Otolaryngology Case Reports 5 (2017) 18e20

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Otolaryngology Case Reports

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Osteoma of the superior petrous portion of the temporal bone

Cynthia Tsay a, Apoorva Tewari Ramaswamy b, Ajay Malhotra c, Elias Michaelides d, *
a
Yale School of Medicine, New Haven, CT, United States
b
Department of Otolaryngology, New York Presbyterian, Columbia-Cornell, New York, NY, United States
c
Department of Radiology, Yale School of Medicine, New Haven, CT, United States
d
Department of Otolaryngology, Yale School of Medicine, New Haven, CT, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Osteomas are benign, often asymptomatic, bony osteoblastic lesions of mesenchymal origin,
Received 18 March 2017 often presenting in the head and neck with an estimated prevalence of 0.42%. Osteomas can be found in
Received in revised form the sinuses, mandible, and rarely in the temporal bone and are often found incidentally in imaging
13 September 2017
studies. Common symptoms for osteomas in the temporal bone include hearing loss, tinnitus, vestibular
Accepted 25 September 2017
Available online 28 September 2017
dysfunction, and external swelling.
Methods: We present a rare case and analysis of the clinical and radiographic presentation of an osteoma
located in the petrous part of the temporal bone.
Discussion: Osteomas of the temporal bone, while rare, most commonly occur in the external auditory
canal. A few cases of osteomas presenting on the petrous part of the temporal bone have been described.
Knowledge of the existence of osteomas in this location can assist in the appropriate diagnosis, man-
agement, and care of patients presenting with sensorineural hearing loss and abnormal radiological
findings.
Conclusion: In patients with auditory symptoms such as tinnitus or hearing loss with abnormal osseous
findings on MRI, CT can assist in diagnosis. The differential diagnosis of such lesions includes osteomas,
pneumoceles, pneumocephalus, parosteal osteosarcoma and osteoblastoma. Thorough radiological
assessment can be valuable in reaching the correct diagnosis, and can prevent unnecessarily aggressive
management and treatment for benign osseous lesions.
© 2017 Published by Elsevier Inc. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).

1. Introduction
Osteomas are benign osseous lesions that arise on the perios-
teum. Their location is most commonly in the skull and sinuses,
particularly in the frontal sinus (70%), and they occur very rarely in
flat bones. Temporal bone osteomas occur more frequently in
women in a 2:1 ratio, while osteomas of the external auditory canal
occur twice as often in men [1,2]. The most common locations of
temporal bone osteomas are in the external auditory canal and then
the mastoid. These lesions are typically asymptomatic, though they
can cause cosmetic issues in more superficial locations, such as a
mass in post-auricular area pushing the pinna forward and in-
fections from obstruction of sinuses [3]. Other functional symptoms
associated with temporal bone osteomas include pain, conductive
hearing loss, chronic external otitis, and ear canal obstruction [4].
* Corresponding author.
E-mail address: elias.michaelides@yale.edu (E. Michaelides).
Neurologic symptoms such as seizures may also arise if the osteoma
is located on the inner table of the skull, though this presentation is
rare [1].
2. Case report
A 58-year old female presented with one year of left-sided
tinnitus and recent history of decreased hearing in the left ear.
She denied any recent head trauma or history and loud noise
exposure and was otherwise healthy. On physical exam, the Weber
test lateralized to the right side, with air conduction greater than
bone on Rinne bilaterally. An audiologic exam demonstrated mild
sensorineural hearing loss from 3000 to 8000 Hz on the left side
and mild sensorineural hearing loss at 8000 Hz on the right.
Magnetic resonance imaging (MRI) was ordered to rule out
retrocochlear pathology due to the asymmetric sensorineural
hearing loss. No abnormal lesion or enhancement was seen in the
internal auditory canal. The inner ear structures including the co-
chlea appeared unremarkable. However, MRI demonstrated a 2 cm

https://doi.org/10.1016/j.xocr.2017.09.001
2468-5488/© 2017 Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 C. Tsay et al. / Otolaryngology Case Reports 5 (2017) 18e20 19

markedly T2 hypointense region that was continuous with and had
similar signal characteristics to the left mastoid air cells (Fig. 1). The
mass extended superiorly from the petrous apex to abut the infe-
rior aspect of the left temporal lobe without any signal changes in
the adjacent brain parenchyma. No abnormal enhancement was
seen. The patient was sent for a computed tomographic scan (CT) of
the brain to further investigate the bony structures, which
demonstrated a densely ossified lesion superior to the petrous
segment of the temporal bone in the same location as the
hypointensity on MRI (Fig. 2). Neurosurgery recommended posi-
tron emission tomography (PET) to rule out osteosarcoma and this
lesion corresponded to a photopenic area (Fig. 2) [5].
After consultation with neurosurgery, the decision to follow the
osteoma was made given the patient's mild symptomatology and
the risks of excision. In six years of follow-up with imaging and
audiologic testing, there has been no growth of the lesion or
worsening of left sided hearing.

Fig. 1. MRI Coronal T1 WI with contrast (a) and Axial T2 WI without IV contrast (b) demonstrate a well circumscribed, lobulated 2 cm rounded hypointense structure on the left that
appeared continuous with the mastoid air cells but extended above the normal superior margin of the temporal bone near the left temporal lobe. Lack of enhancement and signal on
T1, T2, and FLAIR suggested hyperpneumatization of left mastoid air cells (arrows).

Fig. 2. Clockwise from top left a) Coronal and b) Axial CT without IV contrast revealed a 2.1  2.4  2.1 cm lobulated dense cortical bone in the left temporal bone in the same
location as the hypodense region of the MRI. c) PET imaging demonstrated a photopenic area at the lesion site. The osteoma extended superiorly from the petrous bone.
20 C. Tsay et al. / Otolaryngology Case Reports 5 (2017) 18e20
3. Discussion
The differential diagnosis for these osteoblastic lesions includes
parosteal osteosarcoma and osteoblastoma. Unlike the other le-
sions, osteomas do not have extraosseus soft tissue extension or
perilesional changes. Given the extra-axial, intracranial location of
this tumor, meningioma should also be considered, though the CT
findings with the absence of surrounding edema, a dural tail or
adjacent osteolytic lesion should rule it out. The diagnosis was
initially delayed because of the MRI findings suggestive of pneu-
mocele versus pneumocephalus.
The initial concern, given the isointensity of the lesion to the
mastoid air cells, was for pneumocephalus or hyperpneumatization
of mastoid air cells. However, the patient's chronic, non-septic
presentation without history of trauma, instrumentation, or
recent barotrauma was not typical for pneumocephalus. Charac-
teristic findings of osteomas on CT include a well-circumscribed
lobulated, densely calcified mass on CT and on all MRI sequences
a hypointense mass no appreciable medullary cavity [6]. On PET
scan, osteomas present as a photopenic mass.
Osteomas are classified as hamartomas by the World Health
Organization and consist of a highly vascular central nidus often
surrounded by dense reactive sclerosis [7]. In the temporal bone,
they occur most frequently in the mastoid and squama, presenting
on clinical exam as a hard and bony palpable mass. The etiology of
osteomas formation remains uncertain, however studies have hy-
pothesized trauma, infection, irritation from blood vessels, and
hormonal factors may play a role in the development of these tu-
mors [2].
Temporal bone osteomas, such as the one seen in our patient,
are rare. The majority of these arise in the external auditory canal
and the mastoid process, while there are case reports of pre-
sentations in the internal auditory canal [8]. Rarer yet are osteomas
of the petrous portion of the temporal bone with only six case re-
ports currently in the literature [9]. Those localized in the internal
auditory canal can also present with similar symptoms of hearing
impairment and balance problems, and imaging is the best method
of distinguishing between the two.
Histological studies can also help confirm diagnosis of osteomas
and are characterized by hard, dense lamellar bone beneath intact
mucosa [1]. Surgical treatment can be an option in cases of severe
symptomatic sequelae due to compression or for cosmesis, how-
ever the majority of osteomas can be left untreated.
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