Tophaceous Gout of the Middle Ear: Case Report
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An 83 year-old female was evaluated for a progressive decline in her right hearing associated with a middle ear mass. She reported decreased benefit of her right hearing aid over the past few years. Her medical history was relevant for dyslipidemia, hypertension, coronary artery disease and gastroesophageal reflux. Medications included aspirin (81 mg daily dose), atenolol, atorvastatin, omeprazole as well as calcium and vitamin C and D supplementation. There were no laboratory signs of hyperuricemia.

Micro-otoscopy revealed a white mass in the anterior middle ear medial to an otherwise intact tympanic membrane. Tuning fork examination was consistent with a right conductive hearing loss. Audiological evaluation demonstrated right low- to high-frequency downsloping moderate-to-severe mixed hearing loss with an air-bone gap of 30 dBs. The speech discrimination score was normal at 88%. Tympanograms showed a right As-type curve. A noncontrast high-resolution CT scan demonstrated a 4.5-mm heterogeneously hyperdense lesion in the mesotympanum between the tensor tympani and anteromedial aspect of the malleus neck and manubrium.

The images were reviewed with our institution’s neuroradiologist, and the differential diagnosis included a cholesteatoma or a calcified chondroma. Surgical excision was recommended. Intraoperatively, a granular white mass anterior to the malleus and extending up to the tensor tympani tendon was noted. It was granular in consistency, and total removal was possible utilizing microinstruments and an argon laser without disruption of the ossicular chain or tympanic membrane.

The diagnosis of gouty tophus was revealed on final histopathological examination with the identification of negatively birefringent monosodium urate crystals under polarized light. Near-total closure of the air-bone gap was noted on the postoperative audiogram. A serum uric acid level assessment was then ordered and shown to be within the normal range. She was referred to her primary care provider who initiated allopurinol treatment.

Middle ear gouty tophi are uncommon and tend to present as white-colored granular masses. They are frequently mistaken for cholesteatoma or tympanosclerosis in patients who otherwise do not manifest any clinical or biochemical signs of gout.