Unusual cartilaginous lesion of the torus tubarius as a cause of otalgia.

A 72-year-old woman reported a sensation of pressure and otalgia in her left ear of several months' duration. This feeling was aggravated when she blew her nose. She noted a sensation of numbness in the meatus of her left ear, along with occasional "blocking" of the ear and tinnitus. She had no history of hearing loss or dysequilibrium.

On examination, the ear was normal. Audiometric testing showed a mild high-frequency sensorineural hearing loss bilaterally. Tympanograms were normal. Results of a nasal examination were also normal. Because the woman's symptoms had been so persistent, we performed endoscopic nasopharyngoscopy with a 4-mm, 0[degrees] rigid telescope. This investigation revealed the presence of a horn-like, pyramid-shaped lesion on the medial aspect of the left torus tubarius. The lesion was covered with mucosa (figure, A). Initially, computed tomography (CT) of the nose and sinuses was interpreted as normal. However, a re-examination of the scan showed a spur-like projection on the left torus tubarius (figure, B).

The patient was administered oroendotracheal general anesthesia, and she underwent a transnasal endoscopic excision of the torus tubarius lesion. An incision was made along the base of the lesion, and the lesion was excised with a sickle knife (figure, C) and a Bard-Parker #11 knife blade attached to along, thin handle. The lesion was identified as a cartilaginous projection emanating from the torus tubarius. The cut edge was smoothed with a microdebrider. Histologically, the lesion was a cartilaginous mass covered with chronically inflamed mucosa. After a period of healing, the patient's symptoms resolved, and at the 1-year followup she had experienced no recurrence (figure, D).

Since Italian anatomist Bartolommeo Eustachio (1524-1574) first described the auditory tube (eustachian tube) in 1563, research has shown that it has three main functions: ventilation, protection, and clearance of the middle ear. Eustachian tube dysfunction has been linked to recurrent otitis media. [1] Congenital anomalies of the eustachian tube have been found to occur in individuals with cleft palate deformities [1] and in children with Down's syndrome. [2] Anomalies in the absence of either disease process are rare and infrequently reported. Diverticula can develop from the Rosenmuller's fossa or from the tube itself. Among the diverticula of the tube itself, the so-called diverticula of Kirchner (1887, quoted by Altmann [3]) are most numerous. They originate on the floor near the pharyngeal ostium and expand between the tensor and levator veli palatini muscles. [3] Peculiar small polyps have been found in the tubal ostium, on the torus tubarius, and in Rosenmuller's fossa. [3] As a rule, they contain el ements of pharyngeal mucosa and are regarded as tumor-like hyperplasias on the basis of a faulty anlage. In 1924, Henke described a pedunculated tumor in an 8-month-old child. The tumor originated in the anterior wall of the tube near the pharyngeal ostium and protruded into the middle ear and external auditory meatus.[3] A similar lesion was also reported by Eichel and Hallberg. [4]

Sensory innervation of the pharyngeal orifice of the eustachian tube is complex and is predominantly supplied by the glossopharyngeal nerve. [5] The anterior wall is supplied by the nerve to the tensor veli palatini (from the otic ganglion). The posterior wall and fossa of Rosenmuller are innervated via the pharyngeal plexus. The superior wall is innervated by the pharyngeal nerve of Bock, a branch of the sphenopalatine nerve. [5] The bony tube, the anterolateral cartilaginous lamina, and the tubal mucosa are innervated by the tubal branch of Jacobson's nerve and the tympanic plexus. [5] Our patient's symptoms could be explained by this innervation, as inflammations of the tube could lead to otalgia, vertigo, and nausea.

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn., and the Section of Otolaryngology, Hospital of St. Raphael, New Haven (Dr. Hirokawa and Dr. Yanagisawa), and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Hirokawa, Dr. Scher, and Dr. Yanagisawa).

References

(1.) Bluestone CD. Pathogenesis of otitis media: Role of eustachian tube. Pediatr Infect Dis J 1996;15:28l-91.

(2.) Shibahara Y, Sando I. Congenital anomalies of the eustachian tube in Down syndrome. Histopathologic case report. Ann Otol Rhinol Laryngol 1989;98:543-7.

(3.) Altmann P. Malformations of the eustachian tube, the middle ear, and its appendages. Arch Otolaryngol 195l;54:241-66.

(4.) Eichel BS, Hallberg OE. Hamartoma of the middle ear and eustachian tube. Report of a case. Laryngoscope 1966;76:1810-5.

(5.) Proctor B. Embryology and anatomy of the eustachian tube. Arch Otolaryngol 1967;86:503-14.