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Otology

Patient With Hearing Loss and a Middle Ear Mass

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: September 15, 2022

Clinical Challenge

Article Information and Disclosures

Kjell Neutel, BSc¹;

Steven Mes, MD, PhD²;

Paul Merkus, MD, PhD²

Author Affiliations

¹University Medical Center Utrecht, Heidelberglaan , Utrecht, Netherlands
²Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands

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A 65-year-old patient was referred to the ear, nose, and throat department with left-sided hearing loss during the past 6 months without evident cause. He had a medical history of myocardial infarction, sleep apnea, Ménière disease, and congenital cataract. Furthermore, he did not report otalgia, otorrhea, a recent episode of Ménière disease, or other ear, nose, and throat or systemic symptoms. The patient used atorvastatin and acetylsalicylic acid, did not smoke, and reported drinking 2 glasses of wine daily. Otoscopy of the left ear revealed a yellow-whitish calcareous lobular mass located in the mesotympanum anterior to the malleus with an intact tympanic membrane. The lesion was hard and painful during palpation (Figure 1A). Otoscopy results for the right side were normal.

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C. Tophaceous gout

Gout is an inflammatory joint disease characterized by depositions of monosodium urate crystals that are typically found in subcutaneous tissue or peripheral joints. Macroscopic depositions (ie, tophi) in the head and neck region are reported in the auricular helix, nasal bridge, larynx, and cricoarytenoid and the temporomandibular and sternoclavicular joints.¹ Risk factors for these tophi include obesity, hypertension, alcohol use, a fructose-enriched diet, meat and fish consumption, and medication, including acetylsalicylates and diuretics.¹^- 3

Although conductive hearing loss due to a middle ear mass is common, a tophus in the middle ear is an uncommon cause of a middle ear mass.³^- 8 The low incidence combined with the absence of clinical manifestations of gout or hyperuricemia in all known cases, including in this patient, explains why tophaceous gout in the middle ear is often misidentified as osteoma, cholesteatoma, or tympanosclerosis.³^,6^,7 This emphasizes the importance of considering the diagnosis of a tophus in patients with conductive hearing loss and a mass in the middle ear.

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Article Information

Corresponding Author: Paul Merkus, MD, PhD, Otolaryngology-Head and Neck Surgery, Ear & Hearing, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, de Boelelaan 1117, 1081 HV Amsterdam, Netherlands (p.merkus@amsterdamumc.nl).

Published Online: September 15, 2022. doi:10.1001/jamaoto.2022.2589

Conflict of Interest Disclosures: None reported.

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

References

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Saliba I , Bouthiller A , Desrochers P , Berthlet F , Dufour JJ . Tophaceous gout and pseudogout of the middle ear and the infratemporal fossa: case report and review of the literature. J Otolaryngol. 2003;32(4):269-272. doi:10.2310/7070.2003.41738 PubMed Google Scholar Crossref

Reineke U , Ebmeyer J , Schütte F , Upile T , Sudhoff HH . Tophaceous gout of the middle ear. Otol Neurotol. 2009;30(1):127-128. doi:10.1097/MAO.0b013e31817fdfde PubMed Google Scholar Crossref

Saliba J , Sakano H , Friedman RA , Harris JP . Tophaceous gout of the middle ear: case reports and review of the literature. Audiol Neurootol. 2019;24(2):51-55. doi:10.1159/000500514 PubMed Google Scholar Crossref

Gargula S , Poillon G , Daval M , et al. Tophaceous gout of the middle ear. J Otol. 2019;14(4):155-157. doi:10.1016/j.joto.2019.08.002 PubMed Google Scholar Crossref

Vaid S , Kamble Y , Vaid N , et al. Role of magnetic resonance imaging in cholesteatoma: the Indian experience. Indian J Otolaryngol Head Neck Surg. 2013;65(suppl 3):485-492. doi:10.1007/s12070-011-0360-1 PubMed Google Scholar Crossref

FitzGerald JD , Dalbeth N , Mikuls T , et al. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken). 2020;72(6):744-760. doi:10.1002/acr.24180 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.