Inflammatory pseudotumor of the middle ear masquerading as Bell's palsy

Labyrinthine destruction caused by inflammatory pseudotumor of the temporal bone: A report of three cases and review of the literature

BACKGROUND

Inflammatory pseudotumors (IPTs) are rare, idiopathic, and inflammatory lesions that are histopathologically benign. Here, we present three cases of labyrinthine destruction caused by an IPT.

METHODS

The first patient was a 74-year-old male with a mass lesion extending from the inner ear to the external ear canal. The second patient was a 62-year-old female with a foliated polycystic lesion in the petrous bone on the dorsal side of the left internal auditory canal. The third patient was a 68-year-old female with a mass extending from the inner ear to the middle ear, destroying the semicircular canal and cochlea.

RESULTS

In two cases, we performed surgical resection successfully with no recurrence. In the other case, the lesion showed shrinkage after chemotherapy for colorectal cancer incidentally found during the examination process.

CONCLUSION

Surgical technique and indication for IPT should be based on the location and function of the lesion. In addition, there is room to consider pharmacotherapy as a treatment option for IPT of the temporal bone.

LEVEL OF EVIDENCE

4.

Inflammatory Pseudotumor of the Temporal Bone Leading to Atypical Superior Semicircular Canal Dehiscence Syndrome: A Novel Case Report

OBJECTIVE

Inflammatory pseudotumor of the temporal bone is a benign idiopathic inflammatory process that is rarely encountered in clinical practice. We describe a novel case of a patient who developed superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone.

PATIENT

One female patient found to have inflammatory pseudotumor of the temporal bone. After treatment with mastoidectomy and steroids, she subsequently developed superior semicircular canal dehiscence syndrome.

INTERVENTIONS

The patient initially underwent myringotomy and pressure equalization tube placement for a unilateral effusion. Imaging with computed tomography and magnetic resonance imaging revealed a lytic mastoid mass. A complete mastoidectomy was diagnostic for inflammatory pseudotumor and the patient was treated with adjuvant long-term corticosteroids. After this procedure, she was discovered to have new development of symptomatic superior semicircular canal dehiscence syndrome. She eventually underwent a trans-mastoid repair of her superior semicircular canal dehiscence.

MAIN OUTCOME MEASURES

The patient's clinical course is described with emphasis on the development of superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone.

RESULTS

The patient's radiographic and clinical history were found to be consistent with inflammatory pseudotumor of the temporal bone. She underwent a therapeutic mastoidectomy with long-term post-operative corticosteroids. During her post-operative course, she developed symptoms of vertigo, hearing loss, and autophony. She was subsequently diagnosed with superior semicircular canal dehiscence and treated with a trans-mastoid repair of the dehiscence. Her symptoms satisfactorily resolved after this surgery.

CONCLUSIONS

Inflammatory pseudotumor of the temporal bone is a rare benign inflammatory process. We present what is to our knowledge the first description of superior semicircular canal dehiscence syndrome developing in the setting of inflammatory pseudotumor.

Misdiagnosis of Bell's palsy: Case series and literature review

Although Bell's palsy is a common etiology for isolated facial paralysis, it is important clinicians perform a complete neurologic examination to avoid misdiagnosis. Multiple cranial neuropathy is often caused by tumor or infection.

Inflammatory Pseudotumor of the Temporal Bone: A Case Series

OBJECTIVE

Inflammatory pseudotumor of the temporal bone is a benign, idiopathic inflammatory process that is locally invasive and a cause of significant morbidity. This study reviews our experience with seven patients and is currently the largest series to date.

STUDY DESIGN

Retrospective review from January 1, 2014 to January 1, 2016.

SETTING

Single tertiary medical center.

PATIENTS

There were five male and two female (n = 7) subjects with a diagnosis of temporal bone inflammatory pseudotumor. The mean age at presentation was 41 years old. The most common presenting symptoms were hearing loss (7/7) and headache (4/7). Four patients demonstrated an inflammatory aural polyp. Two patients experienced facial nerve paralysis.

INTERVENTION(S)

Seven patients underwent computed tomography and six underwent magnetic resonance imaging. Corticosteroids and antibiotics were the initial treatment of choice. Five patients also underwent surgery. As adjuvant therapy, two patients received Rituximab, one patient received radiation, and one received mycophenolate mofetil.

MAIN OUTCOME MEASURE(S)

Clinical courses were followed with focus on symptoms, disease recurrence, duration, and treatment. Mean follow-up was 17.8 months.

RESULTS

The primary lesions demonstrated T2 hypo-intensity and enhancement as well as diffuse dural thickening on magnetic resonance imaging in five of six patients. Histopathology demonstrated chronic inflammation in the setting of hyalinized fibrosis (7/7). All the patients are currently symptomatically stable.

CONCLUSION

Inflammatory pseudotumor of the temporal bone can cause devastating effects on neurological function and quality of life. Recognition of characteristic imaging and histopathology can expedite appropriate treatment. Patients may require chronic steroid therapy. Adjunctive therapy with radiation and immuno-modulation are currently being explored.

Infantile inflammatory pseudotumor of the facial nerve as a complication of epidermal nevus syndrome with cholesteatoma

The first reported case of facial paralysis due to an inflammatory pseudotumor (IPT) of the facial nerve as a complication of epidermal nevus syndrome (ENS) is herein presented. A 10-month-old female patient was diagnosed with ENS at 3 months of age. She was referred to us because of moderate left facial paralysis. Epidermal nevi of her left auricle extended deep into the external ear canal. Otoscopy revealed polypous nevi and cholesteatoma debris filling the left ear. Computed tomography showed a soft mass filling the ear canal, including the middle ear, and an enormously enlarged facial nerve. Surgical exploration revealed numerous polypous nevi, external ear cholesteatoma, and tumorous swelling of the facial nerve. The middle ear ossicles were completely lost. The facial paralysis was improved after decompression surgery, but recurred 5 months later. A second operation was conducted 10 months after the first. During this operation, facial nerve decompression was completed from the geniculate ganglion to near the stylomastoid foramen. Histological diagnosis of the facial nerve tumor was IPT probably caused by chronic external ear inflammation induced by epidermal nevi. The facial paralysis gradually improved to House-Blackmann grade III 5 years after the second operation.

Inflammatory pseudotumor of the temporal bone: three cases and a review of the literature

Inflammatory pseudotumor (IP) is a clinically aggressive but histologically benign condition of unknown cause. Its appearance in the temporal bone is uncommon. We present clinical, radiological, and histopathologic findings of three cases originating in the temporal bone. In the first case, a simultaneous IP of the temporal bone and parotid gland was found with histopathologic confirmation. In the second case, an enlarged cervical node, which was also believed to be related to IP, was observed accompanied with the temporal lesion. While the third case presented with chronic suppurative otitis media. Two of them were treated by surgery alone with complete resolve of the diseases. Another one underwent tympanomastoidectomy in combination with oral steroids, radiation, and chemotherapy, but the IP still recurred. A comprehensive review of the literature on clinical features of the temporal pseudotumor was conducted.

Inflammatory myofibroblastic tumor of the nose and paranasal sinuses masquerading as a malignancy

Inflammatory myofibroblastic tumor (IMT) of the nose and paranasal sinuses is a rare entity that exhibits a diverse histologic pattern that can mimic malignant tumors clinically and radiologically. We present a case of IMT in an 88-year-old man who presented with an aggressive tumor-like lesion in the nose and paranasal sinuses that had a malignant appearance on radiology. We discuss this tumor's clinicoradiologic resemblance to a malignancy, and we review the treatment options following careful histologic and immunohistochemical analysis.

Inflammatory myofibroblastic tumor involving ear lobule

We present herein an extremely rare case of an inflammatory myofibroblastic tumor (IMT) of the ear lobule with its management. A 50-year-old woman presented with a wart-like mass between the ear lobule and the facial skin. She had been accidentally lacerated her left ear lobule and visited our clinic. The mass had been incidentally found by the patient 1 year before the trauma and growing slowly without pain. Surgical excision and primary closure was performed. Histopathologic examination demonstrated ill-defined margined nodular proliferation of spindle cells in deep dermis with focal stromal hyalinization and lymphoplasmacytic infiltration compatible with the IMT. The patient showed no evidence of recurrence 6 months after surgery. To our knowledge, this is the first report of an IMT occurred in the external ear. Auricular IMT of our case was not aggressive in clinical nature and treated optimally with surgical excision.

Inflammatory pseudotumor of nerve: clinicopathological characteristics and a potential therapy

We sought to determine the clinical, electrophysiological, neuroimaging, and pathological features of inflammatory pseudotumor of nerve. Five patients were identified. All cases presented with a gradually progressive mononeuropathy with symptoms of weakness, sensory loss, and prominent neuropathic pain. The median duration of symptoms was 7 months (range 3-36 months). Electrophysiological results were in keeping with chronic axonal mononeuropathies with variable findings of active denervation and reinnervation. MRI demonstrated irregular, large masses involving and surrounding nerve with heterogenous signal characteristics on T1- and T2-weighted and post-contrast sequences. Histopathological features of the nerve slightly varied but shared commonalities including chronic inflammatory infiltrates, increased collagen, and increased numbers of microvessels. Axonal degeneration and decreased density of myelinated fibers were also noted. Three patients were treated with weekly courses of intravenous steroids for 3 months. All reported improvement in pain and weakness. Inflammatory pseudotumor of nerve is not a neoplasm and has reactive features of inflammation, increased vascularity, and marked fibrosis. It presents as a progressive axonal mononeuropathy with weakness, sensory loss, and pain that may be episodic. The primary pathophysiology is unknown but the inflammation and response to treatment suggests that there may be an immune component.

Psychometric testing of the Gordon Facial Muscle Weakness Assessment Tool

School nurses may be the first health professionals to assess the onset of facial paralysis/muscle weakness in school-age children. The purpose of this study was to test the psychometric properties of the Gordon Facial Muscle Weakness Assessment Tool (GFMWT) developed by Gordon. Data were collected in two phases. In Phase 1, 4 content experts independently rated each of the 22 items on the GFMWT for content relevance. The ratings were used to generate Item and Scale Content Validity Index (CVI) scores. In Phase 2, school nurses (N = 74) attending a state conference independently rated referral urgency on a set of 10 clinical scenarios using the GFMWT. The GFMWT had an item and scale CVI of 1.0. Overall, the interrater reliability was .602 (p < .001). When used by school nurses, the GFMWT was shown to be both a reliable and a valid tool to assess facial muscle weakness in school-age children.

Inflammatory pseudotumor (plasma cell granuloma) of the temporal bone

We report the case of a 41-year-old man who presented with progressive right-sided ear pressure, otalgia, hearing loss, tinnitus, and intermittent otorrhea. Computed tomography and magnetic resonance imaging detected a soft-tissue mass in the right mastoid with intracranial invasion and erosion through the tegmen tympani and mastoid cortex. Histopathologic examination was consistent with an inflammatory pseudotumor (plasma cell granuloma). These lesions rarely occur in the temporal bone. When they do, they are locally destructive and can erode bone and soft tissues. Aggressive surgery is recommended as a first-line treatment, with adjunctive steroid or radiotherapy reserved for residual or refractory disease. Our patient subsequently experienced multiple recurrences, and his treatment required all of these modalities. At the most recent follow-up, he was disease-free and doing well.

Inflammatory pseudotumor of the inner ear: are computed tomography changes pathognomonic?

This case study presents a report of inflammatory pseudotumor of the inner ear in a child, discusses radiographic findings and clinical management, and reviews the current literature on this rare disease. A 2.5-year-old presented with otalgia, transient vertigo, and fluctuating facial palsy partially responsive to myringotomy with tube. Work-up for infectious and neoplastic processes was negative. Computed tomography (CT) of the temporal bone showed a very unusual, expansile, erosive appearance to the otic capsule, and magnetic resonance imaging of the temporal bone revealed soft tissue enhancement of the middle ear, mastoid, and inner ear. The patient's symptoms were transiently responsive to tympanomastoidectomy. Inner ear histopathology after labyrinthectomy revealed changes consistent with pseudotumor. Inflammatory pseudotumor of the inner ear is extremely rare but needs to be considered in cases of refractory otitis media with facial palsy, particularly when certain changes appear on CT of the temporal bone.

Bell's palsy in children: role of the school nurse in early recognition and referral

Bell's palsy is the most common condition affecting facial nerves. It is an acute, rapidly progressing, idiopathic, unilateral facial paralysis that is generally self-limiting and non-life threatening that occurs in all age groups (Okuwobi, Omole, & Griffith, 2003). The school nurse may be the first person to assess facial palsy and muscle weakness in children. Because facial palsy and muscle weakness may be an indicator of a serious or life threatening condition, the school nurse plays a critical role in early recognition and referral. The Gordon Facial Muscle Weakness Assessment Form is presented as a tool designed to assist school nurses in recognizing children with facial muscle weakness and in determining whether a primary health care provider referral should be considered immediate or urgent.

Inflammatory pseudotumor in the middle ear cavity

Inflammatory pseudotumor includes a diverse group of lesions characterized by inflammatory cell infiltration and variable fibrotic responses. It is extremely rare in the middle ear alone. A 7-year-old girl presented right hearing impairment. Because an otitis media with effusion was first suspected, a myringotomy was performed, but it found a mass that was different from a congenital cholesteatoma. Canal wall-down tympanomastoidectomy removed the mass successfully. The pathologic study of the specimen confirmed an inflammatory pseudotumor. We report an extremely rare case of the inflammatory pseudotumor in the middle ear with a review of the poor literature about this subject.