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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

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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