(1134) A Rare Differential of Epistaxis

Introduction: Glomus tympanicum is a paraganglioma that affects the middle ear. It can be challenging to manage due to its hyper-vascularity, location, and advanced stage at diagnosis.

Description: A 48-year-old female with a history of hypertension presented with sudden onset large volume hemoptysis preceded by a rattling breathing sound. She denied use of anticoagulants or antiplatelets. There was no preceding trauma or prior history of nosebleed. On arrival, vitals were normal and physical exam was pertinent for obvious ongoing bleeding from her mouth. Examination revealed increased respiratory effort and bilateral crackles. Laboratory values were pertinent for hemoglobin of 11.8 g/dl. Chest CT showed patchy centrilobular ground glass opacities. Bronchoscopy was deferred due to suspicion of pseudo-hemoptysis from aspirated blood. Ear exam revealed a large vascular appearing mass filling the right ear. MRI face & neck showed an avidly enhancing 3.7 cm x 1.8 cm x 1.2 cm mass within the right middle ear and mastoid cavity, extending into the external auditory canal as well as through the eustachian tube into the nasopharynx. The mass was inseparable from the lateral border of the internal auditory canal in the petrous canal. Due to concern for glomus tympanicum, she underwent urgent embolization and subsequent tumor resection.

Discussion: Glomus tympanicum commonly presents with pulsatile tinnitus and conductive hearing loss. Physical exam is important in demonstrating a pulsatile retrotympanic mass. It is commonly located in the right ear, likely due to the dilated and elevated jugular bulb. As this is a slow glowing tumor, some patients may not require surgery. Considering our patient presented with initial large volume hemoptysis, there was concern for alveolar hemorrhage. However, as she had no increased oxygen requirement, there was suspicion for massive epistaxis mistaken for hemoptysis. Due to large volume epistaxis, she underwent urgent embolization as resection could have been challenging due to increased vascularity. It is important to remain aware that massive epistaxis may not present with blood in the anterior nares, thereby delaying diagnosis and management. Furthermore, probing such tumours should be avoided to avoid a life-threatening bleed.