Journal of Current Research in Otolaryngology

Case Report Volume 1; Issue 1

Osteoma of Facial Nerve Canal with Cholesteatoma: A Rarest of

Rare Presentation

Govind CS*, Rambhau KV, Praful JS and Kaleem S

ENT Department, Maharashtra University of Health Sciences, India

*Corresponding author: Dr. Chintale Sambhaji Govind, Associate professor ENT Department, JIIUS IIMSR, Maharashtra
University of Health Sciences, Warudi Tq, Badnapur dist, Jalna, 431202, India, Tel: 9970323030; Email:
drsamchinto@gmail.com

Received Date: November 27, 2018; Published Date: December 05, 2018

Abstract
Objective: Osteoma Occurs Almost Exclusively in The Head and Neck Region, only Rarely Present into the Facial Canal.
We Reported an Incidental Finding of Osteoma in Facial Nerve Canal.
Material Methods: A 35 yrs. female patient present with left ear foul smelling discharge and hearing loss since last
10yrs. On microscopic examination there was mass in post superior quadrant of tympanic membrane. On high
magnification there was eroded facial canal with cholesteoma. On detail history patient give history of facial weakness
which gets recovered within in 2 month on medication. High resolution computed tomography of temporal bone done to
rule out exact pathology in middle ear and mastoid.
Result: On otoendoscopic examination there was mass in postero superior quadrant of tympanic membrane and eroded
posterior canal wall with choesteatoma. Two pathology were there one is the osteoma at facial nerve canal in vertical
segment of facial nerve approximately 0.7cmx 0.8cm and cholesteoma in attic, aditus, antruma and eroding facial canal
extending to mastoid tip and sinodural angle, eroding sinus plate. We removed both the pathology that is osteoma and
cholesteoma and send to histopathology for confirmation.
Conclusion: Osteomas are diagnosed incidentally in asymptomatic patients. Our case was symptomatic and raised the
question of surgical management. This case report discusses the presentation and management of exceptional osteoma
occurrence site along with presentation of cholesteoma with history of facial nerve palsy operated by mastoid
exploration.

Keywords: Facial nerve dysfunction; Middle ear lesions; Middle ear osteoma; Cholesteoma

Introduction other otologic symptoms. Vascular lesions, such as glomus

tumors, most commonly affect the middle ear [1]. Normal
Tumors of the middle ear space are rare. Like middle ear anatomic variants, such as dehiscent jugular bulb or high-
effusions, they can cause conductive hearing loss and riding carotid artery, may also invade the middle ear

Citation: Govind CS, et al. Osteoma of Facial Nerve Canal with Cholesteatoma: A Copyright © 2018 Govind CS, et al.
Rarest of Rare Presentation. J Current Res Oto 2018, 1(1): 180005.
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space. Lesions arising from the temporal bone itself are Case Report
rare [1,2]. Osteomas are the most widespread neoplasms
of the temporal bone [3]. They tend to occur in the We reported a case of 35 years female patient present
external auditory canal but can also occur in other parts with foul smelling ear discharge since 2 years with pain in
of the temporal bone, such as the middle ear space, where left ear with hard of hearing since 6 month. Patient had
the facial nerve is situated [3,4]. Subsequently, middle ear history of facial nerve weakness 2.5 yrs backs. On through
lesions can cause facial nerve dysfunction. However, facial clinical examination there were no other symptoms and
nerve weakness is usually caused by other pathologies, signs of neurological involvement. Opposite ear was
such as Bell’s palsy or central lesions. Middle ear normal on otoscopic examination. Patient had history of
osteomas are rare benign tumors that may present with left sided facial nerve palsy 2.5 years back on medication
conductive hearing loss and tinnitus [5]. Facial nerve and physiotherapy facial nerve palsy get relieved. After
involvement is extremely rare but requires early 1.5 year patient comes to our ENT department opd for ear
recognition. In the present study, we report a case of discharge. On examination of the patient with otoscope
middle ear osteoma causing incidental facial nerve paresis there was discharge and external auditory canal mass
2 years back which on medication and physiotherapy gets seen. High resolution computed tomography of temporal
relieved after one 1month and later on patient present bone advised to rule out exact middle ear pathology. High
with left ear foul smelling discharge and hearing loss resolution computed tomography suggestive of the left
along with facial nerve weakness. ear Cholesteatoma [Figure 1].

Figure 1: Showing cholesteoma.

Head, neck and vestibular examinations were normal, an which revealed an osseous lesion present over the facial
audiogram revealed left ear mild to moderate conductive canal in tympanic part facial nerve. There was huge
hearing loss. On otoendoscopic examination there was extensive choesteatoma eroding the post canal wall
mass in posterosuperior quadrant of tympanic extending from attic, aditus and antruma reaching
membrane, with white flecks of choesteatoma seen in towards sinodural angle and towards the tip of mastoid
attic with eroded posterior canal wall. All routine blood eroding the sinus plate posteriorly. Cholesteatoma
investigation done for anesthetic purpose. We planned removed completely along with osteoma and the
this patient for mastoid exploration under general specimen sent for histopathological examination
anesthesia with the consent of patient for facial nerve [Figures 2&3] which resulted in a diagnosis of a middle
palsy during operation and other relevant complication of ear osteoma with cholesteatoma.
procedure. Middle ear exploration was then performed,

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Figure 2: A: Cholesteoma eroding posterior canal wall, B: osteoma with choesteatoma eroding cortex
C: Osteoma arising from facial canal, D: Facial canal.

Figure 3: A: specimen of osteoma and cholesteatoma; B: Facial palsy.

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 4 Journal of Current Research in Otolaryngology

Discussion it involves the facial nerve canal which is uncommon for

middle ear osteoma to occur as per the literature.
Osteomas in head neck region are always interesting for
ENT surgeon. Their location is always challenging to Other middle ear lesions that may present similarly
surgeon for excision. When they occurs on the surface of include fenestral otospongiosis, ossifying hemangioma,
skull bone then they are easily to excise but when their osteoid osteoma, benign osteoblastoma, ossifying fibroma,
presentation in the sinuses, middle ear and at frontal fibrous dysplasia, osteochondroma, chondroma, calcified
ethmoidal sinuses then these cases become challenging to meningioma, isolated eosinophilic granuloma, giant cell
excise for surgeons. Temporal bone osteomas are rarely tumor, and malignant masses, such as osteosarcoma and
encountered benign neoplasms resulting from lamellar osteoblastic metastasis [2].
bone deposition most commonly in the external auditory
canal [1,2]. Typically, these tumors appear as solitary, Our patient presented with a left ear foul smelling
unilateral, and pedunculated lesions located in the lateral discharge and conductive hearing loss and history of
bony ear canal [3]. Osteomas can be differentiated from facial nerve weakness 2.5 yrs back which get relived in
exostoses, since the latter usually presents as multiple, month on medication but later patient symptoms of ear
bilateral, and broad-based elevations of the medial bony discharge foul-smelling get progressive facial nerve
external auditory canal [4]. Till date only one other case of weakness, in addition to conductive hearing loss and
middle ear osteoma presenting with facial nerve tinnitus. This was the direct result of the osteoma and
weakness is found in the literature [5]. In most cases, the compressing the tympanic portion of her facial nerve.
confirmation of a diagnosis requires computed Subsequently, surgical removal of the osteoma, along with
tomography imaging, along with visual inspection during the extensive cholesteoma that extends from attic,
surgical exploration with histopathological analysis of the posterior canal wall extending to sinodural angle and
biopsied or excised specimen [6]. mastoid tip, eroding sinus plate and dural plate, was
performed. Her facial nerve was also decompressed at the
A review of the literature of middle ear osteoma cases same time. This has resulted in partial recovery of her
revealed a male preponderance (2:1) with a median age at facial nerve function (House-Brackmann grade II) in
diagnosis of 28 years (mean 28.5 years; range, 5 to 27) follow up period of one year. Central lesions affecting the
[2]. The first report cases involved a pair of siblings and facial nerve, such as cerebellopontine angle tumors, can
thus a genetic etiology was suggested [7]. However other also present similar to our case. Early recognition,
possible causes, such as chronic inflammation due to referral, and treatment may also prevent permanent facial
exudative otitis, have also been proposed and the precise nerve dysfunction in these cases [9].
etiology of middle ear osteoma has yet to be clarified. On
histopathological examination, osteomas of the middle ear Conclusion
resemble those of the external auditory canal and can
generally be characterized by the benign proliferation of Osteomas are diagnosed incidentally in asymptomatic
cancellous bone [7]. They exhibit an abundance of fibro patients. Our case was symptomatic and raised the
vascular channels surrounded by lamellar bone, which question of surgical management. This article discusses
contains few osteocytes or lacunae [4,8]. the presentation and management associated with this
exceptional osteoma location along with presentation of
Given that external auditory canal osteomas have a cholesteoma with history of facial nerve weakness
tendency for very slow growth and many cases are not operated by mastoid exploration. Common causes of facial
associated with any significant clinical problems, some nerve weakness include cerebrovascular accidents,
authors suggest long-term monitoring as a viable cerebellopontine angle tumors, and Bell’s palsy. Very
management option [7]. Yet, most middle ear osteomas rarely, middle ear tumors present with facial nerve
present with an associated feature, such as conductive dysfunction. The weakness is typically due to a
hearing loss and tinnitus, and therefore surgical excision compressive effect on the middle ear portion of the facial
is more readily applied to these lesions [2,7]. Further, nerve. Early recognition is crucial since removal of these
middle ear osteomas can irreversibly injure the facial lesions may lead to the recuperation of facial nerve
nerve and erode into the inner ear, causing vertigo and function.
sensor neural hearing loss [5]. Hence, surgical excision to
prevent these severe complications may be warranted. Consent
Within the middle ear, promontory is the most commonly
involved site, followed by incus, pyramidal process, and Written informed consent was obtained from the patient
the anterolateral wall of the epitympanum [2]. In our case for publication of this case report and any accompanying
images.

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 5 Journal of Current Research in Otolaryngology

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