Case Report
Case Report
Case Report
Presentator:
dr. Hasan Rizky Benokri
Moderator:
dr. SR. Indrasari
2
neurofibroma the tumor cells are not limited (< 0.5 cm) soft tissue involvement or
encapsulated, have dense consistency and tumour involving the middle ear and/or
increased mitosis.5,6 mastoid. T4: tumour eroding the cochlea,
petrous apex, medial wall of the middle ear,
On radiological examination, CT Scan
carotid canal, jugular foramen, or dura, or
shows lesions that are isodens well-defined,
with extensive soft tissue involvement (> 0.5
homogeneous, more clearly with contrast. A
cm), or evidence of facial paresis. N0: no
CT scan can also reveal the spread of
regional lymph node metastasis. N1: a single
schwannoma from other areas such as the
regional metastatic lymph node < 3 cm.
middle ear, mastoid or internal auditory
N2a: a single ipsilateral metastatic lymph
canal.6,7
node measuring 3—6 cm. N2b: several
There is no current consensus about ipsilateral metastatic lymph nodes < 6 cm.
the TNM staging system for these tumors by N2c: contralateral metastatic lymph node
the Union Internationale Contest Cancer N3: metastatic lymph node > 6 cm. Tumor
(UICC) or the American Joint Committee on stage, Stage I: T1 N0, Stage II: T2 N0, Stage
Cancer (AJCC). However, since the III: T3 N0, Stage IV: T4 N0 and T1 - T4 N1
beginning of the 1990s, Pittsburgh has - N3.8
issued EAC carcinoma's classifications
Schwannoma is an encapsulated
based on radioclinical features and has been
lesion, and therefore can easily be removed
widely used in international literature and
from the surrounding tissue. The best
has been proven to be reliable and
therapy for EAC schwannoma is excision
reproducible.7,8
with either the transmeatal or retroauricular
The staging system based on approach. The choice of approach is based
Pittsburgh that has been modified as on tumor size, location and relationship to
follows, T1: tumour limited to the EAC the surrounding area. If complete excision
without bony erosion or evidence of soft has been done, recurrency is very rare.8
tissue involvement. T2: tumour with limited
CASE REPORT
external auditory canal bone erosion (not
full thickness) or limited (< 0.5 cm) soft A 34-years-old female patient came to the
tissue involvement. T3: tumour eroding the ENT Policlinic RSUP dr. Sardjito with a
osseous bone EAC (full thickness) with complaint of a lump in the right ear canal. A
3
lump in the right ear canal was felt since Indirect laryngoscopy is within normal
about 6 months ago. The patient also limits. On neck examination theres is no
complained of decreased hearing in the right presence of palpable mass.
ear and get worsen. Complaints of ringing in
At the tuning fork examination,
the ears, ear pain, discharge, bleeding from
Rinne's right ear is negative and left
the right ear, itchy, dizziness and facial palsy
positive. Weber lateralizes to the right.
are denied.
Examination of the Schwabach on right ear
Patients have no complaints in the extends and the left is the same as the
nose and throat. History of allergies and examiner. CHL impression of the right ear.
asthma are denied. History of diabetes
On audiometry examination, there is mild
mellitus is denied. The patient also had
CHL in the right ear and normal hearing in
never felt a similar complaint before. There
the left ear. Computer tomography (CT)
is no family with a history of the same
scan of the temporal bone demonstrated a
disease.
well-circumscribed soft tissue mass in the
On physical examination, the patient's lateral part of the external auditory canal
general condition is good, compos mentis. posterior wall. The mass showed patchy
The patient's vital signs are blood pressure contrast enhancement with no invasion of
110/70 mmHg, pulse 78x/m, temperature middle ear or surrounding bone or
36.5 0C and breathing 18x/m. cartilaginous structures. in this patient,
preoperative histopathological examination
On the physical examination of the
was performed and schwannoma was
right ear, on EAC was found that the mass
obtained.
covered the ear canal so the right ear
tympanic membrane could not be assessed. Based on anamnesis, physical
Examination of the left ear is within normal examination and adjunct examination the
limit and intact tympanic membrane. patient diagnosed with Schwannoma of
Anterior and posterior rhinoscopic External Auditorius Canal Dextra and
examination there are no visible hyperemic planned to mass resection. The issue of this
mucosa or concha edema and no dischage. case is about the diagnosis.
Oropharyngeal examination there is no
DISCUSSION
visible post nasal drip, T1-T1 tonsils.
4
A nerve fiber consists of an axon complained of a lump in the right ear since 6
wrapped in Schwann cells. Between the months with decreased hearing in the right
axons and Schwann cells there is a myelin ear confirmed by a tuning fork and
sheath that originates from the Schwann audiometry examination with the presence
cell.9 of a mild conductive hearing loss of the right
ear.4
Schwann sheath or also called
neurilema sheath consists of flat cells that On CT scan examination, there is an
form a thin layer around myelin. The isodens lesions in the right EAC which
Schwann sheath and myelin at regular cause narrowing of the distal EAC. Based on
distances are cut off by the ranvi node. the location of the tumor, it is most likely
Schwann cells cover nerve fibers and serve derived from n. VII or n. X. This is in
to accelerate the course of nerve impulses.9 accordance with the theory that EAC
Schwannoma can come from n. V, n. VII, n.
In Schwann cells can grow a slow-
IX, n. X.10
growing benign capsule tumor, called
Schwannoma. Schwannoma covers As the CT scan indicated that the mass
peripheral nerves, cranial nerves and was most likely benign, a presurgical or fine
autonomic nerve fibers. Several studies have needle aspiration (FNA) biopsy was not
reported that these tumors located in the performed. Polyposition CT of the temporal
outer ear, generally involving EAC and are bone including axial and coronal projections
very rare in the auricle.. 2,3,9 is the most informative method of
visualization of the bony part of the EAC.
The age range of schwannoma of EAC
Axial projection covers the anterior and
cases which found in the literature is
posterior walls of the canal whilst coronal
between 30-60 years. In this case, the patient
projection covers the upper and lower walls.
is 34 years old.2
Hence, CT scanning is able to characterize
A common symptom experienced in EAC changes (soft tissue, bone, size,
patients with schwannoma of EAC is the position). Radiological imaging by CT scan
presence of a mass or lump in EAC with or shows schwannomas to be well-
without hearing loss. Very rarely found circumscribed, homogenous masses that
neurogenic symptoms such as pain and enhance with contrast. CT scan is also
paresthesia. In this case, the patient
5
mandatory to rule out the extension of a are usually benign, their resection can be
schwannoma from other temporal bone sites associated with significant postoperative
(middle ear, mastoid or internal auditory morbidity such as cicatricial stenosis or
canal) to present as an external ear canal infection. Appropriate therapy requires
mass.10 complete excision with minimal injury to
uninvolved areas.11,12
Definitive diagnosis should be based
on the histological and immune- Generally, two options have been
histochemical findings. Typically, proposed most frequently: transmeatal and
histological analysis demonstrates that a postauricular approaches. When surgery is
schwannoma is composed of S-100 protein planned, the best approach will inevitably
positive Schwann cells arranged in 2 growth depend on the tumor location, size and its
patterns, namely Antoni A and B. The relations to surrounding structures. Most
former is a highly cellular pattern and cases of schwannoma reported to date have
composed of elongated Schwann cells, only partially occupied the external ear canal
which exhibit nuclear palisading. The cavity and the largest tumor did not exceed 3
Antoni B areas are also composed of cm in diameter. Consequently, transmeatal
elongated Schwann cells, but these are or endaural approaches have been employed
arranged in a less dense myxoid pattern and most frequently.13
are more disorganized than Antoni A areas.
SUMMARY
In contrast to schwannomas, neurofibromas
frequently occur in multiples and are not A 34 years old female patient came to
encapsulated. This along with the fact that the Sardjito Hospital ENT Policlinic with a
they are less likely than schwannomas to chief complaint of a lump in the right ear
undergo cystic degeneration may also help canal since 6 months ago with decreased
6
examination confirmed Schwannoma 5. Lesi Jinak Telinga. Modul otology.
(neurilemmoma) showing Antoni A cells, 2015. Kolegium PERHATI
Antoni B cells, and Verocay bodies.
6. Thompson LD, et al. Update from the
The patient was diagnosed with 4th Edition of the World Health
schwannoma of external auditory canal Organization Classification of Head and
dextra. Then the patient has done mass Neck Tumours: Tumor of the ear. Head
resection without any complication after the and neck pathol 2017; 11:78-87
surgery.
7. McNulty BN, et al. Facial nerve
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the ear and lateral skull base. Dalam
Bailey BJ, Johnson JT. Head & Neck 8. Ouaz K, et al. Cancer of the external
SurgeryOtorhinolaryngology. 5th ed. auditory canal. European Annals of
Philadelphia: Williams & Wilkins 2014. Otorhinolaryngology, Head and Neck
P: 2358-83 diseases 2013; 130 : 175-82
7
Bogaz Ihtis Derg (India). 2015;
25(4):229-231