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.