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Glomus Tympanicum Tumor--A rare presentation in a tertiary care hospital of

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 CASE REPORT

GLOMUS TYMPANICUM TUMOR – A RARE PRESENTA-

TION IN A TERTIARY CARE HOSPITAL OF PESHAWAR
Syed Shahmeer Raza1, Amer Kamal Hussain2, Halla Saboor3, Muhammad Salman Haider Qureshi4

ABSTRACT
INTRODUCTION: Glomus tympanicum tumor is a benign but most common tumour of the middle ear with relatively
good prognosis if detected early. These tumours arise from paraganglionic tissue and are innervated by parasympathet-
ic autonomic nervous system (PANS). They are more common in females. The spread of these tumours is multidirectional
and simultaneous. They may be asymptomatic or present with pulsatile tinnitus. On examination, the eardrum shows a
rising sun or setting sun appearance. On CT scan, we can see a soft tissue mass lateral to the cochlear promontory which
may fill the middle ear cavity. Surgical resection is the treatment of choice.
We present a case of 40 years old anemic female who presented to us with a history of constant pain, progressive left
ear hearing loss and a mass in left ear for the last 3 months. On CT, we saw a soft tissue density lesion enhancing the
middle ear and protruding into the external ear.
KEY WORDS: Glomus tumor, Glomus tympanicum tumor, Glomus jugulare tumor

This article may be cited as: Raza SS, Hussain AK, Saboor H, Qureshi MSH. Glomus Tympanicum Tumor – A
rare presentation in a tertiary care hospital of Peshawar. NJMS. 2016; 1(3):138-40

INTRODUCTION
Glomus tympanicum tumour is a very rare, benign, lo-
cally invasive and slow growing tumor of middle ear. It is
the most common primary neoplasm of the middle ear and
the second most common tumor of the temporal bone.1
Glomus tympanicum is one of the two types of Glomus
tumors. Glomus tumors originates from glomus bodies.2
Glomus bodies are normal constituent of neuro-endocrine
system.3 Glomus tympanicum is the glomus body of mid-
dle ear. It also acts as a chemoreceptor and helps in the
maintenance of optimum middle ear pressure.4
The glomus tumors can classified into Fisch type A and
Fisch type B.5 The former is also known as glomus tym-
panicum tumour and latter is also known as glomus jug-
ulare tumor. Glomus tympanicum tumors originates from
Jacobson’s nerve while on the other hand glomus jugulare
tumors arise from jugular vein that is present in the jugular
fossa.6 Glomus jugulo-tympanicum refers to an extra-ordi-
nary large tumor that cannot be distinguished or it also re-
fers to the glomus jugulare tumor when it reaches the mid-
dle ear. Due to the difference in surgical management of
each type of glomus tumor it is highly significant to make a
1-3
Khyber Medical College, Peshawar Pakistan.
4
Institute of Public Health and Social Sciences, Khyber Medical
University, Peshawar Pakistan.
proper differentiation between Fisch type A and Fisch type
B. The two tumors are differentiated from each other by
determining status of bone erosion on the jugular bulb.
Fisch type B tumor is characterized by extensive erosion.
For that purpose imaging of temporal bone carries a huge
significance. A combination of magnetic resonance imag-
ing along with computed tomography is performed for the
correct diagnosis. In order to evaluate the precise size of
tumor along with the feeding vessels, carotid aeteriogra-
phy is performed. This imaging technique is also helpful for
pre-operative embolisation. However embolisation of glo-
mus tympanicum tumors is not necessary.7 Though most
temporal bone paragangliomas are diagnosed clinically
and radiologically8, they are confirmed histopathologically
by the presence of monomorphic cell nests, vascularized
stroma and S-100 protein immuno-stains for chromogr-
anin, synaptophysin and sustentacular cells.
The presenting features, usually in middle-aged women
include pulsatile tinnitus, recurrent ear bleeding, deafness,
otalgia, dizziness and facial and lower cranial nerve palsies.
9
Glomus tumors can be treated with radiotherapy or sur-
gery. However, the standard treatment is surgical excision
which often requires sophisticated and extensive proce-
dures and can also result in severe peri-operative hemor-
rahage.10

Address for correspondence: CASE PRESENTATION

Dr. Muhammad Salman Haider Qureshi
Institute of Public Health and Social Sciences, Khyber Medical
University, Peshawar, Pakistan. A 40 years old female presented to the otolaryngology
Email: pmc.salmanqureshi@gmail.com outpatient department (OPD) of Khyber Teaching Hospital
Received Date March 03, 2016
Revised Date May 15, 2016
Accepted Date May 29, 2016

138
NJMS Vol. 1 No. 3 July – September 2016
 GLOMUS TYMPANICUM TUMOR – A RARE PRESENTATION IN A TERTIARY CARE HOSPITAL OF PESHAWAR
Peshawar with a history of post operative bleeding after an
attempt to excise a mass in her left ear at some peripher-
al hospital in countryside. She gave a history of constant
pain and mass in the left ear for 3 months duration and
progressive left-sided hearing loss with it. According to her
the pain relieved after taking pain killers. There was no his-
tory of vertigo, diabetes mellitus, hypertension or ischemic
heart disease. There was also no evidence of seventh or
other cranial nerve deficit or vestibular finding.
On examination the patient was anemic but not jaun-
diced, no abnormalities detected in her systemic exam-
ination. Tuning fork tests showed Rinne’s negative in left
ear and Weber’s test showed lateralization to the left ear.
A Computed Tomography (CT) of the temporal bones re-
vealed soft tissue density enhancing middle ear protruding
into external ear. The mass was eroding middle ear ossicles
and basal turn of cochlea. There was no erosion of scutum
and fluid was seen in left mastoid air cells. Para nasal sinus-
DISCUSSION
During fetal development, migration of neural crest
cells occurs which gives rise to paraganglionic tissue, the
tumours of which are called as Paragangliomas or Glomus
tumours. These tumours are innervated by the parasympa-
thetic autonomic nervous system (PANS). They function as
chemoreceptors for the regulation of circulation. Glomus
tympanicum paragangliomas, also called chemodectomas
are the most common middle ear tumors & second most
common head and neck paraganglioma. Glomus tym-
panicum paragangliomas arise from the inferior tympanic
branch of glossopharyngeal nerve or Jacobson nerve at the
cochlear promontory.
Incidence is greatest at age of 40 and more in females
than in males, the ratio being: female to male is equal to
3:1.5,6 Approximately 25% are multicentric, and these tend
to be familial. They may be asymptomatic or present with
pulsatile tinnitus. If the tumour is large, it may cause con-
ductive hearing loss. Facial nerve palsy, sensineural hearing
loss or vertigo may result if the facial nerve or inner ear
becomes involved.
Examination may reveal a retrotympanic vascular mass.
NJMS Vol. 1 No. 3 July – September 2016
es and included sections of brain appeared normal.
FIG (A)(B)(C): In this axial CT scan of the brain of the
patient, soft tissue density lesion enhancing the middle ear
and protruding into the external ear. Mass eroding middle
ear ossicles and basal turn of cochlea. There was no ero-
sion of scutum and fluid was seen in left mastoid air cells.
Para nasal sinuses and included sections of brain appeared
normal.
These findings were suggestive of the possibilities of
cholesteatoma or glomus tumor. A diagnosis of glomus
tympanicum tumor was established and modified radical
mastoidectomy was done in the left ear and all the middle
ear cleft was examined which was occupied by the mass.
Clearance of the mass was done but its clearance from hy-
potympanicum was doubtful because of profuse bleeding.
The patient was kept under observation in the otolaryngol-
ogy ward for couple of days and was then subsequently
discharged.
The eardrum shows a rising sun or setting sun appearance.
On microscopy, we can see a group of Type I or catechol-
amine containing chief cells and Type II or sustentacular
cells, lined with a rich network of capillaries and venules.11
Although histologically benign, these are slow growing,
locally destructive & invasive tumours. Glomus tumours
are non-metastasizing. The spread of these tumours is
multidirectional and simultaneous.
Computed tomography (CT) scan is the best modali-
ty for investigation of Glomus tympanicum. We can see a
normal jugular fossa and a normal carotid canal on Axial
CT and Coronal CT respectively. The jugular bulb is also
intact. CT shows a soft tissue mass lateral to the cochlear
promontory which may fill the middle ear cavity. It usually
spares the ossicles.12
On magnetic resonance imaging (MRI), larger tumours
may show a “salt and pepper” appearance on T1-weighted
signal. Salt is due to the blood products from haemorrhage
which is very uncommon. The pepper can be seen due to
flow voids because of high vascularity which is quite com-
mon.
Angiography demonstrates an intense tumour blush,
with the most common feeding vessel being the ascend-
139
 GLOMUS TYMPANICUM TUMOR – A RARE PRESENTATION IN A TERTIARY CARE HOSPITAL OF PESHAWAR
ing pharyngeal artery. Scintigraphy demonstrates high up-
take.13 14
Surgical resection is the treatment of choice.15 The
size and the extent of the glomus tumour determine the
surgical procedure needed.16 Type 1 glomus tympanicum
tumours are generally approached by trascanal tympanot-
omy while Type 3 tumours require mastoidectomy with
extended facial recess approach. However, Type 4 glomus
tumours need intracranial surgical excision of the tumour.17
ACKNOWLEDGEMENT
We acknowledge the study participants who took time out for this
study and shared their experience and views.
NOTES ON CONTRIBUTORS
The study was part of SSR, AKH, HS & MSHQ all authors were
involved in every part of Manuscript writing, analysis, Protocol
developments, and data collection process.
CONFLICT OF INTEREST
Authors declare no conflict of interest.
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