Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. Imaging Case of the Month A Hurricane, Temporal Bone Paraganglioma, Cholesteatoma, Bezold’s Abscess, and Necrotizing Fasciitis à Nathan R. Lindquist, à Eric N. Appelbaum, à Tanner Fullmer, à Vlad C. Sandulache, and à yzAlex D. Sweeney à Department of Otolaryngology – Head and Neck Surgery; yDepartment of Neurosurgery, Baylor College of Medicine; and zDivision of Otolaryngology, Department of Surgery, Texas Children’s Hospital, Houston, Texas CASE PRESENTATION A 66-year-old woman with a history of advanced cervical cancer undergoing chemotherapy presented to the emergency department of a tertiary care medical center with a progressive history of right otalgia, neck pain, and fever. At the time of presentation, it was reported that the patient had a longstanding history of non-descript hearing loss as well as 2 months of purulent otorrhea, hearing loss, and tinnitus. Furthermore, in recent weeks, her access to medical care had reportedly been limited after being displaced into an emergency shelter during a natural disaster. Physical examination revealed a somnolent patient with purulent debris and polypoid tissue obstructing the right external auditory canal (EAC) to the level of the meatus. The right neck was visibly erythematous and edematous, and palpation demonstrated fluctuance of the mastoid tip with crepitus throughout the ipsilateral neck to the level of the clavicle. Contrasted computed tomography (CT) of the neck and temporal bone showed erosion of the tympanic, mastoid, and petrous portions of the temporal bone, as well as a multiloculated abscess in the right neck with air tracking from the skull base to the clavicle (Fig. 1A and B). There was substantial erosion of the posterior EAC and no clear jugular foramen destruction (Fig. 1C and D). Once hemodynamically stable, the patient was taken to the operating room for a sequential neck exploration and mastoidectomy. These procedures identified a neck abscess seemingly emanating from the mastoid tip. Necrotic soft tissue was prevalent throughout multiple fascial planes deep to the sternocleidomastoid muscle extending to the sternal notch. A mastoidectomy identified posterior EAC erosion, which was largely filled with cholesteatoma and purulence. Debriding the previ- ously noted polyp in the EAC revealed a distinct, vascular tumor that was red and pulsatile. Biopsies of the tumor mass revealed paraganglioma, which was resected where it appeared to be associated with cholesteatoma debris (Figs. 1E and 2). Postoperatively, the patient was treated with antibiotics and hemodynamic support in the ICU, and she ultimately recovered from her infection. Unfortu- nately, she has subsequently been lost to follow-up. DISCUSSION Tympanic paraganglioma (TP) tumors originate from the paraganglion cells of the tympanic plexus (1). In general, these tumors present more commonly in middle- aged women and are associated with conductive hearing loss, pulsatile tinnitus, and aural fullness (2). Clinical examination of patients with a TP frequently reveals a red mass behind the tympanic membrane, and radiographic evaluation with high-resolution computed tomography (CT) of the temporal bone and/or contrast enhanced magnetic resonance imaging (MRI) can be useful in confirming the diagnosis and extent of disease. Gener- ally, axial and coronal CT images of the tympanic cavity are valuable when a temporal bone paraganglioma is suspected. These tumors will cause bony destruction, and destruction of the bone surrounding the jugular bulb help to distinguish a jugular paraganglioma from a tympanic paraganglioma. A contrast-enhanced MRI was not ini- tially performed in this case due to the degree of the patient’s systemic illness, though the identification of flow voids within an otherwise enhancing tumor results in a ‘‘salt-and-pepper’’ appearance that can be suggestive of a paraganglioma. The pathophysiology of this patient’s infection repre- sents a presumably rare sequence of events and constel- lation of imaging findings. Specifically, she had a Glasscock-Jackson grade IV tympanic paraganglioma that had both eroded into the mastoid as well as through the tympanic membrane and external auditory canal (3). Trapped keratinizing epithelium from the tympanic membrane and ear canal injuries facilitated formation Address correspondence and reprint requests to Alex D. Sweeney, M.D., Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, 1977 Butler Blvd., Suite E5.200, Houston, TX 77030; E-mail: Alex.Sweeney@bcm.edu Financial Material & Support: Internal departmental funding was utilized without commercial sponsorship or support. ADS is a consultant for Advanced Bionics Corp., Cochlear Corp., and Oticon Medical. DOI: 10.1097/MAO.0000000000002532 ß 2019, Otology & Neurotology, Inc.