Methods:
A non-contrast temporal bone computed tomography (CT) was obtained as
part of her workup for conductive hearing loss, which revealed an
inconspicuous lenticular process of the incus and head of the stapes,
suggesting a possible malformation. Incidentally, a well-defined,
lipomatous lesion was identified at the junction of the left nasopharynx
and oropharynx, just posterior to the soft palate (Figure 1). Notably,
the patient attributed no symptoms to the mass on further probing,
denying any issues suggesting velopalatal insufficiency or
nasopharyngeal obstruction.
Based on the clinical examination and imaging, our differential
diagnoses for the mass included a benign lesion such as lipoma, abnormal
lymphoid tissue from Waldeyer’s ring, and lower on the list, a
lymphovascular lesion, antrochoanal polyp, juvenile angiofibroma or a
malignancy. After discussing of risks, benefits, and alternatives with
the patient, she elected to pursue a middle ear exploration with
intraoperative nasopharyngeal endoscopy and biopsy. Standard sinonasal
rigid endoscopy was performed in the operating theatre which
demonstrated a well-circumscribed, smooth mass with fine hairs in the
oropharynx (Figure 2A). The mass was noted to be pedicled at the left
lateral wall at the junction between the oro- and naso-pharynx at the
level of the soft palate. After identifying the lesion and determining
that this was unlikely to be malignant or vascular in nature, an
extended tip Bovie was used to truncate the pedicle. Due to its size, a
transoral approach was required to remove the mass. Pathological
analysis revealed a polypoid, tan-white, smooth, and hair-bearing mass
measuring 2.7 x 1.8 x 1.5 cm (Figure 2B).
Histopathological evaluation demonstrated skin appendages and
fibro-adipose stroma, accompanied by mild chronic inflammation and
scattered mast cells. Additionally, the stalk contained minor salivary
gland tissue and cartilage (Figure 2C, 2D). These unexpected findings
were determined to be consistent with an accessory tragus, a rare
developmental abnormality originating from the first pharyngeal arch.
The subsequent middle ear exploration revealed a foreshortened incus
long process and absent stapes capitulum consistent with congenital
ossicular discontinuity. The stapes was found to be mobile and an
ossicular chain reconstruction was performed to connect the tympanic
membrane and malleus to the stapes, bypassing the incus. The patient was
seen in the clinic two weeks post-operatively and was healing well with
no new symptoms. A follow-up audiogram revealed an improvement from a
pre-operative moderate to severe hearing loss to a two-month
post-operative mild hearing loss in the left ear.