Cavernous haemangioma of the external auditory canal: clinical case and review of the literature.
ABSTRACT Although benign vascular lesions are frequent in the head and the neck region, clinical evidence of cavernous haemangioma of the external auditory canal is extremely rare; when present, the lesion invades the middle ear space. Herein, a rare case of a soft mass filling the external auditory canal, not involving the tympanic membrane, in a symptomatic 59-year-old male is described. Clinical and audiological characteristics, imaging studies and surgical treatment with histological evaluation are reported, which led to a diagnosis of a cavernous haemangioma. This is only the seventh case described in the literature, to date, not involving the tympanic membrane and the middle ear space. In addition, a review has been made of the relevant literature with respect to epidemiology, presentation, evaluation, pathology, and management options for haemangiomas arising in the external auditory canal.
- The American journal of otology 02/1983; 4(3):198-9.
- Otolaryngology Head and Neck Surgery 02/2002; 126(1):74-5. · 1.73 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Benign vascular lesions are rarely found on the tympanic membrane. We report a case of such a lesion in a novel location, with review of the relevant literature. We also highlight the significance of accurate classification of such lesions, proposing adoption of more pathophysiologically-correct nomenclature of "haemangioma" and "vascular malformation".Indian Journal of Otolaryngology and Head & Neck Surgery 03/2008; 60(1):59-61. · 0.05 Impact Factor
Cavernous haemangioma of the external auditory
canal: clinical case and review of the literature
Emangioma cavernoso del meato acustico esterno: caso clinico e revisione
F. Martines1, D. Bentivegna2, e. Maira†2, s. Marasà3, s. Ferrara1
1 Otorhinolaryngology Clinic, Department of experimental Biomedicine and Clinical neurosciences, (BioneC),
University of Palermo; 2 audiology Clinic, Department of Biopathology and Medical and Forenses Biotechnologies
DiBiMeF, University of Palermo; 3 Pathology Unit, a.r.n.a.s. Civico, Palermo, italy
although benign vascular lesions are frequent in the head and the neck region, clinical evidence of cavernous haemangioma of the exter-
nal auditory canal is extremely rare; when present, the lesion invades the middle ear space. Herein, a rare case of a soft mass filling the
external auditory canal, not involving the tympanic membrane, in a symptomatic 59-year-old male is described. Clinical and audiological
characteristics, imaging studies and surgical treatment with histological evaluation are reported, which led to a diagnosis of a cavernous
haemangioma. This is only the seventh case described in the literature, to date, not involving the tympanic membrane and the middle ear
space. In addition, a review has been made of the relevant literature with respect to epidemiology, presentation, evaluation, pathology, and
management options for haemangiomas arising in the external auditory canal.
Key wordS: External auditory canal • Vascular lesion • Vascular malformation • Cavernous haemangioma
Le lesioni vascolari benigne sono dei quadri patologici di frequente riscontro nel distretto testa-collo, ma l’evidenza clinica di un eman-
gioma cavernoso limitato al meato acustico esterno è estremamente raro; di solito, infatti, la lesione coinvolge, invadendolo, l’orecchio
medio. Gli autori riportano un raro caso di una massa di tessuto a densità della parti molli che occlude il condotto uditivo esterno senza
interessamento della membrana timpanica, in un uomo di 59 anni sintomatico, descrivendone le caratteristiche cliniche, audiologiche,
radiologiche, e strategia chirurgica ‘en bloc’ con diagnosi finale di emangioma cavernoso. Questo rappresenta il settimo caso descritto in
letteratura senza coinvolgimento della membrana timpanica e dell’orecchio medio. Infine, viene riportata una revisione della letteratura
con riferimento alla epidemiologia, presentazione, valutazione clinica e patologica, e possibili opzioni chirurgiche nel trattamento degli
emangiomi del condotto uditivo esterno.
parolE ChiaVE: Condotto uditivo esterno • Lesione vascolare • Malformazione vascolare • Emangioma cavernoso
Acta Otorhinolaryngol Ital 2012;32:54-57
Haemangiomas are soft tissue tumours, common in chil-
dren and young adults, belonging to vascular anomalies;
more that 60% of these occur in the head and neck re-
gion 1. according to mulliken and Glowacki (1982) hae-
mangiomas are commonly classified as either capillary
or cavernous haemangiomas 2. The former consist of
closely arranged capillary-like channels, and may typi-
cally occur in the skin, subcutaneous tissues, lips, liver,
spleen, or kidneys while cavernous haemangiomas are
composed of large cavernous vascular spaces and often
appear in the skin, mucosal surfaces, and internal or-
gans 1 2.
These tumours, that rarely occur after the sixth decade of
life, usually grow intermittently throughout the first year
of life and then go through a quiescent period and even-
tual spontaneous involution, by 5 or 6 years of age 2 3.
Cavernous haemangioma of the external auditory canal
(eaC) is a rare entity, and, when present, usually involves
the tympanic membrane (Tm); so far, only 6 cases have
been reported in the literature describing a lesion limited
to the eaC.
although some authors have found elevated serum lev-
els of angiogenic peptide basic fibroblast growth factor
(bFGF) revealing possibly a genetic role in the first years
of life, the mechanism of occurrence of haemangiomas of
the eaC in adult patients remains obscure 4.
Herein, a case is reported of a soft mass filling the eaC, not
involving the Tm, in a symptomatic adult male that after
histopathological evaluation was found to be the 7th case of
cavernous haemangioma reported in the literature.
aCTa oTorHInolarynGoloGICa ITalICa 2012;32:54-57
Cavernous haemangioma of the external auditory canal
a 59-year-old male came to our department with a one-
year history of mono-lateral hearing loss, pulsative tin-
nitus, intermittent aural pressure associated with episod-
ic otalgia and bleeding from the right external auditory
canal. He denied having had vertigo or auricular trauma
and had no evidence of facial palsy. His family, medi-
cal and otologic history was unremarkable; in particular,
until onset of symptoms he had never had hearing muf-
fling or eustachian tube dysfunction. upon physical ex-
amination, right otoscopy revealed a mass totally filling
the eaC, with well-defined margins. The lesion was soft,
compressible and non-pulsative with pressure; the base
could not be visualized but it was possible to compress the
mass and to observe the antero-inferior portion of the Tm
that appeared normal. The mass did not extend beyond
the meatus into the concha and the auricle was normal.
otoscopic examination of the left Tm was normal. The
findings upon physical examination of the head and neck
were not significant; in particular, there was no lymphad-
enopathy and flexible fiberoptic nasopharyngoscopy and
vestibular examination were normal.
weber test at 512 Hz was to the right side, and bone con-
duction was greater than air conduction in the same ear.
a pure tone audiogram showed right mild mixed hearing
loss with an average air-bone gap of 35 dB (pure conduc-
tive type at 250-2000 Hz, with a sensorineural hearing loss
component at 4000 and 8000 Hz). The discrimination score
was 96% at 85 dB in the affected ear. High resolution com-
puted tomography (HrCT) of the temporal bone, without
contrast agents, showed a 1.8 cm soft-tissue mass lateral
to the tympanic membrane that filled the right external au-
ditory canal without involvement of the epitympanum and
adjacent bony wall (Fig. 1). There was no evidence of bone
erosion, and the tympanic membrane, the middle ear and
the ossicles appeared normal (Fig. 2a-b).
under general anaesthesia, this lesion was smoothly ex-
cised, under an otomicroscope, by an endo-aural approach.
The mass, based on the postero-inferior portion of the
bony canal, was excised en bloc by elevating the skin in
continuity with the lesion from the canal without entering
the middle ear space; the bone of the eaC was normal in
appearance. Bleeding was controlled with cautery.
The histological diagnosis was characteristic of cavern-
ous haemangioma revealing numerous thick-walled blood
vessels lined by endothelial cells and containing red blood
cells (Fig. 3). The post-operative course was uneventful
and the audiogram showed recovery of the conductive
component of the hearing loss. Further clinical examina-
tions, until now, show no evidence of the original mass.
Benign vascular lesions are tumours that frequently involve
the head and the neck region. In 1982, mulliken and Glow-
acki developed a system of classification that divided these,
on the basis of their histological and natural history char-
acteristics, into 2 categories: haemangiomas and vascular
malformations 2. Haemangiomas, correctly defined as “cap-
illary haemangiomas”, are made up of closed arranged cap-
illary-like channels secondary to a proliferative endothelial
process that more frequently occurs in infancy and progres-
sively disappears before the age of 5-6 years 1-4.
In contrast, “cavernous haemangiomas” are made up of large
cavernous vascular spaces and more frequently appear after
the sixth decade of life; being vascular malformations, their
clinical presentation, anatomical changes and progression are
strongly correlated to infection, trauma, ligation, attempted
excision or changes in serum hormone levels 1-5.
Fig. 1. Axial computed tom-
ography, without contrast me-
dia, showing a mass lateral
to the tympanic membrane
filling the right external audi-
Fig. 2. Coronal computed to-
mography showing: (a) lesion
limited to external auditory ca-
nal without involvement of the
epi-tympanum and adjacent
bony wall; (b) no evidence of
bone erosion; tympanic mem-
brane, middle ear and the os-
sicles appear normal.
Fig. 3. Pathologic examination revealed numerous thick-walled blood ves-
sels lined by endothelial cells and containing red blood cells. The appearance
is characteristic of cavernous haemangioma (haematoxylin and eosin, origi-
nal magnification × 400).
F. martines et al.
as stated above, cavernous haemangiomas of the exter-
nal auditory canal clinically occur in asymptomatic or
symptomatic patients with an average age of 59 ± 2.8
years. These lesions appear to affect both sexes, but oc-
cur more often in females than in males. as in this case,
when present, symptoms are blood-tinged otorrhoea, au-
ral fullness, hearing loss and pulsatile tinnitus. otoscopic
examination reveals the presence of a small sessile or pe-
dunculated, purple mass, based either in the anterior or,
as in this patient, in the posterior segments of the eaC,
not involving the mT. diagnostic tests include a pure tone
audiometry, HrCT of the temporal bone and\or magnetic
resonance imaging (mrI), which are essential to deline-
ate the extent of the tumour, the possible presence of os-
seous erosions and to perform differential diagnosis, bet-
ter clarified by a histopathological evaluation that must
exclude a malignant lesion (carcinoma) and/or other pos-
sible entities such as: glomus tumour, attic chole-steatoma
with aural polyp, arterio-venous malformation, granula-
tion tissue. angiography may be useful to identify and
embolize any feeding vessels supplying advanced lesion
with excessive bleeding expected. To date, the treatment
of choice is complete surgical excision with an end-aural
or trans-canal approach, even if watchful waiting is rec-
ommended for small asymptomatic lesions 10 13 14 16 20 21 23.
The postoperative course is usually uneventful. recur-
rence was described in only one of the 7 cases reported,
which was probably due to the fact that the implant was
based close to the TmJ, and involved the temporal bone,
thus requiring a more extensive approach 21.
In summary, the case described here, in accordance with
the literature, confirms that external auditory canal hae-
These entities usually occur in the head and neck region,
but evidence of a cavernous haemangioma of the eaC,
with or without involvement of the Tm, are extremely
rare. So far, only 19 cases have been described in the lit-
erature, and, only in 7 cases, the patients presented a le-
sion limited to the eaC (Table I) 6-22.
The first of these cases was described, in 1987, by Hawke
and van nostrand, who reported a 55-year-old male pa-
tient in whom a cavernous haemangioma arose from the
left antero-inferior canal wall 10. The patient presented
blood-tinged otorrhoea and no hearing loss. The lesion
was easily removed and bleeding controlled with cautery.
limb et al., in 2002, presented the case of a cavernous
haemangioma situated in the postero-superior left ear ca-
nal adjacent to the anulus occluding the entire external
auditory canal with Tm intact, in a 67-year-old female
with a history of mixed hearing loss, tinnitus and aural
fullness 13. The mass was removed by endaural surgical
resection. In the same year, reeck et al. reported a new
case of cavernous haemangioma isolated in the postero-
inferior portion of the left eaC in a 53-year-old man with
conductive hearing loss and tinnitus, excised by the endo-
aural approach 14. In 2006, yang et al. described a lesion
occupying the left eaC without involvement of the mT
in an asymptomatic 72-year-old female. In this case, exci-
sion was through a trans-cranial approach 16. Covelli et al.,
in 2007, described a small lesion in a 45-year-old female
submitted to surgical treatment by endaural excision 20; fi-
nally, rutherford et al., in 2009, reported a new clinical
case, in a 62-year-old female, situated in the antero-infe-
rior external auditory canal that, after end-aural excision
recurred involving the temporal bone and temporo-man-
dibular joint (TmJ). It was completely excised by a trans-
canal approach and TmJ arthrotomy 21.
Table I. Cavernous haemangiomas limited to external auditory canal described in the literature.
Hawke & van
Limb et al.2002
Reeck et al.200253/M LeftEndaural excision
Yang et al.200672/FLeftTrans-canal
Endaural excisionCovelli et al. 200845/F -Right-
Rutherford et al. 201062/FBleeding, aural
Martines et al.201159/MBleeding, aural
Cavernous haemangioma of the external auditory canal
1 mcClay Je, Zapalac JS. Skin tumors, vascular lesions, face
and neck. emedicine. 2006. http://www.emedicine.com/ent/
2 mulliken JB, Glowacki J. Hemangiomas and vascular malfor-
mations in infants and children: a classification based on en-
dothelial characteristics. Plast reconstr Surg 1982;69:412-22.
3 yeo a, majithia a, Kalan a. Haemangioma or vascular
malformation of the tympanic membrane? a case report and
review of literature. Indian J otolaryngol Head neck Surg
4 mcGill TJI, Forsen JwJ, mulliken JB. Hemangiomas and
vascular anomalies of the head and neck. In: Cummings
Cw, editor. Otolaryngology Head and Neck Surgery. St.
louis: mosby; 1998. p. 66-80.
5 Martines F, immordino V. Arteriovenous malformation of
the base of tongue in pregnancy: case report. acta otorhi-
nolaryngol Ital 2009;29:274-8.
6 Freedman Si, Barton S, Goodhill V. Cavernous angiomas of
the tympanic membrane. arch otolaryngol 1972;96:158-60.
7 Balkany TJ, meyers ad, wong ml. Capillary hemangioma of
the tympanic membrane. arch otolaryngol 1978;104:296-7.
8 andrade Jm, Gehris Cw, Breitenecker r. Cavernous heman-
gioma of the tympanic membrane: a case report. am J otol
9 Kemink Jl, Graham md, mcClatchey Kd. Hemangioma of
the external auditory canal. am J otol 1983;5:125-6.
10 Hawke m, van nostrand P. Cavernous hemangioma of the
external ear canal. J otolaryngol 1987;16:40-2.
11 Jackson CG, levine SC, mcKennan KX. Recurrent hemangi-
oma of the external auditory canal. am J otol 1990;11:117-8.
mangiomas, in an adult age, are rare benign lesions and
it is necessary to take them into consideration in the dif-
ferential diagnosis of external auditory canal masses. The
diagnostic approach therefore requires the use of physi-
cal, audiologic and HrCT evaluation, always associated
with a histo-pathological study by, when possible, ‘en
bloc’ excision of the lesion that reduces the possibility of
address for correspondence: dr. F. martines, via autonomia Si-
ciliana 70, 90143 Palermo, Italy. Fax +39 091 6554271. e-mail:
received: december 3, 2010 - accepted: January 6, 2011
12 Bijelic l, wei Jl, mcdonald TJ. Hemangioma of the tympanic
membrane. otolaryngol Head neck Surg 2001;125:272-3.
13 limb CJ, mabrie dC, Carey JP, et al. Hemangioma of the
external auditory canal. otolaryngol Head neck Surg
14 reeck JB, yen Tl, Szmit a, et al. Cavernous hemangioma of
the external ear canal. laryngoscope 2002;112:1750-3.
15 Hiraumi J, miura m, Hirose T. Capillary hemangioma of the
tympanic membrane. am J otolaryngol 2005;25:351-2.
16 yang T, Chiang y, Chao P, et al. Cavernous hemangioma
of the bony external auditory canal. otolaryngol Head neck
17 Pavamani SP, Surendrababu nrS, ram TS, et al. Capil-
lary haemangioma involving the middle and external ear:
radiotherapy as a treatment method. australasian radiol
18 Verret DJ, Cochran S, DeFatta rJ, et al. External au-
ditory canal hemangioma: case report. Skull Base
19 magliulo G, Fusconi m. Capillary hemangioma of the tym-
panic membrane. am J otolaryngol 2007;28:180-3.
20 Covelli e, Seta ed, Zardo F, et al. Cavernous haemangioma
of external ear canal. J laryngol otol 2008;122:e19.
21 rutherford Kd, leonard G. Hemangiomas of the external
auditory canal. am J otolaryngol 2010;31:384-6.
22 Bovo r, Ciorba a, Castiglione a, et al. Cavernous heman-
gioma of external ear: case report and literature review. B-
23 Zheng Jw, Zhou Q, yang XJ, et al. Treatment guideline for
hemangiomas and vascular malformations of the head and
neck. Head neck 2010;32:1088-98.