Meningiomas presenting in the temporal bone: the pathways of spread from an intracranial site of origin

External auditory canal ectopic atypical meningioma: A case report and brief literature review

Meningiomas are tumours typically derived from the meningothelial cells of the arachnoid mater. They most often arise in intracranial, intraspinal, or orbital locations. Ectopic meningiomas, described as primary meningiomas with no intracranial involvement, are definitely unconventional. In fact, most of the extracranial meningiomas described in the literature, particularly in the outer ear, are effectively spreads of disease with primary intracranial localization. We describe a case of a primary external auditory canal meningioma with demonstrated absence of intracranial involvement, and we provide a full radiological, histological, immunohistochemical and molecular characterization of the lesion.

Primary external auditory canal meningioma: Case report and review of the literature

Meningiomas are tumors that arise from arachnoid cells attached to both the pia mater and the inner portion of the arachnoid. They are common intracranial tumors, representing 12-25% of intracranial neoplasms. Intracranial meningiomas can spread extracranially to involve surrounding structures, including the ear and temporal bone. Ectopic meningiomas, described as primary meningiomas with no intracranial involvement, are rare. We describe a case of a primary external auditory canal meningioma with no evidence of intracranial involvement. We present pre-operative imaging findings proving no intracranial involvement prior to surgical intervention. A literature review of this uncommon clinical entity is presented and a discussion regarding its prognosis and treatment is reviewed.

Anatomy of petrous face

The anatomy of the petrous face of the temporal bone, also known as the petrous pyramid, should be carefully examined to understand the location of, blood supply to, and venous drainage of meningiomas in this area (42%-59% of posterior fossa meningiomas). The petrous face is located in the skull base between the sphenoid and occipital bones. It consists of a base that joins the mastoid laterally and an apex that extends anteromedially to form the foramen lacerum. The anatomy can be divided into three surfaces: anterior/superior, posterior, and inferior. The anterior/superior surface is a continuation of the posteromedial portion of the middle cranial fossa with boundaries extending from the arcuate eminence to the petrous apex. The posterior surface is a continuation of the front part of the posterior cranial fossa with the internal auditory meatus at its center. The inferior surface contains foramina that transmit important vessels and cranial nerves. The vascular anatomy of the petrous face is also described, including branches of the carotid artery and vertebrobasilar systems. It is imperative to understand potential anastomotic routes between extracranial and intracranial arteries, as well as arterial supply to cranial nerves, to facilitate preoperative transarterial embolization of meningiomas and avoid neurologic complications during surgery.

An Infratemporal Meningioma: A Diagnostic Dilemma

A 46-year-old male presented with painless, recurrent bilateral ear discharge and an enlarging right temporal swelling. There were no neurological deficits. Imaging revealed an enhancing, soft tissue mass at the right infratemporal region involving the right temporalis muscle with a small, enhancing intradural component and associated hyperostosis of the greater wing of the right sphenoid bone. Tumour debulking of the right temporalis tumour was performed. Tumour invasion of the right temporalis muscle was noted intraoperatively. Histopathological result was consistent with fibrous meningioma WHO Grade 1 involving surgical resection margins. Follow-up MRI revealed residual right temporal extracranial component. Thus, plans were made for a second stage tumour debulking, however at time of writing, surgery had not been performed. This case highlights the differing appearances of the common meningioma occurring extracranially with elaboration of its differential diagnosis and management.

Facial Nerve Meningioma: A Case Mimicking Facial Nerve Schwannoma

Facial nerve meningioma is exceedingly rare and tends to affect the geniculate ganglion. We present a case of facial nerve meningioma located in the internal auditory canal with a "labyrinthine tail," mimicking facial nerve schwannoma. The clinical and radiological features, growth patterns, and surgical management were reviewed. Progressive facial paralysis was the main syndrome, similar to other facial nerve tumors. When facial nerve function is worse than House-Brackmann grade III, surgical resection should be performed with facial nerve reconstruction.

Clinicoradiologic Characteristics of Temporal Bone Meningioma: Multicenter Retrospective Analysis

OBJECTIVES/HYPOTHESIS

Meningioma is a neoplasm arising from cells related to the arachnoid villi. The aim of the present study was to explore the clinical and radiological characteristics of temporal bone meningioma (TBM) in a multicenter cohort.

STUDY DESIGN

Retrospective cohort study.

METHODS

Thirteen patients diagnosed with TBM at eight medical institutes between 1998 and 2018 were retrospectively enrolled. The clinical procedures, symptoms, signs, and images that led to the diagnosis of TBM were investigated for all patients.

RESULTS

The most common symptom at the initial visit was hearing loss (n = 12/13, 92.3%). All patients exhibited unilateral TBMs with varied symptom durations (1-60 months). Four patients presented masses occupying the external auditory canal; the tympanic membrane (TM) could not be evaluated. The other nine patients did not show TM perforation despite the presence of inflammatory signs. The majority of patients exhibited unilateral conductive or mixed hearing loss. A retrospective review of temporal bone computed tomography (TBCT) images revealed findings suggestive of a tumor in all patients. However, three patients had been misdiagnosed with chronic otitis media and were subjected to tympanomastoidectomy (n = 3/7, 42.9%). TBCT findings that suggested TBM included diffuse trabecular hyperostosis in the middle and posterior cranial fossae and widening and destruction of the temporal bone in the jugular bulb area.

CONCLUSIONS

TBM should be suspected if patients exhibit persistent inflammatory symptoms or signs involving intact TM or unilateral conductive or mixed hearing loss with trabecular hyperostosis or destruction of the temporal bone on computed tomography images.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:173-178, 2021.

Heterotopic Cutaneous Meningioma: An Unusual Presentation Occurring in a Patient With a Remote History of Intracranial Meningioma

Meningioma is a neoplasm of the meninges, which usually occurs in intracranial sites. Extracranial meningioma has been frequently reported in the sinonasal tract and skull bone, often as extension of intracranial meningiomas. Isolated heterotopic meningioma without contiguous intracranial lesion is extremely rare. A 56-year-old woman presented in December 2015 with 2 firm subcutaneous scalp masses; one in the left lateral (temporal) and the other in the left superior (parietal) region. The clinical impression was that of lipoma. Pathologic examination revealed an ill-defined proliferation of uniform meningothelial cells in a fibroblastic stroma interspersed within adipose tissue. The excised lesions had similar histologic features. Immunohistochemical stains were performed and the tumor cells were positive for epithelial membrane antigen and negative for S-100. A diagnosis of extracranial meningioma, WHO grade I was made. The patient's medical history was significant for intracranial meningioma of the frontal lobe in October 2007, which was diagnosed as atypical meningioma, WHO grade II. Comparison of the scalp masses to her previous meningioma revealed a distinctly different morphologic pattern. In light of the 8-year interval between the scalp and intracranial meningioma and the difference in histologic grades, it is unlikely that her most recent tumors represent a recurrence or metastasis of the intracranial tumor.

Primary Atypical Meningioma of the Nasal Cavity: A Case Report and Review of the Literature

Background

Meningioma is a central nervous system tumor that typically arises in proximity to meninges. Extracranial primary atypical meningioma of sinonasal tract is a rare one.

Methods

We discuss the clinical, radiological, and histological presentation of an elderly female with primary atypical meningioma of the nasal cavity, which was excised via endoscopic endonasal approach.

Results

There was no recurrence even up to 20 months of follow-up after endoscopic excision.

Conclusion

Extracranial primary atypical meningioma should be kept in mind as one of the differential diagnoses of nasal mass. Histopathological diagnosis along with immunohistochemistry should be used for definitive diagnosis.

Primary Ectopic Meningioma of the Tongue: Case Report and Review of the Literature

Primary ectopic (extracranial) meningiomas (PEMs) are very rare and have been reported only sporadically. Histologically speaking, PEMs are similar to their intracranial counterparts in being composed of neoplastic arachnoidal (meningothelial) cells. In addition, several types of microscopic cellular morphologies have been observed in intracranial meningiomas: meningothelial (syncytial), psammomatous, atypical, anaplastic, fibrous, and angioblastic. To the best of the authors' knowledge, PEM presenting as a mass in the tongue has not been reported previously. This report describes a case of lingual PEM in a 17-year-old boy. Special attention is given to the unique clinical presentation and management. The literature was reviewed to provide valuable knowledge to clinicians.

Temporal bone meningioma involving the middle ear: A case report

Meningioma is a common intracranial tumor involving the meninges. The localization of this type of tumor is rarely extracranial due to its typically low invasive properties. Furthermore, invasion of the middle ear is exceptional. The present study reported a case of meningioma extending into the middle ear from the middle cranial fossa through the tegmen tympani. The clinical and pathological characteristics, as well as the outcome of the patient, were described.

Posterior mediastinal ectopic meningioma: a case report

Primary ectopic meningiomas occurring in the mediastinal region are extremely rare. So far, only five cases of primary mediastinal meningioma have been reported in the literatures. The imaging characteristics and the clinicopathological significance of mediastinal psammomatous meningioma have not been detailed. Here, we report the case of a 42-year-old male with primary posterior mediastinal psammomatous meningioma. The clinical features, imaging, and pathological findings are carefully analyzed, and the relevant literatures were reviewed.

Middle ear meningiomas: a case series reviewing the clinical presentation, radiologic features, and contemporary management of a rare temporal bone pathology

Meningiomas are the most common extra-axial intracranial neoplasm and frequently develop in the parasagittal region. Rarely, meningiomas may involve the middle ear and mastoid, resulting from contiguous spread of adjacent intracranial tumor, or less commonly as an isolated primary tumor of the middle ear. Patients with primary middle ear meningiomas (MEMs) often present with non-specific otologic complaints including hearing loss, otorrhea and otalgia thereby mimicking common chronic otitis media, while secondary lesions more frequently manifest sensorineural hearing loss, cranial neuropathy and other neurologic symptoms from the associated intracranial component. The radiological appearance of MEMs often overlaps with other tumors of the temporal bone. Therefore, a correct diagnosis cannot always be made prior to surgical biopsy. While gross total resection with preservation of existing neurological function is possible with smaller lesions, complete tumor removal may be extremely morbid with more extensive or adherent MEMs. In such cases, aggressive subtotal resection with close radiologic follow-up should be considered. Given the rarity of the studied condition, the literature addressing MEMs is sparse. The current study reviews ten additional cases of MEMs, highlighting the clinicopathologic and radiological features that distinguish meningiomas from other middle ear and mastoid pathology.

A rare case of large skull base meningioma mimicking otitis media with effusion

A 48-year-old woman presented with unilateral hearing loss and tinnitus for three years associated with middle ear effusion. Previous treatments, including antibiotics, corticoids, and transtympanic tube, were ineffective. Otomicroscopy showed a greyish retrotympanic mass associated with middle ear effusion. High resolution CT scan of the mastoid was in favor of chronic oto-mastoiditis without any evidence of tegmen dehiscence. Surgical exploration revealed a polypoid greyish mass filling the tympanic cavity. Histological examination postoperatively revealed a meningothelial meningioma. Postoperative magnetic resonance imaging (MRI) was obtained and showed a large skull base meningioma, extending from the clivus anteriorly to the porus acusticus posteriorly with middle ear invasion. After discussion with the multidisciplinary tumor board, it was managed by stereotactic radiotherapy due to the high surgical associated neurovascular risks. In conclusion, middle ear meningioma, although still a rare presentation, should be suspected in the presence of atypical chronic OME.

An extracranial invasive meningioma mimicking malignant bone tumor - "carpet meningioma"

Meningioma is a common benign intracranial neoplasm. The incidence of an extracranial extension to other sites is rare. Due to the neglected intracranial component, the chances of an under diagnosis or a misdiagnosis of the extracranial component is there, which may adversely affect the management and therefore, the prognosis. Here, we are reporting a case of a 39 years old male patient with a preoperative probable diagnosis of a malignant bone tumour which involved the skull bone, which was made, based on the imaging studies , which was histopathologically found to be an invasive meningioma with an extensive extracranial skull vault involvement and was confirmed by immunohistochemistry. We have proposed a term, "carpet meningioma" for this extracranial invasive meningioma, because it had covered the skull vault like a carpet. The follow up studies after 1 year have revealed no evidence of a recurrence.

Skull base meningiomas mimicking otitis media

INTRODUCTION

Meningiomas are slow-growing, benign tumours originating from the arachnoid villi of the meninges. They account for 13 to 26 per cent of all intracranial neoplasms. Less than 1 per cent of all meningiomas are primary extracranial tumours of the ear and temporal bone. Intracranial meningiomas extending to the middle-ear cleft are uncommon, with fewer than 100 cases reported to date. Presenting symptoms of the latter condition may include hearing loss, tinnitus, dizziness, vertigo and facial palsy. Otitis media with effusion secondary to eustachian tube dysfunction has also been reported.

AIM

To describe three patients in whom chronic otitis media was the presenting sign of skull base meningioma.

METHOD

Case presentations.

RESULTS

Presentation of clinical and imaging findings as well as management considerations.

CONCLUSION

Meningioma involving the middle ear is an extremely rare condition, and is diagnosed by computed tomography in conjunction with magnetic resonance imaging. When biopsy is performed, the histological features, characteristic immunophenotype and ultrastructural analysis are valuable aids to definitive diagnosis. In patients with no neurological symptoms, 'wait and scan' is often the best management option.

The middle ear mass: a rare but important diagnosis

The authors report a rare case of primary intracranial meningioma presenting as a middle ear mass with conductive hearing loss. The authors aim to highlight the importance of diagnosing a middle ear mass, which although rare, may have a substantial impact on ongoing patient management. A discussion of other middle ear pathologies is made in order to demonstrate the subtle differences in presentation.

Meningiomas intrinsic to the geniculate ganglion

Geniculate ganglion meningiomas are extremely rare lesions-only 14 cases have been reported in the literature. Two new cases of these tumors are described. On computed tomography and magnetic resonance imaging, both lesions appeared centered on the area of the geniculate ganglion, extending to the tympanic cleft and eroding the middle cranial fossa floor. The first case was treated through a middle cranial fossa approach. Because the tumor was so large in the second case, a subtotal petrosectomy was used. The authors review the literature to clarify the clinical and radiological characteristics of these tumors and their surgical treatment.

Primary extracranial meningiomas: an analysis of 146 cases

Primary extracranial meningiomas are rare neoplasms, frequently misdiagnosed, resulting in inappropriate clinical management. To date, a large clinicopathologic study has not been reported. One hundred and forty-six cases diagnosed between 1970 and 1999 were retrieved from the files of the Armed Forces Institute of Pathology. Histologic features were reviewed, immunohistochemistry analysis was performed (n = 85), and patient follow-up was obtained (n = 110). The patients included 74 (50.7%) females and 72 (49.3%) males. Tumors of the skin were much more common in males than females (1.7:1). There was an overall mean age at presentation of 42.4 years, with a range of 0.3-88 years. The overall mean age at presentation was significantly younger for skin primaries (36.2 years) than for ear (50.1 years) and nasal cavity (47.1 years) primaries. Symptoms were in general non-specific and reflected the anatomic site of involvement, affecting the following areas in order of frequency: scalp skin (40.4%), ear and temporal bone (26%), and sinonasal tract (24%). The tumors ranged in size from 0.5 up to 8 cm, with a mean size of 2.3 cm. Histologically, the majority of tumors were meningothelial (77.4%), followed by atypical (7.5%), psammomatous (4.1%) and anaplastic (2.7%). Psammoma bodies were present in 45 tumors (30.8%), and bone invasion in 31 (21.2%) of tumors. The vast majority were WHO Grade I tumors (87.7%), followed by Grade II (9.6%) and Grade III (2.7%) tumors. Immunohistochemically, the tumor cells labeled for EMA (76%; 61/80), S-100 protein (19%; 15/78), CK 7 (22%; 12/55), and while there was ki-67 labeling in 27% (21/78), <3% of cells were positive. The differential diagnosis included a number of mesenchymal and epithelial tumors (paraganglioma, schwannoma, carcinoma, melanoma, neuroendocrine adenoma of the middle ear), depending on the anatomic site of involvement. Treatment and follow-up was available in 110 patients: Biopsy, local excision, or wide excision was employed. Follow-up time ranged from 1 month to 32 years, with an average of 14.5 years. Recurrences were noted in 26 (23.6%) patients, who were further managed by additional surgery. At last follow-up, recurrent disease was persistent in 15 patients (mean, 7.7 years): 13 patients were dead (died with disease) and two were alive; the remaining patients were disease free (alive 60, mean 19.0 years, dead 35, mean 9.6 years). There is no statistically significant difference in 5-year survival rates by site: ear and temporal bone: 83.3%; nasal cavity: 81.8%; scalp skin: 78.5%; other sites: 65.5% (P = 0.155). Meningiomas can present in a wide variety of sites, especially within the head and neck region. They behave as slow-growing neoplasms with a good prognosis, with longest survival associated with younger age, and complete resection. Awareness of this diagnosis in an unexpected location will help to avoid potential difficulties associated with the diagnosis and management of these tumors.

Secretory meningioma of the middle ear: a light microscopic, immunohistochemical and ultrastructural study of one case

A 66-year-old woman was referred with left hearing loss. A probable diagnosis of left secretory otitis media with effusion was formulated. A left myringotomy was performed to remove hyperplastic hard tissue from the tympanic cavity. A high resolution CT scan of the temporal bone disclosed a soft-tissue mass completely involving the mastoid and tympanic cavity, surrounding the ossicular chain which appeared spared with no signs of infiltration. The histopathologic, immunohistochemical and ultrastructural response was secretory meningioma, a rare variant of conventional meningothelial meningioma in atypical sites.

Serous otitis media revealing temporal en plaque meningioma

OBJECTIVES

To present a series of temporal en plaque meningiomas involving the middle ear or mastoid, whose main symptoms suggested a serous otitis media.

STUDY DESIGN AND SETTINGS

Multicentric retrospective study reviewing clinical records originating from eight tertiary referral centers.

MATERIALS AND METHODS

The clinical records of 10 patients presenting with signs and symptoms suggesting serous otitis media and whose neuroimaging studies revealed a temporal en plaque meningioma involving the middle ear or mastoid are reported.

RESULTS

All the patients were women, ranging from 49 to 71 years old. The delay between the onset of symptoms and the diagnosis of meningioma varied from 1 to 10 years. All the patients underwent various procedures usually applied for the treatment of serous otitis media, which failed in all the cases, particularly ventilating tube placement, which was followed by severe episodes of discharge. In all cases, the computed tomographic scans showed three imaging signs: soft tissue mass filling the middle ear or mastoid, hyperostosis of the petrous bone, and hairy aspect of the intracranial margins of the affected bone. This imaging triad must alert the otologist of the possibility of intracranial meningioma. Magnetic resonance imaging was the method of choice to assess the diagnosis of intracranial meningioma involving the middle ear or mastoid. When analyzing management options, it appeared that conventional middle ear procedures were inefficient.

CONCLUSION

Temporal en plaque meningioma involving the middle ear or mastoid can mimic a serous otitis media. A computed tomographic scan is recommended for cases of atypical or prolonged unilateral serous otitis media to investigate indirect signs of a meningioma, which has to be confirmed with magnetic resonance imaging.

Primary ear and temporal bone meningiomas: a clinicopathologic study of 36 cases with a review of the literature

"Primary" ear and temporal bone meningiomas are tumors that are frequently misdiagnosed and unrecognized, resulting in inappropriate clinical management. To date, a large clinicopathologic study of meningiomas in this anatomic site has not been reported. Thirty-six cases of ear and temporal bone meningiomas diagnosed between 1970 and 1996 were retrieved from our files. Histologic features were reviewed, immunohistochemical analysis was performed (n = 19), and patient follow-up was obtained (n = 35). The patients included 24 females and 12 males, aged 10-80 years (mean, 49.6 years), with female patients presenting at an older age (mean, 52.0 years) than male patients (mean, 44.8 years). Patients presented clinically with hearing changes (n = 20), otitis (n = 7), pain (n = 5), and/or dizziness/vertigo (n = 3). Symptoms were present for an average of 24.6 months. The tumors affected the middle ear (n = 25), external auditory canal (n = 4), or a combination of temporal bone and middle ear (n = 7). The tumors ranged in size from 0.5 to 4.5 cm in greatest dimension (mean, 1.2 cm). Radiographic studies demonstrated a central nervous system connection in 2 patients. Histologically, the tumors demonstrated features similar to those of intracranial meningiomas, including meningothelial (n = 33), psammomatous (n = 2), and atypical (n = 1). An associated cholesteatoma was identified in 9 cases. Immunohistochemical studies confirmed the diagnosis of meningioma with positive reactions for epithelial membrane antigen (79%) and vimentin (100%). The differential diagnosis includes paraganglioma, schwannoma, carcinoma, melanoma, and middle ear adenoma. Surgical excision was used in all patients. Ten patients developed a recurrence from 5 months to 2 years later. Five patients died with recurrent disease (mean, 3.5 years), and the remaining 30 patients were alive (n = 25, mean: 19.0 years) or had died (n = 5, mean: 9.5 years) of unrelated causes without evidence of disease. We conclude that extracranial ear and temporal bone meningiomas are rare tumors histologically similar to their intracranial counterparts. They behave as slow-growing neoplasms with a good overall prognosis (raw 5-y survival, 83%). Extent of surgical excision is probably the most important factor in determining outlook because recurrences develop in 28% of cases.