CASE
A 70-year-old white female presented with a 2-year history of right-sided pulsatile tinnitus. Symptoms were most noticeable in quiet environments, such as when she was trying to go to sleep. She denied any associated dizziness, vertigo, or otalgia and did not feel that her hearing had significantly changed in many years. She had no history of chronic ear problems as a child, and her family history was unremarkable. There was no history of trauma to the ear or cotton swab abuse.
On examination, the external auditory canal was unremarkable. When viewed through a handheld otoscope, the right tympanic membrane (TM) demonstrated an erythematous area inferiorly. On binocular microscopy, the erythematous area was well-defined and located primarily along the inferior aspect of the mesotympanum and the hypotympanum medial to the tympanic membrane. The lesion appeared to extend along the floor of the middle ear space. Suspecting a vascular lesion, we ordered magnetic resonance angiography (MRA) focused on the right middle ear space. The MRA was interpreted as negative. Figure 1 shows a similar lesion in the left middle ear space of a patient with complaints like those of our patient.
Given the patient's history and findings on physical examination, she was referred to an otologist at the University of Pittsburgh Medical Center for a second opinion. A subsequent fine-cut CT with contrast revealed a 4-mm soft-tissue density adjacent to the right TM but not involving the jugular bulb.
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