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Hearing Loss, Pulsatile Tinnitus, and Otalgia

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 54-year-old woman with a medical history of hypertension, hyperlipidemia, and migraines presented to a tertiary care otolaryngology clinic reporting 3 months of worsening right ear pain and 1 month of pulsatile tinnitus and hearing loss. She denied a history of fever, otorrhea, prior ear infections, vertigo, or otologic surgery. The patient first saw her primary care physician, who visualized a mass in the right ear canal and attempted needle aspiration, which led to self-resolved bleeding. She was given ciprofloxacin ear drops and trimethoprim/sulfamethoxazole, which did not improve her symptoms. On examination, her right external auditory canal (EAC) was completely obstructed by a fleshy, pulsatile mass with a red hue (Figure 1A). Results of Weber tuning fork examination lateralized to the right ear and a Rinne examination suggested a conductive hearing loss. Formal audiogram results confirmed conductive hearing loss in the right ear and type B tympanometry, which was indicative of poor eardrum mobility. Computed tomography (CT) of the temporal bone without contrast showed a well-circumscribed 9-mm lesion in the EAC with bony erosion along the junction of the anterior wall and floor (Figure 1, B and C). Magnetic resonance imaging results showed a well-circumscribed, contrast-enhancing mass that was confined to the EAC (Figure 1D).

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A. Lobular capillary hemangioma of the EAC

An ear canal cholesteatomas develops spontaneously or after infection, trauma, or surgery. It is not as common as middle ear cholesteatoma and is not a vascular tumor.1 Imaging results would likely reveal bonier canal erosion than seen in this case. Tympanic paraganglioma/glomus tympanicum is a primarily vascular tumor that also presents with conductive hearing loss and bloody otorrhea. However, these tumors arise from the tympanic plexus in the middle ear, not the EAC. High-riding jugular bulbs present with an inferiorly based blue mass behind an intact eardrum. Pulsatile tinnitus and conductive hearing loss are commonly present. The mass may enlarge during a Valsalva maneuver. Imaging results would be diagnostic for this finding.

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Article Information

Corresponding Author: Alex D. Sweeney, MD, Bobby R. Alford Department of Otolaryngology, Baylor College of Medicine, 1977 Butler Blvd, Ste E5.200, Houston, TX 77030 (alex.sweeney@bcm.edu).

Published Online: May 20, 2021. doi:10.1001/jamaoto.2021.0853

Conflict of Interest Disclosures: Dr Sweeney has been a consultant for Advanced Bionics, Cochlear, MED-EL GmbH, and Oticon Medical. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Vrabec  JT , Chaljub  G .  External canal cholesteatoma.   Am J Otol. 2000;21(5):608-614.PubMedGoogle Scholar
2.
Reeck  JB , Yen  TL , Szmit  A , Cheung  SW .  Cavernous hemangioma of the external ear canal.   Laryngoscope. 2002;112(10):1750-1752. doi:10.1097/00005537-200210000-00007 PubMedGoogle ScholarCrossref
3.
Kumar  V , Abbas  A , Aster  J .  Robbins & Cotran Pathologic Basis of Disease. 10th ed. Elsevier; 2020.
4.
Rutherford  KD , Leonard  G .  Hemangiomas of the external auditory canal.   Am J Otolaryngol. 2010;31(5):384-386. doi:10.1016/j.amjoto.2009.04.004PubMedGoogle ScholarCrossref
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