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Characteristics of osteoma of the temporal bone in young adolescents.

Abstract

The author conducted a retrospective review of the clinical presentation, management, and complications of temporal bone osteoma in young adolescents. The study population was made up of g patients--5 girls and 4 boys, aged 12 to 15 years at presentation (mean: 13.7)--who had been seen for radiologically and histopathologically proven temporal bone osteoma at the author's institution over a 9-year period. Of this group, 5 patients had extracanalicular osteoma (3 in the mastoid portion of the temporal bone, 1 in the squamousportion, and 1 in the mastoid antrum) and 4 patients had osteoma of the external auditory canal. Six of the 9 patients underwent surgical treatment; of the remainder, 1 refused surgery and 2 were managed conservatively with ongoing observation. All patients were followed for a minimum of 1 year, and no recurrences and no complications were observed during that time.

Introduction

Osteomas of the temporal bone are rare, slowly growing, benign neoplasms. They can occur in all parts of the temporal bone, including the bony portion of the external auditory canal (EAC). (1-3) Complications of osteomas of the EAC have been reported, including cerebellar abscess and cholesteatoma. (3-5) Aside from cases in which cortical lesions cause noticeable cosmetic deformities, osteomas are usually not suspected until they are found on x-ray. (1) Treatment is indicated for symptomatic osteomas. In this article, the author describes his retrospective review of 9 cases of temporal bone osteoma in young adolescents.

Patients and methods

The study population was made up of 9 patients--5 girls and 4 boys, aged 12 to 15 years at presentation (mean: 13.7)--who had been seen at the author's institution for radiologically and histopathologicaily proven temporal bone osteoma during the 9-year period from January 1999 through December 2007. In addition to demographic data, information was compiled regarding each patient's specific site of involvement, the nature of the presenting complaint, treatment, and any complications that might have occurred.

Results

Computed tomography (CT) had been obtained for all 9 patients, and it demonstrated a bony, dense mass in each (figure 1, A). Of the entire group, 5 patients had extracanalicular osteoma (3 in the mastoid portion of the temporal bone, 1 in the squamous portion, and 1 in the mastoid antrum) and 4 patients had osteoma of the EAC (table). Four of the 5 extracanalicular osteomas occurred in girls, and 3 of the 4 EAC osteomas occurred in boys. Two patients (patients 2 and 6) had associated ear infection. None of these patients had any history of ear surgery, relevant trauma, or glandular dysfunction.

Six of the 9 patients were symptomatic (table). The duration of their symptoms ranged from 5 months to 4 years. The most common presenting complaint was swelling in the mastoid region, which was seen in 3 patients with osteoma of the mastoid portion of the temporal bone. Other symptoms included swelling in other areas and decreased hearing. The osteoma in the mastoid antrum (patient 2) was found during a cortical mastoidectomy to treat an ear infection; in that case, the osteoma had arisen from the medial wall of the aditus.

Of the 4 patients with EAC osteoma, 2 were symptomatic (table). One of them (patient 7) presented with conductive hearing loss, and his hearing returned to normal following surgery. The other (patient 6) presented with a 4-year history of swelling in the ear canal and a 2-year history of a foul-smelling ear discharge along with a cerebellar abscess and a cholesteatoma of the EAC secondary to canal obstruction by the osteoma (figure 1, B). This patient underwent excision with radical mastoidectomy. The 2 asymptomatic patients with EAC osteoma (patients 8 and 9) were monitored with ongoing observational follow-up.

Surgical excision (figure 2) was performed on 6 patients. Histopathologic examination of the resected specimens confirmed the diagnosis of osteoma (figure 3). The patient with osteoma in the squamous portion refused surgery and, as mentioned, 2 patients with EAC osteoma were managed conservatively with observation.

All patients were followed for a minimum of i year, and no recurrences or complications were observed during that time.

Discussion

Etiology. Osteomas occur in all parts of the temporal bone, including the EAC, mastoid and squamous portions, zygomatic process, glenoid fossa, middle ear, eustachian tube, petrous apex, internal auditory canal, and styloid process. (1-3) The etiopathogenesis of osteoma remains controversial. Reported etiologic factors have included trauma, surgery, radiotherapy, chronic infections, heredity, and glandular conditions, such as pituitary dysfunction. (1,5-8) Varboncoeur et al suggested that osteomas arise either from an embryonal cartilaginous rest or from a persistent embryologic periosteum. (9) Yamasoba et al proposed that osteoma may be of a congenital nature, based on their reported case of an osteoma that was seen in conjunction with congenital cholesteatoma. (10) Kaplan et al theorized that a combination of trauma and muscle traction may play a role in the development of osteoma. (11) More recently, others have suggested that osteoma is a product of a post-traumatic or postinflammatory process. (12,13)

None of our patients had any history of ear surgery, relevant trauma, or glandular dysfunction. Two of our patients had an associated ear infection; one of them (patient 2) had an osteoma in the mastoid antrum and an infection of the middle ear cleft, and the other (patient 6) had an EAC cholesteatoma in addition to her EAC osteoma.

Osteomas of the temporal bone probably develop in preosseous connective tissue, which has a relatively thick subcutaneous layer and a rich blood supply. (5,14) Osteomas are commonly seen in the paranasal sinuses, but they are rarely found in the temporal bone. (15,16)

Ohhashi et al reported that extracanalicular osteomas of the temporal bone occur twice as often in females and that EAC osteomas occur twice as often in males. (17) Their findings were borne out in this small sample, as the extracanalicular osteomas were more common in the girls (4:1) and the EAC osteomas were more common in the boys (3:1).

[FIGURE 1 OMITTED]

On CT, osteomas typically appear as a well-circumscribed mass without surrounding bony destruction. (18) Histopathologically, osteomas are made up of discrete fibrovascular channels surrounded by lamellar bone. (5) Pathologically, four types of osteoma has been identified: osteoma compactum, osteoma cancellare, osteoma cartilagineum, and osteoma mixtum. (19)

Symptoms. Temporal bone osteomas are usually asymptomatic, and they are often found incidentally on routine physical examination or during examination for an unrelated complaint. (4) But in some cases they produce swelling and cause asymmetry. (20) Symptoms such as conductive hearing loss or fullness in the ear can arise if an osteoma grows and a canal obstruction occurs as a result of the osteoma itself or cerumen impaction. (5) Other patients may present with definitive pressure symptoms. Van Dellen reported a case in which a mastoid osteoma compressed the posterior fossa structures and caused intracranial complications. (21)

Most of the patients in this series were symptomatic--4 of the 5 patients with extracanalicular osteoma and 2 of the 4 with EAC osteoma. The 4 patients with extracanalicular osteoma sought treatment for cosmetic reasons; of the 2 with EAC osteoma, one had a conductive hearing loss and other had otic swelling and discharge.

Extracanalicular osteomas of the temporal bone. Extracanalicular osteomas are composed primarily of mature bone. (1,8,15,16) They arise in both syndromic and nonsyndromic settings; for example they infrequently occur as a feature of Gardner syndrome. (22) Most extracanalicular osteomas of the temporal bone occur in young women. (1,8,15-17)

Osteomas in the middle ear are extremely rare, as only 23 cases have ever been reported in the English-language literature. (23) When they have occurred, they most commonly arose from the promontory and caused progressive conductive hearing loss, usually from impingement on the ossicular chain. Conductive hearing loss can also be caused by impingement on the tympanic membrane, dislocation of the ossicular chain, and obliteration of the round window. (18,24-27) Middle ear osteomas may also arise from the pyramidal eminence, (10) hypotympanum, (25) and lateral semicircular canal. (27)

Osteomas of the internal auditory canal are also rare, as only 12 cases have been reported in the world literature. (28,29) Affected patients have exhibited a wide variety of symptoms, including asymmetrical sensorineural hearing loss (progressive or sudden), vertigo, tinnitus, facial nerve palsy, and vestibular dysfunction. (2,29)

There were no cases of middle ear or internal auditory canal osteoma in the present study.

Osteoma of the EAC. The prevalence of EAC osteoma among all cases of otologic surgery is estimated to be 0.05%. (3-5) In most cases, these tumors manifest as a solitary, pedunculated, unilateral bony mass of unknown etiology. (4)

[FIGURE 2 OMITTED]

The main complication of osteoma of the EAC is cholesteatoma, which can undergo accelerated growth in the presence of inflammation such as otitis externa. (3-5) In the present study, 1 patient (patient 6) presented with an EAC cholesteatoma.

Treatment. Surgical excision is the treatment of choice for both extracanalicular and EAC osteomas of the temporal bone. Indications for surgery in patients with extracanalicular osteoma include cosmetic disfigurement, a limitation or loss of hearing function, and a significant rate of tumor growth; surgery may also be appropriate to establish a definitive histopathologic diagnosis. (12) The surgical procedure entails removal of the tumor at the base where it attaches to the corticalbone. (30) In patients with EAC osteoma, surgery is recommended if a growing osteoma results in ear canal obstruction and/or cholesteatoma. (4,5) In the present study, excision was performed in 4 of 5 patients with extracanalicular osteoma, including 1 whose tumor was found incidentally during a cortical mastoidectomy, and in 2 of 4 with EAC osteoma. One patient with extracanalicular osteoma refused surgery, and 2 with EAC osteoma were followed with observation.

[FIGURE 3 OMITTED]

Indeed, observation is the preferred management strategy for asymptomatic middle ear osteoma. (22,25) For middle ear osteoma that causes hearing loss, surgical excision is curative. (18) Surgery has remained the treatment of choice for symptomatic internal auditory canal osteoma. (29,31) The type of surgical procedure for internal auditory canal osteoma has varied; both middle cranial fossa and suboccipital approaches have been used, depending on the size and location of the lesion. (28)

References

(1.) Denia A, Perez F, Canalis RR, Graham MD. Extracanalicular osteomas of the temporal bone. Arch Otolaryngol 1979;105(12):706-9.

(2.) Estrem SA, Vessely MB, Oro JJ. Osteoma of the internal auditory canal. Otolaryngol Head Neck Surg 1993;108(3):293-7.

(3.) Viswanatha B. A case of osteoma with cholesteatoma of the external auditory canal and cerebellar abscess. Int J Pediatr Otorhinolaryngol Extra 2007;2(1):34-9.

(4.) Orita Y, Nishizaki K, Fukushima K, et al. Osteoma with cholesteatoma in the external auditory canal. Int J Pediatr Otorhinolaryngol 1998;43(3):289-93.

(5.) Lee DH, Jun BC, Park CS, Cho KJ. A case of osteoma with cholesteatoma in the external auditory canal. Auris Nasus Larynx 2005;32 (3):281-4.

(6.) Gungor A, Cincik H, Poyrazoglu E, et al. Mastoid osteomas: Report of two cases. Otol Neurotol 2004;25(2):95-7.

(7.) Stuart EA. Osteoma of the mastoid: Report of a case with investigations of the constitutional background Arch Otolaryngol 1940;31: 838-54.

(8.) Friedberg S. Osteoma of the mastoid process. Arch Otolaryngol 1938;28(1):20-6.

(9.) Varboncoeur AP, Vanbelois HI, Bowen LL. Osteoma ofthe maxillary sinus. J Oral Maxillofac Surg 1990;48(8):882-3.

(10.) Yamasoba T, Harada T, Okuno T, Nomura Y. Osteoma of the middle ear. Arch Otolaryngol Head Neck Surg 1990;116(10):1214-16.

(11.) Kaplan I, Calderon S, Buchner A. Peripheral osteoma of the mandible: A study of 10 new cases and analysis of the literature. J Oral Maxillofac Surg 1994;52(5):467-70.

(12.) Dalambiras S, Boutsioukis C, Tilaveridis I. Peripheral osteoma of the maxilla: Report of an unusual case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(1):e19-24.

(13.) Park W, Kim HS. Osteomaofmaxillary sinus: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102(6):e26-7.

(14.) Graham MD. Osteomas and exostoses of the external auditory canal. A clinical, histopathologic and scanning electron microscopic study. Ann Otol Rhinol Laryngol 1979;88(4 Pt 1):566-72.

(15.) Cinelli AA. Osteoma eburneum of the mastoid. Arch Otolaryngol 1941;33(3):421-4.

(16.) Coates GM. Osteoma growing from the mastoid cortex. Arch Otolaryngol 1938;28:27-8.

(17.) Ohhashi M, Terayama Y, Mitsui H. Osteoma of the temporal bone--a case report [in Japanese]. Nippon Jibiinkoka Gakkai Kaiho 1984;87(5):590-5.

(18.) Chang CY, MacMillan C, Kamerer DB, et al. Osteoma of the malleus. Otolaryngol Head Neck Surg 1997;117(6):S150-3.

(19.) Morocco WA. Multiple osteoma of mastoid cavity. Arch Otolaryngol 1948;47:673-7.

(20.) Ziccardi VB, Smith JA, Braun TW. Osteoma of the maxillary antrum. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80(4): 378-9.

(21.) Van Dellen JR. A mastoid osteoma causing intracranial complications. A case report. S Afr Med J 1977;51(17):597-8.

(22.) Harley EH, Berkowitz RG. Osteoma of the middle ear. Ann Otol Rhinol Laryngol 1997;106(8):714-15.

(23.) Kim CW, Oh SJ, Kang JM, Ahn HY. Multiple osteomas in the middle ear. Eur Arch Otorhinolaryngol 2006;263(12): 1151-4.

(24.) Britt JC, Hood RJ, Hashisaki GT. Round window obliteration by osteoma of the middle ear. Otolaryngol Head Neck Surg 2000;123 (4):514-15.

(25.) Glasscock ME III, McKennan KX, Levine SC. Osteoma of middle ear: A case report. Otolaryngol Head Neck Surg 1987;97(1):64-5.

(26.) Milroy CM, Phelps PD, Michaels L, Grant H. Osteoma of the incus. J Otolaryngol 1989;18(5):226-8.

(27.) Ito S, Tanaka H, Hirano M. Osteoma of the middle ear. J Laryngol Otol 1990;104(10):803-6.

(28.) Clerico DM, Jahn AF, Fontanella S. Osteoma of the internalauditory canal. Case report and literature review. Ann Otol Rhinol Laryngol 1994;103(8 Pt 1):619-23.

(29.) Davis TC, Thedinger BA, Greene GM. Osteomas of the internal auditory canal: A report of two cases. Am J Otol 2000;21(6):852-6.

(30.) Sayan NB, Ucok C, Karasu HA, Guhnam O. Peripheral osteoma of the oral and maxillofacial region: A study of 35 new cases. J Oral Maxillofac Surg 2002;60(11):1299-1301.

(31.) Vrabec JT, Lambert PR, Chaljub G. Osteoma of the internal auditory canal. Arch Otolaryngol Head Neck Surg 2000;126(7):895-8.

Borlingegowda Viswanatha, MS, DLO

From the Department of ENT, Victoria Hospital and Bangalore Medical College and Research Institute, Bangalore, Karnataka, India.

Correspondence: Borlingegowda Viswanatha, MS, DLO, No. 716, 10th Cross, 5th Main, MC Layout, Vijayangar, Bangalore 560 040, Karnataka, India. E-mail: drbviswanatha@yahoo.co.in
Table. Selected features of the 9 cases

 Sex/ Presenting
Pt. age (yr) Site complaint

1 F/14 Squamous portion Swelling in the left
 of the temporal bone temporal region

2 F/15 Mastoid antrum None (found in the
 mastoid antrum during
 cortical mastoidectomy)

3 F/12 Mastoid portion Swelling in the
 of the temporal bone mastoid region

4 F/15 Mastoid portion Swelling in the
 of the temporal bone mastoid region

5 M/14 Mastoid portion Swelling in the
 of the temporal bone mastoid region

6 F/12 External auditory Swelling in the EAC
 canal (EAC)

7 M/15 EAC Decreased hearing

8 M/12 EAC None (found during
 removal of impacted
 wax)

9 M/14 EAC None (found during
 routine examination)

 Duration of
Pt. symptoms Treatment

1 1 yr None; patient
 refused surgery

2 N/A Excision

3 9 mo Excision

4 1 yr Excision

5 2 yr Excision

6 4 yr Excision with
 radical
 mastoidectomy

7 5 mo Excision

8 N/A Observation

9 N/A Observation
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Title Annotation:ORIGINAL ARTICLE
Author:Viswanatha, Borlingegowda
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:9INDI
Date:Feb 1, 2011
Words:2610
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