Middle ear hemangioma: A novel treatment for a rare problem

1. Introduction 

An 18-month-old, otherwise healthy, white female with the exception of chronic otitis media was referred to our institution for a vascular lesion of the middle ear. During a routine myringotomy with tube placement, she was found to have a vascular mass involving the tympanic membrane. Physical examination upon presentation showed a tube in place and patent as well as a purplish red mass in the posterior superior quadrant of the tympanic membrane. The rest of her exam was otherwise normal.

2. CT findings 

Axial and reformatted coronal images performed without contrast revealed soft tissue opacity within the middle ear in the mesotympanum. The soft tissue opacity surrounded the ossicles, but there was no evidence of ossicular destruction. Some of the soft tissue mass was adjacent to the scutum which was not eroded (Fig. 1).

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Fig. 1. Axial CT scan of left ear: Soft tissue opacity within the middle ear surrounding the ossicles, but no evidence of destruction.

3. Treatment 

Canal wall-up mastoidectomy, tympanoplasty, and excision of middle ear hemangioma were performed using a CO2 laser to assist in excision of the hemangioma. A tympanotomy flap was elevated to reveal a large hemangioma filling the posterior–superior segment of the middle ear and extending anteriorly into the protympanum over the malleus. The back half of the tympanic membrane involved with the lesion was resected. A canal wall-up mastoidectomy was performed revealing the hemangioma medial to the incus, extending into the epitympanum. With the aid of the CO2 laser at 1W, the hemangioma was evaporated from the epitympanum forward until the middle ear was reached. It was resected off the malleus, the incudostapedial joint, and off the suprastructure of the stapes with the aid of the laser. The facial nerve was protected during the lasering by covering it with a saline soaked cotton pledget. The ossicular chain remained intact and the tympanic membrane defect was repaired with a temporalis fascia underlay graft (Fig. 2).

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Fig. 2. Operative findings: CO2 assisted resection of middle ear hemangioma with saline soaked cotton pledget covering the facial nerve.

4. Histopathology 

The specimen was sent for permanent pathology and upon final report; the vascular spaces were lined by a single layer of endothelium with some of the spaces filled with blood, consistent with a benign juvenile hemangioma (Fig. 3).

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Fig. 3. Histopathology: Juvenile hemangioma with collapsed vascular spaces and sparse stroma.

5. Discussion 

Although hemangiomas of the head and neck are very common lesions, their incidences in the middle ear are very rare. However, they can form anywhere vasoformative tissue is present, including the middle ear [3]. This case brings the total number of reported cases to 13: 7 capillary hemangiomas, 3 cavernous hemangiomas, and 2 juvenile hemangiomas (this case being the second), Fig. 3 [1]. Capillary hemangiomas tend to be superficial in location, cavernous hemangiomas are deeper, and juvenile hemangiomas are an infantile form of capillary hemangiomas [7]. The signs and symptoms can vary tremendously from an asymptomatic mass found on physical exam to pulsatile tinnitus, conductive hearing loss, recurrent bloody otorrhea, recurrent otitis media, otalgia, and dizziness [2], [4], [5].

When a middle ear hemangioma is suspected, imaging studies should be performed to rule out other vascular lesions. Dayal et al. described a classification of vascular, glomus-like tumors: (1) vascular lesions (high jugular bulb, uncovered or aberrant intratympanic internal carotid artery, and arteriovenous malformations; (2) neoplastic lesions: meningioma, hemangioma, rhabdomyosarcoma, leukemia, histiocytosis X, carcinoma, melanoma, and pyogenic granuloma; and (3) inflammatory lesions: cholesterol granuloma and aural polyp [2], [3], [5], [6]. Because of this broad differential, biopsy is often required to get a definitive diagnosis.

When a middle ear hemangioma is diagnosed, the treatment of choice is surgical excision; however, there has been a report of spontaneous involution [3]. The size and location of the lesion dictate the method of excision, but complete excision should be performed to prevent recurrence. As demonstrated in this case, the CO2 laser provides another option for excision. The ability to vaporize the tissue while dissecting it decreases the risk of bleeding allowing better visualization in the confined space of the middle ear. However, the facial nerve must be protected at all time from accidental injury from the laser.