Annals of Otolaryngology and Rhinology

An En Plaque Meningioma of the Temporal Bone, Complicating with a Cholesteatoma, Chronic Otitis Media and an Intracranial Abscess.

Short Communication | Open Access

  • 1. Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, USA
  • 2. Department of Neurologic Surgery, Thomas Jefferson University, USA
+ Show More - Show Less
Corresponding Authors
Marc Rosen, Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, 925 Chestnut St 6th floor, Philadelphia, PA, USA Tel: 2159556760, Fax: 215503-3736

Introduction: Large cranial base defects after transsphenoidal surgery exposes  the brain to iatrogenic injury via insertion of endonasal tubes. It has been reported in  the literature that nasogastric tubes have inadvertently been placed into the brainstem  or spinal cord postoperatively. This can have devastating ramifications including  neurologic sequelae or fatality. For these reasons, it is prudent to implement surgical  techniques to help protect the cranial base against iatrogenic injury after endoscopic,  endonasal skull base surgery.
Methods: We performed a Pub Med literature review of cases of inadvertent  intracranial placement of a NGT. We categorized the causes as traumatic, nontraumatic, and surgical, and identified trends to assess potential risk factors. Articles  not in English were excluded from our review.
Results: We identified 37 articles describing 41 instances of a misguided NGT  intracranially. Twenty-seven cases (65.8%) were in the setting of trauma, 7 (17%) in  non-traumatic settings, and 7 (17%) after surgery. Sixteen of forty-one (39%) died  of various causes and 5 (31.3%) were directly attributable to intracranial insertion of  the NGT.
Discussion: We describe several techniques to protect the cranial base including  middle turbinate preservation and medialization, limited posterior nasal septectomy  and trans-septal approaches. In addition, we provide a video illustrating the how the  cranial base is protected using these methods.
Conclusion: Operative techniques in endoscopic transsphenoidal skull base  surgery that facilitate closure of the sphenoid sinus likely decrease the risk of  postoperative iatrogenic injury via inadvertent placement of  tubes.

Cite this article

 Saat R, Lempinen LJ, Laulajainen-Hongisto A, Markkola A, Jero J (2015) An En Plaque Meningioma of the Temporal Bone, Complicating with a Cholesteatoma, Chronic Otitis Media and an Intracranial Abscess. Ann Otolaryngol Rhinol 2(7): 1050.


CT: Computed Tomography; MRI: Magnetic Resonance Imaging; CPA: Cerebellopontine Angle


Meningiomas are mostly benign tumors that represent 13– 26% of all intracranial neoplasms [1]. They have been found to be more common in the sixth and seventh decade of life and in female patients [2]. There are two well-established risk factors for meningioma development: a deletion in NF2 gene and exposure to ionizing radiation. Meningiomas developing after high dose irradiation of cerebral glioma, lymphoma, leukemia or metastases tend to have higher rate of atypism than in average population [3].

Meningioma enplaque is a rare clinical-biological form of meningioma, characterized by carpet-like growth along the meninges, and invasion of dura along with underlying bone hyperostosis [4]. The prevalence of meningioma en plaque is reported to be 2-9% of all meningiomas [4]. The most common site for en plaque meningiomas is sphenoid wing; Intraosseous meningiomas of the temporal bone make up less than 1% of all meningiomas [4,5].

The bony changes, caused by meningioma, are often called “reactive hyperostosis”. Histological samples from meningioma en plaque, however, have revealed true tumor growth inside the bone, which is likely to induce periosteal new bone formation [6,7]. Affected bone typically becomes thick and sclerotic, narrowing the intraosseous spaces and canaliculae, and compressing cranial nerves and vascular structures. Obliteration of the external ear canal and middle ear spaces can further predispose for inflammation and cholesteatoma development [8,9].



A 76-year-old Caucasian female patient was referred to ENT surgeon because of a fistulous lesion and complaints of recurrent inflammation of the right ear. She had a previous medical history of atrial fibrillation, and a right temporal lobe low-grade astrocytoma that had been treated by surgical removal and radiotherapy 15 years ago. Years after she developed narrowing of the external ear canal and a fistulous lesion anterior and caudal to the right auricle that had been surgically excised. A postoperative CT scan showed thickening of the right temporal bone reminiscent of fibrous dysplasia or Paget´s disease. No signs of brain tumor recurrence were noted in CT.

Current physical examination revealed a hard prominence in the right mastoid process region. External ear canal was almost obliterated. Anterior and caudal to the right auricle was a fistula that excreted pus and slightly hemorrhagic fluid. Laboratory findings where unremarkable except for the elevated C-reactive protein level (44mg/l). The patient underwent another CT scan in order to further characterize the nature and extent of the fistula, as well as its possible connection to skull base pathology and previous brain tumor. CT revealed marked sclerotic thickening of the right temporal bone, obliteration of the middle ear air spaces, and an expansile mass in the right cerebellopontine angle (CPA). In MRI, this CPA mass had cystic appearance, showed strong rimenhancement after gadolinium administration and had restricted diffusion. It was first erroneously interpreted to be a cystic vestibular schwannoma.

Operation was performed by retroauricular translabyrinthic approach, extended with canal-wall-down tympanomastoidectomy, aiming at tumor removal, cleaning of mastoid process, and opening of the external ear canal. Surgical exploration revealed immature, highly vascularized bone, reminiscent of fibrous dysplasia. External ear canal was completely obliterated by fibrous tissue. The tympanic cavity, attic and antrum were filled by edematous mucous membrane and excessive soft tissue. Small cholesteatomas were found in the medial part of the external ear canal and in the tympanic cavity. Extended mastoidectomy towards the medial and posterior cranial fossa revealed pathological dura. Behind the posterior wall of the internal acoustic meatus, surprisingly, a capsulated collection of pus was found in the inner acoustic meatus and CPA. No soft tissue tumor additional to the abscess was noted in the intracranial space during surgical exploration. In the postoperative period, the patient received antimicrobial treatment with vancomycin 0.5 x 2 i.v. and ceftriaxone 2.0 x 1 i.m. Due to concomitant diseases and deterioration of her general condition the patient was transferred to the internal medicine department where she unfortunately died of pleuropneumonia on the 6-th postoperative day. Intraoperatively taken histological samples from the external ear canal, middle ear cavity and mastoid region showed inflammatory changes as expected. Samples from the temporal bone, however, contained Intraosseous meningothelial neoplastic growth, compatible with benign meningothelial meningioma. Post mortem examination confirmed pleuropneumonia as the cause of death. Neuropathological examination revealed residual inflammation and post-treatment changes in the right temporal lobe and cerebellum. No signs of meningioma or recurrent astrocytoma appeared in the brain parenchyma. Cerebral pathology was excluded to be the cause for patient’s death.


Our patient had a history of previous radiotherapy for ipsilateral cerebral glioma that may have provoked the meningioma development. However, the exact extension of previous radiation field is not known to the authors, and the causal relation between previous radiation and current tumor remains hypothetical. The meningioma had an en plaque growth pattern inside the temporal bone, invading tympanic cavity and narrowing the external ear canal. Latter induced cholesteatoma development, which later complicated with chronic recurrent middle and external ear infection, formation of a fistula and an intracranial abscess.

Intratemporal meningiomas can affect external ear canal, tympanic cavity and temporal bone per se or multiple subsides. Associated cholesteatoma is present in 25% of cases [5]. Histologically, intratemporal meningiomas are similar to their intracranial counterparts, exhibiting a variety of histological patterns, out of which the most prevalent is meningothelial variant [5]. Compared to the prominent bony changes, the intracranial soft tissue component of a meningioma en plaque is usually unremarkable, which often poses diagnostic problems for the radiologist. The diagnostic entities, that meningioma en plaque can be confused with, are fibrous dysplasia, osteoma, Paget’s disease, chronic osteomyelitis, and sclerotic metastases of the scull – fibrous dysplasia likely being the most common misdiagnosis. In our case, radiological studies were performed elsewhere and bony changes were initially misdiagnosed as fibrous dysplasia, and CPAtumor as a cystic vestibular schwannoma.

Kim et al. have proposed some typical CT features suggestive for meningioma en plaque that could help discriminating it from fibrous dysplasia. These are: periosteal pattern of hyperostosis, inward bulging of scull vault, surface irregularity of the hyperostotic bone, and intracranial changes such as vasogenic edema of the brain adjacent to the hyperostotic bone [10]. MRI features suggestive to meningioma en plaque are linear dural thickening and enhancing soft tissue around the affected bone, which correlate with the extraosseous soft tissue component of the tumor [11]. Latter aids differentiating meningiomas from intrinsic fibro-osseous skull base lesions which show no such extraosseous soft tissue component. The differential diagnosis of dural thickening and enhancement includes several diseases ranging from sarcoid, bacterial or granulomatous meningitis, lymphomas, gliomas, and post-irradiation changes to meningeal carcinomatosis. In actual diagnostic work-up, CT and MRI are completing each other: CT shows better details of the bone involvement whereas MRI demonstrates the dural enhancement and soft tissue components of the tumor. Second look at our patient’s CT images revealed typical features for meningioma en plaque, described by Kim: the irregular margins of the thickened bone, periosteal hyperostosis, and inward bulging of the inner table (Figure 1). In MRI, meningeal thickening and enhancement were apparent (Figure 2). None of these is typical for fibrous dysplasia, which in skull base usually causes bone expansion without changing its general shape and anatomical peculiarities. Another characteristic finding in fibrous dysplasia is the ground glass appearance of the affected bone that should not be confused with the bone thickening and sclerosis caused by a meningioma. In contrary to meningioma, fibrous dysplasia does not cause irregularities of bone margins nor does it cause extraosseous soft tissue growth around the affected bone [11].

Another confusing finding in our case was the mass-lesion at the CPA, initially misdiagnosed as a cystic vestibular schwannoma. Vestibular schwannomas with large cystic component may cause differential diagnostic difficulties, as opposed to typical solid and strongly enhancing counterparts. In this case, however, diffusion weighted imaging was performed and showed strong diffusion restriction inside the lesion, which is not characteristic for cystic vestibular schwannomas. Non-enhancing, extra-axial CPA lesion with restricted diffusion is typically an epidermoid

with practically no other differentials [12]. Now, with this case, an otogenic intracranial abscess can be added to this differential diagnostic list. In radiological community, brain abscesses are generally known to present with such diffusion characteristics. This time, the unusual location of the abscess might have been the reason for misdiagnosis.

In conclusion, in the diagnostic work-up of sclerotic expansive skull base lesions a meningioma en plaque should be kept in mind. In the temporal bone, bone-invasive meningioma may lead to serious otological complications. By using some helpful imaging criteria, provided in the literature and summarized in this article, misdiagnoses could possibly be avoided.


Preparation of the manuscript has been supported by Helsinki University Hospital research funds.


1. Marosi C, Hassler M, Roessler K, Reni M, Sant M, Mazza E, et al. Meningioma. Crit Rev Oncol Hematol. 2008; 67: 153-171.

2. Jääskeläinen J, Haltia M, Laasonen E, Wahlström T, Valtonen S. The growth rate of intracranial meningiomas and its relation to histology. An analysis of 43 patients. Surg Neurol. 1985; 24: 165-172.

3. Sadetzki S, Flint-Richter P, Ben-Tal T, Nass D. Radiation-induced meningioma: a descriptive study of 253 cases. J Neurosurg. 2002; 97: 1078-1082.

4. Amirjamshidi A, Abbasioun K, Amiri RS, Ardalan A, Hashemi SM. Lateral orbitotomy approach for removing hyperostosing en plaque sphenoid wing meningiomas. Description of surgical strategy and analysis of findings in a series of 88 patients with long-term follow up. Surg Neurol Int. 2015; 6: 79.

5. Thompson LD, Bouffard JP, Sandberg GD, Mena H. Primary ear and temporal bone meningiomas: a clinicopathologic study of 36 cases with a review of the literature. Mod Pathol. 2003; 16: 236-245.

6. Pieper DR, Al-Mefty O, Hanada Y, Buechner D. Hyperostosis associated with meningioma of the cranial base: secondary changes or tumor invasion. Neurosurgery. 1999; 44: 742-746.

7. Matschke J, Addo J, Bernreuther C, Zustin J. Osseous changes in meningioma en plaque. Anticancer Res. 2011; 31: 591-596.

8. Becker BC, Tos M. Post inflammatory acquired atresia of the external auditory canal: treatment and results of surgery over 27 years. Laryngoscope. 1998; 108: 903-907.

9. Ayache D, Trabalzini F, Bordure P, Gratacap B, Darrouzet V, Schmerber S, et al. Serous otitis media revealing temporal en plaque meningioma. Otol Neurotol. 2006; 27: 992-998.

10.Kim KS, Rogers LF, Goldblatt D. CT features of hyperostosing meningioma en plaque. AJR Am J Roentgenol. 1987; 149: 1017-1023.

11.Kösling S, Neumann K, Brandt S. CT and MRI of intrinsic spaceoccupying lesions of the bony skull base. Radiologe. 2009; 49: 598- 607.

12Lakshmi M, Glastonbury CM. Imaging of the cerebellopontine angle. Neuroimaging Clin N Am. 2009; 19: 393-406.

Received : 09 Sep 2016
Accepted : 10 Oct 2016
Published : 12 Oct 2016
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X