Glomulus Tympanicus

History - 50 year old male with a history of 6 months of pulsatile tinnitus and progressive diminished right sided hearing of 3 months, intermittent otorrhea from the right ear for ten years, disease free asymptomatic, no history of vertigo,

• hypertensive for three years
• no history of diabetes mellitus or ischemic heart disease
• stenosis of right external auditory canal and presence of pulsatile mass behind the right tympanic membrane
• brown's sign was performed and positive
• no evidence of seventh (facial) or other cranial nerve deficit or vestibular finding
• systematic examination was essentially normal
• suggest cholesteatoma
• needs CT/MRI imaging will show enhanced mass occupying the middle ear, with extension to mastoid, infiltrating tegmen plate
• ossicles surrounded by mass which engulfed the tympanic membrane
• extended anteriorly into the eustachian tube, posteriorly into the mastoid cavity and superiorly in contact with the dura
• as get heartbeat up the tinnitus is worse

Otoscopy - asymmetrical, rising sun sign, vascular mass, 

Glomus tympanicum is the most common primary neoplasm of the middle ear and the second most common tumor of the temporal bone

• slow growing, locally destructive, spreading along paths of least resistance
• conductive hearing loss and pulsatile tinnitus
  • most common presenting symptoms
• CT and MRI scans are the primary imaging modalities used in evaluating the size and extent of glomus tumors
• superselective angiography with embolisation aids in identifying and blocking the feeding arteries, thereby reducing bleeding during surgery
• surgery and radiotherapy are the two modalities of treatment available
• arise from neuroectodermal tissues
• there are two anatomic groups of paragangliomas
  • cervical paraganliomas
    • carotid body tumors
    • glomus vagale tumors
  • temporal bone (jugulotympanic)
    • glumus jugulare
    • glomus tympanicum
      • more common than glomus tumors around jugular vein and are the most common primary neoplasms of the middle ear and second most common tumor of the temporal bone
• 1941, guild first described "glomic tissue" in temporal bone
• slow growing, locally destrctive non-metastiasizing spreading along paths of least resistance
• spread is multidirectional and simultaneous
• main routes of the spread are the air cell tracts of the temporal bone but spread through and beyond the temporal bone is not uncommon, via eustachian tube, vascular lumens and neurovascular foramina
• patient age averages 50 to 60 years at presentation
• female:male incidence is 4:1
• most common presenting symptoms include conductive hearing loss and pulsatile tinnitus
• conductive hearing loss occurs when tumor impairs the normal vibration of the ossicles or bones behind the eardrum
• sensorineural hearing loss and/or dizziness can result rarely, if the tumor has invaded the inner ear
• other symptoms may include aural hemorrhage or otorrhea, otalgia and facial palsy
• aquino's sign is the blanching of the tympanic mass with gentle pressure on the carotid artery
• while brown's sign descrbves the pulsation elicited by pneumatic compression that is abolished with further compression
• on physical examination, the hallmark of a jugulotympanic gloumus tumor is a reddish-blue mass seen behind the tympanic membrane.
• hypertension, tachycardia, tremor, or complaints of vascular headaches alerts the possibility of a functional tumor

other symptoms

• one ear normal, one ear conductive
• one ear could show high frequency loss since it effects people that are 50-60
• the other ear needs to show a conductive hearing loss
• this means that tymps are normal one ear and conductive for another
• reflexes would be normal in one ear and show a tumor in the other
  • depending on facial nerve palsy
• srt would show conductive in one ear and normal in the other
• word recognition would be 100% with amplification
• ucl would be normal in one ear and off the charts in the conductive ear

​https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923042/