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Clinical Challenge
November 29, 2018

An Indolent Middle Ear Mass

Author Affiliations
  • 1The University of Tennessee Health Science Center College of Medicine, Memphis
  • 2Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas
JAMA Otolaryngol Head Neck Surg. 2019;145(2):181-182. doi:10.1001/jamaoto.2018.2956

A woman in her 30s presented with a 1-year history of left ear fullness. She reported diminished left-sided hearing that would temporarily improve with autoinsufflation. She denied facial numbness or weakness, and reported no dizziness or vertigo. Physical examination revealed a retrotympanic, nonpulsatile, tan-gray mass anterior to the malleus handle. A tuning fork examination revealed lateralization to the left ear and bone conduction louder than air conduction on the left side with a 512-Hz tuning fork. The remainder of the physical examination, including facial nerve function, was normal. An audiogram confirmed mild conductive hearing loss in the left ear. Computed tomography (CT) revealed a middle ear lesion lateral to the geniculate ganglion with possible extension into the peritubal space. Magnetic resonance imaging (MRI) demonstrated an enhancing lesion lateral to the geniculate ganglion (Figure, A-C). The patient was initially observed but then experienced progressive hearing loss that no longer improved with the Valsalva maneuver, persistent ear fullness, and rare facial twitching. The middle ear mass appeared enlarged on repeated MRI and began to obstruct the eustachian tube. Transcanal endoscopy demonstrated a gray middle ear mass occupying the anterior mesotympanum and epitympanum and extending into the eustachian tube (Figure, D). The tegmen was intact. The specimen revealed predominantly spindled stroma with a focus of tumor that was positive for antiepithelial membrane antigen and somatostatin receptor 2A.