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These actual case reports in Penn’s complex cases series reveal the intricacy, sophistication, and complexity of the surgeries performed every day at Penn Otorhinolaryngology — Head and Neck Surgery.

Case Study from our Complex Cases Series

Douglas C Bigelow, MD, Director, Division of Otology/Neurotology; Associate Professor of Otorhinolaryngology – Head and Neck Surgery
Jason A. Brant, MD, Assistant Professor of Otorhinolaryngology – Head and Neck Surgery

Ms. S, a 49-year-old female, presented to our clinic with right sudden sensorineural hearing loss, facial numbness, and taste changes, seeking further evaluation after an MRI showed a mass in her temporal bone (Figure 1).

Scan of head and neck
Figure 1. Axial cut MRI showing a right enhancing lesion in the petrous apex of the right temporal bone.

The mass surrounded important structures in the temporal bone adjacent to the brainstem, including her inner ear, carotid artery, facial nerve, and jugular bulb (Figure 2).

Initially, this mass was thought to be a benign entity called a glomus tumor, but her surgeon at Penn felt that there were imaging characteristics atypical for this diagnosis.

Corona MRI
Figure 2. Coronal cut MRI showing a right enhancing lesion adjacent to the brainstem, extending into the internal auditory canal and involving the jugular bulb.

Her imaging was reviewed at a multi-disciplinary conference for complex skull base patients with specialists from rhinology, neuro-otology, neurosurgery, radiation oncology, neuro-radiology, and genetics. She underwent biopsy and tumor debulking in the operating room through a retrosigmoid approach with her neuro-otologist, Dr. Douglas Bigelow, and neurosurgeon, Dr. Jonathan Lee. Results by surgical pathology demonstrated that the mass was actually a invasive tumor—a chordoma. A PET scan was performed, showing the temporal bone lesion as noted, but no other lesions throughout the body (Figure 3).

PET of head and neck
Figure 3. Axial cut PET scan showing activity in the right temporal bone lesion.

The patient subsequently underwent resection by a transcochlear and translabyrinthine approach, again with a collaborative effort between Drs. Bigelow and Lee. The patient underwent surgical resection without complications or lower cranial nerve injury, and the lateral skull base defect was reconstructed with a fat graft and bone cement (Figure 4). She will undergo future radiotherapy with proton beam therapy.

Post op MRI
Figure 4. Axial cut MRI showing post-operative appearance with resection of the mass and abdominal fat graft reconstruction of the lateral skull base.

Discussion

This case illustrates how the experience, expertise, and collaborative approach at Penn Medicine has the power and potential to improve patient care. The diagnosis of chordoma in this case was particularly unusual, as these tumors usually have different imaging characteristics and are centrally located, which was not seen in this case. Thanks to the coordinated efforts between otolaryngology, neurosurgery, radiology, radiation therapy, and pathology, Ms. S was able to get appropriate and skillful care in a coordinated fashion for an unusual and complex diagnosis.

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