Primary meningioma of the middle ear

A 61-year-old woman presented with a 3-month history of dizziness and right-sided hearing loss which started after an upper respiratory tract infection. She reported no previous ear problems and no symptoms related to the nose or throat. Examination of the right ear revealed a normal external auditory canal and a congested tympanic membrane. Audiometry showed a 70 db mixed low frequency hearing loss in the right ear (Figure 1) and a flat impedance. An initial diagnosis of right middle ear inflammation with effusion was made. The patient underwent right-sided myringotomy with grommet insertion. At the time of operation it was noted that the middle ear was full of granulation tissue. At 3-month follow-up, the patient reported mild improvement in symptoms but audiometry revealed a persistent right-sided sensorineural deficit. MRI (unenhanced) showed no significant abnormality at the CP angle, internal acoustic meatus or within the cerebral hemispheres. The appearance of fluid within the right mastoid air cells was noted (Figure 2). The patient was conservatively managed at 12, 18 and 24-month follow-up. At 36-month follow-up otoscopy revealed a bulging posterior quadrant of the right tympanic membrane. A tympanotomy was performed using endaural incision. A tympanomeatal flap was raised revealing a middle ear filled with fleshy tumour. This was attached to the incudostapedial joint, filling the hypotympanum. On retrospective evaluation of the MRI, the possible presence of soft tissue in the right mastoid was noted but there was no clear evidence of a lesion consistent with the operative findings. At follow-up 6months after surgery, the patient showed no clinical evidence of recurrence. A repeat MRI (gadolinium-enhanced) showed that the soft tissue previously noted had been removed. An area of abnormal signal situated posterior to the middle ear cavity was still present, enhanced and had not changed in size over the interval, most likely representing inflammatory tissue (Figure 3).