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Home(/)>Diagnosisandmanagementofatympanicmembranehemangioma

Diagnosisandmanagementofatympanic
membranehemangioma
|Reprints
June14,2016
byGlenWatson,MBBS,FRCSAmandaMcSorley,MBChB,BSc,MRCSVivekKaushik,MBBS,FRCS,
DLO

Abstract
Vasculartumorsarisinginthetemporalbonerepresent0.7%ofalllesionsinthisarea.Hemangiomas
confinedtothetympanicmembraneareexceptionallyrare.Wereportanewcaseoftympanicmembrane
hemangiomathatarosein59yearoldmanwhopresentedwitha2monthhistoryofconstantrightsided
pulsatiletinnitusandassociatedneckdiscomfort.Thelesionandacuffofhealthytympanicmembrane
wereexcised,andtheresultingdefectwasrepairedwithatemporalisfasciagraft.At3months,the
neotympanumwaswellhealedandthepatient'ssymptomshadresolved.Wealsoreviewthelimited
numberofpreviouslypublishedcasesoftympanicmembranehemangioma,andwediscussthe
presentationandmanagementoftheselesions.Sometympanichemangiomasareasymptomaticand
otherspresentashearingloss,tinnitus,otalgia,and/orotorrhea.Puretoneaudiometryandhigh
resolutioncomputedtomographyofthetemporalbonesareessentialtodeterminetheextentofthe
lesion.Anexcisionalbiopsyisrecommendedbecauseitiscurativeanditprovideshistologicconfirmation
ofthediagnosis.Excisionrequireselevationofatympanomeatalflap,enblocresection,and
reconstructionofthetympanicmembranedefect.Smalllesionscanbeexcisedviaapermeatalor
endauralapproach,whilelargerlesionsrequireapostauricularapproach.

Introduction
Vasculartumorsarisinginthetemporalbonerepresent0.7%ofalllesionsinthisareahemangiomasof
thetympanicmembraneareevenmorerare.1,2(/print/article/diagnosisandmanagementtympanic
membranehemangioma#refs)Inthisarticle,wereportanewcaseoftympanicmembranehemangioma,
andwediscussthepresentationoftheselesionsandthepossiblemanagementoptions.Wealsoreview
theliteratureonthelimitednumberofpreviouslyreportedcases.

Casereport
A59yearoldmanpresentedwitha2monthhistoryofconstantrightsidedpulsatiletinnitusand
associatedneckdiscomfort.Hereportednohistoryofhearingloss,vertigo,otalgia,orotorrhea.His
comorbiditiesincludedhypertension,hypothyroidism,type2diabetes,andosteoarthritis.Hewasa
nonsmoker.

Onexaminationwithmicrootoscopy,araisedredmasswasnotedintheposterosuperiorquadrantofthe
tympanicmembrane(figure1(/print/article/diagnosisandmanagementtympanicmembrane
hemangioma#fig1)).Puretoneaudiometry(PTA)identifiedamixedhearinglossof30to40dBthe
tympanogramwasnormal.Althoughthelesionappearedtobesuperficial,themainclinicalconcernwas
thatitmightrepresentaglomustumorarisingfromthemiddleearcleft.

Figure1.Atpresentation,microotoscopy
showstheraisedmassinthe
posterosuperiorquadrantofthetympanic
membrane.

Highresolutioncomputedtomography(HRCT)ofthetemporalboneswasrequestedtodeterminethe
extentofthelesion.HRCTindicatedthatitwasconfinedtothetympanicmembraneanddidnotextend
intothemiddleearcleftnobonyerosionwasseen(figure2(/print/article/diagnosisandmanagement
tympanicmembranehemangioma#fig2)).Afteradiscussionofthebenefitsandrisksofsurgery,the
patientprovidedinformedconsenttohavethelesionexcisedundergeneralanesthesia.

Figure2.CoronalHRCTdemonstratesthat
thelesionisconfinedtothetympanic
membraneanddoesnotextendintothe
middleearcleft.Nobonyerosionisseen.
Intheoperatingtheater,anendauralincisionwasmadeandaposteriortympanomeatalflapwasraised.
Intraoperatively,themiddleearcleftwashealthy,ashadbeensuggestedbytheHRCT.Thelesionanda
cuffofhealthytympanicmembranewereexcisedwithBelluccimicroscissors(figure3
(/print/article/diagnosisandmanagementtympanicmembranehemangioma#fig3)).Theresultingdefect
wasrepairedwithatemporalisfasciagraft,andtheearcanalwaspackedwithribbongauzeimpregnated
withbismuthiodoformparaffinpaste.Histologyidentifiedthelesionasacavernoushemangioma(figure4
(/print/article/diagnosisandmanagementtympanicmembranehemangioma#fig4)).

Figure3.Thelesionandacuffofhealthy
tympanicmembraneareseenfollowing
excision.
Figure4.Histologyofthelesionshows
multiplethinwalledbloodvessels,which
werediagnosticofahemangioma
(hematoxylinandeosinoriginal
magnificationx50).

Thepackingwasremoved3weekspostoperativelytorevealanintactneotympanum.Thepatient
reportedthepulsatiletinnitushadresolved.At3monthspostoperatively,PTAshowedthattheconductive
componentofthehearinglosshadresolved.However,thepreexistinghighfrequencysensorineural
hearingloss,consistentwithpresbycusis,remainedunchangedfromthepreoperativelevel.Sincethe
tympanicmembranehadhealedandthetinnitushadresolved,thepatientwasdischargedatthispoint.

Discussion
Theexacthistopathogenesisoftympanicmembranehemangiomasispoorlyunderstood.Someauthors
believethattheselesionsrepresentbenignlymphovascularmalformations,whileothersregardthemas
hamartomas.2(/print/article/diagnosisandmanagementtympanicmembranehemangioma#refs)

Thetwotypesofhemangiomaarecapillaryandcavernous:

Capillaryhemangiomasconsistoftightlyarrangedbloodvesselsthatusuallyaffectthesquamous
layerofthetympanicmembrane.

Cavernoushemangiomasconsistoflargervascularspacesthataffectboththesquamouslayerand
thelaminapropria.

Theselesionsarisepredominantlyfromtheposterosuperiorquadrantofthetympanicmembrane,and
theydonotextendbeyondthelaminapropriaintothemiddleearspace.317(/print/article/diagnosisand
managementtympanicmembranehemangioma#refs)

Hemangiomasinvolvingonlythetympanicmembranearerare.OuronlinesearchofthePubMed,
MEDLINE,andEmbasedatabasesusingthekeywordshemangiomaandtympanicmembranefoundonly
12previouslypublishedcasesintheEnglishlanguageliteraturesince1972(table1).313
(/print/article/diagnosisandmanagementtympanicmembranehemangioma#refs)Ouranalysisofthese
data,combinedwithourowncase,revealedthatthemeanageofaffectedpatientswas57.6(range:49to
78).

Table1.Summaryofreportedcasesof
tympanicmembranehemangiomas
Histologic
Author Age/sex History Clinicalfindings Management Followup
type

Freedmanetal,3
Right
(/print/article/diagnosis Surgical
sided
andmanagement Massposterior resection
52/M incidentally 18mo Cavernous
tympanicmembrane totheTM/EAC (permeatal
found
hemangioma#refs) approach)
mass
1972

Massinthe
Leftsided posterosuperior Surgical
57/M NR Cavernous
otalgia quadrantofthe resection
TM

Conservative
Balkanyetal,4 management
Polypoidmass
(/print/article/diagnosis initiallylater,
inthe No
andmanagement Leftsided squame/lamina
63/F posterosuperior recurrence Capillary
tympanicmembrane mass excisedwith
quadrantofthe at24mo
hemangioma#refs) local
TM
1978 anesthesiano
grafting

Andradeetal,5
Right Surgical
(/print/article/diagnosis
sided excision
andmanagement Central
59/M incidentally (endaural NR Cavernous
tympanicmembrane vascularmass
found approach)and
hemangioma#refs)
mass grafting
1983

Jacksonetal,6
(/print/article/diagnosis Mixed
Recurrent Massposterior Meatoplasty
andmanagement capillary
60/F otitis totheTM/EAC and NR
tympanicmembrane and
externa recurrent tympanoplasty
hemangioma#refs) cavernous
1990

MagliuloandFusconi,7
(/print/article/diagnosis Massinthe
andmanagement posterosuperior Nogrowth
58/F Tinnitus Notexcised
quadrantofthe at15mo
tympanicmembrane TM
hemangioma#refs)
1997

Bijelicetal,8
(/print/article/diagnosis
andmanagement Right Massinthe
tympanicmembrane sided posterosuperior Surgical
hemangioma#refs) 78/F otalgiaand quadrantofthe excisionand NR NR
2001 itching TM grafting

Surgical
Hiraumietal,9
Right excisiontaking No
(/print/article/diagnosis Massinthe
sided onlythe recurrence,
andmanagement posterosuperior
51/F hearing squame/lamina lengthof Capillary
tympanicmembrane quadrantofthe
lossand (permeatal followup
hemangioma#refs) TM/EAC
otalgia approach)no NR
2005
grafting

Yeoetal,10
Right
(/print/article/diagnosis Massinthe
sided
andmanagement anteroinferior Nogrowth
49/F hearing Notexcised NR
tympanicmembrane quadrantofthe at18mo
lossand
hemangioma#refs) TM
otalgia
2008

Jangetal,11
Surgical No
(/print/article/diagnosis Right Massinthe
excision recurrence,
andmanagement sided posterosuperior
49/M (postauricular lengthof Cavernous
tympanicmembrane pulsatile quadrantofthe
approach)and followup
hemangioma#refs) tinnitus TM
grafting NR
2011

Spectoretal,12
No
(/print/article/diagnosis
Hearing recurrence,
andmanagement Surgical
59/F lossand lengthof Capillary
tympanicmembrane excision
tinnitus followup
hemangioma#refs)
NR
2011

Mevioetal,13
Leftsided
(/print/article/diagnosis Massinthe Surgical
otalgia, No
andmanagement superomedial excision
55/M hearing recurrence Cavernous
tympanicmembrane quadrantofthe (permeatal
loss,and at1yr
hemangioma#refs) TM approach)
tinnitus
2012
 Right Massinthe Surgical No
Watsonetal,*2016 59/M sided posterosuperior excision recurrence Cavernous
pulsatile quadrantofthe (endaural at3mo
tinnitus TM approach)and
grafting

*Presentcase.

Key:TM=tympanic
membraneEAC=
externalauditorycanal
NR=notreported.

Thepresentationoftympanicmembranehemangiomahasrangedfromincidentalfindingstohearing
loss,tinnitus,otalgia,and/orotorrhea.Histologically,thecavernoustypeoflesionwasslightlymore
commonthanthecapillarytype.Mostcasesweremanagedsurgicallyweadvocatethisapproach
becauseitiscurativeanditallowsforhistologicconfirmationofthediagnosis.

Thedifferentialdiagnosisofvascularlesionsinvolvingthetympanicmembraneandmiddleearcleftis
varied(table2).AllpatientsshouldundergoPTAandtympanometryaspartoftheirevaluation.HRCTof
thetemporalboneishelpfulindeterminingtheextentofthelesionandidentifyinganysurroundingbony
destruction.Ifahemangiomaisconfinedtothetympanicmembrane,CTisusuallytheonlyinvestigation
required.However,ifthereareanydoubtsabouttheextentofthelesion,furtherimaging,including
magneticresonanceimagingand/ormagneticresonanceangiography,shouldbeconsidered.

Table2.Differentialdiagnosesofvascular
typelesionsinvolvingthetympanic
membrane
Typeoflesion Differentialdiagnosis

Vascular Highjugularbulberodingthetympanicmembrane,arteriovenousmalformation

Neoplastic Rhabdomyosarcoma,leukemia,histocytosisX,melanoma

Inflammatory Pyogenicgranuloma,cholesterolgranuloma,inflammatorypolyp

Ourreviewofthepreviouslyreportedcasesrevealedthatonly2patientswithapresumedhemangiomaof
thetympanicmembraneweremanagedconservatively.7,10(/print/article/diagnosisandmanagement
tympanicmembranehemangioma#refs)Balkanyetalinitiallyoptedtomanagetheirpatientexpectantly,
buttheyeventuallydecidedonsurgicalexcisionasthemasscontinuedtogrowoveraperiodof2years.4
(/print/article/diagnosisandmanagementtympanicmembranehemangioma#refs)MagliuloandFusconi
reportedcontinuedconservativemanagementat15months,butnofurtherfollowupwasreported.7
(/print/article/diagnosisandmanagementtympanicmembranehemangioma#refs)Yeoetalreportedno
increaseinsizeoveraperiodof18months.10(/print/article/diagnosisandmanagementtympanic
membranehemangioma#refs)Betablockertherapyhasnotyetbeenreportedasatreatmentforthese
cases.
Surgerycanbeperformedwitheitherlocal4(/print/article/diagnosisandmanagementtympanic
membranehemangioma#refs)orgeneral5,6,812(/print/article/diagnosisandmanagementtympanic
membranehemangioma#refs)anesthesia.Thesurgicalapproachisdeterminedbytheextentofthe
lesion.Forsmallerlesions,apermeatalorendauralapproachissuitable,whereaslargerlesionsmay
requireapostauricularapproach.Inmostofthereportedcases,surgeonsundertookanenbloc
resection,elevatingatympanomeatalflapandrepairingthedefectwithasuitablegraft.

Tympanicmembranehemangiomashavebeendescribedinchildren,buttheirlesionsseemtoregress
naturally,unlikethoseinadults.13,14(/print/article/diagnosisandmanagementtympanicmembrane
hemangioma#refs)

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FromtheDepartmentofOtolaryngology,SteppingHillHospital,Stockport,U.K.
Correspondingauthor:Dr.AmandaMcSorley,DepartmentofOtolaryngology,SteppingHillHospital,
PoplarGrove,StockportSK27JE,UK.Email:dramcsorley@googlemail.com
(mailto:dramcsorley@googlemail.com)[1]
EarNoseThroatJ.2016June95(6):E12

Topics

Tympanum(http://www.entjournal.com/category/otology/tympanum)[2]
Hemangioma(http://www.entjournal.com/category/keywordtopics/hemangioma)[3]
Otology(http://www.entjournal.com/category/section/otology)[4]

SourceURL:http://www.entjournal.com/article/diagnosisandmanagementtympanicmembranehemangioma
Links
[1]mailto:dramcsorley@googlemail.com
[2]http://www.entjournal.com/category/otology/tympanum
[3]http://www.entjournal.com/category/keywordtopics/hemangioma
[4]http://www.entjournal.com/category/section/otology