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Capillary hemangioma of the tympanic membrane
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 26 (2005) 351 – 352 www.elsevier.com/locate/amjoto
Capillary hemangioma of the tympanic membrane Harukazu Hiraumi, MDa,T, Makoto Miura, MD, DMScb, Tomoko Hirose, MDc a
Department of Otolaryngology –Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan b Department of Otolaryngology, Toyooka Hospital, Hyogo, Japan c Department of Otolaryngology, Takatsuki Red Cross Hospital, Osaka, Japan Revised 11 November 2004
Abstract
We report a case of capillary hemangioma of the tympanic membrane in a 51-year-old man with conductive hearing loss, otalgia, and otorrhea. On examination, the external auditory canal was obstructed with a hard, dark red tumor, and purulent discharge was observed. The infection was controlled with antibiotics, but hearing loss persisted. Therefore, transcanal resection was performed. The tumor was attached to the postero-superior quadrant, and arose from the lamina propria. Histologically, the tumor was composed of multiple capillary-sized vessels surrounded by fibrous connective tissue and diagnosed as capillary hemangioma. After surgical treatment, hearing loss was diminished, and there has not been any sign of recurrence for 3 years despite the positive surgical margin. D 2005 Elsevier Inc. All rights reserved.
1. Introduction Hemangioma is a common vascular lesion, but it rarely occurs in the tympanic membrane. Most of the reported cases of hemangioma of the tympanic membrane were cavernous hemangiomas. To our knowledge, only 4 cases of capillary hemangiomas have been reported in the English medical literature [1- 4]. All 4 cases arose from the posterosuperior quadrant, and 2 cases were asymptomatic. We report a case of capillary hemangioma of the tympanic membrane that was accompanied by conductive hearing loss, otalgia, and otorrhea. 2. Case report A 51-year-old man presented with a 2-month history of right otalgia and otorrhea. He also noticed right hearing loss 8 months before the onset. Otoscopic examination demonstrated a hard and dark red tumor occluding the external auditory canal (Fig. 1). Purulent discharge was T Corresponding author. Department of Otolaryngology–Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan 54, Kawahara-cho, Shogoin, Sakyo-ku, Kyoto City, Kyoto, 6068507, Japan. Tel.: +81 75 751 3592; fax: +81 75 751 7225. E-mail address: [email protected] (H. Hiraumi). 0196-0709/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2005.02.006
observed around the tumor, and Staphylococcus aureus was isolated on culture. Pure tone audiogram showed right conductive hearing loss with an air-bone gap of 35 dB. The infection was controlled with antibiotics, and otalgia and otorrhea were diminished. However, the tumor did not show regression in size and the hearing loss persisted. Computed tomography scan showed a round tumor just lateral to the tympanic membrane, but there was no middle ear lesion observed. A transcanal surgical resection was performed to improve hearing and obtain histological findings. The tumor had a pedicle in the postero-superior quadrant and arose from the lamina propria. As the tumor margin was unclear, the exophytic part and the lamina propria were excised so as to avoid making perforation in the tympanic membrane. The postoperative course was uneventful, and conductive hearing loss disappeared. The specimen, 10 mm in diameter, was fixed in 10% buffered formalin and stained with hematoxylin and eosin. Histologically, the tumor was composed of capillary-sized vessels surrounded by fibrous connective tissue (Fig. 2) and was diagnosed as capillary hemangioma. The surgical margin was positive, but the patient refused to undergo further surgical treatment. There has not been any gross tumor recurrence for 3 years postoperatively.
352
H. Hiraumi et al. / American Journal of Otolaryngology –Head and Neck Medicine and Surgery 26 (2005) 351–352
3. Discussion Hemangiomas are benign vascular lesions that are most common in infancy and childhood. There are several histological and clinical variants. Capillary hemangiomas are composed of capillary-sized blood vessels. They are bright red to blue, on a level with the surface of the skin, or slightly elevated. Occasionally, peduncled lesions are formed, attached by a broad-to-slender stalk [5]. They are usually seen in the skin, subcutaneous tissues, and oral mucosa [5], and rarely occur in the tympanic membrane. In the English medical literature, only 4 cases of capillary hemangioma of the tympanic membrane have been reported [1-4]. In all these cases, tumors had pedicles in the posterior part of the tympanic membrane. In 2 cases, surgical resection was performed, and the lesions were found to arise from the lamina propria. Our case shared the same characteristics. In cases of hemangiomas of the tympanic cavity, recurrence and local destruction were reported [6]. On the other hand, hemangiomas of the external auditory canal do not have invasive nature, and the middle ear is generally unaffected [7]. In our case, the tumor was comparatively large but extended only laterally. In previously reported cases of hemangiomas of the tympanic membrane, 2 cases showed only lateral extension [1,2]. Other cases showed both lateral and medial extension, but there was no evidence of ossicular or bony erosion [4]. In the other case, the extension of the tumor was not mentioned [3]. These may imply that hemangiomas of the tympanic membrane are more close to hemangiomas of the external auditory canal than to hemangiomas of the tympanic cavity. Hemangiomas have characteristic findings on inspection and on palpation. They are usually soft and the color is red or purple. Therefore, the diagnosis is usually easy. In our case, however, the tumor was hard and dark red, and histological study was necessary to establish the diagnosis. The tumor was accompanied by infection, and this may have been the cause of the atypical features. As for
Fig. 2. Histological image of the tumor consisting of capillary-sized vessels surrounded by fibrous connective tissue. The vessels were lined with a single layer of endothelial cells (hematoxylin and eosin, original magnification 400).
treatment, Balkany et al [1] and Bijelic et al [2] chose surgical resection. Bijelic et al [2] performed excision of the tympanic membrane with subsequent reconstruction of the tympanic membrane because this procedure is curative and allows histopathological diagnosis. In the case of Balkany et al [1], they chose initially to follow the lesion conservatively, but the tumor doubled in 18 months, and surgical resection was performed. They left the fibrous and mucosal layers intact. Magliulo and Fusconi [3] and Hecht et al [4] chose to follow the lesion conservatively because the tumor did not grow during 15 months of follow-up [3] or spontaneously regressed [4]. In our case, the tumor was relatively large and caused symptoms including conductive hearing loss, otalgia, and otorrhea. Therefore, surgical resection was performed. However, capillary hemangiomas are benign tumors and rarely undergo malignant transformation. Actually, our case has not shown recurrence for 3 years despite the positive surgical margin. If the tumor is asymptomatic and does not show rapid growth, follow-up may be sufficient.
References
Fig. 1. Appearance of the tumor under a microscope (arrowhead). The tumor was occluding the external ear canal. The patient was lying supine, and the tragus was noted in the left upper side.
[1] Balkany TJ, Meyers AD, Wong ML. Capillary hemangioma of the tympanic membrane. Arch Otolaryngol 1978;104:296 - 7. [2] Bijelic L, Wei JL, McDonald TJ. Hemangioma of the tympanic membrane. Otolaryngol Head Neck Surg 2001;125:272 - 3. [3] Magliulo G, Fusconi M. Capillary hemangioma of the tympanic membrane. Otolaryngol Head Neck Surg 1997;116:137. [4] Hecht DA, Jackson CG, Grundfast KM. Management of middle ear hemangiomas. Am J Otolaryngol 2001;22:362 - 6. [5] Cotran RS, Kumar V, Robbins SL. Blood Vessels: Robbins Pathologic Basis of Disease. 4th ed. Philadelphia (Pa)7 WB Saunders;, 1989. p. 553 - 95. [6] Tokyol C, Yilmaz MD. Middle ear hemangioma: a case report. Am J Otolaryngol 2003;24:405 - 7. [7] Limb CJ, Mabrie DC, Carey JP, et al. Hemangioma of the external auditory canal. Otolaryngol Head Neck Surg 2002;126:74 - 5.
Capillary hemangioma of the tympanic membrane Harukazu Hiraumi, MDa,T, Makoto Miura, MD, DMScb, Tomoko Hirose, MDc a
Department of Otolaryngology –Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan b Department of Otolaryngology, Toyooka Hospital, Hyogo, Japan c Department of Otolaryngology, Takatsuki Red Cross Hospital, Osaka, Japan Revised 11 November 2004
Abstract
We report a case of capillary hemangioma of the tympanic membrane in a 51-year-old man with conductive hearing loss, otalgia, and otorrhea. On examination, the external auditory canal was obstructed with a hard, dark red tumor, and purulent discharge was observed. The infection was controlled with antibiotics, but hearing loss persisted. Therefore, transcanal resection was performed. The tumor was attached to the postero-superior quadrant, and arose from the lamina propria. Histologically, the tumor was composed of multiple capillary-sized vessels surrounded by fibrous connective tissue and diagnosed as capillary hemangioma. After surgical treatment, hearing loss was diminished, and there has not been any sign of recurrence for 3 years despite the positive surgical margin. D 2005 Elsevier Inc. All rights reserved.
1. Introduction Hemangioma is a common vascular lesion, but it rarely occurs in the tympanic membrane. Most of the reported cases of hemangioma of the tympanic membrane were cavernous hemangiomas. To our knowledge, only 4 cases of capillary hemangiomas have been reported in the English medical literature [1- 4]. All 4 cases arose from the posterosuperior quadrant, and 2 cases were asymptomatic. We report a case of capillary hemangioma of the tympanic membrane that was accompanied by conductive hearing loss, otalgia, and otorrhea. 2. Case report A 51-year-old man presented with a 2-month history of right otalgia and otorrhea. He also noticed right hearing loss 8 months before the onset. Otoscopic examination demonstrated a hard and dark red tumor occluding the external auditory canal (Fig. 1). Purulent discharge was T Corresponding author. Department of Otolaryngology–Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan 54, Kawahara-cho, Shogoin, Sakyo-ku, Kyoto City, Kyoto, 6068507, Japan. Tel.: +81 75 751 3592; fax: +81 75 751 7225. E-mail address: [email protected] (H. Hiraumi). 0196-0709/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2005.02.006
observed around the tumor, and Staphylococcus aureus was isolated on culture. Pure tone audiogram showed right conductive hearing loss with an air-bone gap of 35 dB. The infection was controlled with antibiotics, and otalgia and otorrhea were diminished. However, the tumor did not show regression in size and the hearing loss persisted. Computed tomography scan showed a round tumor just lateral to the tympanic membrane, but there was no middle ear lesion observed. A transcanal surgical resection was performed to improve hearing and obtain histological findings. The tumor had a pedicle in the postero-superior quadrant and arose from the lamina propria. As the tumor margin was unclear, the exophytic part and the lamina propria were excised so as to avoid making perforation in the tympanic membrane. The postoperative course was uneventful, and conductive hearing loss disappeared. The specimen, 10 mm in diameter, was fixed in 10% buffered formalin and stained with hematoxylin and eosin. Histologically, the tumor was composed of capillary-sized vessels surrounded by fibrous connective tissue (Fig. 2) and was diagnosed as capillary hemangioma. The surgical margin was positive, but the patient refused to undergo further surgical treatment. There has not been any gross tumor recurrence for 3 years postoperatively.
352
H. Hiraumi et al. / American Journal of Otolaryngology –Head and Neck Medicine and Surgery 26 (2005) 351–352
3. Discussion Hemangiomas are benign vascular lesions that are most common in infancy and childhood. There are several histological and clinical variants. Capillary hemangiomas are composed of capillary-sized blood vessels. They are bright red to blue, on a level with the surface of the skin, or slightly elevated. Occasionally, peduncled lesions are formed, attached by a broad-to-slender stalk [5]. They are usually seen in the skin, subcutaneous tissues, and oral mucosa [5], and rarely occur in the tympanic membrane. In the English medical literature, only 4 cases of capillary hemangioma of the tympanic membrane have been reported [1-4]. In all these cases, tumors had pedicles in the posterior part of the tympanic membrane. In 2 cases, surgical resection was performed, and the lesions were found to arise from the lamina propria. Our case shared the same characteristics. In cases of hemangiomas of the tympanic cavity, recurrence and local destruction were reported [6]. On the other hand, hemangiomas of the external auditory canal do not have invasive nature, and the middle ear is generally unaffected [7]. In our case, the tumor was comparatively large but extended only laterally. In previously reported cases of hemangiomas of the tympanic membrane, 2 cases showed only lateral extension [1,2]. Other cases showed both lateral and medial extension, but there was no evidence of ossicular or bony erosion [4]. In the other case, the extension of the tumor was not mentioned [3]. These may imply that hemangiomas of the tympanic membrane are more close to hemangiomas of the external auditory canal than to hemangiomas of the tympanic cavity. Hemangiomas have characteristic findings on inspection and on palpation. They are usually soft and the color is red or purple. Therefore, the diagnosis is usually easy. In our case, however, the tumor was hard and dark red, and histological study was necessary to establish the diagnosis. The tumor was accompanied by infection, and this may have been the cause of the atypical features. As for
Fig. 2. Histological image of the tumor consisting of capillary-sized vessels surrounded by fibrous connective tissue. The vessels were lined with a single layer of endothelial cells (hematoxylin and eosin, original magnification 400).
treatment, Balkany et al [1] and Bijelic et al [2] chose surgical resection. Bijelic et al [2] performed excision of the tympanic membrane with subsequent reconstruction of the tympanic membrane because this procedure is curative and allows histopathological diagnosis. In the case of Balkany et al [1], they chose initially to follow the lesion conservatively, but the tumor doubled in 18 months, and surgical resection was performed. They left the fibrous and mucosal layers intact. Magliulo and Fusconi [3] and Hecht et al [4] chose to follow the lesion conservatively because the tumor did not grow during 15 months of follow-up [3] or spontaneously regressed [4]. In our case, the tumor was relatively large and caused symptoms including conductive hearing loss, otalgia, and otorrhea. Therefore, surgical resection was performed. However, capillary hemangiomas are benign tumors and rarely undergo malignant transformation. Actually, our case has not shown recurrence for 3 years despite the positive surgical margin. If the tumor is asymptomatic and does not show rapid growth, follow-up may be sufficient.
References
Fig. 1. Appearance of the tumor under a microscope (arrowhead). The tumor was occluding the external ear canal. The patient was lying supine, and the tragus was noted in the left upper side.
[1] Balkany TJ, Meyers AD, Wong ML. Capillary hemangioma of the tympanic membrane. Arch Otolaryngol 1978;104:296 - 7. [2] Bijelic L, Wei JL, McDonald TJ. Hemangioma of the tympanic membrane. Otolaryngol Head Neck Surg 2001;125:272 - 3. [3] Magliulo G, Fusconi M. Capillary hemangioma of the tympanic membrane. Otolaryngol Head Neck Surg 1997;116:137. [4] Hecht DA, Jackson CG, Grundfast KM. Management of middle ear hemangiomas. Am J Otolaryngol 2001;22:362 - 6. [5] Cotran RS, Kumar V, Robbins SL. Blood Vessels: Robbins Pathologic Basis of Disease. 4th ed. Philadelphia (Pa)7 WB Saunders;, 1989. p. 553 - 95. [6] Tokyol C, Yilmaz MD. Middle ear hemangioma: a case report. Am J Otolaryngol 2003;24:405 - 7. [7] Limb CJ, Mabrie DC, Carey JP, et al. Hemangioma of the external auditory canal. Otolaryngol Head Neck Surg 2002;126:74 - 5.