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Petrified ears due to auricular ossification: an underreported clinical sign in acromegaly

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION Acromegaly due to growth hormone (GH) secreting pituitary macroadenoma (Hardy II A, KNOSP 3) had been diagnosed in a 43yearold man, and he had subsequently been treated with endoscopic transsphenoidal surgery (twice in an interval of 6 months) and gamma knife radiosurgery (4 months after the second surgery). Due to persistent disease, he visited us for longacting somatostatin analogue therapy 2 years after the first surgery. Diabetes mellitus (DM) was diagnosed 4 years back, which was adequately controlled with metformin. In addition, he was on levothyroxine and hydrocortisone supplementation due to postoperative central hypothyroidism and hypoadrenalism (morning cortisol: 3.1 μg/dL). Preoperative morning and synacthenstimulated serum cortisol were 8.34 μg/dL and 20.2 μg/dL, respectively. He complained of occasional bilateral auricular pain for many years, preceding his pituitary surgery and diagnosis of DM. Clinical examination revealed thick lips, broad nose, seborrhea, acral enlargement and petrified and tender ears (figure 1). CT scan documented bony density (Hounsfield unit: >1100) over both auricular cartilages (figure 2), which was subsequently confirmed with 3D reconstruction (figure 3). Ossification with cortical and trabecular components was evident on Xray (figure 4). Elevated serum insulinlike growth factor1 (543 ng/mL (Ref.: 101–267)) and unsuppressed postglucose GH (1 hour: 10.9 ng/mL; 2 hours: 10.7 ng/mL) confirmed active disease. Serum calcium (8.7 mg/ dL), phosphate (3.7 mg/dL) and intact parathormone (iPTH) (30.8 pg/mL) were within normal limits. His glycated haemoglobin (HbA1c) was 6.8% and urine spot albumin creatinine ratio was 22 mg/g. Petrified or stony hard pinnae result from calcification or ossification of the elastic auricular cartilages. This is commonly associated with trauma, frostbite or inflammation, and rarely with endocrinopathies. Endocrine causes of such conditions include adrenal insufficiency (both primary and secondary), acromegaly, DM, thyrotoxicosis, hypothyroidism, pseudohypoparathyroidism (Albright’s hereditary osteodystrophy) and hyperparathyroidism (primary and secondary). Adrenal insufficiency, either primary or secondary, is the most frequently described endocrine cause associated with petrified ears. True auricular ossification, in which the normal cartilaginous structures are replaced by bone, is rare and may be encountered in occasional patients with Addison’s disease or acromegaly. Ectopic calcification of the auricular cartilages on the other hand is relatively common and is of two types: dystrophic (deposition of calcium