hemangiomas are common lesions of the head and neck area , and they predominantly originate from the lips , tongue and buccal mucosa .
the capillary type is lobulated and it lacks a capsule , it is purplish in color and it infiltrates the involved glands .
microscopically , solid masses of cells and multiple anastomosing capillaries that replace the acinar structure of the gland are seen .
the cavernous type is formed by dilated blood vessels or sinusoids lined by endothelium ( 1 ) .
cavernous hemangioma of the external auditory canal ( eac ) and tympanic membrane is rare , but this lesion is more common in the eac . according to the previously reported cases ( 2 - 8 ) , cavernous hemangioma seems to most frequently arise in the posterior portion of the eac .
however their incidence in the tympanic membrane is very rare and there have been only 4 such case reports in the literature according to a medline search from 1970 to 2008 ( 9 - 12 ) .
we report here the 5th case of isolated cavernous hemangioma that was limited to the tympanic membrane and we review the relevant literature .
a 49-year - old man patient was referred to our department for evaluation of right - sided pulsatile tinnitus that he had experienced for the previous 2 years .
the patient denied having hearing loss or vertigo and he had no evidence of facial palsy .
endoscopic examination of the eac revealed a red - colored soft non - pulsatile mass that occupied part of the tympanic membrane ( fig .
the tympanic membrane was partially obscured by the mass and it was not clearly mobile .
a pure tone audiogram ( pta ) showed high frequency mild sensorineural hearing loss in the right ear at 3,000 - 8,000 hz ( fig .
2 ) . temporal bone computerized tomography ( ct ) showed an isolated soft tissue mass just lateral to the tympanic membrane .
a tympanomeatal flap was elevated to reveal a mass with involvement of the tympanic membrane .
the mass was spongy on palpation , and it was removed en bloc with little bleeding .
the defect of the tympanic membrane was reconstructed by type i tympanoplasty and using a piece of fascia taken from the temporal muscle .
pathologic examination of the specimen showed a well - demarcated nodular lesion composed of dilated vascular spaces lined by a single layer of flat endothelial cells ( fig .
the postoperative endoscopic examination showed an intact state of the neo - drum with good ventilation .
in 1983 , andrade et al . ( 10 ) reported the first case of cavernous hemangioma limited to the tympanic membrane in a 59-year - old man with a contralateral ear infection . according to the previously reported cases , cavernous hemangioma seems to most frequently arise in the posterior portion of the eac .
conductive hearing loss , tinnitus and aural fullness may be present . in the present case ,
the differential diagnosis includes aural polyp , glomus tumor , arteriovenous malformation , granulation tissue and carcinoma of the eac .
a temporal bone ct scan is the first choice for the evaluating the location and size of the lesion and middle ear involvement .
the majority of the previously reported cases showed a normal middle ear . only 1 case reported by magliudo et al .
( 8) had cavernous hemangioma that initially involved the middle ear space through a small perforation in the tympanic memrane and the tumor had reached the handle and the short process of the malleus . for an advanced lesion , diagnostic angiography should be obtained to identify the blood supply to preoperatively assess the safety and feasibility of performing embolization ( 5 ) .
surgical treatment with en bloc excision is generally curative , and preoperative embolization is usually not necessary except for an advanced lesion .
the endaural approach is generally used . in this case , we removed the mass by the postauricular approach due to the size of the mass .
 cavernous hemangioma seems to most frequently arise in the posterior portion of the external auditory canal . 
 however , they rarely occur in the tympanic membrane . 
 a 49-year - old male patient was referred for evaluation of right - sided pulsatile tinnitus that he 'd experienced for the previous 2 years . 
 temporal bone computerized tomography showed an isolated soft tissue mass just lateral to the tympanic membrane . 
 there was no evidence of bony erosion or middle ear invasion . 
 the patient underwent excision of the mass using a postauricular approach . 
 the mass was removed en bloc and the defect of the tympanic membrane was repaired by tympanoplasty type i. there was no recurrence after 1 year of follow - up . 