- Email: [email protected]
Fibroma of the tympanic membrane
Available online at www.sciencedirect.com
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 288 – 290 www.elsevier.com/locate/amjoto
Fibroma of the tympanic membrane Chang Woo Kim, MDa,⁎, So Jung Oh, MDa , Young-Soo Rho, MDa , Seong Jin Cho, MDb , Eun Soek Koh, MDa , Jeong Min Kang, MDa a
Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University, Seoul, Korea b Department of Pathology, College of Medicine, Hallym University, Seoul, Korea Received 5 March 2008
Abstract
A primary tumor of the tympanic membrane is very rare. Herein, we describe a patient with a thick tympanic membrane that caused progressive hearing loss. The patient was treated with total resection of the tympanic membrane and was diagnosed with fibroma after histopathologic examination. There was no evidence of recurrence 2 years after the operation, and the patient's hearing was normal. Fibroma may arise in the tympanic membrane and should be regarded as a possible cause of the mass of the tympanic membrane. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Conductive hearing loss may be caused by a lesion in the sound energy conducting system. Disease of the tympanic membrane, including a mass lesion, is one of the possible causes. However, a primary tumor of the tympanic membrane is very rare, and only a few cases have ever been reported in the English literature, for example, hemangioma, schwannoma, paraganglioma, and squamous cell carcinoma [1-4]. These tumors may cause symptoms such as hearing loss, otalgia, otorrhea, and sometimes asymptomatic conditions. Herein, we describe a patient with a thick tympanic membrane that caused progressive hearing loss. The patient was treated with total resection of the tympanic membrane and was diagnosed with fibroma after histopathologic examination. To our knowledge, this is the first reported case of a fibroma of the tympanic membrane.
experiencing otalgia, dizziness, otorrhea, previous otologic surgery, or trauma. The patient was a housewife, and she had had no specific factor that might influence on the external auditory canal such as frequent swimming, ear picking, or listening to a radio by earphone. Results of physical examination revealed a thick tympanic membrane that showed whitish masslike bulging of the pars tensa and projected no middle ear structure (Fig. 1). There was no
2. Case report A 65-year-old woman presented with a 1-year history of progressive hearing loss in her right ear. She denied
⁎ Corresponding author. Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, 445 Gil-Dong, Gangdong-gu, Seoul, 134-701, Korea. Tel.: +82 2 2224 2279; fax: +82 2 482 2279. E-mail address: [email protected] (C.W. Kim). 0196-0709/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2008.06.008
Fig. 1. Otoscopic image reveals a thick tympanic membrane that showed masslike bulging of the pars tensa (arrows) and projected no middle ear structure.
C.W. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 288–290
289
facial paralysis, and examination of the cervical lymph node was unremarkable. Audiologic examination revealed normal hearing on the left and conductive hearing loss on the right. The 4-frequency pure tone average was 40 dB for air conduction and 10 dB for bone conduction. Results of a computerized tomographic (CT) scan revealed a diffuse thickening of the right tympanic membrane and inferior external auditory canal skin with no bony destruction or erosion (Fig. 2). The patient underwent total resection of the tympanic membrane through a postauricular approach. A circumferential incision was made along the external
Fig. 3. Histopathologic finding shows spindled fibroblasts closely packed with abundant collagenous stroma (hematoxylin and eosin stain, original magnification ×200).
auditory canal skin approximately 5 mm lateral to the annulus. The mass arose from the pars tensa of the tympanic membrane, and the thickest portion was 5 mm thick. The inferior portion of the fibrous annulus was displaced laterally. The mass was easily detached from the bony canal with no destruction or erosion. The ossicular chain was intact, and the middle ear cavity was normal. Grafting of the tympanic membrane and bony ear canal was performed with deep temporalis muscle fascia, and the grafted material was situated onto the malleus handle. The mass was subjected to histopathologic assessment, which revealed a well-circumscribed mass composed of typical spindled fibroblasts closely packed with abundant collagenous stroma consistent with fibroma (Fig. 3). Immunohistochemical reactions were not detected for S-100 or CD34. After surgical resection, the patient recovered uneventfully. There was no evidence of recurrence 2 years after operation, and the patient's hearing was normal, with an intact tympanic membrane. 3. Discussion
Fig. 2. Computed tomographic scan images. (A) Axial CT scans show thickening of the tympanic membrane. Pars tensa area (arrow) is thicker than pars flaccida area (arrowhead). (B) Coronal CT scans show triangularshaped tympanic membrane (arrow). Pars flaccida (arrowhead) has a thin membrane.
A fibroma is a benign tumor that is composed of fibrous or connective tissue. It can grow in all organs arising from mesenchymal tissue, but its occurrence around the external ear is very rare [5]. Fibroma of the tympanic membrane has not yet been reported in the English literature. We think that this tumor has been underestimated because it does not cause specific symptoms. In this case, the patient's only symptom was progressive hearing loss, and she had no other otologic complaints. Differential diagnosis of this tumor includes hemangioma, schwannoma, paraganglioma, malignancy, and medial canal fibrosis. Hemangioma is a benign vascular tumor and usually has a peduncle in the posterior part of the tympanic membrane as a partly elevated lesion [3]. It is usually soft, and the color is reddish or dark blue. It may cause massive bleeding when a deep biopsy is performed.
290
C.W. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 288–290
Only 2 cases of schwannoma of the tympanic membrane have been reported [2,6]. These tumors revealed as a pinkish mass obstructing the external auditory canal and partly attached to the tympanic membrane. Squamous cell carcinoma may arise in the tympanic membrane. The previous report mentioned some thickening of the tympanic membrane with normal temporal bone CT findings [1]. Incidence of these tumors is very rare, but any masslike lesion of the tympanic membrane should be considered as a possible tumor. Medial canal fibrosis is not a tumor but is difficult to differentiate from a tumor of the tympanic membrane clinically and radiologically. It is an uncommon disease entity that occurs as a result of external otitis, chronic dermatitis, or trauma in the bony external auditory canal and results in formation of fibrous tissue in the medial third of the bony canal abutting the tympanic membrane [7]. Medial canal fibrosis may show partial obliteration with blunting of the anterior tympanomeatal angle, or complete obliteration of the medial bony canal, causing it to be misread as a lateralized tympanic membrane. There may be a space between the tympanic membrane and the obliterated fibrous tissue, and sometimes medial canal fibrosis may be associated with cholesteatoma [8]. Surgical treatment is usually indicated, and it is needed to remove the fibrous plug and allow the epithelium to grow over the bony canal and tympanic membrane. It is usually easy to separate the fibrous tissue from the tympanic membrane's lamina propria. This is a clinically important feature to distinguish between a medial canal fibrosis and a fibroma of the tympanic membrane. In our case, the tumor might arise from the tympanic membrane's fibrous layer. The tympanic membrane is composed of 3 layers as follows: the modified skin of the external auditory canal on its outer
surface, the mucous membrane of the middle ear cavity internally, and a middle fibrous layer or lamina propria [9]. The lamina propria of the pars tensa consists of 2 layers of connective tissue, outer radial fibers, and inner circular fibers, whereas the pars flaccida does not share this fibrous organizational pattern. This patient's tumor was confined within the pars tensa and grew laterally, and the fibrous annulus was displaced laterally, too. The tumor caused conductive hearing loss, so surgical resection was performed. The patient's hearing recovered to normal with no recurrence of the tumor 2 years postoperatively. Conclusively, fibroma may arise in the tympanic membrane and should be regarded as a possible cause of the mass of the tympanic membrane. References [1] Somers T, Vercruysse JP, Goovaerts G, et al. Isolated squamous cell carcinoma of the tympanic membrane. Otol Neurol 2002;23:808. [2] Yang CH, Su CY, Wei YC, et al. Schwannoma of the tympanic membrane. J Laryngol Otol 2006;120:247-9. [3] Hiraumi H, Miura M, Hirose T. Capillary hemangioma of the tympanic membrane. Am J Otolaryngol 2005;26:351-2. [4] Pusalkar A, Steinbach E, Shah D. Paraganglioma of the tympanic membrane. J Laryngol Otol 1985;99:481-3. [5] Sen MK, Ghosal SK. Fibroma of the pinna. J Indian Med Assoc 1995; 93:328. [6] Supiyaphun P, Lekaul S, Shuangshoti S. Solitary schwannoma of the tympanic membrane: a case report. Auris Nasus Larynx 1999;26:191-4. [7] Slattery III WH, Saadat P. Postinflammatory medial canal fibrosis. Am J Otol 1997;18:294-7. [8] El-Sayed Y. Acquired medial canal fibrosis. J Lryngol Otol 1998;112: 145-9. [9] Cruz OLM. Anatomy of the skull base, temporal bone, external ear, and middle ear. In: Cummings CW, Fredrickson JM, Harker LA, et al, editors. Otolaryngology—head and neck surgery, 4th ed., vol. 4. St Louis: Mosby; 2005.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 288 – 290 www.elsevier.com/locate/amjoto
Fibroma of the tympanic membrane Chang Woo Kim, MDa,⁎, So Jung Oh, MDa , Young-Soo Rho, MDa , Seong Jin Cho, MDb , Eun Soek Koh, MDa , Jeong Min Kang, MDa a
Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University, Seoul, Korea b Department of Pathology, College of Medicine, Hallym University, Seoul, Korea Received 5 March 2008
Abstract
A primary tumor of the tympanic membrane is very rare. Herein, we describe a patient with a thick tympanic membrane that caused progressive hearing loss. The patient was treated with total resection of the tympanic membrane and was diagnosed with fibroma after histopathologic examination. There was no evidence of recurrence 2 years after the operation, and the patient's hearing was normal. Fibroma may arise in the tympanic membrane and should be regarded as a possible cause of the mass of the tympanic membrane. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Conductive hearing loss may be caused by a lesion in the sound energy conducting system. Disease of the tympanic membrane, including a mass lesion, is one of the possible causes. However, a primary tumor of the tympanic membrane is very rare, and only a few cases have ever been reported in the English literature, for example, hemangioma, schwannoma, paraganglioma, and squamous cell carcinoma [1-4]. These tumors may cause symptoms such as hearing loss, otalgia, otorrhea, and sometimes asymptomatic conditions. Herein, we describe a patient with a thick tympanic membrane that caused progressive hearing loss. The patient was treated with total resection of the tympanic membrane and was diagnosed with fibroma after histopathologic examination. To our knowledge, this is the first reported case of a fibroma of the tympanic membrane.
experiencing otalgia, dizziness, otorrhea, previous otologic surgery, or trauma. The patient was a housewife, and she had had no specific factor that might influence on the external auditory canal such as frequent swimming, ear picking, or listening to a radio by earphone. Results of physical examination revealed a thick tympanic membrane that showed whitish masslike bulging of the pars tensa and projected no middle ear structure (Fig. 1). There was no
2. Case report A 65-year-old woman presented with a 1-year history of progressive hearing loss in her right ear. She denied
⁎ Corresponding author. Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, 445 Gil-Dong, Gangdong-gu, Seoul, 134-701, Korea. Tel.: +82 2 2224 2279; fax: +82 2 482 2279. E-mail address: [email protected] (C.W. Kim). 0196-0709/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2008.06.008
Fig. 1. Otoscopic image reveals a thick tympanic membrane that showed masslike bulging of the pars tensa (arrows) and projected no middle ear structure.
C.W. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 288–290
289
facial paralysis, and examination of the cervical lymph node was unremarkable. Audiologic examination revealed normal hearing on the left and conductive hearing loss on the right. The 4-frequency pure tone average was 40 dB for air conduction and 10 dB for bone conduction. Results of a computerized tomographic (CT) scan revealed a diffuse thickening of the right tympanic membrane and inferior external auditory canal skin with no bony destruction or erosion (Fig. 2). The patient underwent total resection of the tympanic membrane through a postauricular approach. A circumferential incision was made along the external
Fig. 3. Histopathologic finding shows spindled fibroblasts closely packed with abundant collagenous stroma (hematoxylin and eosin stain, original magnification ×200).
auditory canal skin approximately 5 mm lateral to the annulus. The mass arose from the pars tensa of the tympanic membrane, and the thickest portion was 5 mm thick. The inferior portion of the fibrous annulus was displaced laterally. The mass was easily detached from the bony canal with no destruction or erosion. The ossicular chain was intact, and the middle ear cavity was normal. Grafting of the tympanic membrane and bony ear canal was performed with deep temporalis muscle fascia, and the grafted material was situated onto the malleus handle. The mass was subjected to histopathologic assessment, which revealed a well-circumscribed mass composed of typical spindled fibroblasts closely packed with abundant collagenous stroma consistent with fibroma (Fig. 3). Immunohistochemical reactions were not detected for S-100 or CD34. After surgical resection, the patient recovered uneventfully. There was no evidence of recurrence 2 years after operation, and the patient's hearing was normal, with an intact tympanic membrane. 3. Discussion
Fig. 2. Computed tomographic scan images. (A) Axial CT scans show thickening of the tympanic membrane. Pars tensa area (arrow) is thicker than pars flaccida area (arrowhead). (B) Coronal CT scans show triangularshaped tympanic membrane (arrow). Pars flaccida (arrowhead) has a thin membrane.
A fibroma is a benign tumor that is composed of fibrous or connective tissue. It can grow in all organs arising from mesenchymal tissue, but its occurrence around the external ear is very rare [5]. Fibroma of the tympanic membrane has not yet been reported in the English literature. We think that this tumor has been underestimated because it does not cause specific symptoms. In this case, the patient's only symptom was progressive hearing loss, and she had no other otologic complaints. Differential diagnosis of this tumor includes hemangioma, schwannoma, paraganglioma, malignancy, and medial canal fibrosis. Hemangioma is a benign vascular tumor and usually has a peduncle in the posterior part of the tympanic membrane as a partly elevated lesion [3]. It is usually soft, and the color is reddish or dark blue. It may cause massive bleeding when a deep biopsy is performed.
290
C.W. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 288–290
Only 2 cases of schwannoma of the tympanic membrane have been reported [2,6]. These tumors revealed as a pinkish mass obstructing the external auditory canal and partly attached to the tympanic membrane. Squamous cell carcinoma may arise in the tympanic membrane. The previous report mentioned some thickening of the tympanic membrane with normal temporal bone CT findings [1]. Incidence of these tumors is very rare, but any masslike lesion of the tympanic membrane should be considered as a possible tumor. Medial canal fibrosis is not a tumor but is difficult to differentiate from a tumor of the tympanic membrane clinically and radiologically. It is an uncommon disease entity that occurs as a result of external otitis, chronic dermatitis, or trauma in the bony external auditory canal and results in formation of fibrous tissue in the medial third of the bony canal abutting the tympanic membrane [7]. Medial canal fibrosis may show partial obliteration with blunting of the anterior tympanomeatal angle, or complete obliteration of the medial bony canal, causing it to be misread as a lateralized tympanic membrane. There may be a space between the tympanic membrane and the obliterated fibrous tissue, and sometimes medial canal fibrosis may be associated with cholesteatoma [8]. Surgical treatment is usually indicated, and it is needed to remove the fibrous plug and allow the epithelium to grow over the bony canal and tympanic membrane. It is usually easy to separate the fibrous tissue from the tympanic membrane's lamina propria. This is a clinically important feature to distinguish between a medial canal fibrosis and a fibroma of the tympanic membrane. In our case, the tumor might arise from the tympanic membrane's fibrous layer. The tympanic membrane is composed of 3 layers as follows: the modified skin of the external auditory canal on its outer
surface, the mucous membrane of the middle ear cavity internally, and a middle fibrous layer or lamina propria [9]. The lamina propria of the pars tensa consists of 2 layers of connective tissue, outer radial fibers, and inner circular fibers, whereas the pars flaccida does not share this fibrous organizational pattern. This patient's tumor was confined within the pars tensa and grew laterally, and the fibrous annulus was displaced laterally, too. The tumor caused conductive hearing loss, so surgical resection was performed. The patient's hearing recovered to normal with no recurrence of the tumor 2 years postoperatively. Conclusively, fibroma may arise in the tympanic membrane and should be regarded as a possible cause of the mass of the tympanic membrane. References [1] Somers T, Vercruysse JP, Goovaerts G, et al. Isolated squamous cell carcinoma of the tympanic membrane. Otol Neurol 2002;23:808. [2] Yang CH, Su CY, Wei YC, et al. Schwannoma of the tympanic membrane. J Laryngol Otol 2006;120:247-9. [3] Hiraumi H, Miura M, Hirose T. Capillary hemangioma of the tympanic membrane. Am J Otolaryngol 2005;26:351-2. [4] Pusalkar A, Steinbach E, Shah D. Paraganglioma of the tympanic membrane. J Laryngol Otol 1985;99:481-3. [5] Sen MK, Ghosal SK. Fibroma of the pinna. J Indian Med Assoc 1995; 93:328. [6] Supiyaphun P, Lekaul S, Shuangshoti S. Solitary schwannoma of the tympanic membrane: a case report. Auris Nasus Larynx 1999;26:191-4. [7] Slattery III WH, Saadat P. Postinflammatory medial canal fibrosis. Am J Otol 1997;18:294-7. [8] El-Sayed Y. Acquired medial canal fibrosis. J Lryngol Otol 1998;112: 145-9. [9] Cruz OLM. Anatomy of the skull base, temporal bone, external ear, and middle ear. In: Cummings CW, Fredrickson JM, Harker LA, et al, editors. Otolaryngology—head and neck surgery, 4th ed., vol. 4. St Louis: Mosby; 2005.