PMC5362871_01
(a) The medial portion of the left external ear canal is filled with strongly and homogeneously contrast-enhancing soft tissue attenuating material (1). The ear canal lining is moderately contrast enhancing (compared with the right). The left tympanic bulla is filled with mildly and homogeneously contrast-enhancing material (3). Similar moderately enhancing material is seen extending ventromedially from the left bulla tympanica. A rim of strong contrast enhancement outlines this region (2). (b) The material seen ventromedial to the tympanic bulla continues caudally and forms a 1.6 cm (width) x 1.3 cm (height) x 2.5 cm (length) soft tissue structure, poorly enhancing centrally but strongly enhancing peripherally (1). This mass (*) distorts local tissue architecture such that the nasopharyngeal lumen is narrowed >50%, and the hyoid bones are displaced laterally. Additionally, at this level, there is a rim of contrast enhancement seen in the ventral aspect of the left temporal lobe of the cerebrum (2). (c) At the level of the caudal aspect of the left tympanic bulla, the soft tissue lesion can still be seen ventromedial to the bulla (1). Additionally, there is a rim of contrast enhancement outlining a hypoattenuating area in the left lateral cerebellum (2). There is poorly contrast-enhancing soft tissue attenuating material in the caudal fossa that is displacing the brainstem dorsally and to the right (3). Additionally, there is strong meningeal contrast enhancement in this region. (d) The poorly contrast-enhancing material in the cranial cavity can be followed further caudally, to the level of the atlas. This image, at the level of the foramen magnum, demonstrates abnormal tissue (arrow) displacing and compressing the cervical spinal cord (*) dorsally and to the right. (e) Bone window computed tomography image at the most caudal aspect of the bulla. Note the discontinuity of the temporal bone (black arrows), indicative of bony lysis
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A CT (Siemens Emotion Duo 2 slice CT scanner; GE Healthcare Australia) examination of the head was performed using soft tissue and bone spatial reconstruction algorithm and 1 mm slice thickness pre- and postintravenous contrast (iohexol; 10 ml [300 mmol/l] IV) (Figure 1), followed by video-otoscopic examination. The medial portion of the left external ear canal and left tympanic bulla were filled with homogenous, contrast-enhancing soft tissue attenuating material (Figure 1a). Ventromedial and rostral to the tympanic bulla, a region (1.6 cm width x 1.3 cm height x 2.5 cm length) of poorly contrast-enhancing tissue, outlined by a rim of strong contrast enhancement (Figure 1b) causing a mass effect, was seen, which compressed the nasopharyngeal lumen by >50% and displaced the hyoid bones laterally (Figure 1b). In the caudal left bulla, there was bony lysis of the temporal bone (Figure 1e). Adjacent to the lytic region of the temporal bone, contrast enhancement outlining a hypoattenuating area with broad dural base was seen (Figure 1c). Poorly enhancing material extended caudally along the left ventral portion of the brainstem to mid first cervical vertebra, displacing and compressing the brainstem and cranial spinal cord, accompanied by strong meningeal contrast enhancement (Figure 1d).
Video-otoscopic photograph of the left tympanic membrane, which appears to have been breached by abnormal inflammatory tissue (arrows), which extends into the tympanic bulla
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The mass traversed the tympanic membrane, and was contiguous the tympanic bulla (Figure 2), in agreement with CT findings.