Capillary hemangioma – postoperative radiosurgery for residual tumor

SKULL BASE REGION	Jugular foramen
HISTOPATHOLOGY	Capillary hemangioma
PRIOR SURGICAL RESECTION	Yes
PERTINENT LABORATORY FINDINGS	None

Case description

The patient is a 60-year-old male who presented with right unilateral conductive hearing loss associated with a reddish mass involving the inferior aspect of the tympanic membrane and the medial external auditory canal. He had no lower cranial nerve deficits prior to presentation. Magnetic resonance imaging (MRI) with contrast revealed an avidly enhancing lesion involving the middle ear with extension inferiorly to the lateral jugular bulb (ipsilateral dominant sinus) ( Figure 10.46.1 ). The location was a bit unusual for either a tympanic or jugular paraganglioma given that it was neither centered on the promontory nor the jugular bulb. In addition, it did not demonstrate the typical pattern of osseous erosion or prominent flow voids. The patient elected to undergo initial surgical resection for pathologic diagnosis, improvement of conductive hearing loss, and possible curative treatment. Intraoperatively, a subtotal resection was performed as the tumor involved the jugular bulb, and the surgeon elected to leave the dominant sinus intact. The lateral aspect of the tumor was removed and the patient’s conductive hearing loss resolved ( Figure 10.46.2 ). Although intraoperative frozen section pathology was consistent with paraganglioma, final pathology confirmed a diagnosis of intraosseous capillary hemangioma. Following subtotal resection, the patient and skull base team elected to treat the residual tumor with stereotactic radiosurgery (SRS) 6 months after surgery ( Figure 10.46.3 ).