- Email: [email protected]
Pulsatile tinnitus and a temporal bone mass
G Model
ARTICLE IN PRESS
ANORL-515; No. of Pages 2
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
Pulsatile tinnitus and a temporal bone mass D.T. Ginat a,∗ , M.B. Gluth b a b
Department of Radiology, University of Chicago, Pritzker School of Medicine, 5841, S. Maryland Avenue, 60637 Chicago, IL, United States Department of Otolaryngology, University of Chicago, Pritzker School of Medicine, 5841, S. Maryland Avenue, 60637 Chicago, IL, United States
1. Description The patient is a 56-year-old male with a history of hypertension and familial adenomatous polyposis. The patient presented with four months of left hearing loss, ear pressure, and pulsatile tinnitus. The patient also developed constant dizziness, imbalance, nausea, and vomiting, diplopia, and oscillation of the eyes. The patient had previously consulted an otolaryngologist elsewhere one month earlier, at which point he had a left tympanostomy tube placed in order to help relieve the pressure and was started on Meclizine to help control his nausea and vomiting, but symptoms persisted. At our institution, an audiogram revealed moderate-to-severe left mixed hearing loss. Aside from an extruded left tympanostomy tube and spontaneous right beating nystagmus with left esotropia, the physical exam was unremarkable. CT with venography was performed, which showed an expansile lytic lesion involving the left lateral skull base with extension into the left jugular fossa (Fig. 1a). CTV showed associated compression of the left jugular vein (Fig. 1b). A MRI was also performed, which showed that the lesion enhanced. In addition, a bone scan showed foci of increased activity in pelvis as well as in the left skull base. The serum PSA level was elevated (55 ng/mL). The patient underwent left mastoidectomy for biopsy of the left temporal bone mass, along with decompression of the facial nerve and jugular bulb.
Fig. 1. a: axial CT image shows an expansile lytic lesion involving the left temporal bone with extension into the left jugular fossa (arrow); b: 3D CT venogram image shows compression of the left jugular vein (oval) by the mass.
∗ Corresponding author. Tel.: +773 702 6039. E-mail address: [email protected] (D.T. Ginat).
What is your diagnosis?
http://dx.doi.org/10.1016/j.anorl.2015.06.010 1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Ginat DT, Gluth MB. Pulsatile tinnitus and a temporal bone mass. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2015.06.010
G Model ANORL-515; No. of Pages 2
ARTICLE IN PRESS D.T. Ginat, M.B. Gluth / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
2
2. Answer Initial presentation of prostate cancer as pulsatile tinnitus due to a temporal bone metastasis.
Table 1 Differential diagnoses for the patient’s lytic temporal bone lesion. Differential diagnoses
Pros
Colon cancer metastasis
Can be the result of colon cancer associated with suspected Gardner syndrome Common cancer; elevated PSA Can be associated with suspected Gardner syndrome and can display aggressive features on CT
3. Discussion The left temporal bone biopsy specimen demonstrated tumor cells with diffuse, strong positivity for PSA. The patient was started on bicalutamide and received goserelin injections, which led to a decrease in the serum PSA level. However, at 2 months follow-up after biopsy of the temporal bone lesion, the patient had persistent pain left temporal area, as well as persistent problems with vision, balance, left-sided hearing loss, and constant left tinnitus. The patient was also referred for palliative radiotherapy to the left temporal bone metastasis. A variety of conditions can cause pulsatile tinnitus, including venous dehiscences and diverticula, an aberrant internal carotid artery, vascular malformations and fistulas, vascular stenoocclusive diseases, pseudotumor cerebri, and tumors. The presence of accompanying new cranial nerve deficits, as in this case, should raise the suspicion for a malignancy involving the skull base [1]. On autopsy, metastases to the temporal bones have been reported in over 20% of patients with primary non-disseminated malignant neoplasms, most commonly breast cancer [1,2]. However, initial presentation of metastatic disease from pulsatile tinnitus is unusual [1]. Pulsatile tinnitus associated with neoplasms can result from tumor hypervascularity, arteriovenous shunting, or vascular compression. Diagnostic imaging plays an important role in the evaluation of pulsatile tinnitus. In particular, MR or CT angiography, including arteriography and venography are useful modalities [3,4]. With respect to diagnosing and planning treatment for temporal bone region tumors in general, both CT and MRI are suitable options and often function as complementary modalities [5]. Nuclear medicine bone scans or 18FDG-PET are useful tests for staging patients with metastases. Of note, prostate cancer metastases are typically sclerotic on CT, in contrast to the lesion in this case. The differential diagnoses for lytic lesions in the temporal bone are listed in the Table 1.
Prostate cancer metastasis Desmoid tumor
Cons
Lytic prostate cancer metastases are atypical
In summary, a general algorithm for the work up of an adult patient with new onset pulsatile tinnitus may consist of obtaining diagnostic imaging of the temporal bone region including CT and/or MRI along with dedicated vascular imaging, clinical and laboratory testing for detecting potential underlying malignancies, and whole body screening imaging exams. Ultimately, a definite diagnosis may require surgical pathology. Disclosure of interest The authors declare that they have no competing interest. References [1] Moore A, Cunnane M, Fleming JC. Metastatic breast carcinoma presenting as unilateral pulsatile tinnitus: a case report. Ear Nose Throat J 2015;94(2): E6–8. [2] Gloria-Cruz TI, Schachern PA, Paparella MM, Adams GL, Fulton SE. Metastases to temporal bones from primary nonsystemic malignant neoplasms. Arch Otolaryngol Head Neck Surg 2000;126:209–14. [3] Ginat DT, Gluth MB. Pulsatile tinnitus and an unusual ossicular anomaly. Eur Ann Otorhinolaryngol Head Neck Dis 2015. [4] Sismanis A. Pulsatile tinnitus: contemporary assessment and management. Curr Opin Otolaryngol Head Neck Surg 2011;19:348–57. [5] Juliano AF, Ginat DT, Moonis G. Imaging review of the temporal bone: part I. Anatomy and inflammatory and neoplastic processes. Radiology 2013;269:17–33.
Please cite this article in press as: Ginat DT, Gluth MB. Pulsatile tinnitus and a temporal bone mass. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2015.06.010
ARTICLE IN PRESS
ANORL-515; No. of Pages 2
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
Pulsatile tinnitus and a temporal bone mass D.T. Ginat a,∗ , M.B. Gluth b a b
Department of Radiology, University of Chicago, Pritzker School of Medicine, 5841, S. Maryland Avenue, 60637 Chicago, IL, United States Department of Otolaryngology, University of Chicago, Pritzker School of Medicine, 5841, S. Maryland Avenue, 60637 Chicago, IL, United States
1. Description The patient is a 56-year-old male with a history of hypertension and familial adenomatous polyposis. The patient presented with four months of left hearing loss, ear pressure, and pulsatile tinnitus. The patient also developed constant dizziness, imbalance, nausea, and vomiting, diplopia, and oscillation of the eyes. The patient had previously consulted an otolaryngologist elsewhere one month earlier, at which point he had a left tympanostomy tube placed in order to help relieve the pressure and was started on Meclizine to help control his nausea and vomiting, but symptoms persisted. At our institution, an audiogram revealed moderate-to-severe left mixed hearing loss. Aside from an extruded left tympanostomy tube and spontaneous right beating nystagmus with left esotropia, the physical exam was unremarkable. CT with venography was performed, which showed an expansile lytic lesion involving the left lateral skull base with extension into the left jugular fossa (Fig. 1a). CTV showed associated compression of the left jugular vein (Fig. 1b). A MRI was also performed, which showed that the lesion enhanced. In addition, a bone scan showed foci of increased activity in pelvis as well as in the left skull base. The serum PSA level was elevated (55 ng/mL). The patient underwent left mastoidectomy for biopsy of the left temporal bone mass, along with decompression of the facial nerve and jugular bulb.
Fig. 1. a: axial CT image shows an expansile lytic lesion involving the left temporal bone with extension into the left jugular fossa (arrow); b: 3D CT venogram image shows compression of the left jugular vein (oval) by the mass.
∗ Corresponding author. Tel.: +773 702 6039. E-mail address: [email protected] (D.T. Ginat).
What is your diagnosis?
http://dx.doi.org/10.1016/j.anorl.2015.06.010 1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Ginat DT, Gluth MB. Pulsatile tinnitus and a temporal bone mass. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2015.06.010
G Model ANORL-515; No. of Pages 2
ARTICLE IN PRESS D.T. Ginat, M.B. Gluth / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
2
2. Answer Initial presentation of prostate cancer as pulsatile tinnitus due to a temporal bone metastasis.
Table 1 Differential diagnoses for the patient’s lytic temporal bone lesion. Differential diagnoses
Pros
Colon cancer metastasis
Can be the result of colon cancer associated with suspected Gardner syndrome Common cancer; elevated PSA Can be associated with suspected Gardner syndrome and can display aggressive features on CT
3. Discussion The left temporal bone biopsy specimen demonstrated tumor cells with diffuse, strong positivity for PSA. The patient was started on bicalutamide and received goserelin injections, which led to a decrease in the serum PSA level. However, at 2 months follow-up after biopsy of the temporal bone lesion, the patient had persistent pain left temporal area, as well as persistent problems with vision, balance, left-sided hearing loss, and constant left tinnitus. The patient was also referred for palliative radiotherapy to the left temporal bone metastasis. A variety of conditions can cause pulsatile tinnitus, including venous dehiscences and diverticula, an aberrant internal carotid artery, vascular malformations and fistulas, vascular stenoocclusive diseases, pseudotumor cerebri, and tumors. The presence of accompanying new cranial nerve deficits, as in this case, should raise the suspicion for a malignancy involving the skull base [1]. On autopsy, metastases to the temporal bones have been reported in over 20% of patients with primary non-disseminated malignant neoplasms, most commonly breast cancer [1,2]. However, initial presentation of metastatic disease from pulsatile tinnitus is unusual [1]. Pulsatile tinnitus associated with neoplasms can result from tumor hypervascularity, arteriovenous shunting, or vascular compression. Diagnostic imaging plays an important role in the evaluation of pulsatile tinnitus. In particular, MR or CT angiography, including arteriography and venography are useful modalities [3,4]. With respect to diagnosing and planning treatment for temporal bone region tumors in general, both CT and MRI are suitable options and often function as complementary modalities [5]. Nuclear medicine bone scans or 18FDG-PET are useful tests for staging patients with metastases. Of note, prostate cancer metastases are typically sclerotic on CT, in contrast to the lesion in this case. The differential diagnoses for lytic lesions in the temporal bone are listed in the Table 1.
Prostate cancer metastasis Desmoid tumor
Cons
Lytic prostate cancer metastases are atypical
In summary, a general algorithm for the work up of an adult patient with new onset pulsatile tinnitus may consist of obtaining diagnostic imaging of the temporal bone region including CT and/or MRI along with dedicated vascular imaging, clinical and laboratory testing for detecting potential underlying malignancies, and whole body screening imaging exams. Ultimately, a definite diagnosis may require surgical pathology. Disclosure of interest The authors declare that they have no competing interest. References [1] Moore A, Cunnane M, Fleming JC. Metastatic breast carcinoma presenting as unilateral pulsatile tinnitus: a case report. Ear Nose Throat J 2015;94(2): E6–8. [2] Gloria-Cruz TI, Schachern PA, Paparella MM, Adams GL, Fulton SE. Metastases to temporal bones from primary nonsystemic malignant neoplasms. Arch Otolaryngol Head Neck Surg 2000;126:209–14. [3] Ginat DT, Gluth MB. Pulsatile tinnitus and an unusual ossicular anomaly. Eur Ann Otorhinolaryngol Head Neck Dis 2015. [4] Sismanis A. Pulsatile tinnitus: contemporary assessment and management. Curr Opin Otolaryngol Head Neck Surg 2011;19:348–57. [5] Juliano AF, Ginat DT, Moonis G. Imaging review of the temporal bone: part I. Anatomy and inflammatory and neoplastic processes. Radiology 2013;269:17–33.
Please cite this article in press as: Ginat DT, Gluth MB. Pulsatile tinnitus and a temporal bone mass. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2015.06.010