2025 Poster Presentations
P146: SURGICAL MANAGEMENT OF A PAINFUL TEMPORAL BONE EN-PLAQUE MENINGIOMA: A CASE REPORT AND REVIEW OF THE LITERATURE
Prishae Wilson, BS1; Alok A Bhatt, MD2; Mark A Edgar, MD3; Alfredo Quinones-Hinojosa, MD4; Joao Paulo Almeida, MD, PhD4; Mallory Raymond, MD1; 1Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic Florida; 2Department of Radiology, Mayo Clinic Florida; 3Department of Laboratory Medicine and Pathology, Mayo Clinic Florida; 4Department of Neurosurgery, Mayo Clinic Florida
Background: Temporal bone en-plaque meningiomas can be challenging to diagnose and manage in the symptomatic setting of pain. We present a case and a literature review of the surgical management of pain associated with temporal bone en-plaque meningiomas.
Case Report: A 42-year-old female with a history of a left tympanomastoidectomy for chronic otitis media and conductive hearing loss presented for evaluation of worsening headache, otalgia, hearing loss, pulsatile tinnitus, and facial numbness. Otoscopic examination revealed a narrowed external auditory canal and a severely thickened, hypervascular tympanic membrane. An outside preoperative computed tomography (CT) and an updated postoperative CT (Figures 1A and 1B) demonstrated hyperostosis of the external auditory canal, the septa within the mastoid air cells, and the central skull base. Magnetic resonance imaging (MRI) (Figure 2) demonstrated abnormal enhancement in the middle ear cavity, and along the floor of the left middle cranial fossa, suggesting reactive changes or an intraosseous meningioma. She underwent a revision tympanomastoidectomy and ossicular chain reconstruction to obtain a diagnosis and attempt to re-establish middle ear function. Immunohistochemical staining revealed epithelial membrane antigen (EMA)-positive and S100-/SOX10-negative cells (Figure 3), characteristic of meningothelial cells and consistent with an intraosseous meningioma. The postoperative course was uneventful, but debilitating headaches recurred, and her otologic exam reverted to preoperative status three months later. She elected to undergo a temporal craniotomy, subtotal petrosectomy, resection of the meningioma, and abdominal fat graft. Postoperatively she developed temporal encephalopathy, which resolved. The postoperative MRI demonstrated left lateral skull base resection (Figure 4). At six-month follow-up, she reported significant pain improvement.
Literature Review: There have been 24 temporal bone en-plaque meningiomas reported in the literature. Presenting symptoms included tinnitus, hearing loss, aural fullness, headaches, nausea, vertigo, otorrhea, vision loss, dizziness, hoarseness, and shoulder weakness. Four patients presented with pain, but only the patient with trigeminal neuralgia underwent surgery and despite a subtotal resection had resolution of pain. This suggests that factors beyond local inflammation may contribute to pain. Conservative management for the other three patients may have reflected tumor location, comorbidities, or surgical risks. Among the remaining 20 patients without pain, 10 underwent surgery, one received radiation, six were managed conservatively, and management was indeterminate in three cases. No postoperative complications were reported in the surgically managed cases with follow-up.
Conclusion: We report a case of a patient with a temporal bone en-plaque meningioma who experienced significant pain relief after surgical resection. While otologic symptoms are common in temporal bone meningiomas, pain is less frequently reported. Potential sources of pain in this case included osteitis of the middle fossa floor, meningeal inflammation, and both direct and indirect involvement of the facial nerve. Understanding potential pain mechanisms in en-plaque meningiomas is crucial for guiding surgical decisions, even if total resection is not feasible.
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