A 69-year-old man with a three-month history of ear drainage has an audiogram that shows a 30 dB conductive hearing loss. He has been treated by his primary care physician and an ENT doctor with multiple courses of topical and oral antibiotics and steroids. His medical history includes diabetes and cardiovascular disease. He has not had surgery on his ear. Examination of the ear reveals wet debris in the ear canal. After cleaning the debris, a fleshy mass was found in the medial ear canal close to the tympanic membrane. The patient denies significant pain.
Diagnosis: Pyogenic Granuloma
A mass in the ear canal of a 69-year-old should always alert a clinician to the possibility of a malignant tumor of the external auditory canal. If there is evidence of infection or inflammation, one or two courses of antibiotics and anti-inflammatory drugs are warranted. In general, topical antibiotics achieve a few thousand times concentration than oral antibiotics in the ear canal. Therefore, using oral antibiotics to treat ear canal infections are usually not warranted, except for patients who may have early malignant otitis externa (skull base osteomyelitis). Most oral antibiotics have no efficacy against bacteria that typically cause ear canal infections. Pseudomonas aeruginosa is the most common organism that causes otitis externa, and many primary care physicians usually prescribe amoxicillin or amoxicillin clavulanate (Augmentin), which has no activity against this organism. The only oral antibiotics that can potentially kill this organism are fluoroquinolone antibiotics such as ciprofloxacin and levofloxacin.
In the presence of a mass lesion in the ear canal, a biopsy needs to be obtained after a course of antibiotics. Sometimes a biopsy may come out to be inflammatory in origin. Therefore, it is imperative to observe these patients closely and re-biopsy the mass. Lesions in the ear canal are often biopsied with small instruments used for otologic surgery. This results in a superficial biopsy, which can lead to an erroneous diagnosis; a pathologist may consider the lesion to be inflammatory in origin when there is, in fact, underlying carcinoma. Even in the presence of carcinoma, a biopsy of the superficial layer of the tumor may only show dysplasia. If a biopsy does not include the basement membrane, a pathologist is unable to diagnose invasive squamous cell carcinoma. Therefore, if an ear canal biopsy shows dysplasia, it is necessary for the clinician to re-biopsy the patient, ideally in the operating room where a deeper and wider biopsy specimen could be obtained from the ear canal skin.
In addition to a biopsy, the patient workup should include imaging studies. CT scan of the temporal bone is the best way to get an image of the bony destruction in the ear canal, middle ear ossicles, or the mastoid. However, a CT of the temporal bone cannot distinguish between fluid, inflammatory tissue, cholesteatoma, or mass. All these structures look exactly the same on a CT of the temporal bone. MRI is the best imaging modality to identify and characterize soft tissue abnormalities in the temporal bone. MRI uses the characteristics of the hydrogen atoms to help identify the likely origin of soft tissue abnormalities. Since hydrogen atoms are densely packed in the bone, details of bony structures cannot be identified on an MRI. In fact, bone and air look very similar on an MRI and appear black. If malignant otitis externa or skull base osteomyelitis is suspected, a technetium-99 scan must be obtained to check for significant inflammation within the bone. If suspicion for this condition is low, such as when the patient has no pain but has granulation tissue, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) blood tests can be obtained. An infection of the temporal bone (malignant otitis externa) is associated with a significantly elevated ESR and/or CRP. If the test results are positive, a technetium scan should be done.
This patient had a biopsy of the mass in the ear canal, which was reported to be a pyogenic granuloma. The mass was treated with silver nitrate, and the patient was given topical antibiotics and anti-inflammatory drugs. A week later, a second biopsy was performed due to high suspicion for carcinoma, and the topical antibiotics and anti-inflammatory drugs were continued. After 10 days, the mass had nearly resolved, and it was once again confirmed as a pyogenic granuloma in another pathology report.
Imaging showed complete opacification of the middle ear, mastoid and ear canal. No bony destruction was found. Since suspicion was low for skull base osteomyelitis, ESR and CRP tests were obtained, which showed normal findings.
Pyogenic granuloma is an inflammatory response in the presence of a break in the epithelial lining. As this rupture heals, the body produces an inflammatory tissue to destroy any foreign body. Sometimes this inflammatory tissue will grow uncontrollably into a very large, fleshy mass. Pyogenic granuloma is most commonly seen during pregnancy when this tissue is believed to develop due to hormonal changes. Treatment usually involves surgical removal of the base with topical silver nitrate. When found in the ear, pyogenic granuloma can be controlled with topical anti-inflammatory drugs. Once the mass has resolved, an investigation is needed to identify the underlying cause of the growth. For cases of pyogenic granuloma in the ear, there may be an underlying cholesteatoma or tympanic membrane perforation. This patient was found to have tympanic membrane perforation. Inflammation in the middle ear resulted in a large pyogenic granuloma, which protruded through the tympanic membrane perforation.
BONUS VIDEOS: VISUAL DIAGNOSIS
Read this month's Clinical Consultation case, then watch the accompanying videos from Hamid R. Djalilian, MD, to review the patient's imaging for yourself.
- Video 1. Axial (horizontal) CT of the temporal bone showing the ear canal filled with the mass and fluid.
- Video 2. Coronal CT (parallel to the face superiorly-inferiorly) of the temporal bone showing a well-developed mastoid and soft tissue/fluid in the middle ear and ear canal not involving the entire mastoid.
- Video 3. Sagittal (looking outside-in laterally) CT of the temporal bone demonstrating no destruction of the bony canal.
- Video 4. Axial post-gadolinium T1-weighted MRI of the temporal bone in the same patient showing the enhancement (white) of the middle ear mucosa and the ear canal.
- Video 5. Axial T2 MRI showing the mastoid filled with fluid (white) and the middle ear not filled with fluid but likely soft tissue.
- Video 6. Coronal (parallel to the face superiorly-inferiorly) HASTE sequence showing no underlying cholesteatoma present (no white area seen in middle ear or mastoid).
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