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Clinical Challenge
May 2017

Middle Ear Mass Causing Vertigo and Facial Nerve Weakness

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
  • 2Department of Otolaryngology–Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan
JAMA Otolaryngol Head Neck Surg. 2017;143(5):515-516. doi:10.1001/jamaoto.2016.3222

An elderly woman presented with 2 episodes of vertigo lasting a few minutes while stationary over 1 day and a several-year history of right-sided hearing loss. She had not experienced otalgia, otorrhea, or tinnitus. Physical examination revealed a mass obstructing the right external auditory canal and House-Brackmann grade 2 facial nerve weakness on the right. Audiogram revealed right-sided moderate to profound mixed hearing loss. Computed tomography revealed a soft-tissue mass emanating from the middle ear involving the facial canal with surrounding bony erosion, including dehiscence of the tegmen, cochlea, bony labyrinth, lateral semicircular canal, and jugular foramen. The patient underwent transtemporal mastoidectomy and debulking. However, owing to the mass’s vascularity and significant bleeding, the operation was aborted, and she was sent for embolization (Figure, A). Magnetic resonance imaging during embolization revealed intense enhancement in the right middle ear extending from the epitympanum to the hypotympanum with extension into the right external auditory canal (Figure, B). She returned to the operating room, and the vascular mass was found to extend inferiorly to the jugular bulb and carotid and anteriorly into the eustachian tube. The mass was adherent to the underlying bone and had invaded the facial canal but not the nerve itself. Both malleus and incus were eroded. Immunohistochemical stains of the specimen indicated cells positive for synaptophysin with a sustentacular pattern of cells positive for S-100 (Figure, C and D).

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