still complained of rustling sound on her right ear, especially during swallowing and phonation. The audiogram showed normal hearing for her age, and impedance audiometry was also normal. On the contrary, sonotubometry revealed complete blockage of the right Eustachian tube even during swallowing; whereas, the left tube opened well. The acoustic rhinomanometry showed severe right-sided nasal obstruction even though she had never experienced nasal obstruction. A large pharyngeal mass almost fully occupied the nasopharynx and obstructed the right choana. The greater part of the tumor was behind the middle and inferior turbinates and could not be observed well. After thorough opening of the nasal cavity using an epinephrine-soaked gauze, a pedicle of the tumor was observed around the choana just anterior to the orifice of the sphenoid sinus ( Fig. 1 ). This mass was in contact with the orifice of the Eustachian tube and also protruded into the left side. It moved during phonation and swallowing, and the rustling tinnitus was generated by the movement of tumor near the tubal orifice. No adhesion was noted, except for the pedicle. On magnetic resonance (MR) imaging, the tumor showed high intensity at T2-weighted-image and was well enhanced after administration of gadolinium. This tumor was limited to the nasopharynx and did not show invasion to the sphenoid sinus or skull base. From these findings, endoscopic endonasal removal was planned.
