We present an extensive capillary hemangioma of right ear in an 11-year-old child involving external auditory canal, middle ear and mastoid. Patient was presented with chronic purulent discharge and aural mass in right ear. The Computarize tomography (CT) scan revealed enhancing soft tissue filled density in external ear, middle ear and mastoid for that modified radical mastoidectomy (MRM) was done. The histopathological report of surgical specimen confirmed the diagnosis of capillary hemangiom

Bhandary, Sangita

Karki, Smirti

Singh, Rakesh Kumar

Tiwary, Awadhesh

English

Rakesh Kumar Singh

Sangita Bhandary

Awadhesh Tiwary

Smirti Karki

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Capillary hemangioma of tympanic cleft

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Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 7, Issue 4; Oct-Dec 2008
Capillary hemangioma of tympanic cleft
Authors
Rakesh Kumar Singh,
Ex Assistant Professor, Department of Otolaryngology Head and Neck Surgery,
Sangita Bhandary,
Associate Professor, Department of Otolaryngology Head and Neck Surgery,
Awadhesh Tiwary,
Assistant Professor, Department of Radiology,
Smirti Karki,
Assistant Professors, Department of Pathology
B.P. Koirala Institute of Health Science, Dharan, Nepal
Address For Correspondence
Rakesh Kumar Singh,
Assistant Professor
Department of ENT,
Himalayan Institute of Hospital Trust,
Jollygrant, Doiwala,
Dehradun 248140
E-mail: rksent5@gmail.com
Citation
Singh RK, Bhandary S, Tiwary A, Karki S. Capillary hemangioma of tympanic cleft Online J Health Allied 
Scs. 2008;7(4):8
URL
http://www.ojhas.org/issue28/2008-4-8.htm
http://ojhas.org
OJHAS Vol 7 Issue 4(8)   Singh RK, Bhandary S, Tiwary A, Karki S. Capillary hemangioma of tympanic cleft
1
 Case Report
Submitted: Oct 1, 2008; Accepted: Jan 19, 2009 Published: Feb 25, 2009
Abstract:
We present  an extensive  capillary  hemangioma of  right  ear  in  an  11-year-old  child  involving  external 
auditory canal, middle ear and mastoid. Patient was presented with chronic purulent discharge and aural 
mass in right ear. The Computarize tomography (CT) scan revealed enhancing soft tissue filled density in 
external  ear,  middle  ear  and  mastoid  for  that  modified  radical  mastoidectomy (MRM)  was  done.  The 
histopathological report of surgical specimen confirmed the diagnosis of capillary hemangioma
Key Words: Hemangioma, Capillary, Tympanic cleft.
Introduction:
Hemangiomas are well-known,  benign,  vascular 
tumor commonly seen in head and neck region.1 
They  usually  present  as  a  cutaneous  lesion 
around the parotid gland or in the sub-glottis area 
of larynx. It is extremely rare in external or middle 
ear.2 Only 18 such cases have been reported in 
English literature and out of which, only one with 
hemangioma of middle ear was extended to the 
mastoid cavity. In eight cases, the hemangioma 
was confined to middle ear while,  in other nine 
cases  there  were  isolate  involvement  of  the 
external  auditory  canal  and/or  tympanic 
membrane.1,3 With best of our knowledge, this is 
the  first  case  report  of  tympanic  cleft 
hemangioma  simultaneously  involving  external 
auditory canal, middle ear and mastoid.
Case Report:
A  11  years  old  boy  was  presented  to  the 
Otolaryngology  clinic  of  our  Institution  with  a 
history of right ear discharge since childhood and 
protruding mass from the same ear for 7 years. 
The discharge was non-foul smelled, intermittent, 
purulent,  blood  staining,  increased  with  upper 
respiratory tract infection. He also had gradually 
progressive diminished hearing for last six years. 
There  was  no  history  of  tinnitus,  vertigo,  facial 
nerve symptoms. The review of systems, medical 
and  surgical  history,  and  family  history  were 
unremarkable.  The  local  inspection  of  ear 
revealed  pale,  polypoidal,  painless,  none 
bleeding,  non-friable  mass seems attach to the 
posterior,  superior  and  anterior  wall  of  external 
auditory  canal.  The  tympanic  membrane  could 
not be seen because the mass occluded almost 
the entire external auditory canal. The mass did 
not blanch on pneumatic otoscopy. Left – sided 
otoscopy  was  normal.  Tuning  fork  tests  were 
consistent  with  a  left  conductive  hearing  loss. 
Vestibular examination was unremarkable. There 
was no lymphadenopathy,  and the remainder of 
the head and neck and neurological examination 
was  normal.  Audiological  evaluation  showed  a 
moderate conductive hearing loss in the right ear 
and normal hearing in the left ear. Non-contrast 
CT (Fig 1) followed by contrast enhancing CT of 
mastoid  done  by  3X3mm  axial  and  coronal 
section  revealed  highly  enhancing  soft  tissue 
shadow  in  right  ear  extending  from  external 
auditory  canal,  middle  ear  and  mastoid  air  cell 
system.
Fig 1: CT scan of the temporal bone showing 
soft tissue density in external auditory canal, 
middle ear and mastoid antrum in right ear.
Based  on  the  clinical,  audiological  and 
radiological  evaluation,  the  plan  of  mastoid 
exploration was made under general anesthesia. 
The mastoid drilling revealed vascular mass filled 
the  mastoid  cavity  and  surrounding  air  cell 
system. The mass from the mastoid was cleared 
with  packing and drilling method.  The posterior 
canal wall was lowered carefully that revealed the 
continuity of the same mass in the middle ear and 
external auditory canal with its attachment to the 
canal  wall  skin in  posterior,  superior  and some 
part of the anterior quadrant. At the same time, a 
medium  size  central  perforation  was  noted  in 
tympanic  membrane.  The  entire  mass  was 
removed carefully along with the involve skin of 
the external auditory canal. The long process of 
malleous  and  lanticular  process  of  incus  was 
eroded  while,  stapes  and  facial  canal  were 
normal  in  appearance  and  position.  No  other 
abnormality  was  found  during  operation.  There 
was  complete  cessation  of  bleeding  after 
clearance  of  mass.  The  tympanic  membrane 
perforation  was  closed  with  placement  of  graft 
over the stapes head.  The total amount of blood 
loss was nearly 200ml. Histopathological report of 
the  specimen  revealed  capillary  hemangioma 
(Fig  2).  The  patient  had  an  uneventful 
postoperative  recovery  with  well-epithelialised 
cavity within third postoperative months.
http://ojhas.org
OJHAS Vol 7 Issue 4(8)   Singh RK, Bhandary S, Tiwary A, Karki S. Capillary hemangioma of tympanic cleft
2
Fig  2:  Microscopic  picture  of  the  surgical 
specimen  showing  features  of  capillary 
hemangioma
Discussion:
Hemangiomas  are  well  known  benign  vascular 
malformation  in  head  and  neck  region.  However, 
Intra temporal hemangioma is a rare clinical entity, if 
occurs,  mostly  involves  inner  ear  or  geniculate 
ganglion.4 The  hemangioma  of  external  ear  and 
tympanic cleft is extremely exceptional. Most of the 
reported cases of such hemangiomas were localized 
either to the external auditory canal or to middle ear. 
Tabor  J  R  1965  has  reported  a  case  of  intra 
temporal  hemangioma  involving  middle  ear  and 
mastoid.5 That  was the only case report  revealing 
hemangioma  with  mastoid  involvement,  and  was 
treated with modified radical mastoidectomy (MRM). 
Literature  review  also  revealed  no  case  of 
hemangioma  incorporating  external  canal,  middle 
ear and mastoid simultaneously.  The present case 
is the first case of hemangioma of such extension. 
Hemangiomas typically develop by the age of 1 year 
in  children  and  involutes  by 5  or  6  years  of  age. 
Most of the reported cases of external auditory canal 
and middle ear were diagnosed in adulthood or later 
in life.1 
Hemangiomas  are  commonly  classified  as  either 
capillary or cavernous type. Capillary hemangiomas 
consist  of  closely  arranged  capillary-like  channels 
while,  Cavernous  hemangiomas  are  composed  of 
large cavernous vascular spaces. They are sessile, 
soft, bright red to blue, on a level with the surface of 
the  skin,  or  slightly  elevated,  easily  compressible 
and blench on pressure. Occasionally, pedunculated 
lesions are formed, attached by a broad-to-slender 
stalk.2,6 
The most common presenting features are conduc-
tive hearing loss, pulsatile tinnitus, bloody otorrhoea, 
otalgia and otitis media in order of decreasing fre-
quency. The tumor may accompanied by infection, 
and this may present the atypical features.1,6 Hetche 
D A in 2001 has reported a case of right sided tym-
panic  membrane  and  external  auditory  canal  he-
mangioma in a 4-month-old girl presented with puru-
lent  otorrhoea.4 The otoscopic finding in that  case 
revealed purulent discharge, reddish, polypoidal le-
sion attached to the posterior-superior  quadrant  of 
tympanic membrane extending up to the medial por-
tion of  external  auditory canal  and a small  central 
perforation in tympanic membrane. 
Most  recommended  treatment  is  the  complete  re-
section of the mass. However, only one case of he-
mangioma of middle ear was reported in English lit-
erature underwent spontaneous regression. The re-
currence may occur after incomplete resection.1,4
Our case possessed atypical feature. The initial pre-
sentation was  non-foul  smelled,  intermittent,  puru-
lent, blood staining, increased with upper respiratory 
tract infection. He also had gradually progressive di-
minished hearing for last six years. This was due to 
the presence of concomitant chronic suppurative oti-
tis media in the same year. We did not get the clas-
sic picture of hemangioma that compled us to make 
a clinical  diagnosis of  CSOM with aural  polyp and 
decided  for  mastoid  exploration.  The  excessive 
bleeding tendency of mass with absence of infective 
feature in mastoid gave the suspicion of vascular le-
sion that was confirmed by histopathological report. 
The mass there in mastoid was in the continuity with 
the same mass found in the middle ear and external 
auditory canal. In this respect, this is the first case of 
tympanic cleft hemangioma simultaneously involving 
external auditory canal, middle ear and mastoid.
References:
1. Tokyol  C,  Yilmaz  MD.  Middle  ear  heman-
gioma: A case report. Am J Otolaryngol 2003; 
24:405-407.
2. Reeck  JB,  Yen  TL,  Szmit  A,  Cheung  SW. 
Cavernous Hemangioma of the External Ear 
Canal.  The  Laryngoscope 2002;  112: 
1750-1752.
3. Yang  TH,  Chiang  YC,  Chao  PZ,  Lee  FP. 
Cavernous hemangioma of the body of exter-
nal  auditory  canal.  Otolaryngol  Head  and 
Neck Surg 2006; 134: 890-891.
4. Hecht DA, Jackson CG, Grundfast K M. Man-
agement of middle ear hemangiomas.  Am J 
Otolaryngol 2001; 22: 362-366.
5. Tabor  JR.  Cavernous  hemangioma  of  the 
middle ear and mastoid. Laryngoscope 1965; 
75:673-677.
6. Hiraumi H, Miura M, Hirose T. Capillary he-
mangioma of the tympanic membrane.  Am J 
Otolaryngol 2005; 26:351-352.
http://ojhas.org
OJHAS Vol 7 Issue 4(8)   Singh RK, Bhandary S, Tiwary A, Karki S. Capillary hemangioma of tympanic cleft
3


Capillary hemangioma of the tympanic membrane.

Cavernous hemangioma of the body of external auditory canal. Otolaryngol Head and Neck Surg

Cavernous Hemangioma of the External Ear Canal. The Laryngoscope

Cavernous hemangioma of the middle ear and mastoid. Laryngoscope

Management of middle ear hemangiomas.

Middle ear hemangioma: A case report.

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Capillary hemangioma of tympanic cleft

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