Volume 138, Issue 6, Pages 1500-1504 (December 2010) A Patient With Hearing Loss, Mediastinal Lymphadenopathy, and Cavitatory Pulmonary Nodules  Huck Chin Chew, MBBS, MMed, Yew Meng Chan, MBBS, Al Jajeh Issam, MD, Mariko Siyue Koh, MBBS, FCCP  CHEST  Volume 138, Issue 6, Pages 1500-1504 (December 2010) DOI: 10.1378/chest.09-2599 Copyright © 2010 The American College of Chest Physicians Terms and Conditions

Figure 1 A, CT scan of right temporal bones. B, CT scan of left temporal bones. Scans show bilateral otomastoiditis (black arrows) with opacification of external auditory canals (white arrows). CHEST 2010 138, 1500-1504DOI: (10.1378/chest.09-2599) Copyright © 2010 The American College of Chest Physicians Terms and Conditions

Figure 2 A, Chest radiograph showing a soft tissue mass obscuring the left hilum and a portion of the aortic arch as well as enlargement of the right hilum with nodular contour consistent with the presence of adenopathy. B, A contrast-enhanced study demonstrated extensive, homogenous, low-density, nonnecrotic, soft tissue infiltration of the left hilum and mediastinum with encasement of the left main pulmonary artery. C, Narrowing of the left-upper-lobe bronchus and bilateral extensive adenopathy is demonstrated. D, Bilateral extensive adenopathy is demonstrated. E, CT scan of the thorax (pulmonary windows) showed bilateral lower-lobe cavitatory pulmonary nodules. 4L = left inferior paratracheal lymph node station; PA = pulmonary artery mediastinal lymph node station. CHEST 2010 138, 1500-1504DOI: (10.1378/chest.09-2599) Copyright © 2010 The American College of Chest Physicians Terms and Conditions

Figure 3 Eustachian tube biopsy specimen showing necrotizing granulomatous inflammation with epithelioid histiocytes and multinucleated giant cells (black arrow). Adjacent to the giant cells are numerous neutrophils forming a neutrophil microabscess (white arrow) (Papanicolaou stain, original magnification × 600). CHEST 2010 138, 1500-1504DOI: (10.1378/chest.09-2599) Copyright © 2010 The American College of Chest Physicians Terms and Conditions

Figure 4 Chest radiograph done at 2 months, showing dramatic resolution of mass lesion following a course of prednisolone and cyclophosphamide. CHEST 2010 138, 1500-1504DOI: (10.1378/chest.09-2599) Copyright © 2010 The American College of Chest Physicians Terms and Conditions