Giant-cell reparative granuloma of the temporal bone: a case report and review of the literature - Original Article

Ear, Nose & Throat Journal, Dec, 2003 by Carsten Christof Boedeker, Gian Kayser, Gerd Jurgen Ridder, Wolfgang Maier, Jorg Schipper

Abstract

Giant-cell reparative granuloma (GCRG) is an unusual, non-neoplastic fibrous lesion that most often arises in the mandible and maxilla. GCRG of the temporal bone is exceedingly rare. To the best of our knowledge, only 17 cases have been previously reported in the international medical literature. Although no case of metastasis has been reported, this malignancy can be locally aggressive, and it often recurs following incomplete excision. We report the case of a young woman with a very large GCRG of the right temporal bone. We discuss the clinical picture, differential diagnosis, histologic evaluation, appearance on computed tomography and magnetic resonance imaging, and treatment options. We also review the cases of temporal bone GCRG that have been reported in the literature so far.

Introduction

The term giant-cell reparative granuloma (GCRG) was introduced by Jaffe in 1953 to describe a lesion of the mandible and maxilla that occurred following a trauma-induced intraosseous hemorrhage. (1) He also distinguished GCRG, which is not a true neoplasm, from giant-cell tumor. Since 1953, GCRG has been reported in many other sites, including the axial skeleton and long bones, (2) the hands and feet, (3) the facial bones, (4) the cranial vault, (5) the sphenoid and ethmoid bones, (6-8) the orbit, (9) and the nose. (10) GCRG of the temporal bone was first described by Hirschl and Katz in 1974. (11) Up to now, only 16 other cases have been published in the international medical literature (table).

Although GCRG of the temporal bone has been purported to be a reaction to cranial trauma, (1,2,11,12) its pathogenesis remains unclear. (13,14) It can occur at any age, and there does not appear to be a clear gender predilection. (13) Reported symptoms include hearing loss, tinnitus, a palpable mass, pain, vertigo, and facial weakness. (14) Complete surgical excision is regarded as the treatment of choice. (12-14) Curettage of the lesion is not sufficient. (13,14) Whenever complete removal is not possible, radiotherapy should be considered. (13-15) Following complete excision, the prognosis is good, and reported recurrence rates have ranged from 10 to 15% in most studies. (11,16-18)

In this article, we report a new case of temporal bone GCRG, in which a large tumor infiltrated the sphenoid bone, infratemporal fossa, pterygoid fossa, temporomandibular joint, middle cranial fossa, and temporal lobe. To our knowledge, infiltration of the temporal lobe by a temporal bone GCRG has not been previously described in the literature.

Case report

A 17-year-old girl came to the Department of Otorhinolaryngology-Head and Neck Surgery in October 1998 with a 2-month history of hearing loss in her right ear. She reported no other symptoms, and she had no history of head or acoustic trauma or exposure to ototoxic agents. Her family history was negative for hearing loss.

Examination of the head and neck revealed that a mass was obstructing the right auditory canal and had almost completely occluded the lumen. Pure-tone audiometry revealed normal function in the right inner ear and a 20 dB air-bone gap at all frequencies tested. Serum levels of calcium, alkaline phosphatase, phosphorus, and parathyroid hormone were within normal limits. Computed tomography (CT) demonstrated a 4-cm osteolytic lesion of the right temporal bone and infratemporal fossa with intracranial but extradural extension. The temporomandibular joint was not involved. On magnetic resonance imaging (MRI), the lesion reflected low-intensity signals on both T1- and T2-weighted images, but there was some strong enhancement following the application of gadolinium contrast.

Because of the contrast enhancement, a preoperative embolization of the lesion was performed. Intraoperative rapid section revealed a tumor of unclear dignity. For that reason, the operation was abandoned after the mastoidectomy and without complete removal of the tumor. The definitive histology revealed that the tumor was a GCRG. The patient was scheduled to undergo a complete removal of the lesion, but unfortunately she and her mother refused the recommended surgery.

In February 2001, the young woman returned to our institution. Since her initial treatment, time tumor had grown significantly and the patient was experiencing total right-sided sensorineural deafness, intermittent vertigo, tinnitus, facial weakness (House-Brackmann grade II-III), and paresthesia in the area of the right mandibular nerve.

CT and MRI showed a very large tumor in the right temporal bone that involved the sphenoid bone, infratemporal fossa, pterygoid fossa, temporomandibular joint, and middle cranial fossa with extension into the right temporal lobe (figure 1). There were erosions of the labyrinth and the bony canal of the internal carotid artery as well as destruction of the right cochlea.

[FIGURE 1 OMITTED]

The lesion was resected via a combined pterional and infratemporal approach. The operation was performed in cooperation with the Department of Maxillofacial Surgery and the Department of Neurosurgery, and we were continuously assisted by computer-navigation control (Stryker Leibinger Navigation System; Freiburg, Germany). The tumor had damaged a large portion of the right temporal bone. The internal carotid artery, the facial nerve, and the mandibular nerve were ensheathed. During the operation, large portions of time temporal bone (including the cochlea and the labyrinth) and the temporomandibular joint (including the articular disk, masseter, and medial pterygnid muscle), parts of the temporal muscle, the greater wing of the sphenoid, the adventitia of the internal carotid artery, the maxillary artery, the mandibular nerve, parts of the temporal dura, and a small part of the caudal temporal lobe had to be resected. By performing such a radical operation, we were able to remove all tumor tissue as well as a margin of grossly uninvolved tissue. We were able to spare the facial nerve, and we treated it with a nerve stimulator at the completion of surgery. We reconstructed the dura with fascia lata and temporal muscle. Finally, we used a titanium mesh to restore the integrity of the middle cranial fossa and the temporal calotte.