Case 36-2015

Dr. Konstantina M. Stankovic: A 27-year-old woman was seen in an outpatient otolaryngology clinic of the Massachusetts Eye and Ear Infirmary, which is affiliated with this hospital, because of a pruritic lesion of the left ear canal, with recurrent bleeding. One year before this presentation, a ballooning lesion had developed in the patient’s left ear canal that partially occluded the lumen and was associated with pruritus and recurrent bleeding. An unknown medication was administered topically into the ear canal, with improvement in both bleeding and pruritus. Two weeks before this presentation, bleeding from the left ear canal recurred, with associated pruritus of both ear canals. The patient was seen by a physician at another clinic, who prescribed an otic suspension (consisting of neomycin, polymyxin B sulfate, and hydrocortisone) and a 5-day course of oral azithromycin, as well as topical clobetasol propionate ointment (0.05%) for pruritus; the symptoms did not improve, and the bleeding did not resolve. She was referred to the outpatient otolaryngology clinic of the Massachusetts Eye and Ear Infirmary. The patient reported brief episodes of sharp, stabbing otalgia on the left side, with episodes of disequilibrium that lasted for a few seconds and were not associated with vertigo, tinnitus, or changes in hearing. She had not had recurrent otitis media during childhood, exposure to loud noises, or head trauma with loss of consciousness. She took no other medications and had no known allergies. She worked in a health-related field. She did not smoke or drink alcohol. On examination, the patient appeared to be well, with no craniofacial dysmorphism. A light pink raised lesion (approximately 1.0 cm by 1.0 cm by 0.5 cm), with a cobblestone appearance and several prominent vessels, was present on the posterior tragus of the left ear; on examination with an operating microscope, the lesion extended medially along the anterior wall of the external auditory canal. The eardrums, medial left ear canal, and entire right ear canal were normal. There was no tragal tenderness. A 512-Hz tuning fork was used to show that the Rinne test was positive bilaterally (with air conduction greater than bone conduction) and that, on the Weber test, the sound was located along the midline. The remainder of the From the Departments of Otolaryngolo‐ gy (K.M.S.) and Pathology (P.M.S.), Mas‐ sachusetts General Hospital, the Depart‐ ments of Otolaryngology (K.M.S., P.M.S.) and Laser and Reconstructive Surgery (O.T.T.), Massachusetts Eye and Ear Infir‐ mary, and the Departments of Otology and Laryngology (K.M.S., O.T.T.) and Pa‐ thology (P.M.S.), Harvard Medical School — all in Boston.