Gross appearances are those of a granular or even gritty mass. Microscopically, the neoplasm takes the same forms as any of the well-described intracranial types of meningioma. The commonest variety seen in the middle ear is the meningothelial type, in which the tumour cells form masses of epithelioid, regular cells often disposed into whorls, which may be large or small. Fibro-blastic and psammomatous varieties are also sometimes seen in the middle ear.

Histological diagnosis of meningioma may be difficult because the above features are indistinct. Under these circumstances immunocytochemistry may be of some diagnostic value. Meningiomas are negative for most markers, including cytokeratins. The majority of meningiomas, however, are positive for vimentin and epithelial membrane antigen.

Nager's review of temporal bone meningiomas indicated that only 2 out of 30 patients survived a 5-year period [78]. More recent experience of middle ear meningiomas signals a better outlook after careful local excision. In a recent study of 35 patients with follow up in which the tumour was sited mainly in the middle ear [116] surgical excision was used in all patients. Ten patients developed a recurrence from 5 months to 2 years later and 5 patients died with recurrent disease (mean, 3.5 years); the remaining 30 patients were alive (n=25, mean: 19.0 years) or had died (n=5, mean: 9.5 years) of unrelated causes without evidence of disease. Menin-giomas of the middle ear behave as slow-growing neoplasms with a good overall prognosis (raw 5-year survival, 83%). Extent of surgical excision is probably the most important factor in determining outlook because recurrences develop in 28% of cases.

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