A previously healthy 50-year-old man presented in clinic with a three-month history of discomfort in his left ear and zygomatic area, more notice able on performing Valsalva manoeuvre. He noted some hearing loss and a pulsatile tinnitus, but no vertigo. There was no evidence of systemic pathology, apart from gout and a mild hypertension. Clinical examination revealed a diffuse non-tender soft tissue swelling in the left parotid region, approximately 6 cm in diameter. Otoscopy of the left ear showed exostosis in the posterior meatal wall and a middle ear effusion. The right ear was unremarkable, as was the remainder of ENT examination. There was no cervical lymphadenopathy. Pure tone audiogram showed a mild conductive hearing loss of 20 dB on the left side and a tympanogratn showed a type B curve. Full blood count, immunological screening (including auto-antibodies) and liver function tests were normal but the ESR was elevated. There was no clinical evidence of renal impairment, and there was no macroscopic or microscopic haernaturia. Parotid sialography was normal.

Over the next four weeks, he developed a red polypoid swelling in the anterosuperior part of the external ear canal, which was biopsied, and resulted in profuse bleeding. The pre-auricular swelling gradually increased in size and a fine needle aspiration (FNA) was performed but did not yield anything of diagnostic value. The histology of the aural polyp was strongly suggestive for carcinoma.

A magnetic resonance image (MRI) scan of the parotid and the brain showed an extensive tumour of the temporal bonc, involving the left temporal lobe and extending just into the subcutaneous tissues. There was no evidence of lymphadenopathy and the parotid gland was normal.

An open biopsy was performed and histology confirmed the diagnosis of careinoma, probably from renal origin. Ultrasound and DMSA scan of the kidneys revealed a 20 mm diameter tumour in the right kidney.

The patient underwent a decompression and subtotal resection of the intracranial extension making a good recovery. and a right nephrectomy was performed four weeks later. Histology confirmed the diagnosis of renal cell carcinoma with extensive vascular invasion. The patient was treated palliatively with radiotherapy but developed other bony secondaries and pathological fractures, eventually dying 10 months after his first clinical presentation.

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