Video-Assisted Ventral Bulla Osteotomy to Remove a Bullet Foreign Body in a Cat.

A 7 yr old castrated male domestic shorthair presented for assessment of a chronic left head tilt, losses of balance, and positional nystagmus. A computed tomographic scan of the head revealed several fragments of a metallic foreign body in the left tympanic cavity. The foreign material was removed under endoscopic assistance through a minimally invasive ventral bulla osteotomy. No complications were noted during the immediate postoperative period. Follow-up 5 mo after surgery revealed complete resolution of the neurological signs with no evidence of recurrence. Foreign bodies associated with middle ear infection have not been previously reported in the cat. They should now be included in the differential diagnosis of vestibular disease. Endoscopic-assisted foreign body removal in the middle ear seems to be a safe and efficient way to retrieve small foreign bodies in bullae in cats.

Outcome of Endoscopic Myringoplasty Using Gelfoam Versus no Gelfoam in Tympanic Cavity and External Auditory Canal.

Background Absorbable gelatin sponge (gelfoam) is used routinely during myringoplasty as a scaffold that supports tympanic membrane grafts and ossicular chain and to promote hemostasis. However, gelfoam could cause fibrosis, adhesions, granulations, new bone formation within the middle ear cavity and could obstruct the tympanic ostium of the eustachian tube and affects inner ear function and also interferes with the healing process of neodrum and middle ear cavity. Objective To compare the outcome of endoscopic myringoplasty with and without use of gelfoam in external auditory canal and tympanic cavity. Method Fifty patients, with 25 patients in each group who underwent endoscopic myringoplasty with and without gelfoam packing in middle ear cavity and external auditory canal were enrolled in the study. The hearing outcome was assessed by comparing pre-operative ABG (Air bone gap) with post-operative air bone gap and air bone gap closure in speech frequencies (0.5kHz,1kHz, 2kHz,4kHz). The status of graft and hearing results was evaluated on 3months of follow-up in both the groups. Result Out of total 25 patients enrolled for study in both non gelfoam packing group (NGFPG) and gelfoam packing group (GFPG), 24(96%) had graft uptake in each group. The audiological gain in non gelfoam packing group was 11.15±2.4dB whereas in gelfoam packing group it was 12.45±0.81dB. The audiological gain between the two groups did not show any statistically significant (p= 0.190). However, the pre and postoperative hearing difference was statistically significant(p=0.001) in both non gelfoam packing group and gelfoam packing group. Conclusion This study concluded that non gelfoam packing group has similar graft uptake and hearing gain when compared with gelfoam packing group in endoscopic myringoplasty. Hence, myringoplasty can be performed safely without using any gelfoam in the middle ear cavity.

[Selection of inner ear fenestration strategy and surgical effect of patients with oval window atresia accompanied by facial nerve aberration].

Objective: To summarize the clinical features and postoperative efficacy of patients with oval window atresia accompanied by facial nerve aberration. Methods: The clinical data of patients with congenital middle ear malformation with facial nerve aberration admitted to our hospital from January 2015 to March 2023 were retrospectively analyzed. There were 97 cases (133 ears) in total. Among them, 39 patients (44 ears) had complete follow-up data, including 27 male patients and 12 females, aged 7-48 years old, with an average age of 17.8 years old. Of these, 14 cases (16 ears) were patients combined with facial nerve aberration, and 25 cases (28 ears) were without facial nerve aberration. The results of imaging examination, pure-tone audiometry, selection of surgical strategy, intraoperative findings and postoperative hearing improvement were summarized and analyzed. The malformations of malleus, incus, stapes, oval window and facial nerve were recorded. Prism 9 software was used to statistically analyze the mean bone conductance and air-bone gap of patients before and after surgery. Results: All the 14 patients (16 ears) with middle ear malformation accompanied by facial nerve aberration and oval window atresia showed poor hearing and no facial palsy since childhood. High resolution CT (HRCT) examination of temporal bone, pure tone audiometry and Gelle test were performed before surgery. The malformations of malleus, incus, stapes, oval window and facial nerve were recorded. Preoperative high-resolution CT (HRCT) examination of temporal bone found 12 ears with 4 or more deformities, accounting for 75.00%, in the group of patients with facial nerve malformation. The preoperative average bone conductive threshold was (15.3±10.4) dB and the average air-bone gap was (46.3±10.6) dB in pure-tone audiometry (0.5, 1, 2, 4kHz). According to the different degrees of facial nerve and ossicle malformation, we performed three different hearing reconstruction strategies for the 14 patients (16 ears) with facial nerve aberration and oval window atresia, including 7 ears of incus bypass artificial stape implantation, 7 ears of Malleostapedotomy (MS) and 2 ears of Malleus-cochlear-prothesis (MCP). After 3 months to 18 months of follow-up, all patients showed no facial paralysis. The postoperative mean bone conductive threshold was (15.7±7.9) dB and air-bone gap was (19.8±8.5) dB. There were significant differences in mean air-bone gap before and after operation (t=7.766, P<0.05), and there was no significant difference between the mean bone conductive threshold before and after surgery (t=0.225, P=0.824). There was no significant difference of mean reduction of air-bone gap between patients with and without facial nerve aberration (t=1.412, P=0.165). There was no significant difference between the three hearing reconstruction strategies. There was no significant displacement of the Piston examined by U-HRCT. Conclusion: For patients of middle ear malformation whose facial nerve cover the oval window partially, incus bypass artificial stape implantation or Malleostapedotomy (MS) can be selected according to the specific condition of auditory ossis malformation, and for patients whose facial nerve completely covers the oval window area, Malleus-cochlear-prothesis (MCP) can be selected. Three types of stapes surgery are safe and reliable for patients with oval window atresia accompanied by facial nerve aberration. There was no significant difference in efficacy between them. Preoperative HRCT assessment of middle ear malformation is effective. There is no significant difference of surgical effect with or without facial nerve aberration. The U-HRCT can be used to evaluate the middle ear malformation before surgery and the Piston implantation status after surgery. Due to the risks of surgery, those who do not want to undergo surgery can choose artificial hearing AIDS, such as hearing aid, vibrating soundbridge, bone bridge or bone-anchored hearing aid.

Conductive Hearing Loss Associates With Dementia, and Middle Ear Reconstruction Mitigates This Association: A Multinational Database Study.

OBJECTIVE: To test the hypothesis that conductive hearing loss (CHL) is associated with dementia, and that middle ear reconstruction (MER) associates with improved outcomes for these measures in a multinational electronic health records database. STUDY DESIGN: Retrospective cohort study with propensity-score matching (PSM). SETTING: TriNetX is a research database representing about 110 million patients from the United States, Taiwan, Brazil, and India. PATIENTS: Subjects older than 50 years with no HL and any CHL (ICD-10: H90.0-2). Subjects of any age with and without any MER (CPT: 1010174). MAIN OUTCOME MEASURES: Odds ratios (ORs) and hazard ratios with 95% confidence intervals (95% CIs) for incident dementia (ICD-10: F01, F03, G30). RESULTS: Of 103,609 patients older than 50 years experiencing any CHL, 2.74% developed dementia compared with 1.22% of 38,216,019 patients with no HL (OR, 95% CI: 2.29, 2.20-2.37). Of patients experiencing CHL, there were 39,850 who received MER. The average age was 31.3 years, with 51% female patients. A total of 343,876 control patients with CHL were identified; 39,900 patients remained in each cohort after 1:1 PSM for HL- and dementia-related risk factors. Matched risk for developing dementia among MER recipients was 0.33% compared with 0.58% in controls (OR: 0.58, 0.46-0.72). CONCLUSIONS: CHL increases the odds for dementia, and MER improves the odds for incident dementia. This study represents the first population study on the topic of CHL, MER, and dementia.

Hearing Aid Silicone Impression Material Discovered During Exploration of the Middle Ear: 2 Case Reports and Literature Review.

It is unusual to see complications with the preparation of ear mold in order to get hearing aids for children who are in need. However, we came across 2 cases who had a foreign body retained in the middle ear after a long period of time from taking silicon mold impression for hearing aid fitting. One patient presented after 2 years, and the other patient presented after 10 years of hearing aid fitting. We are reporting 2 cases with silicon impression material left in the middle ear for a long period of time after taking an impression for hearing aid fitting and found unexpectedly during exploratory tympanotomy. These reported cases are among the few cases reported worldwide without clear known incidence. This necessitates proper examination by otolaryngologists and the audiologists who are responsible for taking the impression to prevent such complications.

Comparison of the Impacts of Different Middle Ear Mucosal Conditions on Type I Tympanoplasty Outcomes.

BACKGROUND: This study aimed to explore the impacts of different middle-ear mucosal conditions on the outcomes of type I tympanoplasty. METHODS: A retrospective analysis of 164 patients with chronic otitis media was carried out. The patients were divided into 4 groups according to their mucosal condition. Preoperative hearing levels and air-bone gap (ABG) before and after surgery were compared via the Kruskal‒Wallis H test. The chi-squared test and Fisher's exact test were used to assess the postoperative complications and impact factors of functional success. RESULTS: Preoperatively, neither the air conduction nor bone conduction values differed significantly among groups with different mucosal conditions. All of the ABG closed dramatically after type I tympanoplasty (P < .05) regardless of the mucosal conditions. The functional success rates were lower when the intratympanic mucosa was moderately or severely edematous compared with mildly edematous or normal (P < .05). The disease course, perforation site, and perforation size, as well as the status of the opposite ear, were not related to the auditory functional outcome. The differences in postoperative reotorrhea and reperforation among the 4 groups were not statistically significant. CONCLUSION: Preoperative hearing levels were not affected by middle-ear mucosal conditions. The functional success rate was influenced by mucosal conditions, but hearing levels were significantly enhanced after surgical intervention regardless of the mucosal status. Postoperative complications were not related to the mucosal conditions. Thus, type I tympanoplasty is adoptable for mucosal abnormalities when pharmacotherapy cannot result in a healthy tympanum.

Effects of Tranexamic Acid on Intraoperative Bleeding and Surgical Field Visualization During Middle Ear Surgery: A Narrative Review.

Tranexamic acid is an antifibrinolytic agent widely used in several surgical procedures to reduce intraoperative bleeding. Intraoperative bleeding is a crucial problem for the ear surgeon, as it prevents good visualization of the surgical field. The aim of this work was to analyze the relevant literature about the use of tranexamic acid in ear surgery. A literature search was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement, across 3 databases (Medline, Cochrane, and Google Scholar), with the terms "tranexamic acid," and "ear," and "surgery." Three prospective, randomized, and double-blind clinical trials met the inclusion criteria. Studies were not able to be pooled because of heterogeneity in material, methods of delivery and evaluation, and procedures used. Despite these limitations, all 3 papers found a significant reduction in intraoperative bleeding, allowing a better visualization of the operating field. Despite the scarcity of published trials, tranexamic acid is safe and seems to be useful in reducing intraoperative bleeding in ear surgery, thus improving operative field visualization.

[Simultaneous occurrence of facial neurinoma in internal auditory canal and middle ear paraganglioma in patient. Unusual combination and difficult surgical task]. / Odnovremennoe vozniknovenie nevrinomy litsevogo nerva vo vnutrennem slukhovom prokhode i paragangliomy srednego ukha u patsientki: neobychnoe sochetanie i neprostaya khirurgicheskaya zadacha.

CLINICAL CASE: The 59-year-old patient complained of hearing loss on the left, ear murmur for a long time, periodic pain and discomfort in the left ear, dizziness for 6 months. She was found to have concurrent vestibular schwannoma in the internal auditory canal and temporal bone paraganglioma. Both tumors were removed in one operation. The schwannoma was removed by translabirinth access due to preoperative deafness, while the glomus tumor was removed during this access. Postoperative biopsy showed the presence of two unrelated diseases: paraganglioma (ICD-0 code 8690/3) and schwannoma (ICD-0 code 9560/0).

Tympanic Cavity Packing in Tympanoplasty Type 1: A Meta-Analysis.

Packing of tympanic cavity is generally considered an essential step in myringoplasty. However, each packing material comes with one or another side effect. The objective of this meta-analysis was to compare the results of Type 1 myringoplasty with or without packing. Pubmed, Cochrane database, Embase, Google Scholar, and clinicaltrials.gov were searched using 'tympanoplasty or myringoplasty and packing' as the search query. All RCTs / quasi-RCTs comparing tympanoplasty Type 1 with packing (control) versus without packing (intervention) of tympanic cavity in the human population were included. For dichotomous and continuous outcomes, relative risks (RR) and mean differences (MD) were calculated with 95% confidence interval, respectively. Heterogeneity was assessed using I2 statistics. Publication bias was checked using funnel plot and Egger's test, if applicable. Quality of evidence was assessed for each outcome using GRADE approach. Eleven studies were deemed eligible. For graft uptake and functional success rate, RR of 1.01 and 1.05 were obtained, respectively, showing no significant differences between the intervention and control groups. At 1st and 3rd postoperative month, no-packing group showed 3.86 dB and 2.08 dB better air-bone gap (ABG) closure than the packing group, respectively. Also, intervention with no-packing was 9.28-minute shorter procedure. With RR 0.35, no-packing had significantly lesser postoperative aural fullness. Type 1 tympanoplasty performed with or without packing show comparable results in terms of graft uptake and functional success rate. However, if performed without packing, it takes shorter time, provides early hearing improvement and causes less aural fullness. Key Words: Tympanoplasty Type 1, Packing, Gelfoam, No-packing, Meta-analysis, Endoscopic myringoplasty.

Middle Ear Neuroendocrine Tumor: Case Report of a Tympanic Adenoma.

Middle ear neuroendocrine tumors (MeNETs) are an exceptionally rare occurrence. These benign tumors stem from the tympanic mucosa and can easily be misinterpreted by the clinician and the pathologist. Clinical characteristics, otoscopic findings and medical imaging in these cases are non-specific. We present a case of a 60-year-old male patient with bilateral hearing loss following recent coronavirus disease 2019 disease. Diagnostic work-up revealed a soft tissue neoplasm of the left middle ear. Surgical resection of the tumor mass with implantation of a partial ossicular replacement prosthesis (PORP) was the main modality of treatment. Middle ear neuroendocrine tumors was confirmed through positive immunohistochemistry for neuroendocrine tumor markers. Follow-up magnetic resonance imaging 12 months after the surgery reported no tumor recurrence or significant residual disease with a stable PORP. Our report highlights challenges in diagnosing and treating these rare tumors, while emphasizing surgical resection pitfalls and resulting improvement of quality of life of the patient. We recommend a through followup of patients with unclear soft tissue masses in the middle ear to obtain a definitive diagnosis.

[Exploration of technique for preservation of external-middle ear structure in surgery of jugular foramen paraganglioma （appended 2 case reports）].

Objective:To investigate the feasibility and effect of the modified surgery of the classic infratemporal fossa type A approach for the surgical treatment of jugular foramen paraganglioma with preservation of the external and middle ear structures. Methods:The medical data of 2 patients with jugular foraminal paraganglioma treated by sublabyrinthic-transmastoid approach were retrospectively analyzed. The clinical feature, degree of tumor resection, postoperative facial nerve function and hearing retention, and the incidence of postoperative complications were evaluated. Results:Two patients were both female, and were pathologically confirmed as paraganglioma. The tumor of case 1 was staged as C2De1, and case 2 as C1De1. Tumors were completely resected in both patients. Case 1 suffered infection after surgery, with residual tympanic membrane perforation and mixed deafness. Case 2 developed mild facial paralysis（grade Ⅱ） after surgery, and recovered after symptomatic treatment. There was no tumor residue or recurrence during half a year of follow-up. Conclusion:Surgical treatment of certain paragangliomas in the jugular foramen with a combined sublabyrinthic-transmastoid and upper neck approach might achieve both complete resection of the tumor and preserving the structure and function of the outer-middle ear. This procedure is suitable for paragangliomas restricted in the jugular foramen area, with no or limited involvement of the internal carotid artery（C1 or C2）, and with no or mild hearing loss.

Combined underwater endoscopic and microscopic surgery for tympanic paraganglioma: A case report.

The resection of middle ear paragangliomas can be challenging given their vascular nature and the small volume of the tympanic cavity, particularly when the tumor in the hypotympanum is close or attached to the internal carotid artery (ICA). We performed combined underwater endoscopic and microscopic surgery for a Class B1 middle ear paraganglioma according to the modified Fisch classification. The suspicious bone in the hypotympanum and around the petrous ICA was drilled with underwater endoscopy. The feeding arteries, the caroticotympanic and inferior tympanic arteries, were suctioned and cauterized under microscopy. To the best of our knowledge, no case of middle ear paraganglioma treated with underwater endoscopy has been reported. Underwater endoscopy, providing a clear operative field with blood and bone dust irrigation, is a good indication for middle ear paragangliomas. In contrast, microscopic preparation for unexpected bleeding is important, particularly when the tumor closely extends to vital structures, such as the ICA or the jugular bulb.

The impact of round window reinforcement on middle and inner ear mechanics with air and bone conduction stimulation.

The round window (RW) membrane plays an important role in normal inner ear mechanics. Occlusion or reinforcement of the RW has been described in the context of congenital anomalies or after cochlear implantation and is applied as a surgical treatment for hyperacusis. Multiple lumped and finite element models predict a low-frequency hearing loss with air conduction of up to 20 dB after RW reinforcement and limited to no effect on hearing with bone conduction stimulation. Experimental verification of these results, however, remains limited. Here, we present an experimental study measuring the impact of RW reinforcement on the middle and inner ear mechanics with air and bone conduction stimulation. In a within-specimen repeated measures design with human cadaveric specimens (n = 6), we compared the intracochlear pressures in scala vestibuli (PSV) and scala tympani (PST) before and after RW reinforcement with soft tissue, cartilage, and bone cement. The differential pressure (PDIFF) across the basilar membrane - known to be closely related to the hearing sensation - was calculated as the complex difference between PSV and PST. With air conduction stimulation, both PSV and PSTincreased on average up to 22 dB at frequencies below 1500 Hz with larger effect sizes for PST compared to PSV. The PDIFF, in contrast, decreased up to 11 dB at frequencies between 700 and 800 Hz after reinforcement with bone cement. With bone conduction, the average within-specimen effects were less than 5 dB for either PSV, PST, or PDIFF. The inter-specimen variability with bone conduction, however, was considerably larger than with air conduction. This experimental study shows that RW reinforcement impacts air conduction stimulation at low frequencies. Bone conduction stimulation seems to be largely unaffected. From a clinical point of view, these results support the hypothesis that delayed loss of air conduction hearing after cochlear implantation could be partially explained by the impact of RW reinforcement.

Importance of preoperative HRCT temporal bone in the orientation of the cochlea and its relation to intra-operative difficulties in cochlear implantation - predicting the grades of difficulty.

OBJECTIVE: This study emphasizes the role of preoperative high-resolution computed tomography (HRCT) temporal bone in evaluating the variation in cochlear orientation and proposes a grading system to determine the level of intraoperative difficulties encountered. METHODS: Preoperative correlation of middle ear and inner ear structures along with the basal turn angle (BTA) was done to assess the orientation. Patients were divided into three groups depending on BTA and radiology findings. RESULTS: Group A (BTA = 55°-60°) had statistically significant (p < 0.05) correlation between middle ear to inner ear structures on HRCT, whereas group B (BTA >60°) and C (BTA <55°) had variations in the alignment of middle ear structures to their corresponding inner ear structures. CONCLUSION: The association of BTA to the correlation between middle ear and inner ear structures can determine the orientation of the cochlea. This evaluation makes the surgeon aware of intraoperative challenges and helps in surgical planning.

[Features of otosurgery in children after blast injuries]. / Osobennosti rekonstruktivnoi otokhirurgii u detei posle minno-vzryvnykh ranenii.

An explosion is a process that rapidly releases a huge amount of energy in the form of heat, kinetic energy, and high-pressure shock waves. Since the organ of hearing is most susceptible to pressure changes, damage to the sound-conducting or sound-receiving systems is inevitable in case of an explosive injury. This article examines the mechanism of formation of explosive injuries of the middle and inner ear in children and adolescents, the features of diagnosis and tactics of surgical reconstructive treatment of explosive ear injuries based on the data available in the scientific literature and their own experience.

[Clinical features of congenitally enlarged bony portion of Eustachian tube].

Objective:To investigate the clinical features of patients with congenitally enlarged bony portions of the Eustachian tube（ET）. Methods:The medical history, physical examination, hearing test, temporal bone high resolution computed tomography（HRCT） of six patients（nine ears） with congenitally enlarged bony portion of the ET were retrospectively analyzed. Results:Four patients were men and two were women. The minimum, maximum, and average ages were 5, 21, and（14.7±6.4） years, respectively. Three malformations were bilateral and three were left-sided. Three ears had conductive hearing loss（average bone and air conduction thresholds were 13.7 dB and 71.3 dB）, three had mixed hearing loss（average bone and air conduction thresholds were 27.7 dB and 83.7 dB）, and one had extremely severe sensorineural hearing loss. The average maximum length and width of the enlarged bony ET on temporal bone HRCT were（22.61±2.94） mm and（6.50±2.33） mm, respectively. The enlargement was combined with an external auditory canal malformation in six ears, narrow tympanic cavity in six, tympanic antrum malformation in five, ossicular chain malformation in seven, cochlear malformation in six, helicotrema malformation in three, vestibule widening in two, semicircular canal malformation in three, vestibular window malformation in six, facial nerve abnormality in five, internal auditory meatus malformation in two, low middle cranial fossa in eight, and severe internal carotid artery malformation in one. Conclusion:Bony ET enlargement is a rare congenital middle ear malformation which could combined with other ear malformations. Patients can have no ET dysfunction but different patterns of hearing loss. The defect is usually found unintentionally during imaging, and the HRCT of temporal bone is significant.

Integration of 3D-printed middle ear models and middle ear prostheses in otosurgical training.

BACKGROUND: In otosurgical training, cadaveric temporal bones are primarily used to provide a realistic tactile experience. However, using cadaveric temporal bones is challenging due to their limited availability, high cost, and potential for infection. Utilizing current three-dimensional (3D) technologies could overcome the limitations associated with cadaveric bones. This study focused on how a 3D-printed middle ear model can be used in otosurgical training. METHODS: A cadaveric temporal bone was imaged using microcomputed tomography (micro-CT) to generate a 3D model of the middle ear. The final model was printed from transparent photopolymers using a laser-based 3D printer (vat photopolymerization), yielding a 3D-printed phantom of the external ear canal and middle ear. The feasibility of this phantom for otosurgical training was evaluated through an ossiculoplasty simulation involving ten otosurgeons and ten otolaryngology-head and neck surgery (ORL-HNS) residents. The participants were tasked with drilling, scooping, and placing a 3D-printed partial ossicular replacement prosthesis (PORP). Following the simulation, a questionnaire was used to collect the participants' opinions and feedback. RESULTS: A transparent photopolymer was deemed suitable for both the middle ear phantom and PORP. The printing procedure was precise, and the anatomical landmarks were recognizable. Based on the evaluations, the phantom had realistic maneuverability, although the haptic feedback during drilling and scooping received some criticism from ORL-HNS residents. Both otosurgeons and ORL-HNS residents were optimistic about the application of these 3D-printed models as training tools. CONCLUSIONS: The 3D-printed middle ear phantom and PORP used in this study can be used for low-threshold training in the future. The integration of 3D-printed models in conventional otosurgical training holds significant promise.

Middle Ear Tophi: A Case Series of Two Unusual Lesions and a Report of Facial Weakness and Review of the Literature.

OBJECTIVE: Tophaceous lesions of the middle ear from calcium pyrophosphate deposition disease (CPPD, or pseudogout) and gout are infrequently reported. Recognizing its characteristic findings will allow clinicians to accurately narrow the differential diagnosis of bony-appearing middle ear lesions and improve management. PATIENTS: Two consecutive cases of tophaceous middle ear lesions presenting to a tertiary care center between January 2021 and December 2021. Neither with previous rheumatologic history. INTERVENTIONS: Surgical excision of tophaceous middle ear lesions. MAIN OUTCOME MEASURE: Improvements in facial weakness and conductive hearing loss. RESULTS: The first case was a 66-year-old gentleman with progressive conductive loss, ipsilateral progressive facial weakness over years, and an opaque, irregular-appearing tympanic membrane anterior to the malleus found to have CPPD on surgical pathology, with immediate postoperative improvement of facial function. The second was a 75-year-old gentleman with progressive conductive loss and similar appearing tympanic membrane as case 1, previously diagnosed with tympanosclerosis, found to have gout on surgical pathology. In both cases, the CT showed a heterogenous, bony-appearing lesion in the middle ear, and both tophaceous lesions were a of gritty, chalky consistency intraoperatively. CONCLUSION: Tophaceous lesions of the middle ear are rare but have similar findings. Notably, the tympanic membrane can appear opaque and irregular, and the CT demonstrates a radiopaque, heterogeneous appearance. Facial weakness is an unusual finding. Specimens of suspected tophi must be sent to pathology without formalin for accurate diagnosis.