Cavernous Hemangioma of the Tympanic Membrane. Case Report and Review of Literature

Cruz Toro, Paula; Mesa Marrero, Margarita; Hernández Montero, Elena; Pané Foix, María

doi:10.1016/j.otoeng.2019.09.003

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A propósito de un caso y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 372 "Ancho" => 1305 "Tamanyo" => 54343 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Otomicroscopy and computerised tomography where the lesion is shown with density of soft tissues adhering to the right tympanic membrane." ] ] ] "textoCompleto" => "Clinical CaseA 62-year-old male patient was referred for otorhinolaryngology consultation after presenting with a 6-month onset of a sensation of aural blockage and aural fullness in the right ear. He referred to occasional serous discharge, with no other associated symptoms. Right otomicroscopy revealed a sessile, non pulsile, crumbling, purplish mass which occupied the whole distal third of the external auditory canal. On examination, there was evidence of it being pedunculated and dependent on the upper quadrants of the tympanic membrane, with no involvement of the skin of the external auditory canal. (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A pure tone audiogram showed right conductive hearing loss with a hearing differential threshold of approximately 20 dB. All other examination results were normal. Temporal bone computerised tomography showed a soft tissue 8 × 8 × 6 mm nodular density mass, attached to the right tympanic membrane. The eardrum, ossicular chain and mastoid cells were well pneumaticised, free, and normal in appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).We decided to operate with an endaural approach to the right ear. It was confirmed that the tumour exclusively depended on the attic region of the tympanic membrane. The tumour was completely removed together with the superficial (squamous) layer of the tympanic membrane where the pedicle had been found. There was no evidence of involvement of the other layers of the membrane nor invasion of the middle ear. After excision a minimal aticc perforation was observed, which was reconstructed solely with Spongostan®sheets.Pathologic examination of the specimen showed a nodular lesion covered by squamous non-atypia epithelial cells, comprised of well-demarcated dilated vascular structures, with a thin wall and flat endothelium, with little underlying stroma. These findings indicated a benign vascular proliferation compatible with cavernous hemangioma (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>At present, one year after surgery, there has been no evidence of a relapse, with closure of the differential threshold and appropriate evolution.DiscussionVascular anomalies are basically classified into 2 categories: hemangiomas and vascular malformations. Hemangiomas are divided into 2: capillary type characterised by a lobular, non encapsulated proliferation of blood vessels of a capillary size and the cavernous type which are composed of larger vascular spaces or sinusoids lined by endothelium. The capillary hemangiomas occur more commonly in childhood and the cavernous hemangiomas are more common in adults after the fifth decade of life. Their aetiology is unknown. It would appear, at paediatric ages there is a genetic predisposition to the growth of lesions during the first year of life and later spontaneous involution, whilst in adults some authors point to the relationship with trauma or previous contusion in the affected area.Cavernous hemangiomas are common tumours of the head and neck area, and they predominantly originate from the lips and oral cavity. However, they are uncommon in the ear and rarely arise from the tympanic membrane. Most of them present in the external auditory canal or are large sized lesions which affect many different spaces of the ear, with several cases and reviews having been published.<a class="elsevierStyleCrossRefs" href="#bib0005">1–4</a> Notwithstanding, presentation limited to the tympanum is unusual: to date only 5 cases have been described that are exclusive to the tympanic membrane.In 1983, Andrade et al<a class="elsevierStyleCrossRef" href="#bib0025">5</a>. Described the first case of cavernous hemangioma limited to the tympanic membrane and since then only 4 further cases have been reported.<a class="elsevierStyleCrossRefs" href="#bib0025">5–9</a> Aetiology is unknown and it would appear that they arise from the lamina propia of the tympanic membrane.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Most patients are usually asymptomatic although they may have a sensation of otic blockage and aural fullness, together with self-limiting ear discharges. Differential diagnosis includes aural polyp, glomus tumour, arteriovenous malformation, granulation tissue and carcinoma of the EAC. Computerised tomography is the first choice for assessing location and dependence of the tumour, together with its size and middle ear involvement.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4,9</a>Treatment is surgical, generally with an enaural approach if there is enough exposure or depending on the size of the mass. No previous embolisation of the tympanic membrane is required and generally en bloc excision and reconstruction of the tympanic membrane (if necessary) is sufficient for treatment.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,4,9</a>To conclude, although tympanic cavernous hemangiomas are rare and incidence is low, they should be included in the differential diagnosis of polypoid lesions of the external auditory canal and tympanic membrane.Conflict of InterestsThe authors have no conflict of interests to declare." 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ISSN: 2173-5735

Acta Otorrinolaringológica Española, the official publication of the Spanish Society of Otolaryngology and Head and Neck Surgery and the Ibero-American Society of Otorhinolaryngology, is the most important journal in Spanish dedicated to Otorhinolaryngology, which reflects the continuous scientific and technical progress of the specialty. It has become an important tool to be kept up to date. The Journal publishes Original Articles (articles on basic research and clinical investigation), reviews, brief communications, case studies and images, which are subjected to a rigorous peer review process.

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Acta Otorrinolaringológica Española has received its first journal Impact Factor (JCR) in 2023. Instructions for authors - Submit an article

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

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Impact factor 2023

0.9

Citescore

CiteScore measures average citations received per document published.

Citescore 2023

1.4

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.326

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.54

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Journal Information

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Vol. 71. Issue 6.