A Case of Intracranial Meningioma Involving The External Auditory Canal Directly Through The Temporal Bone : Case Description

A Case of Intracranial Meningioma Involving The External Auditory Canal Directly Through The Temporal Bone : Case Description | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Case of Intracranial Meningioma Involving The External Auditory Canal Directly Through The Temporal Bone : Case Description Fengzhang Zhu, Heji Ma, Hao Ma, Shizhou Tang, Hui Guo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8433135/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract This case report describes a rare instance of a 46-year-old female presenting with left ear stuffiness, hearing loss, and purulent discharge. Initially misdiagnosed with mastoiditis, imaging and biopsy ultimately revealed a meningioma. The case's uniqueness lies in the tumor's pathway: it originated in the cerebellopontine angle and extended directly through the temporal bone to involve the external auditory canal, a route seldom documented in scientific literature.The diagnostic challenge was significant due to the atypical symptoms, which mimic common conditions like cholesteatoma. Computed tomography (CT) demonstrated bone erosion, suggesting the direct pathway, while enhanced magnetic resonance imaging (MRI) was crucial for illustrating the continuity between the intracranial mass and the external auditory canal lesion, including a characteristic dural tail sign.This case adds substantial value to the literature by highlighting an unusual mechanism of tumor spread. It underscores the importance for clinicians and radiologists to include meningioma in the differential diagnosis of aural masses, particularly when imaging shows a connection to intracranial structures, to guide appropriate surgical management and avoid diagnostic delays. Meningioma external auditory canal Temporal bone Figures Figure 1 Figure 2 Figure 3 Introduction Meningioma is the most common tumor in the central nervous system, accounting for more than 30 % [1,2].Meningiomas originate from arachnoid cap cells embedded in arachnoid villi [3].Meningiomas can arise from any part of the dura mater, the most common is the cranial fornix, skull base(sphenoid plane, sphenoid wing, petrous ridge, cavernous sinus and perisphenoidal region), and dural reflex sites (cerebral falx, tentorial and dura mater adjacent to venous sinus) [4].Meningiomas Related Articles on Extracranial Meninges Less offerings [5],There are fewer meningiomas involving the external auditory canal. Due to the atypical clinical features, it is easy to be misdiagnosed as cholesteatoma or osteoma. The vast majority of patients receive partial or complete surgical resection [6] .Therefore, accurate diagnosis is of great significance to guide the correct clinical treatment. Case Presentation The patient was a 46-year-old female patient. The main symptoms of the patient were left ear stuffiness, hearing loss, and yellowish secretions more than a month ago. The patient reported no significant family history of tumors or hearing loss, and no personal history of psychiatric disorders. The patient's personal medical history was otherwise unremarkableThe patient was first diagnosed in the Army General Hospital of the Northern Theater Command (Peace Hospital District). The following related examinations were performed : Pure tone audiometry : left ear 250-500-1000-2000-4000 Hz bone conduction hearing threshold 0-0-10-25-30 dBHL, air conduction hearing threshold 40-40-30-35-55 dBHL, right 250-500-1000-2000-4000 Hz bone conduction hearing threshold 0-0-10-25-30 dBHL. The air conduction hearing threshold was 25-25-15-20-20dBHL. Middle ear computed tomography (CT) : consider the left middle ear mastoiditis, paranasal sinusitis, left inferior turbinate hypertrophy, nasal septum deviation. Acoustic immittance left ear type B curve, right ear type A curve. Otoendoscopy : purulent secretions were seen around the external auditory canal and tympanic membrane of the left ear, and a reddish mass was seen below the tympanic membrane of the left ear. According to the relevant examination, the General Hospital of the Northern Theater Command recommended surgical treatment. The patient was not adopted at that time. Local ear drops were used for treatment, and the symptoms were not significantly relieved. In order to further diagnose and treat the First Affiliated Hospital of Jinzhou Medical University, the otology examination at admission : bilateral auricles were not deformed, no traction pain, yellow mucopurulent secretions were seen in the left external auditory canal, tympanic membrane relaxation and invagination were seen after cleaning, and granulation samples were seen on the surface of the tension part.The right external auditory canal was clean, and the right tympanic membrane had no congestion and perforation, with clear signs. Acoustic immittance : pure tone audiometry : left ear 250-500-1000-2000-4000Hz bone conduction hearing threshold 15-20-15-35-55dBHL, air conduction hearing 45-40-30-45-70dBHL, 250-500-1000-2000-4000Hz bone air conduction hearing threshold 20-20-15-25-30dBHL. There were no obvious abnormalities in biochemical items, coagulation four items, blood routine, blood type, HIV test and preoperative immunity. General bacterial culture : no bacterial growth. There was no obvious abnormality in the examination.CT of the temporal bone revealed poor pneumatization of the left mastoid air cells with associated mucosal thickening and opacification. A soft tissue density (approximately 32 Hounsfield Units) was noted filling the tympanic cavity. Bone resorption was observed involving the medial tympanic wall and the petrous portion of the temporal bone.The imaging findings are suggestive of otomastoiditis. The presence of external auditory canal cerumen cannot be excluded. Definitive tissue characterization remains challenging due to inherent limitations of the non-contrast CT protocol in differentiating soft tissue compositions (Figure 1A-D). Enhanced magnetic resonance imaging(MRI)of the inner ear : A nodule was seen in the left cerebellopontine angle, which showed equal signal on T1-weighted image(T1WI)and slightly higher signal on T2-weighted image (T2WI). The estimated size was 1.5cm x1.6cm x1.7cm.In the contrast-enhanced phase, the enhanced scan was significantly enhanced, and the corresponding adjacent left cerebellar meninges were thickened and enhanced. An enhanced T1WI low signal and T2WI high signal patch shadow were seen in the left external auditory canal, as shown in (Figure.2A-M). Preoperative imaging failed to provide a clear diagnosis.The patient underwent endoscopic tissue biopsy (1 site):(left external auditory canal) a grayish red polypoid, with a maximum diameter of 0.3 cm, pedicle, pedicle length of 0.3 cm, diameter of 0.3 cm, the specimen can be seen in the focal small round cell distribution, incomplete exclusion of tumor lesions, see (Figure 3A-B). Immunohistochemical results showed that tumor cells : CK (+), EMA( weak+), PR (+), S100 (-), SOX10( -), KI67( +, proliferation index of about 3 % ), SYN (-), CGA( -) P40( -) CK5/6 (-) The combined diagnosis of pathology and immunohistochemistry suggested meningioma. The diagnostic criteria were in line with the 5th edition of central nervous system tumors : World Health Organization classification of tumors.The patient underwent surgical intervention at our hospital. Histopathological examination confirmed that the tumor was completely resected with negative margins. The patient recovered well and was discharged successfully. Structured telephone follow-ups were conducted by our hospital at 1, 3, 6, and 12 months post-discharge. Apart from reporting symptoms of headache and hearing impairment at the one-month follow-up, the patient reported no other abnormal discomfort during all subsequent assessments and remained in good general health throughout the follow-up period.The patient's medication adherence showed a pattern of initial hesitation followed by significant improvement. Initially, the patient declined surgical advice due to misdiagnosis. However, as symptoms persisted, the patient proactively sought a second opinion, actively cooperated with further examinations—including enhanced MRI and tissue biopsy—and ultimately accepted surgical treatment after a clear diagnosis was established. The patient also demonstrated consistent adherence to regular postoperative follow-ups, indicating high compliance . Additionally, the patient exhibited considerable tolerance toward months of ear discomfort and the complex diagnostic-therapeutic process.Regarding adverse events, the most significant risk arose from diagnostic delay caused by the disease's rarity and atypical symptoms, which itself constituted an adverse event and increased the risk of disease progression. Although the surgery carried potential medium to low risks such as nerve injury, bleeding, or infection, the fact that the patient recovered well with only expected minor reactions like headache and hearing impairment suggests that serious adverse events were effectively controlled, resulting in an overall favorable prognosis. This case underscores the importance of timely and precise differential diagnosis for atypical ear conditions to prevent diagnostic delays and guide patients toward appropriate treatment pathways. Discussion Meningiomas are mostly benign (WHO grade I)sporadic, and a few can reach grade II-III [7,8] . The clinical manifestations depend on the location of tumor growth and can occur in any part of the brain covered by the meninges [1].About 20 % of the cases will eventually extend to the skull, but meningiomas invading the external auditory canal are very rare [9,10].It can be a primary intracranial invasion of the external auditory canal, or it can be a primary ectopic meningioma of the external auditory canal. Most of the reports in the literature are more extensive meningiomas, and it is rare to enter the external auditory canal directly through the temporal bone [11] Therefore, the diagnosis of meningioma involving the external auditory canal is challenging. According [12,13] According to the location, diffusion medium and related symptoms of meningiomas, the study showed that they were divided into three groups : conductive hearing loss and otitis media caused by the involvement of the middle ear cavity through the tympanic lid and jugular foramen, and nerve hearing loss, tinnitus, facial paralysis, dizziness and other related symptoms caused by the spread to the cochlea and vestibule through the internal auditory canal. However, in this study, no cases were found to spread directly through the temporal bone to the external auditory canal, which also indicated the rarity of cases that entered the external auditory canal directly through the temporal bone.This case is a case of left cerebellopontine angle area of temporal bone meningioma directly through the temporal bone involving the external auditory canal. According to the study, the primary meningioma in the cerebellar peduncle area has the tendency to develop to the external auditory canal [10].It is considered that this part of the temporal bone is good and the density is poor, so it is easy to be compressed and absorbed [14].Meningiomas involving the external auditory canal usually cause hearing loss, purulent secretions and other atypical symptoms. There is no clinical specificity and it is easy to be confused with other lesions in this part. Therefore, the focus is on the identification of other lesions in this part, such as cholesteatoma, squamous cell carcinoma and other lesions [15].The preferred treatment for meningioma involving the external auditory canal is surgical treatment [10]. Contrast-enhanced MRI is highly sensitive in demonstrating the structures of the external auditory canal, inner ear, and adjacent intracranial regions. In this case, the lesion appeared isointense on T1WI, slightly hyperintense on T2WI, with well-defined borders and homogeneous signal intensity. Post-contrast images showed moderate homogeneous enhancement of the lesion. Adjacent to the left cerebellopontine angle, thickened and enhanced cerebellar dura was observed, displaying the typical "dural tail sign," which is consistent with classical imaging findings of meningioma. Multiple patchy T2WI hyperintensities were seen in the left mastoid, indicative of mastoiditis resulting from involvement by the tumor. Enhanced MRI clearly revealed continuity between the intracranial lesion and the lesion in the external auditory canal, confirming that the intracranial tumor had extended directly into the external auditory canal through the temporal bone. However, since meningioma only rarely involves the external auditory canal in this manner, radiologists typically consider infectious etologies as the primary differential diagnosis. CT imaging of the middle ear offers distinct advantages in evaluating surrounding bony structures. In this case, absorption of the medial wall of the tympanic cavity and temporal bone resulted in an irregular "brush-border" appearance, supporting the conclusion that the tumor did not extend via the typical route through the labyrinthine structures of the inner ear, but rather by compressing and eroding the temporal bone to directly reach the external auditory canal—an uncommon pathway of spread. That said, CT provides limited soft tissue detail and offers little help in differentiating this entity from other pathologies in the region.The patient acknowledged that despite a complex diagnostic journey, the definitive diagnosis enabled her active cooperation with treatment. In summary, due to the lack of characteristic clinical features and the rarity of meningiomas involving the external auditory canal, arriving at a definitive diagnosis is challenging. Early diagnosis of such tumors is crucial for determining appropriate clinical management. Therefore, radiologists should include this condition in the differential diagnosis when evaluating pathologies in this anatomical region. Declarations The patient provided written informed consent to participate in the publication of this case report. The consent process included a detailed explanation of the potential use of their clinical data and images in a scientific publication, and they understood that their anonymity cannot be guaranteed entirely, though all identifiable details have been removed or disguised. This consent form will be retained by the authors as per institutional guidelines . Clinical Trial Number Clinical trial number: not applicable Consent to Publish declaration The authors confirm that they have obtained written informed consent from the patient for the publication of this case report, including any accompanying images and clinical details. The patient has been advised that her identity will be anonymized to the extent possible, and that despite these efforts, complete anonymity cannot be guaranteed. This consent process was conducted in accordance with the ethical standards of the institutional review board (IRB) of The First Affiliated Hospital of Jinzhou Medical University. Consent to Participate Declaration Informed consent was obtained from the patient for the inclusion of her clinical data and case details in this study. The consent process was conducted in accordance with the ethical standards of the institutional review board (IRB) of The First Affiliated Hospital of Jinzhou Medical University and with the 1964 Helsinki Declaration and its later amendments. Funding statement This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ethics statement This study was granted an exemption from ethical approval by the Institutional Review Board (IRB) of The First Affiliated Hospital of Jinzhou Medical University. Author contributions statement The authors confirm their contribution to the paper as follows: Zhu Fengzhang was responsible for writing the original draft and collected the patient's radiological data, medical history, and treatment history. Ma Heji contributed to the conceptualization of the study and the development of the methodology. Ma Hao was involved in reviewing and editing the manuscript. Tang Shizhou provided funding acquisition and technical support. Guo Hui, as the corresponding author, supervised the project, provided guidance throughout the writing process, and was responsible for liaison with the publisher. All authors reviewed the results and approved the final version of the manuscript Competing interests policy The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Authorship As the corresponding author, I confirm that I have read and understood this journal's policies, and I submit this manuscript in accordance with these policies. The author list has been confirmed by all contributors, each of whom has made substantial contributions to the research work. Permission to use third-party material Not applicable. Data availability The original de-identified data supporting the findings of this case report are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy and ethical restrictions concerning patient confidentiality. Acknowledgements The authors would like to express their sincere gratitude to the Department of Radiology at The First Affiliated Hospital of Jinzhou Medical University for providing an excellent and reliable scientific research platform. The advanced equipment and supportive academic environment were instrumental in completing this work. References Buerki RA, Horbinski CM, Kruser T, Horowitz PM, James CD, Lukas RV. An overview of meningiomas. Future Oncol . 2018;14(21):2161-2177. https://doi.org/10.2217/fon-2018-0006 Boetto J, Birzu C, Kalamarides M, Peyre M, Sanson M. Les méningiomes : mise au point sur les connaissances actuelles [Meningiomas: A review of current knowledge]. Rev Med Interne . 2022;43(2):98-105.https://doi.org/10.1016/j.revmed.2021.06.011 Alexiou GA, Gogou P, Markoula S, Kyritsis AP. Management of meningiomas. Clin Neurol Neurosurg . 2010;112(3):177-182.https://doi.org/10.1016/j.clineuro.2009.12.011 Whittle IR, Smith C, Navoo P, Collie D. Meningiomas. Lancet . 2004;363(9420):1535-1543.https://doi.org/10.1016/S0140-6736(04)16153-9 George M, Ikonomidis C, Pusztaszeri M, Monnier P. Primary meningioma of the middle ear: case report. J Laryngol Otol . 2010;124(5):572-574.https://doi.org/10.1017/S0022215109991745 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.ModPathol2003;16(3):236-245.https://doi.org/10.1097/01.MP.0000056631.15739.1B Maggio I, Franceschi E, Tosoni A, et al. Meningioma: not always a benign tumor. A review of advances in the treatment of meningiomas. CNS Oncol . 2021;10(2):CNS72.https://doi.org/10.2217/cns-2021-0003 Wang JZ, Landry AP, Raleigh DR, et al. Meningioma: International Consortium on Meningiomas consensus review on scientific advances and treatment paradigms for clinicians, researchers, and patients. Neuro Oncol . 2024;26(10):1742-1780.https://doi.org/10.1093/neuonc/noae082 Uppal HS, Kabbani M, Reddy V, Kaur S. Ectopic extra-cranial meningioma presenting as an aural polyp. Eur Arch Otorhinolaryngol . 2003;260(6):322-324.https://doi.org/10.1007/s00405-003-0582-2 Munshi A, Dutta D, Muzumdar D, Jalali R. An atypical presentation of recurrent temporal lobe meningioma with external auditory canal mass. Indian J Cancer . 2007;44(3):119-121.https://doi.org/10.4103/0019-509X.38945 Dixon J, Zammit-Maempel I, Hill J. External auditory canal meningioma: imaging features in a series of three cases. J Laryngol Otol . 2017;131(3):273-279.https://doi.org/10.1017/S0022215117000044 Nicolay S, De Foer B, Bernaerts A, Van Dinther J, Parizel PM. A case of a temporal bone meningioma presenting as a serous otitis media. Acta Radiol Short Rep . 2014;3(10):2047981614555048.https://doi.org/10.1177/2047981614555048 Hamilton BE, Salzman KL, Patel N, et al. Imaging and clinical characteristics of temporal bone meningioma. AJNR Am J Neuroradiol . 2006;27(10):2204-2209. Tsunoda R, Fukaya T. Extracranial meningioma presenting as a tumour of the external auditory meatus: a case report. J Laryngol Otol . 1997;111(2):148-151. https://doi.org/10.1017/S0022215100136692 Prayson RA. Middle ear meningiomas. Ann Diagn Pathol . 2000;4(3):149-153. https://doi.org/10.1016/S1092-9134(00)90037-6 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Dec, 2025 Editor assigned by journal 29 Dec, 2025 Submission checks completed at journal 29 Dec, 2025 First submitted to journal 23 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:33:30","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52026,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8433135/v1/0dc8d3f6c56deefac80bbb4c.html"},{"id":99217980,"identity":"6eb39e1a-6d42-4db7-9252-225b4818db3a","added_by":"auto","created_at":"2025-12-30 09:14:42","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5015587,"visible":true,"origin":"","legend":"\u003cp\u003eCT axial images of the middle ear, ( A, B ) soft tissue window images showed soft tissue density shadow filling in the tympanic cavity and temporal bone, ( C, D ) bone window images showed bone absorption in the tympanic cavity and temporal bone. CT:computed tomography.\u003c/p\u003e","description":"","filename":"f1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8433135/v1/a9b7047fd5ff102e5bd05c1d.jpg"},{"id":99217979,"identity":"91b350be-2717-4a29-b045-3852c6d82194","added_by":"auto","created_at":"2025-12-30 09:14:42","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":575879,"visible":true,"origin":"","legend":"\u003cp\u003eEnhanced magnetic resonance imaging of the inner ear. ( A, B ) axial T1-weighted imaging showed equal signals in the left cerebellar peduncle area and tympanic lesions. ( E, F, G, H ) axial T2-weighted imaging showed slightly higher signals in the lesions. ( J, K ) T2-weighted three-dimensional magnetic resonance imaging showed slightly higher signals in the lesions extending from the left cerebellar peduncle area to the tympanic cavity. In the enhanced phase ( C, D, L, M ), the lesions were significantly uniformly enhanced. Long arrow ( tumor part ), short arrow ( mastoiditis change ).\u003c/p\u003e","description":"","filename":"f2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8433135/v1/d6e2c08ee57b8c7b6c639d3f.jpg"},{"id":99217982,"identity":"614d6aa7-950f-4320-bf2d-174b89991557","added_by":"auto","created_at":"2025-12-30 09:14:42","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1582242,"visible":true,"origin":"","legend":"\u003cp\u003e( A ) The pathological diagram of the submitted tumor showed a grayish red polypoid, with a maximum diameter of 0.3 cm and a pedicle, with a length of 0.3 cm and a diameter of 0.3 cm. ( B ) HE staining showed the distribution of focal small round cells. HE : hematoxylin-eosin staining.\u003c/p\u003e","description":"","filename":"f3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8433135/v1/82fbd2f04ebf5df13c1d837a.jpg"},{"id":99788479,"identity":"106c2171-b9ad-49cc-ac0e-903cdb18d65d","added_by":"auto","created_at":"2026-01-08 12:46:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7598384,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8433135/v1/3c1a7592-26e0-4d6c-b9f2-bd169975ce06.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Case of Intracranial Meningioma Involving The External Auditory Canal Directly Through The Temporal Bone : Case Description","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMeningioma is the most common tumor in the central nervous system, accounting for more than 30 % [1,2].Meningiomas originate from arachnoid cap cells embedded in arachnoid villi [3].Meningiomas can arise from any part of the dura mater, the most common is the cranial fornix, skull base(sphenoid plane, sphenoid wing, petrous ridge, cavernous sinus and perisphenoidal region), and dural reflex sites (cerebral falx, tentorial and dura mater adjacent to venous sinus) [4].Meningiomas Related Articles on Extracranial Meninges Less offerings [5],There are fewer meningiomas involving the external auditory canal. Due to the atypical clinical features, it is easy to be misdiagnosed as cholesteatoma or osteoma. The vast majority of patients receive partial or complete surgical resection [6]\u003cstrong\u003e.Therefore, accurate diagnosis is of great significance to guide the correct clinical treatment.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Case Presentation ","content":"\u003cp\u003eThe patient was a 46-year-old female patient. The main symptoms of the patient were left ear stuffiness, hearing loss, and yellowish secretions more than a month ago. The patient reported no significant family history of tumors or hearing loss, and no personal history of psychiatric disorders. The patient\u0026apos;s personal medical history was otherwise unremarkableThe patient was first diagnosed in the Army General Hospital of the Northern Theater Command (Peace Hospital District). The following related examinations were performed : Pure tone audiometry : left ear 250-500-1000-2000-4000 Hz bone conduction hearing threshold 0-0-10-25-30 dBHL, air conduction hearing threshold 40-40-30-35-55 dBHL, right 250-500-1000-2000-4000 Hz bone conduction hearing threshold 0-0-10-25-30 dBHL. The air conduction hearing threshold was 25-25-15-20-20dBHL. Middle ear computed tomography (CT) : consider the left middle ear mastoiditis, paranasal sinusitis, left inferior turbinate hypertrophy, nasal septum deviation. Acoustic immittance left ear type B curve, right ear type A curve. Otoendoscopy : purulent secretions were seen around the external auditory canal and tympanic membrane of the left ear, and a reddish mass was seen below the tympanic membrane of the left ear. According to the relevant examination, the General Hospital of the Northern Theater Command recommended surgical treatment. The patient was not adopted at that time. Local ear drops were used for treatment, and the symptoms were not significantly relieved. In order to further diagnose and treat the First Affiliated Hospital of Jinzhou Medical University, the otology examination at admission : bilateral auricles were not deformed, no traction pain, yellow mucopurulent secretions were seen in the left external auditory canal, tympanic membrane relaxation and invagination were seen after cleaning, and granulation samples were seen on the surface of the tension part.The right external auditory canal was clean, and the right tympanic membrane had no congestion and perforation, with clear signs. Acoustic immittance : pure tone audiometry : left ear 250-500-1000-2000-4000Hz bone conduction hearing threshold 15-20-15-35-55dBHL, air conduction hearing 45-40-30-45-70dBHL, 250-500-1000-2000-4000Hz bone air conduction hearing threshold 20-20-15-25-30dBHL. There were no obvious abnormalities in biochemical items, coagulation four items, blood routine, blood type, HIV test and preoperative immunity. General bacterial culture : no bacterial growth. There was no obvious abnormality in the examination.CT of the temporal bone revealed poor pneumatization of the left mastoid air cells with associated mucosal thickening and opacification. A soft tissue density (approximately 32 Hounsfield Units) was noted filling the tympanic cavity. Bone resorption was observed involving the medial tympanic wall and the petrous portion of the temporal bone.The imaging findings are suggestive of otomastoiditis. The presence of external auditory canal cerumen cannot be excluded. Definitive tissue characterization remains challenging due to inherent limitations of the non-contrast CT protocol in differentiating soft tissue compositions (Figure 1A-D).\u003c/p\u003e\n\u003cp\u003eEnhanced magnetic resonance imaging(MRI)of the inner ear : A nodule was seen in the left cerebellopontine angle, which showed equal signal on T1-weighted image(T1WI)and slightly higher signal on T2-weighted image (T2WI). The estimated size was 1.5cm x1.6cm x1.7cm.In the contrast-enhanced phase, the enhanced scan was significantly enhanced, and the corresponding adjacent left cerebellar meninges were thickened and enhanced. An enhanced T1WI low signal and T2WI high signal patch shadow \u0026nbsp;were seen in the left external auditory canal, as shown in (Figure.2A-M).\u003c/p\u003e\n\u003cp\u003ePreoperative imaging failed to provide a clear diagnosis.The patient underwent endoscopic tissue biopsy (1 site):(left external auditory canal) a grayish red polypoid, with a maximum diameter of 0.3 cm, pedicle, pedicle length of 0.3 cm, diameter of 0.3 cm, the specimen can be seen in the focal small round cell distribution, incomplete exclusion of tumor lesions, see (Figure 3A-B).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImmunohistochemical results showed that tumor cells :\u003cem\u003e\u0026nbsp;CK\u0026nbsp;\u003c/em\u003e(+),\u003cem\u003e\u0026nbsp;EMA(\u003c/em\u003eweak+),\u003cem\u003e\u0026nbsp;PR\u003c/em\u003e(+), \u003cem\u003eS100\u0026nbsp;\u003c/em\u003e(-), \u003cem\u003eSOX10(\u003c/em\u003e-), \u003cem\u003eKI67(\u003c/em\u003e+, proliferation index of about 3 % ),\u003cem\u003e\u0026nbsp;SYN\u003c/em\u003e(-), \u003cem\u003eCGA(\u003c/em\u003e-) \u003cem\u003eP40(\u003c/em\u003e-)\u003cem\u003e\u0026nbsp;CK5/6\u003c/em\u003e(-) The combined diagnosis of pathology and immunohistochemistry suggested meningioma. The diagnostic criteria were in line with the 5th edition of central nervous system tumors : World Health Organization classification of tumors.The patient underwent surgical intervention at our hospital. Histopathological examination confirmed that the tumor was completely resected with negative margins. The patient recovered well and was discharged successfully. Structured telephone follow-ups were conducted by our hospital at 1, 3, 6, and 12 months post-discharge. Apart from reporting symptoms of headache and hearing impairment at the one-month follow-up, the patient reported no other abnormal discomfort during all subsequent assessments and remained in good general health throughout the follow-up period.The patient\u0026apos;s medication adherence showed a pattern of initial hesitation followed by significant improvement. Initially, the patient declined surgical advice due to misdiagnosis. However, as symptoms persisted, the patient proactively sought a second opinion, actively cooperated with further examinations\u0026mdash;including enhanced MRI and tissue biopsy\u0026mdash;and ultimately accepted surgical treatment after a clear diagnosis was established. The patient also demonstrated consistent adherence to regular postoperative follow-ups, indicating high compliance . Additionally, the patient exhibited considerable tolerance toward months of ear discomfort and the complex diagnostic-therapeutic process.Regarding adverse events, the most significant risk arose from diagnostic delay caused by the disease\u0026apos;s rarity and atypical symptoms, which itself constituted an adverse event and increased the risk of disease progression. Although the surgery carried potential medium to low risks such as nerve injury, bleeding, or infection, the fact that the patient recovered well with only expected minor reactions like headache and hearing impairment suggests that serious adverse events were effectively controlled, resulting in an overall favorable prognosis. This case underscores the importance of timely and precise differential diagnosis for atypical ear conditions to prevent diagnostic delays and guide patients toward appropriate treatment pathways.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMeningiomas are mostly benign (WHO grade I)sporadic, and a few can reach grade II-III [7,8] . The clinical manifestations depend on the location of tumor growth and can occur in any part of the brain covered by the meninges [1].About 20 % of the cases will eventually extend to the skull, but meningiomas invading the external auditory canal are very rare [9,10].It can be a primary intracranial invasion of the external auditory canal, or it can be a primary ectopic meningioma of the external auditory canal. Most of the reports in the literature are more extensive meningiomas, and it is rare to enter the external auditory canal directly through the temporal bone [11] Therefore, the diagnosis of meningioma involving the external auditory canal is challenging.\u003c/p\u003e\n\u003cp\u003eAccording [12,13] According to the location, diffusion medium and related symptoms of meningiomas, the study showed that they were divided into three groups : conductive hearing loss and otitis media caused by the involvement of the middle ear cavity through the tympanic lid and jugular foramen, and nerve hearing loss, tinnitus, facial paralysis, dizziness and other related symptoms caused by the spread to the cochlea and vestibule through the internal auditory canal. However, in this study, no cases were found to spread directly through the temporal bone to the external auditory canal, which also indicated the rarity of cases that entered the external auditory canal directly through the temporal bone.This case is a case of left cerebellopontine angle area of temporal bone meningioma directly through the temporal bone involving the external auditory canal. According to the study, the primary meningioma in the cerebellar peduncle area has the tendency to develop to the external auditory canal [10].It is considered that this part of the temporal bone is good and the density is poor, so it is easy to be compressed and absorbed [14].Meningiomas involving the external auditory canal usually cause hearing loss, purulent secretions and other atypical symptoms. There is no clinical specificity and it is easy to be confused with other lesions in this part. Therefore, the focus is on the identification of other lesions in this part, such as cholesteatoma, squamous cell carcinoma and other lesions [15].The preferred treatment for meningioma involving the external auditory canal is surgical treatment [10].\u003c/p\u003e\n\u003cp\u003eContrast-enhanced MRI is highly sensitive in demonstrating the structures of the external auditory canal, inner ear, and adjacent intracranial regions. In this case, the lesion appeared isointense on T1WI, slightly hyperintense on T2WI, with well-defined borders and homogeneous signal intensity. Post-contrast images showed moderate homogeneous enhancement of the lesion. Adjacent to the left cerebellopontine angle, thickened and enhanced cerebellar dura was observed, displaying the typical \u0026quot;dural tail sign,\u0026quot; which is consistent with classical imaging findings of meningioma. Multiple patchy T2WI hyperintensities were seen in the left mastoid, indicative of mastoiditis resulting from involvement by the tumor. Enhanced MRI clearly revealed continuity between the intracranial lesion and the lesion in the external auditory canal, confirming that the intracranial tumor had extended directly into the external auditory canal through the temporal bone. However, since meningioma only rarely involves the external auditory canal in this manner, radiologists typically consider infectious etologies as the primary differential diagnosis.\u003c/p\u003e\n\u003cp\u003eCT imaging of the middle ear offers distinct advantages in evaluating surrounding bony structures. In this case, absorption of the medial wall of the tympanic cavity and temporal bone resulted in an irregular \u0026quot;brush-border\u0026quot; appearance, supporting the conclusion that the tumor did not extend via the typical route through the labyrinthine structures of the inner ear, but rather by compressing and eroding the temporal bone to directly reach the external auditory canal\u0026mdash;an uncommon pathway of spread. That said, CT provides limited soft tissue detail and offers little help in differentiating this entity from other pathologies in the region.The patient acknowledged that despite a complex diagnostic journey, the definitive diagnosis enabled her active cooperation with treatment.\u003c/p\u003e\n\u003cp\u003eIn summary, due to the lack of characteristic clinical features and the rarity of meningiomas involving the external auditory canal, arriving at a definitive diagnosis is challenging. Early diagnosis of such tumors is crucial for determining appropriate clinical management. Therefore, radiologists should include this condition in the differential diagnosis when evaluating pathologies in this anatomical region.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eThe patient provided written informed consent to participate in the publication of this case report. The consent process included a detailed explanation of the potential use of their clinical data and images in a scientific publication, and they understood that their anonymity cannot be guaranteed entirely, though all identifiable details have been removed or disguised. This consent form will be retained by the authors as per institutional guidelines .\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that they have obtained written informed consent from the patient for the publication of this case report, including any accompanying images and clinical details. The patient has been advised that her identity will be anonymized to the extent possible, and that despite these efforts, complete anonymity cannot be guaranteed. This consent process was conducted in accordance with the ethical standards of the institutional review board (IRB) of The First Affiliated Hospital of Jinzhou Medical University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient for the inclusion of her clinical data and case details in this study. The consent process was conducted in accordance with the ethical standards of the institutional review board (IRB) of The First Affiliated Hospital of Jinzhou Medical University and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was granted an exemption from ethical approval by the Institutional Review Board (IRB) of The First Affiliated Hospital of Jinzhou Medical University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm their contribution to the paper as follows: Zhu Fengzhang was responsible for writing the original draft and collected the patient\u0026apos;s radiological data, medical history, and treatment history. Ma Heji contributed to the conceptualization of the study and the development of the methodology. Ma Hao was involved in reviewing and editing the manuscript. Tang Shizhou provided funding acquisition and technical support. Guo Hui, as the corresponding author, supervised the project, provided guidance throughout the writing process, and was responsible for liaison with the publisher. All authors reviewed the results and approved the final version of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the corresponding author, I confirm that I have read and understood this journal\u0026apos;s policies, and I submit this manuscript in accordance with these policies. The author list has been confirmed by all contributors, each of whom has made substantial contributions to the research work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to use third-party material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original de-identified data supporting the findings of this case report are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy and ethical restrictions concerning patient confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to the Department of Radiology at The First Affiliated Hospital of Jinzhou Medical University for providing an excellent and reliable scientific research platform. The advanced equipment \u0026nbsp;and supportive academic environment were instrumental in completing this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBuerki RA, Horbinski CM, Kruser T, Horowitz PM, James CD, Lukas RV. An overview of meningiomas. \u003cem\u003eFuture Oncol\u003c/em\u003e. 2018;14(21):2161-2177. https://doi.org/10.2217/fon-2018-0006\u003c/li\u003e\n\u003cli\u003eBoetto J, Birzu C, Kalamarides M, Peyre M, Sanson M. Les m\u0026eacute;ningiomes : mise au point sur les connaissances actuelles [Meningiomas: A review of current knowledge]. \u003cem\u003eRev Med Interne\u003c/em\u003e. 2022;43(2):98-105.https://doi.org/10.1016/j.revmed.2021.06.011\u003c/li\u003e\n\u003cli\u003eAlexiou GA, Gogou P, Markoula S, Kyritsis AP. Management of meningiomas. \u003cem\u003eClin Neurol Neurosurg\u003c/em\u003e. 2010;112(3):177-182.https://doi.org/10.1016/j.clineuro.2009.12.011 \u003c/li\u003e\n\u003cli\u003eWhittle IR, Smith C, Navoo P, Collie D. Meningiomas. \u003cem\u003eLancet\u003c/em\u003e. 2004;363(9420):1535-1543.https://doi.org/10.1016/S0140-6736(04)16153-9\u003c/li\u003e\n\u003cli\u003eGeorge M, Ikonomidis C, Pusztaszeri M, Monnier P. Primary meningioma of the middle ear: case report. \u003cem\u003eJ Laryngol Otol\u003c/em\u003e. 2010;124(5):572-574.https://doi.org/10.1017/S0022215109991745 \u003c/li\u003e\n\u003cli\u003eThompson 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.ModPathol2003;16(3):236-245.https://doi.org/10.1097/01.MP.0000056631.15739.1B \u003c/li\u003e\n\u003cli\u003eMaggio I, Franceschi E, Tosoni A, et al. Meningioma: not always a benign tumor. A review of advances in the treatment of meningiomas. \u003cem\u003eCNS Oncol\u003c/em\u003e. 2021;10(2):CNS72.https://doi.org/10.2217/cns-2021-0003\u003c/li\u003e\n\u003cli\u003eWang JZ, Landry AP, Raleigh DR, et al. Meningioma: International Consortium on Meningiomas consensus review on scientific advances and treatment paradigms for clinicians, researchers, and patients. \u003cem\u003eNeuro Oncol\u003c/em\u003e. 2024;26(10):1742-1780.https://doi.org/10.1093/neuonc/noae082\u003c/li\u003e\n\u003cli\u003eUppal HS, Kabbani M, Reddy V, Kaur S. Ectopic extra-cranial meningioma presenting as an aural polyp. \u003cem\u003eEur Arch Otorhinolaryngol\u003c/em\u003e. 2003;260(6):322-324.https://doi.org/10.1007/s00405-003-0582-2 \u003c/li\u003e\n\u003cli\u003eMunshi A, Dutta D, Muzumdar D, Jalali R. An atypical presentation of recurrent temporal lobe meningioma with external auditory canal mass. \u003cem\u003eIndian J Cancer\u003c/em\u003e. 2007;44(3):119-121.https://doi.org/10.4103/0019-509X.38945 \u003c/li\u003e\n\u003cli\u003eDixon J, Zammit-Maempel I, Hill J. External auditory canal meningioma: imaging features in a series of three cases. \u003cem\u003eJ Laryngol Otol\u003c/em\u003e. 2017;131(3):273-279.https://doi.org/10.1017/S0022215117000044\u003c/li\u003e\n\u003cli\u003eNicolay S, De Foer B, Bernaerts A, Van Dinther J, Parizel PM. A case of a temporal bone meningioma presenting as a serous otitis media. \u003cem\u003eActa Radiol Short Rep\u003c/em\u003e. 2014;3(10):2047981614555048.https://doi.org/10.1177/2047981614555048\u003c/li\u003e\n\u003cli\u003eHamilton BE, Salzman KL, Patel N, et al. Imaging and clinical characteristics of temporal bone meningioma. \u003cem\u003eAJNR Am J Neuroradiol\u003c/em\u003e. 2006;27(10):2204-2209.\u003c/li\u003e\n\u003cli\u003eTsunoda R, Fukaya T. Extracranial meningioma presenting as a tumour of the external auditory meatus: a case report. \u003cem\u003eJ Laryngol Otol\u003c/em\u003e. 1997;111(2):148-151. https://doi.org/10.1017/S0022215100136692\u003c/li\u003e\n\u003cli\u003ePrayson RA. Middle ear meningiomas. \u003cem\u003eAnn Diagn Pathol\u003c/em\u003e. 2000;4(3):149-153. https://doi.org/10.1016/S1092-9134(00)90037-6\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Meningioma, external auditory canal, Temporal bone","lastPublishedDoi":"10.21203/rs.3.rs-8433135/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8433135/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis case report describes a rare instance of a 46-year-old female presenting with left ear stuffiness, hearing loss, and purulent discharge. Initially misdiagnosed with mastoiditis, imaging and biopsy ultimately revealed a meningioma. The case's uniqueness lies in the tumor's pathway: it originated in the cerebellopontine angle and extended directly through the temporal bone to involve the external auditory canal, a route seldom documented in scientific literature.The diagnostic challenge was significant due to the atypical symptoms, which mimic common conditions like cholesteatoma. Computed tomography (CT) demonstrated bone erosion, suggesting the direct pathway, while enhanced magnetic resonance imaging (MRI) was crucial for illustrating the continuity between the intracranial mass and the external auditory canal lesion, including a characteristic dural tail sign.This case adds substantial value to the literature by highlighting an unusual mechanism of tumor spread. It underscores the importance for clinicians and radiologists to include meningioma in the differential diagnosis of aural masses, particularly when imaging shows a connection to intracranial structures, to guide appropriate surgical management and avoid diagnostic delays.\u003c/p\u003e","manuscriptTitle":"A Case of Intracranial Meningioma Involving The External Auditory Canal Directly Through The Temporal Bone : Case Description","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 09:14:37","doi":"10.21203/rs.3.rs-8433135/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-30T10:21:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-29T10:37:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-29T10:37:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Oncology","date":"2025-12-23T11:23:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66dcd7e5-db9e-4fbf-9e3c-30b9eaf1ea8a","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T11:23:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 09:14:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8433135","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8433135","identity":"rs-8433135","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}