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Audiology and Hearing

Pulsatile Tinnitus in a Patient With a Skull Base Lesion

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

1 Credit CME

JAMA Otolaryngology–Head & Neck Surgery

Published Online: July 15, 2021

Clinical Challenge

Article Information and Disclosures

Robert M. Conway, DO¹;

Nathan C. Tu, MD²;

Christopher A. Schutt, MD²

Author Affiliations

¹Otolaryngology–Head and Neck Surgery, Ascension Macomb-Oakland Hospital, Madison Heights, Michigan
²Department of Neurotology, Michigan Ear Institute, Farmington Hills

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An 80-year-old woman presented with a 1-year history of right pulsatile tinnitus and aural fullness. Her symptoms were more prominent at night and in the quiet and improved when upright. Physical examination demonstrated an intact tympanic membrane with no middle ear mass; there was no neck mass palpated or bruit auscultated. The patient had further workup with magnetic resonance imaging (MRI) and a computed tomographic scan (Figure 1). The patient was taken to the operating room for a right transtemporal biopsy. Operative findings demonstrated extensive tumor extending along the posterior fossa dura and deep to the jugular foramen that filled the area of the skull base. The tumor was debulked and sent for pathologic evaluation.

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D. Plasmacytoma

Results of testing showed that the patient had a plasmacytoma of the skull base involving the jugular foramen. The MRI demonstrated a 2.7 × 2.2 × 1.7-cm mass involving the posterior skull base, which was hyperintense on T2 fluid-attenuated inversion recovery and isointense with brain on T2. The precontrast T1 images demonstrated a slight hyperintensity with intense enhancement on T1 postcontrast. A subsequent computed tomographic scan of the temporal bone demonstrated a destructive lesion of the right occipital temporal skull base adjacent to the jugular foramen. Pathological findings identified kappa monotypic plasma cells, which coexpressed CD56 and CD117 (Figure 2). Morphologically, there were sheets of plasma cells with round nuclear borders and course chromatin, consistent with plasmacytoma.

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Article Information

Corresponding Author: Christopher A. Schutt, MD, Department of Neurotology, Michigan Ear Institute, 30055 Northwestern Hwy, #101, Farmington Hills, MI 48334 (caschutt13@gmail.com).

Published Online: July 15, 2021. doi:10.1001/jamaoto.2021.1510

Conflict of Interest Disclosures: None reported.

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

References

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Kilciksiz S , Karakoyun-Celik O , Agaoglu FY , Haydaroglu A . A review for solitary plasmacytoma of bone and extramedullary plasmacytoma. ScientificWorldJournal. 2012;2012:895765. doi:10.1100/2012/895765 PubMed Google Scholar

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Na’ara S , Amit M , Gil Z , Billan S . Plasmacytoma of the skull base: a meta-analysis. J Neurol Surg B Skull Base. 2016;77(1):61-65. doi:10.1055/s-0035-1560047 PubMed Google Scholar Crossref

Ghiassi-Nejad Z , Ru M , Moshier E , Chang S , Jagannath S , Dharmarajan K . Overall survival trends and clinical characteristics of plasmacytoma in the United States: a national cancer database analysis. Clin Lymphoma Myeloma Leuk. 2019;19(5):310-319. doi:10.1016/j.clml.2019.01.004 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.