Fibroinflammatory pseudotumor of the temporal bone

Imaging features, therapies, and outcomes of fibrosing inflammatory pseudotumor of the nasopharynx: A systematic review

BACKGROUND AND PURPOSE

Fibrosing inflammatory pseudotumor (FIP) of the nasopharynx is a rare nonneoplastic inflammatory lesion that is frequently mistaken for malignancy or infection. It is often misdiagnosed by radiologists as nasopharyngeal carcinoma or lymphoma, resulting in multiple biopsies and delays in diagnosis. The purpose is to understand trends in clinical presentation, imaging findings, treatment modalities, and patient outcomes of nasopharyngeal FIP.

METHODS

MEDLINE and EMBASE databases were queried for articles related to FIP of the nasopharynx. Articles that described cases of FIP involving the nasopharynx were selected. Studies that described inflammatory pseudotumor of the nasopharynx associated with known distinct pathologic entities were excluded.

RESULTS

A total of 19 articles describing 37 patients were included. MRI findings were reported in 32 patients. All cases demonstrated avid gadolinium enhancement. T2-weighted imaging characteristics were described or displayed for 21 patients: 95% demonstrated hypointensity compared to surrounding mucosa. Fluorodeoxyglucose (FDG) PET/CT findings were reported for 6 patients, all demonstrating mild FDG avidity.

CONCLUSIONS

Nasopharyngeal FIP is a histological diagnosis of exclusion that presents with facial pain and, often, cranial neuropathies. Relatively low T2-weighted MRI signal should inform the interpreting neuroradiologist to include FIP as a differential consideration for both the ordering provider and pathologist. Corticosteroid therapy is the most frequently employed therapy and results in partial or complete response in most patients. Radiation therapy and anti-inflammatory medications have also been reported to have potential therapeutic roles.

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: 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.

Inflammatory Pseudotumors of the Skull Base: Meta-Analysis

OBJECTIVE

To describe the presentation, treatment, and outcome of inflammatory pseudotumors (IPs) of the skull base.

DATA SOURCES

English-language articles in PubMed, Web of Science, and EMBASE from earliest available through April 2014.

STUDY SELECTION

Articles were identified using a keyword search for "inflammatory pseudotumor," "inflammatory myofibroblastoma," or "plasma cell granuloma," including a keyword localizing to the skull base.

DATA EXTRACTION

One hundred papers with 157 cases met inclusion criteria. History, tumor site, initial and subsequent treatment, outcomes, and complications were extracted. Student t test, z test, and analysis of variance were used to analyze demographics, symptoms, sites involved, and outcomes. Odds ratios for site versus initial treatment were calculated.

DATA SYNTHESIS

At diagnosis, average patient age was 41 years. Approximately 70% of lesions primarily involved the anterior skull base, 29% the lateral skull base, and 1.2% the occiput. The most common initial treatments were steroids (44%), surgery (28%), and surgery with steroids (16%). Anterior lesions were 55.8 times more likely than lateral lesions to be treated initially with steroids (CI, 14.7-212). Seventy-six percent of patients had stable or resolved symptoms after a single course of treatment.

CONCLUSION

Diagnosis of skull base IP requires ruling out other aggressive pathologies, such as malignancy and infection, and maintaining a high index of suspicion. Surgery is favored for lesions that can be removed in toto with minimal morbidity, as well as steroids for those sites where anatomy limits complete resection, such as within the orbit, cavernous sinus, or brain. An option for larger lesions involving vital anatomy is debulking, followed by postoperative steroids.

Inflammatory pseudotumor of the endolymphatic sac: a case report

The authors present a case of Endolymphatic Sac Inflammatory Pseudotumour treated at our institution and reviewed the relevant literature. This is a benign lesion which arises due to chronic inflammation. It has similar clinical and radiological features as endolymphatic sac tumors and is diagnosed through histopathological examination. To date, there have been over 200 case reports of ELSTs but only 2 case reports of endolymphatic sac pseudotumour. This report highlights the clinical presentation, radiological features, histological characteristics, treatment, and clinical outcomes of endolymphatic sac inflammatory pseudotumours and explores their likely etiology and discusses possible treatment options. Endolymphatic sac inflammatory pseudotumour may represent the end of a spectrum of immune-mediated inflammatory disease of the endolymphatic sac. Based on the experience of managing inflammatory pseudo-tumours elsewhere in the body, there may be a role for high dose steroids in its management.

Inflammatory myofibroblastic tumor of the temporal bone presenting with pulsatile tinnitus: a case report

Introduction

Inflammatory myofibroblastic tumor of the temporal bone is an unusual but distinct disease entity. The most common presenting symptoms are otalgia, otorrhea, hearing loss, facial palsy, and vertigo. We describe here what we believe to be the first reported case of a patient presenting with persistent pulsatile tinnitus. The clinical features, radiological and histopathologic findings, and treatment outcomes of the patient are presented.

Case presentation

A 59-year-old woman of Chinese Han origin presented with complaints of left-sided pulsatile tinnitus and progressive hearing loss for several years. Clinical evaluations revealed a reddish mass behind the intact tympanic membrane, and a moderately severe conductive hearing loss in the left ear. The computed tomographic imaging of the temporal bone demonstrated a slightly ill-defined left middle ear soft tissue mass involving the posterior portion of the mesotympanum and epitympanum, and the mastoid antrum. The patient underwent surgical excision of the lesion which subsequently resolved her symptoms. Postoperative pathology was consistent with an inflammatory myofibroblastic tumor.

Conclusions

An inflammatory myofibroblastic tumor of the temporal bone can present clinically with pulsatile tinnitus and masquerade as venous hum or vascular tumors of the middle ear; therefore, it should be included in the differential diagnosis of pulsatile tinnitus.

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.

Successful treatment of an unresectable inflammatory myofibroblastic tumor of the frontal bone using a cyclooxygenase-2 inhibitor and methotrexate

Inflammatory myofibroblastic tumor (IMT) is a disease characterized by tumorous lesions consisting of myofibroblastic spindle cells and inflammatory cells that occur primarily in the soft tissues and viscera of children and young adults. Total excision is the most effective therapy. Steroids have been used to treat unresectable lesions with some success. We herein report a case of IMT involving the frontal bone accompanied by pachymeningitis. The tumor was characterized by an aggressive clinical course that was refractory to prednisolone. Performing total excision seemed difficult. Celecoxib and methotrexate were effective treatments. Our experience suggests the efficacy of celecoxib and methotrexate as alternatives for treating unresectable IMT.

Cochlear implantation in patients with chronic otitis: indications for subtotal petrosectomy and obliteration of the middle ear

Normally, active chronic suppurative otitis media is regarded as a contraindication for cochlear implantation. In case of a radical cavity after surgical treatment for cholesteatoma, the electrode covered by the epithelial lining of the mastoid will likely become exposed or extruded. Under these circumstances we suggest the subtotal petrosectomy, obliteration of the middle ear cleft with abdominal fat, and the blindsac closure of the external ear canal before cochlear implantation.Fourteen patients with chronic otitis media were successfully implanted with an intracochlear multichannel cochlear implant. After an average follow-up of 28 months a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a tumefactive inflammatory pseudotumor developed a massive inflammation in the implanted ear 2 months after surgery which could not be controlled by conservative treatment. The implant had to be removed and after administration of cyclophosphamide she could be successfully reimplanted 7 months later.Implantation of a foreign body in a potentially infected space which communicates with the endocranium means a surgical challenge which can be managed by obliteration of the middle ear. In case of massive inflammation we prefer a two-stage procedure.

Spontaneous hearing improvement in a patient with an inflammatory myofibroblastic tumor of the temporal bone

Inflammatory myofibroblastic tumor (IMT) is a rare lesion of unknown etiology and difficult diagnosis. The treatment of IMT is controversial. We report a case of IMT of the temporal bone in a young man presenting with a progressive hearing loss. Three years after diagnosis, partial hearing improvement has been documented.

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.

Immunoglobulin G4 related systemic sclerosing disease involving the temporal bone

Objective:

To report a rare condition affecting the temporal bone. Immunoglobulin G4 related systemic sclerosing disease is a recently described autoimmune condition with manifestations typically involving the pancreas, biliary system, salivary glands, lungs, kidneys and prostate. Histologically, it is characterised by T-cell infiltration, fibrosis and numerous immunoglobulin G4-positive plasma cells. This condition previously fell under the umbrella diagnosis of inflammatory pseudotumour and inflammatory myofibroblastic tumour.

Case report:

We present the case of a 58-year-old woman with multiple inflammatory masses involving the pharynx, gall bladder, lungs, pelvis, omentum, eyes and left temporal bone, over a seven-year period. We describe this patient's unusual clinical course and pathological features, which resulted in a change of diagnosis from metastatic inflammatory myofibroblastic tumour to immunoglobulin G4 related systemic sclerosing disease. We also review the literature regarding the management of inflammatory pseudotumours of the temporal bone, and how this differs from the management of immunoglobulin G4 related systemic sclerosing disease.

Conclusion:

We would recommend a full review of all histological specimens in patients with a diagnosis of temporal bone inflammatory pseudotumour or inflammatory myofibroblastic tumour. Consideration should be given to immunohistochemical analysis for anaplastic lymphoma kinase and immunoglobulin G4, with measurement of serum levels of the latter. Management of the condition is medical, with corticosteroids and immunosuppression, rather than surgical excision.