|Year : 2020 | Volume
| Issue : 2 | Page : 111-114
Aural polyp with chronic suppurative otitis media dissembling glomus tympanicum
Surya Kanta Pradhan, Sanjeev Gupta, Kamala Kanta Jena
Department of ENT - Head Neck Surgery, Apollo Hospitals, Bhubaneswar, Odisha, India
|Date of Submission||25-Feb-2020|
|Date of Acceptance||25-Apr-2020|
|Date of Web Publication||18-Jun-2020|
Surya Kanta Pradhan
Department of ENT - Head Neck Surgery, Apollo Hospitals, 251, Sainik School Road, Unit-15, Bhubaneswar - 751 005, Odisha
Source of Support: None, Conflict of Interest: None
Glomus tumors are benign, slow-growing tumors of the temporal bone and most commonly present as hearing loss and tinnitus with an intact tympanic membrane. Most of the time, the diagnosis is delayed and sometimes missed as it is associated with chronic suppurative otitis media (CSOM). History of the disease and proper clinical examination followed by radiological investigations are required for diagnosis and management. Surgery is the treatment of choice, but larger tumors may require other modalities of treatment. Histopathology with immunohistochemistry confirms the diagnosis. We report a case of 63-year-old female patient with glomus tympanicum associated with CSOM. She had symptoms for the last 10 years, but the diagnosis was missed because of coexisting CSOM. She was diagnosed with the help of radiological investigative modalities. She underwent mastoidectomy with complete excision of tumor. She was managed successfully without recurrence. Glomus tumor is an uncommon disease in the middle ear, and sometimes, its diagnosis is missed because of the presence of other diseases. Radiology helps in diagnosis and management of the tumor. Complete surgical excision with regular follow-up prevents recurrence.
Keywords: Chronic suppurative otitis media, glomus tympanicum, histopathology, high-resolution computed tomography, temporal bone
|How to cite this article:|
Pradhan SK, Gupta S, Jena KK. Aural polyp with chronic suppurative otitis media dissembling glomus tympanicum. Apollo Med 2020;17:111-4
| Introduction|| |
Glomus tympanicum is the most common slow-growing tumor of the middle ear cleft. They usually present in 50–60 years of age group. Most common presenting symptoms are hearing loss, pulsatile tinnitus, and ear pain. Clinically, it present as a reddish mass behind the intact ear drum. However, its association with chronic suppurative otitis media (CSOM) makes the diagnosis difficult as it mimics granulation tissue. Computed tomography (CT) scan of the temporal bone helps in diagnosis and management, but confirmation can only be done by histopathology. Complete surgical excision is the treatment of choice followed by regular follow-ups to prevent and manage recurrences. We present a case of CSOM with glomus tympanicum which was managed successfully.
| Case Report|| |
A 63-year-old female patient presented to us with right ear discharge, hearing loss, and bleeding. The discharge and hearing loss were there for 10 years; however, recently, the ear started bleeding. On otoscopy, a reddish mass was protruding through the large subtotal perforation in the right ear through. In the left ear, she had central perforation. She has moderate conductive hearing loss in both the ears in pure tone audiometry. She also had central perforation in the left ear with mild discharge. CT scan with contrast and magnetic resonance imaging (MRI) scan of the temporal bone were done. There was an enhancing nodular lesion in the right ear with broad-based attachment to the cochlear promontory measuring 9 mm × 7.5 mm. Inferiorly, the mass was eroding the floor of the middle ear cavity with extension into the hypotympanum. Nonenhancing soft tissue in the bilateral middle ear cavity involving hypo-, meso-, epi-tympanum with sclerosis of the bilateral mastoid air cells was seen. Hence, the provisional diagnosis was bilateral CSOM with glomus tympanicum paraganglioma (Fisch Type B) in the right ear [Figure 1] and [Figure 2].
|Figure 1: Computed tomography scan with contrast of temporal bone showing enhancing nodular lesion in right ear|
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|Figure 2: Magnetic resonance imaging of temporal bone showing nodular lesion in the right ear with attachment to the cochlear promontory measuring 9 mm x 7.5 mm and inferiorly the mass was eroding the floor of middle ear cavity with extension to hypotympanum|
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Glomus tumor excision was planned. Postaural incision was performed. Cortical mastoidectomy was done. Facial canal was removed and bridge lowered. Tumor from the antrum was removed. Tympanic membrane (TM) flap elevated. Glomus tumor from the middle ear was excised using bipolar cautery. Body of the incus and malleus were removed to remove the disease from the medial part of epitympanum. Tissue measuring around 1 cm in greatest diameter excised and sent for biopsy [Figure 3]. Inlay grafting was done over the suprastructure of the stapes. Intraoperatively, there was minimal blood loss and there were no complications.
Histopathological section showed a nodular lesion composed of slit-like vascular spaces lined by delicate endothelial cells with frequent nuclear hob nailing. Frequent delicate vascular spaces show papillary proliferation of the endothelial cells. Other areas showed round-to-oval tumor cells having uniform hyperchromatic nuclei and granular eosinophilic cytoplasm arranged in small nests separated by fibrovascular stroma, and further, immunohistochemical (IHC) studies including S-100 confirmed the diagnosis of glomus tumor [Figure 4].
|Figure 4: Tumor cells in organoid nests separated by fibrovascular stroma|
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Postoperatively, she was observed for 3 days and then discharged. She is under regular follow-up and there is complete healing of the ear cavity.
| Discussion|| |
Glomus tumor or paraganglioma arises from the neuroendocrine tissue and is a slow-growing benign tumor. If it arises from cervical parasympathetic chain, it is classified as a carotid body tumor and glomus vagale tumor. The jugulotympanic glomus tumors are divided into two types: glomus tympanicum and glomus jugulare. Glomus tympanicum is the most common benign tumor of the middle ear and mastoid and the second most common temporal bone tumor. Paragangliomas arise from the paraganglial cells which were ovoid cells found along with Arnold's nerve and Jacobson's nerve. They are also found in the adventitia of the jugular bulb. Their main function is to sense and regulate oxygen pressure in the middle ear cleft. They consist of Type I (chief cells) and Type II (modified Schwann cells) along with capillaries and precapillary vessels. The prevalence of glomus tumor is 1 in 1 lakh, and it affects more females as compared to males. Moreover, sometimes, it is multicentric, so it is always advisable to look for other involved sites which may be the other ear or carotid body tumor. Glomus tumor is locally advancing, and it destroys adjacent bones and nerves causing neurological deficits. It has been classified by various persons, but the most accepted classification was proposed by Fisch.
- Type A tumor – Tumor limited to the middle ear (carries the best prognosis)
- Type B tumor – Tumor limited to the tympanomastoid area with no infralabyrinthine compartment involvement
- Type C tumor – Tumor involving the infralabyrinthine compartment of the temporal bone with extension to petrous apex; this is divided into three types: C1, C2, and C3.
- Type C1 - Tumor with limited involvement of the vertical portion of the carotid canal
- Type C2 - Tumor invading the vertical portion of the carotid canal
- Type C3 - Tumor invasion of the horizontal portion of the carotid canal.
Type D tumor has two types
- Type D1 - Tumor with an intracranial extension <2 cm in diameter
- Type D2 - Tumor with an intracranial extension >2 cm in diameter.
These tumors are slow-growing, for which the diagnosis is mostly delayed. The presenting symptoms may include conductive hearing loss, pulsatile tinnitus, middle ear mass, ear discharge, bleeding from ear, facial nerve palsy, imbalance, and other neurological deficits. Sometimes, they present atypically as single-sided progressive sensorineural hearing loss. However, the most common symptoms are thefirst two. A red mass behind the intact TM is the most common sign for the diagnosis of glomus tumor. On otomicroscopy, the pulsation over the mass is prominently visible. There will be blanching on seigelization. Different investigations were done to confirm the diagnosis. Pure tone audiometry reveals conductive or mixed hearing loss. Some of the tumor presents with sensorineural hearing loss due to inner ear involvement. CT and MRI scan with contrast give information about the nature and extent of the disease. It presents as a soft tissue mass in the middle ear involving mastoid, hypotympanum, and ossicles and extends up to the external ear. Cholesteatoma with granulations is very rarely associated with this tumor, and its differentiation is difficult. Granulations enhance with contrast, but its enhancement is very less as compared to glomus tumors. MRI mainly delineates the relationship of the tumor with surrounding vital structures, such as jugular bulb, carotid artery, and cranial nerves. Differential diagnosis includes high jugular bulb, aberrant carotid artery, hamartoma, meningioma, and squamous cell carcinoma. However, with all the available investigative modalities, the preoperative diagnostic sensitivity has increased. MR angiography can delineate the feeding vessels which can be embolized for larger tumors if required. After the diagnosis, surgery remains the mainstay of treatment, but radiotherapy is also useful in some cases. Tumors up to Stage C can be excised completely, but Fisch Type D tumors are difficult to treat. The approach to the tumor depends on the extent of the disease. Complications include cranial nerve palsy, bleeding, cerebrospinal fluid leak, and meningitis. There is always a chance of recurrence if it is not cleared completely during surgery or not followed up regularly. Sometimes, it may mimic granulation tissue of CSOM or may coexist with the same as in our case., Proper history and clinical examination  along with radiological investigations should be done to diagnose and manage successfully without any complications. Follow-up after the surgery is very essential to prevent any recurrence.
| Conclusion|| |
Glomus tumor is a very common entity, but its association with CSOM is very uncommon, and it delays the diagnosis of the tumor. Along with proper clinical examination, radiology has got a very crucial role in diagnosis and management of the disease. Histopathology with IHC confirms the diagnosis. Surgery along with regular follow-ups prevents the recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]