But when he saw the dental CT, he immediately ordered a conventional CT of her head. The dental scan was developed to give a three-dimensional image of the jaw and teeth, so it can’t be expected to show the entire skull. The full CT confirmed that there was a small mass in the left sinus. Based on its appearance, her doctor suspected it was a remnant of an infection from years before. But on the right side there was something else: A mass about the size of a strawberry had destroyed much of the mastoid bone just behind her ear. It was in the same place as the much smaller abnormality seen in the first M.R.I. years earlier. Now it was large enough to compress one of the vessels leading to the jugular vein. The radiologist said it looked like an infection. Or possibly a rare kind of bone cancer.
Stray Cells in the Brain
With cancer a possibility, the patient decided she needed a second opinion. She reached out to the Arizona branch of the Mayo Clinic, in Phoenix, and was scheduled to see Dr. Peter Weisskopf two weeks later. Weisskopf listened as the patient described the vertigo, tinnitus and loss of hearing, along with the debilitating fatigue and terrifying sense of impending doom. “I’m not sure this mass could cause all that,” he told her, but he agreed that an M.R.I. would provide important diagnostic information. He suspected that she had something known as a cholesteatoma. These are benign growths of cells that get trapped inside the ear — or, rarely, as in this patient’s case, inside the brain — and start to grow. Sometimes these cells are imported into the ear after a chronic infection, but most of the time they get left there during fetal development.
Weisskopf reviewed the M.R.I. The brain tissue showed up, as expected, as stripes of light and dark gray surrounded by fluid, which appears black. But just behind this patient’s ear, nestled into the lower edge of the mastoid bone of the skull, was a big bright cloud of white. Based on that appearance, Weisskopf knew what she had. It was a cholesteatoma. Although this is not a cancer, these sorts of tumors have to be removed. Left in place, they continue to enlarge until they cause real trouble. The patient was eager to have the thing removed. She felt certain that it had to be behind the symptoms she had been living with these past few years.
Removing the large mass took two operations, the second one late last spring. But it was worth it, the patient told me. The worst symptoms are completely gone. Her fatigue and sense of oppression and doom disappeared after the first surgery. But even after the second, she still has the tinnitus, which is very loud at times. She still has trouble with her balance. Her hearing is not as good as it used to be.
Weisskopf doesn’t believe the mass caused the patient’s symptoms. The patient respectfully disagrees; where it really mattered, with her mood, her sense of well-being, she feels back to something like her old self. And even though her doctor can’t see the link, she’s certain it all came from that growth, which, she thinks, maybe wasn’t quite as benign as her doctors and the textbooks say.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share with Dr. Sanders, write her at Lisa .Sandersmd@gmail.com.
