Ann Otol Rhinal LaryngollOl:1992
IMAGING CASE STUDY OF THE MONTH
METASTATIC TUMOR PRESENTING AS CHRONIC OTITIS AND FACIAL PARALYSIS DAVID S. MARTIN, MD
JAMES BENECKE,
COREY MAAS, MD
MD ST LOUIS, MISSOURI
CASE REPORT
the right external auditory canal. The left ear appeared normal. The remainder of the examination findings of the head and neck were normal.
A 71-year-old man presented with a 4-week history of right-sided facial paresis of insidious onset. He reported a long history of intermittent otorrhea that began after a traumatic perforation of the tympanic membrane. The patient denied tinnitus or vertigo. Additionally, he relayed a history of right shoulder pain and auricular paresthesia.
The patient's laboratory values were unremarkable. Cultures taken from the right external auditory canal failed to grow significant organisms. Changes consistent with chronic obstructive pulmonary disease and perihilar densities were observed on chest radiographs. Audiometry revealed bilateral severe high-frequency sensorineural hearing loss and a flat tympanogram on the right. Electronystagmography showed no response on the right.
The patient had a medical history of recurrent pneumonia, chronic obstructive pulmonary disease, and peptic ulcer disease. He had undergone partial gastrectomy and saphenous vein stripping in the past. He had a 60-pack-year history of smoking and admitted to occasional use of alcohol.
A computed tomogram of the temporal bone accompanied the patient and demonstrated opacification of the mastoid air cells on the right and evidence of bone destruction involving the mastoid (Fig lA). A mass inferior to the mastoid was also observed (Fig IB). Gadolinium-enhanced magnetic resonance imaging demonstrated the extent of the mass from the base of the styloid process to the mid-
On physical examination, a grade 6 (HouseBrackmann) right-sided facial nerve paralysis was noted. His tongue deviated to the right. The remainder of the findings on cranial nerve examination were unremarkable. Otorrhea was observed from the right ear with ceruminous debris filling
Fig 1. Axial computed tomograms. A) Demonstrating right mastoid opacification and adjacent bone destruction. B) At level of styloid process, showing mass (arrows). From the Departments of Radiology (Martin) and Otolaryngology-Head and Neck Surgery (Benecke, Maas), St Louis University Medical Center, St Louis, Missouri. REPRINTS - David S. Martin, MD, Dept of Radiology, St Louis University Hospital, 3635 Vista at Grand, St Louis, MO 63110-0250.
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otorrhea and a facial paralysis on the same side, the immediate thought is that this represents a complication of chronic suppurative otitis media. Such a complication mandates a careful evaluation and expeditious surgery. 1 Of course, one also is compelled to formulate a differential diagnosis in such a situation. Primary tumors of the skull base such as paragangliomas and schwannomas rarely produce a draining ear, and infrequently present with a facial paralysis. Malignant tumors of the temporal bone are rare, but adenocarcinoma and other glandular tumors could potentially cause facial paralysis and otorrhea." Finally, metastatic tumors must be given consideration." The history of a known primary malignancy will usually lead to this diagnosis.
Fig 2. Coronal Tl-weighted magnetic resonance image with gadolinium enhancement illustrates extent of mass (arrows).
dIe ear cavity (Fig 2). A subsequent computed tomogram of the chest demonstrated a left lower lobe mass (not illustrated) that was determined to be small cell carcinoma of the lung. DISCUSSION
When one is confronted with a patient who has
This patient had symptoms due to a huge tumor involving the temporal bone. The tumor had destroyed the stylomastoid foramen, producing the facial paralysis. It had also eroded into the middle ear space and through the tympanic membrane, presumably resulting in otorrhea. The extensive bone destruction shown by computed tomography and the extensive mass demonstrated by magnetic resonance imaging excluded suppurative disease. The chest radiograph provided the clue that the patient's symptoms were due to a malignant process originating in the lung.
REFERENCES 1. Coker NJ, Fisch V. Disorders of the facial nerve. In: English GM, ed. Otolaryngology. Voll. Philadelphia, Pa: JB Lippincott, 1990:1-43. 2. Benecke JE, Brackmann DE. Differential diagnosis of temporal bone skull base lesions. Self-instruction package. Washing-
ton, DC: American Academy of Otolaryngology-Head and Neck Surgery, 1988. 3. Schuknecht HF, Allam AF, Murakami Y. Pathology of secondary malignant tumors of the temporal bone. Ann Otol Rhinol Laryngol 1968;77:5-22.
FIRST EUROPEAN SYMPOSIUM ON PEDIATRIC COCHLEAR IMPLANTATION The First European Symposium on Pediatric Cochlear Implantation will be held September 24-27, 1992, at University Hospital, Nottingham. For further information, contact the University of Nottingham, Office for Professional and Industrial Training, University Park, Nottingham NG7 2RD, England; telephone: (0602) 792841; fax: (0602) 501718.
Downloaded from aor.sagepub.com at Bobst Library, New York University on May 2, 2015
IMAGING CASE STUDY OF THE MONTH
METASTATIC TUMOR PRESENTING AS CHRONIC OTITIS AND FACIAL PARALYSIS DAVID S. MARTIN, MD
JAMES BENECKE,
COREY MAAS, MD
MD ST LOUIS, MISSOURI
CASE REPORT
the right external auditory canal. The left ear appeared normal. The remainder of the examination findings of the head and neck were normal.
A 71-year-old man presented with a 4-week history of right-sided facial paresis of insidious onset. He reported a long history of intermittent otorrhea that began after a traumatic perforation of the tympanic membrane. The patient denied tinnitus or vertigo. Additionally, he relayed a history of right shoulder pain and auricular paresthesia.
The patient's laboratory values were unremarkable. Cultures taken from the right external auditory canal failed to grow significant organisms. Changes consistent with chronic obstructive pulmonary disease and perihilar densities were observed on chest radiographs. Audiometry revealed bilateral severe high-frequency sensorineural hearing loss and a flat tympanogram on the right. Electronystagmography showed no response on the right.
The patient had a medical history of recurrent pneumonia, chronic obstructive pulmonary disease, and peptic ulcer disease. He had undergone partial gastrectomy and saphenous vein stripping in the past. He had a 60-pack-year history of smoking and admitted to occasional use of alcohol.
A computed tomogram of the temporal bone accompanied the patient and demonstrated opacification of the mastoid air cells on the right and evidence of bone destruction involving the mastoid (Fig lA). A mass inferior to the mastoid was also observed (Fig IB). Gadolinium-enhanced magnetic resonance imaging demonstrated the extent of the mass from the base of the styloid process to the mid-
On physical examination, a grade 6 (HouseBrackmann) right-sided facial nerve paralysis was noted. His tongue deviated to the right. The remainder of the findings on cranial nerve examination were unremarkable. Otorrhea was observed from the right ear with ceruminous debris filling
Fig 1. Axial computed tomograms. A) Demonstrating right mastoid opacification and adjacent bone destruction. B) At level of styloid process, showing mass (arrows). From the Departments of Radiology (Martin) and Otolaryngology-Head and Neck Surgery (Benecke, Maas), St Louis University Medical Center, St Louis, Missouri. REPRINTS - David S. Martin, MD, Dept of Radiology, St Louis University Hospital, 3635 Vista at Grand, St Louis, MO 63110-0250.
280
Downloaded from aor.sagepub.com at Bobst Library, New York University on May 2, 2015
Martin et al, Imaging Case Study oj the Month
281
otorrhea and a facial paralysis on the same side, the immediate thought is that this represents a complication of chronic suppurative otitis media. Such a complication mandates a careful evaluation and expeditious surgery. 1 Of course, one also is compelled to formulate a differential diagnosis in such a situation. Primary tumors of the skull base such as paragangliomas and schwannomas rarely produce a draining ear, and infrequently present with a facial paralysis. Malignant tumors of the temporal bone are rare, but adenocarcinoma and other glandular tumors could potentially cause facial paralysis and otorrhea." Finally, metastatic tumors must be given consideration." The history of a known primary malignancy will usually lead to this diagnosis.
Fig 2. Coronal Tl-weighted magnetic resonance image with gadolinium enhancement illustrates extent of mass (arrows).
dIe ear cavity (Fig 2). A subsequent computed tomogram of the chest demonstrated a left lower lobe mass (not illustrated) that was determined to be small cell carcinoma of the lung. DISCUSSION
When one is confronted with a patient who has
This patient had symptoms due to a huge tumor involving the temporal bone. The tumor had destroyed the stylomastoid foramen, producing the facial paralysis. It had also eroded into the middle ear space and through the tympanic membrane, presumably resulting in otorrhea. The extensive bone destruction shown by computed tomography and the extensive mass demonstrated by magnetic resonance imaging excluded suppurative disease. The chest radiograph provided the clue that the patient's symptoms were due to a malignant process originating in the lung.
REFERENCES 1. Coker NJ, Fisch V. Disorders of the facial nerve. In: English GM, ed. Otolaryngology. Voll. Philadelphia, Pa: JB Lippincott, 1990:1-43. 2. Benecke JE, Brackmann DE. Differential diagnosis of temporal bone skull base lesions. Self-instruction package. Washing-
ton, DC: American Academy of Otolaryngology-Head and Neck Surgery, 1988. 3. Schuknecht HF, Allam AF, Murakami Y. Pathology of secondary malignant tumors of the temporal bone. Ann Otol Rhinol Laryngol 1968;77:5-22.
FIRST EUROPEAN SYMPOSIUM ON PEDIATRIC COCHLEAR IMPLANTATION The First European Symposium on Pediatric Cochlear Implantation will be held September 24-27, 1992, at University Hospital, Nottingham. For further information, contact the University of Nottingham, Office for Professional and Industrial Training, University Park, Nottingham NG7 2RD, England; telephone: (0602) 792841; fax: (0602) 501718.
Downloaded from aor.sagepub.com at Bobst Library, New York University on May 2, 2015
