Metastatic breast carcinoma presenting as unilateral pulsatile tinnitus: A case report

February 2, 2015     Andrew Moore, MRCS, DOHNS; Max Cunnane, BMBS, BMedSci; Jason C. Fleming, MRCS, DOHNS, MEd


Pulsatile tinnitus is a rare symptom, yet it may herald life-threatening pathology in the absence of other symptoms or signs. Pulsatile tinnitus tends to imply a vascular cause, but metastatic disease also can present in this way. Clinicians should therefore adopt a specific diagnostic algorithm for pulsatile tinnitus and always consider the possibility of metastatic disease. A history of malignant disease and new cranial nerve palsies should raise clinical suspicion for skull base metastases. We describe the case of a 63-year-old woman presenting with unilateral subjective pulsatile tinnitus and a middle ear mass visible on otoscopy. Her background included the diagnosis of idiopathic unilateral vagal and hypoglossal nerve palsies 4 years previously, with normal magnetic resonance imaging (MRI). Repeat MRI and computed tomography imaging were consistent with metastatic breast carcinoma. This case raises important questions about imaging protocols and the role of serial scanning in patients at high risk of metastatic disease.

Introduction Tinnitus can be defined broadly as the perception of sound when there is no external stimulus. It is possible to further categorize tinnitus as to whether it is unilateral or bilateral and whether it is subjective or objective, or by the quality of the perceived sound.

Endoscopic view of a medial ethmoid drainage pathway into the middle meatus

February 2, 2015     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

The ostium of the ethmoid bulla is often found in the hiatus semilunaris superior, but that it can also be found in the anterior or lateral wall of the bulla, the ethmoid infundibulum, the hiatus semilunaris inferior, or the retrobullar recess.

A 38-year-old male patient was referred to our office because of recurrent facial discomfort and discomfort between the eyes. He had been treated medically for recurrent sinus infections. Computed tomography (CT) of the sinuses showed bilateral sinusitis. An unusual finding on the CT scan was what appeared to be an ostium or drainage pathway from...

Giant palatal pyogenic granuloma

February 2, 2015     Yu-Hsuan Lin, MD; Yaoh-Shiang Lin, MD

The differential diagnosis for a pyogenic granuloma should include hemangioma, bacillary angiomatosis, peripheral giant cell granuloma, peripheral ossifying fibroma, and some malignancies, such as Kaposi sarcoma, squamous cell carcinoma, and achromic melanoma.

A mucosal pypogenic granuloma is a reactive angiomatous proliferation with a higher preponderance for the maxillary gingiva. A giant growth within the oral cavity is rarely encountered. Tentative diagnosis is made by recognizing a rapidly growing pedunculated or sessile mass characterized by a friable surface, bleeding tendency, and an ulceration...

Mixed verrucous and squamous cell carcinoma of the larynx

February 2, 2015     Giuseppe V. Staltari, BS; John W. Ingle, MD; Clark A. Rosen, MD

The lesion was removed en bloc, including the involved thyroarytenoid muscle.

Primary thyroid-like papillary adenocarcinoma of the nasal septum: A case report

February 2, 2015     Kerem Ozturk, MD; Rasit Midilli, MD; Ali Veral, MD; Yesim Ertan, MD; Bulent Karci, MD


Primary thyroid-like papillary adenocarcinomas are extremely rare neoplasms that generally originate in the nasopharynx. We report the case of a 24-year-old woman who was diagnosed with a thyroid-like papillary adenocarcinoma that originated in the nasal septum. The tumor was surgically removed, and the patient showed no evidence of local recurrence during 4 years of follow-up.

Palliative endoscopic surgery for sinonasal metastases: A case report and literature review

February 2, 2015     Jason M. Roberts, MD; Christopher Brook, MD; Steven Parnes, MD


Cancer metastatic to the paranasal sinuses often presents with ophthalmologic and facial deformities, as well as sinonasal complaints. These diminutive tumors are difficult to effectively treat, often leading to poor quality of life. Although breast cancer is a common cancer affecting more than 150,000 women each year,1 rarely is metastatic breast cancer found within the sinuses. We report our palliative treatment approach and outcomes of a 40-year-old patient with breast cancer metastatic to the paranasal sinuses. While providing a better understanding of this tumor's metastasis through a review of the literature, our report describes the role of palliative surgery for metastases to the paranasal sinuses.

Absence of the long process of the incus

February 2, 2015     Christina H. Fang, BS; Robert W. Jyung, MD

A definitive diagnosis of an ossicular defect, such as absence of the incus long process, requires an exploratory tympanotomy.

A 51-year-old man was referred to our department with a 3-year history of left-sided hearing loss. He had a history of otitis media that had required myringotomy and fluid aspiration. He also recalled being hit in the left ear by an ocean wave when he was 10 years old but did not think he lost hearing at that incident. He denied tinnitus, vertigo...

Bilateral Eagle syndrome causing dysphagia

February 2, 2015     Lyndsay L. Madden, DO; Roxann Diez Gross, PhD; Libby J. Smith, DO

Patients with Eagle syndrome often report symptoms that include dysphagia, otalgia, throat pain, globus sensation, facial pain, headache, taste disturbances, and dental pain that worsen with chewing, head and tongue movements, and swallowing.

A 62-year-old man presented with complaints of dysphagia to solids and liquids, a globus sensation, and dysphonia. He recently had undergone emergent surgery via a right anterior cervical approach for cervical fusion. After surgery he noted an increased effort to swallow, without aspiration. Flexible nasolaryngoscopy revealed right vocal fold...

Vestibular dehiscence syndrome caused by a labyrinthine congenital cholesteatoma

February 2, 2015     Francesco Fiorino, MD; Francesca B. Pizzini, MD, PhD; Barbara Mattellini, MD; Franco Barbieri, MD


A 40-year-old man presented with conductive hearing loss and pressure- and sound-related vestibular symptoms. Computed tomography and diffusion-weighted magnetic resonance imaging revealed the presence of a cholesteatoma involving the vestibular labyrinth. The patient underwent a canal-wall-up tympanoplasty, which revealed evidence of a disruption of the vestibular labyrinth and a wide dehiscence of the vestibule, which was immediately resurfaced. At the 2-month follow-up, the patient's pressure- and sound-related vestibular symptoms had disappeared. Pure-tone audiometry showed a reduction in the air-bone gap with a slight deterioration of bone conduction and an improvement in the air-conduction threshold. Fistulization of the otic capsule produces a “third window,” which can lead to a dehiscence syndrome. One possible cause is a cholesteatoma of the middle ear or petrous bone. When the vestibule is invaded by a cholesteatoma, hearing is almost invariably lost, either pre- or postoperatively. However, in our case, wide opening of the vestibule resulted in hearing preservation.

Bilateral keratin horns arising from the tympanic membranes: A case report

February 2, 2015     Chu Qin Phua, MRCS, DOHNS; Vikas Malik, FRCS(ORL-HNS); Patrick Zaid Sheehan, FRCS(ORL)


A keratin horn is a horn-like projection composed of dense keratotic material. It usually arises in sun-exposed areas of the body. It can be derived from a variety of underlying benign, premalignant, or malignant epidermal lesions. Risk factors associated with malignant change within a keratin horn include a wide base, male sex, and increasing age, in addition to an origin in a sun-exposed area. The mainstay of management is to obtain a biopsy from the base of the horn and subsequent excision if the histopathologic analysis suggests a malignancy. We report an extremely rare case of bilateral keratin horns arising from the tympanic membranes in a 64-year-old woman. To the best of our knowledge, this is the first report of its kind to be published in the English-language literature.

Introduction A keratin horn is a conical projection that resembles an animal horn. It is composed of dense keratotic material. This fairly common lesion typically arises in the sun-exposed areas of the body, such as the face, nose, scalp, pinna, back of the hands, and forearms.1 We present an unusual case of bilateral keratin horns that arose...
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