The oncology of otology

Carcinomas of the external auditory canal: Management and results: A multicenter REFCOR propensity score matching study

OBJECTIVES

To analyse prognostic factors and survival outcomes of malignant tumors of the external auditory canal, to investigate the role of regional surgery, and adjuvant radiotherapy in early stages and to investigate the role of surgery in operable T4 stage.

SETTING

A retrospective analysis was conducted on all patients prospectively included in the national database of the French Expertize Network for Rare ENT Cancers (REFCOR) from January 2000 to December 2016.

PARTICIPANTS

103 patients from 19 reference centers were included. A propensity score matching analysis was applied to enable comparisons between treatments.

MAIN OUTCOMES AND MEASURES

Event-free survival, overall survival and factors of poor prognosis of the cohort were described. The interest of local and regional surgery and postoperative radiotherapy were evaluated.

RESULTS

The factors of poor prognosis on event-free survival were immunosuppression (p = 0.002), Karnofsky status less than 90% (p = 0.02), body mass index less than 19 Kg / m2 (p = 0.0009), peripheric facial palsy (p = 0.0016), and positive margin (p = 0.0006). In early stages, locoregional surgery was associated with an increase in event-free survival (p = 0.003, HR = 0.21) versus local surgery alone, while postoperative radiotherapy was not associated with an increase in event-free survival (p = 0.86, HR = 0.91) or overall (p = 0.86, HR = 0.91). In locally advanced stages, locoregional surgery followed by radiotherapy was associated with an increase in event-free survival (p = 0.03, HR = 0.39) and overall (p = 0.02, HR = 0.34) versus chemoradiotherapy alone.

CONCLUSION AND RELEVANCE

Regional surgery is recommended for early stages of cancers of the external auditory canal. In operable cases, locoregional surgery followed by radiotherapy is recommended.

Temporal bone management in external and middle ear carcinoma

PURPOSE OF REVIEW

The purpose of this review is to outline the temporal bone management of external and middle ear carcinoma. The review will outline the current evidence involved in deciding which surgical approach to take, as well as new advances in auditory rehabilitation and immunotherapy.

RECENT FINDINGS

Traditional surgical approaches include lateral temporal bone resection, subtotal temporal bone resection and total temporal bone resection. They can also involve parotidectomy and neck dissection depending on extension of disease into these areas. Options for auditory rehabilitation include osseointegrated hearing aids, transcutaneous bone-conduction implants, and active middle ear implants. Recent advances in immunotherapy have included the use of anti-PD-1 monoclonal antibodies.

SUMMARY

The mainstay of management of temporal bone disease involves surgical resection. Early-stage tumours classified according to the Pittsburgh staging tool can often be treated with lateral temporal bone resection, whereas late-stage tumours might need subtotal or total temporal bone resection. Parotidectomy and neck dissection might also be indicated if there is a risk of occult regional disease. Recent advances in immunotherapy have been promising, particularly around anti-PD-1 inhibitors. However, larger clinical trials will be required to test the extent of efficacy, particularly around combination use with surgery.

Risk Factors for Locoregional Recurrence and Distant Metastasis in 143 Patients with Adenoid Cystic Carcinoma of the External Auditory Canal

AIMS

Adenoid cystic carcinoma (ACC) grows slowly and is characterised by potential recurrence and metastasis to distant organs. This study aimed to evaluate the risk factors for locoregional recurrence (LRR) and distant metastasis in patients with ACC of the external auditory canal (EAC).

MATERIALS AND METHODS

Demographic, pathological, therapeutic and survival data of 143 patients with EAC ACC were reviewed in this study. Univariate and multivariate Cox proportional hazard regression analyses were carried out to determine the risk factors for LRR and distant metastasis. Factors associated with overall survival after LRR and distant metastasis were also analysed.

RESULTS

During a median follow-up of 49 months, 31 of 143 patients were observed with LRR and 34 developed distant metastasis. Bone invasion and histological subtype were independent risk factors for locoregional recurrence-free survival. T stage and LRR were independent risk factors for distant metastasis-free survival. Salvage surgery and adjuvant radiotherapy or chemoradiotherapy for LRR resulted in better survival, whereas extrapulmonary metastasis and LRR were associated with a higher risk of poor survival after distant metastasis.

CONCLUSION

Patients with distant metastases, especially those with LRR, are at significant risk of poor prognosis. Our findings emphasise the importance of long-term regular follow-up and recommend surgical intervention with radiotherapy for recurrent EAC ACC.

Role of the otologist/neurotologist in managing auricular and periauricular cutaneous malignancies: A 10-year otologic oncology experience

Objective

Auricular/periauricular cutaneous malignancies can be challenging to manage surgically due to the complex anatomy of the region. Otologists/neurotologists have unique skillsets that are well-suited to surgically treat these patients. We aim to highlight the role of otologists and neurotologists in providing surgical care of patients with auricular and periauricular malignancies by describing the experience of a single fellowship-trained neurotologist over a 10-year period.

Methods

Retrospective chart review of 387 patients with auricular and periauricular malignancy treated by a single neurotologist between 2012 and 2022 was completed. Tumor histology and procedures performed for each patient were extracted. Additional data was collected for a subset of 84 patients with complex cases requiring selective neck dissection, parotidectomy, lateral temporal bone resection, regional advancement or rotational flap reconstruction, and/or free tissue transfer reconstruction.

Results

Within the series of 387 patients, squamous cell carcinoma was the most common histology (42.6%, n = 165), followed by basal cell carcinoma (40.8%, n = 158), and melanoma (9.8%, n = 38). Common surgical procedures included wide local excision (61.8%, n = 239), partial/sub-total auriculectomy 18.3% (n = 71), or total auriculectomy 5.2% (n = 20). Within the 84-patient subset, median age at diagnosis was 71.9 years. Dermatologists provided most patient referrals (50.0%, n = 42). Most common tumor locations included: auricular (58.3%, n = 49), pre-auricular (21.4%, n = 18), and parotid (27.4%, n = 23). Revision surgery occurred in 22.6% of cases (n = 19), of which 26.3% (n = 5) for positive margins and 31.6% (n = 6) for recurrence. Mean follow-up was 22.8 months. Disease-specific 5-year survival was 91%.

Conclusions

We demonstrate the feasibility of an otologist/neurotologist incorporating the surgical management of auricular and periauricular malignancies into their practice.

Level of Evidence

4.

Patterns of spread and anatomical prognostic factors of pre-auricular cutaneous squamous cell carcinoma extending to the temporal bone

BACKGROUND

Improvements can be made in the management and staging of advanced pre-auricular cutaneous squamous cell carcinoma (cSCC). We aimed to analyze radiological patterns of spread and clinico-anatomical prognostic factors.

METHODS

Retrospective review of 54 patients with pre-auricular cSCC (cutaneous/nodal) who underwent temporal bone resection with curative intent.

RESULTS

Involvement of the cartilaginous external auditory canal (EAC) (79.6%) and retromandibular space (63.0%) was common. Styloid process/anterior carotid sheath (ACS) (11.1%) and bony EAC (7.4%) involvement were rare. ACS involvement resulted in high rates of involved surgical margins (100%) and poor outcomes on univariable analysis. Negative prognostic factors on multivariable analysis included salvage surgery and invasion of the bony EAC, mandible, pterygoid muscle(s), and dura.

CONCLUSION

The bony EAC and ACS can form temporary barriers to tumor spread, with the latter representing a potential limit of resectability. Prognostic factors revealed can lead to the development of a more appropriate staging tool.

Temporal Bone Resection for Squamous Cell Carcinoma of the Lateral Skull Base: Systematic Review and Meta-analysis

OBJECTIVE

Temporal bone squamous cell carcinoma (TBSCC) is rare and often confers a poor prognosis. The aim of this study was to synthesize survival and recurrence outcomes data reported in the literature for patients who underwent temporal bone resection (TBR) for curative management of TBSCC. We considered TBSCC listed as originating from multiple subsites, including the external ear, parotid, and external auditory canal (EAC), or nonspecifically from the temporal bone.

DATA SOURCES

PubMed, Cochrane Library, Embase, and manual search of bibliographies.

REVIEW METHOD

A systematic literature review conducted in December 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Survival data were collected from 51 retrospective studies, resulting in a pooled cohort of 501 patients with TBSCC. Compared to patients undergoing lateral TBR (LTBR), patients undergoing subtotal (SBTR) or total (TTBR) TBR exhibited significantly higher rates of stage IV disease (P < .001), positive surgical margins (P < .001), facial nerve involvement (P < .001), and recurrent disease (P < .001). A meta-analysis of 15 studies revealed a statistically significant 97% increase in mortality in patients who underwent STBR or TTBR. On multivariate analysis, recurrent disease was independently associated with worse overall survival (P < .001). On univariate analysis, facial nerve involvement was also associated with decreased overall survival (P < .001).

CONCLUSION

Recurrent disease was associated with risk of death in patients undergoing TBR. Larger prospective multi-institutional studies are needed to ascertain prognostic factors for a wider array of postoperative outcomes, including histology-specific survival and recurrence outcomes.

Epidemiology and treatment outcomes of cutaneous squamous cell carcinoma extending to the temporal bone

BACKGROUND

Accurate epidemiological and outcomes data regarding cutaneous squamous cell carcinoma (cSCC) extending to the temporal bone is lacking.

METHODS

Retrospective analysis of 167 Australian patients with primary and peri-temporal bone cSCC.

RESULTS

cSCC extending from secondary subsites (93.4%) was 14 times more frequent than primary temporal bone SCC (6.6%). For patients who underwent curative surgery ± post-operative radiotherapy (n = 146, 87.4%), 5-year disease-free survival, locoregional recurrence-free survival, disease-specific survival, and overall survival was 53.0%, 59.4%, 67.9%, and 44.7%, respectively. External ear and pre-auricular tumors, salvage surgery, tumor size (≥40 mm medial-lateral), nodal disease, and involved margins were negative predictors of survival in multivariable analysis.

CONCLUSION

In regions of high sun exposure, cSCCs extending to the temporal bone are more common than primary cancers. Outcomes are improved with clear margins, justifying the need for radical resection. Further research regarding pre-auricular cancers is required given poorer associated survival outcomes.

Treatment Strategies for Malignancies of the External Auditory Canal

Malignant tumors of the external auditory canal (EAC) are rare tumors in the head and neck. Delayed diagnosis is not uncommon because the symptoms of early tumors are nonspecific. Various surgical and oncological treatment modalities have been reported. Decision-making depends on pathological feature and stage of the lesions, patient’s general condition and preference, and physician’s experience and skill. Radical surgery is widely accepted as the primary treatment of choice. Postoperative radiotherapy is used more often to improve local and regional control of the disease. Chemotherapy is usually recommended for advanced disease, residual disease, and metastasis. Prognosis is affected by multiple factors such as TNM stage, surgical margin, pathological type and differentiation of tumor, involvement of facial nerve, and so on. Although the survival rate is improved significantly over the past several decades with the development of skull base surgery, neuroradiology, anesthesiology, and oncology, it remains challenging to diagnose and treat EAC malignancies due to the rarity, the local anatomical complexity of temporal bone, and the lack of standard TNM staging system.

Perineural Invasion of the Intratemporal Facial Nerve: How Far Proximally Do We Chase the Positive Margin?

OBJECTIVE

To determine recurrence patterns in patients with head and neck cancers requiring facial nerve sacrifice and to determine the optimal management of the positive proximal facial nerve margin.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

PATIENTS

One hundred fifty-five patients with head and neck malignancies who underwent sacrifice of the facial nerve between March 1, 1999 and October 31, 2020. Demographics, preoperative facial nerve function, prior oncologic treatment, histologic type, operative details, adjuvant treatment, recurrence patterns, and overall survival were reviewed.

MAIN OUTCOME MEASURES

Recurrence rates and recurrence location.

RESULTS

Thirteen patients (8%) had positive proximal margins on final pathologic evaluation. Six of 13 (46%) experienced disease recurrence. No disease recurred proximally along the facial nerve. The recurrence rate was 26% for negative proximal facial nerve margins. Segments of the facial nerve biopsied included: extratemporally (n = 78), at the stylomastoid foramen (36), mastoid segment (22), second genu (7), tympanic (6), geniculate (3), labyrinthine (1), and IAC (2). Median patient follow-up was 30.3 months.

CONCLUSIONS

Our data suggest that a conservative approach to a positive proximal facial nerve margin is optimal with respect to operative planning, patient morbidity, and disease recurrence patterns. Recurrence proximally along the facial nerve is an exceedingly rare event and the necessity of biopsy proximal to the geniculate ganglion, and in some cases even to the second genu, is called into question.

Lateral temporal bone resection for cutaneous carcinomas of the external auditory canal and peri-auricular region

OBJECTIVES

To evaluate the outcomes for patients after lateral temporal bone resection surgery for cutaneous squamous cell carcinoma and basal cell carcinoma, and to ascertain predictors of survival and treatment failure.

METHODS

A retrospective review was conducted of the medical records for all patients who underwent lateral temporal bone resection for cutaneous squamous cell carcinoma or basal cell carcinoma between 2007 and 2019 in Western Australia.

RESULTS

Thirty-seven patients underwent lateral temporal bone resection surgery. Median follow-up duration was 22 months. Twenty-five patients had squamous cell carcinoma and 12 had basal cell carcinoma. The overall survival rate at two years for patients with squamous cell carcinoma was 68.5 per cent. Pre-operative facial nerve involvement (determined via clinical or radiological evidence) was identified as a predictor of mortality (hazard ratio = 3.411, p = 0.006), with all patients dying before two years post-operatively. Locoregional tumour control was achieved in 81 per cent of cases (n = 30).

CONCLUSION

Lateral temporal bone resection offers acceptable local control rates and survival outcomes. Caution should be used in offering this surgery to patients with clinical or radiological evidence of facial nerve involvement because of the relatively poorer survival outcomes in this subgroup.

Malignancies requiring temporal bone resection: An Australian single-institution experience

BACKGROUND

Malignancies in and around the temporal bone are aggressive and difficult to manage. In Queensland (Australia), where skin cancer rates are exceedingly high, tumours extending to the temporal bone from surrounding structures occur more commonly than primary cancers. Yet, a paucity of evidence exists as to their management and outcomes. This study aimed to review an Australian centre's experience of managing temporal and peritemporal bone malignancies, reporting on patient and tumour characteristics, treatment, and survival outcomes.

METHODS

Retrospective analysis of patients with primary temporal bone cancer and cancers extending to the temporal bone managed by the Queensland Skull Base Unit (Princess Alexandra Hospital) between 2000 and 2019.

RESULTS

A total of 222 patients were identified, of which 203 (91.4%) had cutaneous primaries, with 167 (75.2%) being squamous cell carcinoma (SCC). 73.9% presented with locoregionally recurrent or residual disease. Secondary tumours (92.8%) were 12 times more frequent than primary malignancies (7.2%), with the preauricular subsite the most common (45.5%). In the 201 patients (90.5%) who underwent curative intent surgery, 5-year overall survival, disease-free survival (DFS), and disease-specific survival was 46.6%, 52.2%, and 65.9%, respectively. The preauricular subsite (p = 0.004), melanoma (vs. SCC, p = 0.027), involved margins (p < 0.001), and pathologically involved nodes (p < 0.001) were associated with significantly worse DFS.

CONCLUSION

This is one of the largest studies of temporal bone malignancy in the literature, comprised primarily of secondary cutaneous malignancies. Although clear differences in epidemiological characteristics exist around the world, survival remains poor. Treatment should focus on achieving a clear margin of resection to optimize outcomes.

Survival outcomes of lateral skull base tumors following temporal bone resection

BACKGROUND

Lateral skull base tumors often necessitate temporal bone resection (TBR), although clinical outcomes can be unfavorable. Factors influencing survival and recurrence after TBR for cutaneous and salivary malignancies were evaluated.

METHODS

Twenty-six TBR subjects were included. Survival and recurrence outcomes were estimated at 1, 2, and 5 years postresection. Prognostic factors were analyzed using univariate and multivariate Cox regression.

RESULTS

Two years postresection, the overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS) rates were 61%, 74%, and 49%, respectively, and 51%, 63%, and 45% at 5 years. On univariate analysis, preoperative facial nerve dysfunction and intraoperative nerve sacrifice worsened OS, DSS, and RFS. Prior surgery and adjuvant radiation independently predicted reduced OS, DSS, and RFS on multivariate analysis.

CONCLUSIONS

Mortality is highest in the first 2 years following resection. Preoperative facial nerve dysfunction, facial nerve sacrifice, and prior radiation are negative predictors of survival and recurrence.

A systematic review of the primary squamous cell carcinoma of the external auditory canal: survival outcome based on T-staging and proposal of a new classification

OBJECTIVE

This study aimed to provide a systematic review on survival outcome based on Pittsburgh T-staging for patients with primary external auditory canal squamous cell carcinoma.

METHOD

This study was a systematic review in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines performed until January 2018; pertinent studies were screened. Quality of evidence was assessed using the grading of recommendation, assessment, development and evaluation working group system.

RESULTS

Eight articles were chosen that reported on 437 patients with external auditory carcinoma. The 5-year overall survival rate was 53.0 per cent. The pooled proportion of survivors at 5 years for T1 tumours was 88.4 per cent and for T2 tumours was 88.6 per cent. For the combined population of T1 and T2 cancer patients, it was 84.5 per cent. For T3 and T4 tumours, it was 53.3 per cent and 26.8 per cent, respectively, whereas for T3 and T4 tumours combined, it was 40.4 per cent. Individual analysis of 61 patients with presence of cervical nodes showed a poor survival rate.

CONCLUSION

From this review, there was not any significant difference found in the survival outcome between T1 and T2 tumours. A practical classification incorporating nodal status that accurately stratifies patients was proposed.

A Case of External Auditory Canal Sebaceous Carcinoma: Literature Review and Treatment Discussion

Sebaceous neoplasms are a rare type of skin cancer that may occur in any area with sebaceous glands, including the outer third of the external auditory canal. However, documentation of the tumor originating in this location is limited to scarce case reports. In this location, malignancies can invade the temporal bone, typically requiring en bloc resection and radiation therapy. We describe a case managed with limited surgical excision based on criteria for primary squamous cell carcinoma of the external auditory canal with only close observation following surgery. Margins were free of disease following excision and histology demonstrated a favorable prognosis. The patient was disease free after a follow-up period of over 3 years postoperatively. A review of relevant literature is utilized to discuss clinical characteristics, staging, treatment, and prognosis to assist in clinical decision making for these patients.

Prognostic Impact of Tumor Extension in Patients With Advanced Temporal Bone Squamous Cell Carcinoma

Objective: The extreme rarity of temporal bone squamous cell carcinoma (TB-SCC) has delayed the accumulation of high-quality clinical evidence. Our objective here was to explore anatomical factors associated with the prognosis of T4 TB-SCC cases.

Study Design: Case series with chart review.

Setting: Two academic tertiary care medical centers.

Subjects and Methods: The medical records of all TB-SCC cases were retrospectively reviewed in two institutions. The resulting data set contained 30 cases of primary T4 cancer eligible for initial definitive (curative) treatment. Disease-specific survival was calculated according to the Kaplan–Meier method. Cox proportional hazards model was used to identify anatomical prognosis factors.

Results: The disease-specific 5-years survival rate of 30 cases of T4 TB-SCC was 53.9%. The tumor invasion to the pterygoid muscle, posterior fossa dura, and sigmoid sinus and destruction of the ossicles were associated with poor prognosis in univariate analysis. The multivariate analysis reveals that the invasion of the ossicles, posterior fossa dura, and sigmoid sinus is an independent prognostic factor [hazard ratio (HR): 4.528 (95% CI: 1.161–17.658), p = 0.030; HR: 5.135 (95% CI: 1.616–16.315), p = 0.006; HR: 4.292 (95% CI: 1.385–13.303), p = 0.012]. The invasion of the carotid canal, petrous apex, middle fossa dura, otic capsule, pterygoid muscle, and middle ear had a high HR (HR > 2). The more invaded anatomical factors present in patients resulted in a poorer patient disease-specific prognosis, with a statistically significant difference.

Conclusions: Assessing which anatomical structures are susceptible to invasion by tumors may be important for predicting TB-SCC patient prognosis and selecting appropriate treatment planning, especially surgical intervention. In addition to previously reported factors, the destruction of the ossicles in the middle ear cavity can be an anatomical prognosis factor.

Left Chronic Otitis Media with Squamous Cell Carcinoma of the Middle Ear and Postauricular Mastoid Fistula: A Case Report

Though squamous cell carcinoma is the commonest tumor, it rarely presents in the middle ear and follows a history of chronic ear discharge. Postauricular mastoid fistula is also a rare complication of chronic otitis media. These two pathological changes occurring simultaneously are even rarer. We report a rare case of a 37 years old male with a history of left-sided chronic ear discharge and conductive hearing loss. Squamous cell carcinoma along with postauricular mastoid fistula was diagnosed based on high-resolution computed tomography scan and histopathology. Left modified radical mastoidectomy with tympanic membrane grafting was done under general anesthesia. Often middle ear tumor is associated with long-standing ear discharge and this case is a very good example. The co-occurrence of the middle ear tumor with mastoid fistula is extremely rare as both the entities are rare in itself.

External auditory canal carcinoma: clinical characteristics and long-term treatment outcomes

PURPOSE

Evidence-based treatment recommendations for external auditory canal (EAC) carcinoma are lacking in available literature. This study aims to evaluate the clinical characteristics and long-term outcomes of EAC carcinoma in a tertiary referral centre in a period of 15 years and identify independent prognostic factors.

METHODS

Retrospective observational study enrolling all patients with primary EAC carcinoma who underwent primary surgical treatment at the Portuguese Institute of Oncology (Lisbon) between 2004 and 2018. Epidemiological, clinical, histopathological and surgical data were retrieved from clinical records and analysed.

RESULTS

Twenty-seven patients were identified, with a median age of 77 years (range 29-92 years) and a slight female predominance (59.3%). Squamous cell carcinoma (55.6%) was the most common histological type, followed by basal cell carcinoma (40.7%) and ceruminous adenocarcinoma (3.7%). Pittsburgh tumour staging was distributed as early stage in 51.9% (I: 40.7%; II: 11.1%) and advanced stage in 48.1% (III: 29.6%; IV: 18.5%). Median follow-up period was 21 months (interquartile-range: 47). Four patients (14.8%) showed recurrence; recurrence rate was significantly higher in individuals aged < 60 years (p = 0.025) and with lymphovascular invasion (p = 0.049). Median overall survival was 88 months and estimated 2-year and 5-year overall survival rates were both 66%. Survival rates were higher in early stage patients (p = 0.021) and in those without facial palsy (p = 0.032).

CONCLUSION

Based on the available evidence in this review, individuals aged < 60, facial nerve impairment, advanced stage lesions, presence of lymphovascular invasion and squamous cell carcinoma histology are all associated with poor outcome and may be considered when discussing optimal treatment strategies in patients with EAC carcinoma.

Temporal bone resection for lateral skull-base malignancies

INTRODUCTION

Malignancies involving the temporal bone are increasingly common and require specialized multi-disciplinary care. Given this complex location, involvement of the lateral skull base and local neurovascular structures is common. In this review we discuss general principles for temporal bone resection, as well as alternative and complementary surgical approaches that should be considered in the management of patients with temporal bone cancer.

METHODS

A comprehensive review on literature pertaining to temporal bone resection was performed.

RESULTS

The primary surgical strategy for malignancies of the temporal bone is temporal bone resection. This may be limited to the ear canal and tympanic membrane (lateral temporal bone resection) or may include the otic capsule and its contents (subtotal temporal bone resection), and/or the petrous apex (total temporal bone resection). Management of adjacent neurovascular structures including the facial nerve, the carotid artery, and the jugular bulb/sigmoid sinus should be considered during surgical planning. Finally, adjunctive procedures such as parotidectomy and neck dissection may be required based on tumor stage.

CONCLUSIONS

Temporal bone resection is an important technique in the treatment of lateral skull-base malignancies. This strategy should be incorporated into a multi-disciplinary approach to cancer.

Squamous cell carcinoma of the temporal bone: A current review

OBJECTIVES

The rarity of temporal bone squamous cell carcinoma (TBSCC) precludes a clear understanding of the disease and approach to its management. This review provides general background on the disease and discusses the current and emerging oncologic and rehabilitative management options.

DATA SOURCES

PubMed literature review.

METHODS

A review of the current literature was conducted to assess and collate up-to-date information regarding TBSCC management.

RESULTS

TBSCC is a rare and aggressive disease arising in the ear canal, temporal bone, or extratemporal sites. Prior radiation, chronic ear disease, or habitual ear picking may contribute to primary disease development. Because the symptoms of TBSCC and benign otologic disease are similar, TBSCC diagnosis may be delayed, allowing the tumor time to spread throughout the anatomically intricate temporal bone. The extent of the disease is determined based on imaging and is usually staged with the Pittsburgh Staging System. Temporal bone resection with parotidectomy and neck dissection is the current standard of care. Survival is generally good for early disease and poor for advanced disease, but chemotherapy is emerging as a promising treatment option. Auditory rehabilitation with osseointegrated hearing aids is recommended at initial oncologic resection.

CONCLUSIONS

The knowledge of and outcomes for TBSCC have improved with time, but because of the aggressive nature of the disease and the anatomic intricacy of the temporal bone, TBSCC treatment is complex and should be delivered by a multidisciplinary team. Inter-institutional collaboration may accelerate research for this rare disease.

LEVEL OF EVIDENCE

5.

Management of Temporal Bone Malignancy in Ireland

Objectives  Lateral temporal bone malignancy remains a challenging rare disease. We report 17 years of multidisciplinary care of these tumors with univariate and multivariate analyses of key prognostic indicators for consideration in contemporary oncological management. Design  This is a retrospective cohort study. Setting  This is set at a tertiary referral center. Participants  All patients presenting with histopathologically newly diagnosed cases of temporal bone malignancy between 2000 and 2017 were included. Main Outcome Measures  The main outcome measures are disease-specific and recurrence-free survival rates. Results  In this study, 48 cases of temporal bone malignancy were diagnosed. Median age at diagnosis was 69 years (range: 5-88). Fourteen patients were female. Squamous cell carcinoma was the predominant malignancy in 34 cases (71%). Surgical treatment was undertaken in 37 patients. Mean length of follow-up was 32 months (range: 0.7-117). Overall 5-year disease-specific survival was 52.4%, while overall 5-year recurrence-free survival was 53.5%. On univariate analysis, significantly worse survival was seen in females ( p  = 0.008), those with distant metastatic disease ( p  = 0.041), and in middle ear involvement ( p  = 0.012) with no difference for involvement of the external auditory canal ( p  = 0.98) or mastoid ( p  = 0.78). Only middle ear involvement remained significant on multivariate analysis. Conclusion  A wide variety of malignant pathology may present in the temporal bone. Recurrence-free survival is equivalent to international data; however, this figure is low. This emphasizes the need to treat these tumors appropriately with radical resection, where possible, at first presentation. Therefore, multidisciplinary surgical input is recommended. Middle ear involvement was a negative prognosticator for disease-specific and recurrence-free survivals.

Temporal bone carcinoma: Treatment patterns and survival

OBJECTIVES/HYPOTHESIS

Carcinomas of the temporal bone are rare, and appropriate treatment, staging, and survival data are limited. This study evaluates clinical characteristics and survival rates for patients with temporal bone carcinoma treated with resection at a single tertiary-care institution, with a focus on the outcomes of patients with locally advanced disease including skull base and/or dural invasion.

STUDY DESIGN

Retrospective chart review.

METHODS

Demographic, tumor-specific, and survival data were collected for patients with primary carcinomas of the external auditory canal with involvement of the temporal bone from 2003 to 2015. All patients were staged according to the modified Pittsburgh system. Kaplan-Meier and logistic regression analysis were used to calculate factor-specific survival outcomes.

RESULTS

Sixty-seven patients met inclusion criteria; 85% were male. There were 43 squamous cell carcinomas (64%) and 24 basal cell carcinomas (BCCs) (36%). Tumor stage was 24 (36%) T2, 12 (18%) T3, and 31 (46%) T4 tumors; 53% had recurrent disease. Surgical management included 49 lateral temporal bone resections and 18 subtotal temporal bone resections. Kaplan-Meier analyses revealed more favorable 5-year survival rates associated with BCC histology (P = .01), lateral temporal bone resection compared to subtotal temporal bone resection (P < .01), lack of immunocompromise (P = .04), and absence of perineural/lymphovascular invasion (P = .01). Multivariate regression analysis did not yield statistically significant results.

CONCLUSIONS

Factors predictive of more favorable survival include lack of immunocompromise, BCC histology, absence of perineural/lymphovascular invasion, and disease extent amenable to lateral temporal bone resection. Dural invasion is not an absolute contraindication to surgery, with a subset of patients surviving >5 years.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:E11-E20, 2020.

Pedicled Temporalis Muscle Flap Stuffing after a Lateral Temporal Bone Resection for Treating Mastoid Osteoradionecrosis

Objective The aim of this study was to compare the outcomes of lateral temporal bone resection and pedicled temporalis muscle flap stuffing with external auditory canal closure with those of canal wall down mastoidectomy for the treatment of mastoid osteoradionecrosis. Study Design Prospective nonrandomized case-control clinical study. Setting Department of Otolaryngology of the First People's Hospital of Foshan. Subjects and Methods Seventy-seven postirradiation nasopharyngeal carcinoma patients with mastoid osteoradionecrosis were included. Forty patients (40 ears) underwent lateral temporal bone resection in the temporalis muscle flap group. Their pedicled temporalis muscle flaps were laid on the surgical cavity, and the external canal opening was simultaneously closed. Thirty-seven patients (37 ears) underwent a canal wall down mastoidectomy in the mastoidectomy group. The surgical wounds and complications following surgery were retrospectively analyzed. Results The patients were followed for 2 years. The percentage of patients with purulent otorrhea and persistent osteoradionecrosis in the temporalis muscle flap group was lower than that in the mastoidectomy group. Conclusion Our preliminary results suggest that lateral temporal bone resection with the pedicled temporalis muscle flap filled into the surgical cavity, followed by closure of the external auditory canal, represents a valuable approach for treating mastoid osteoradionecrosis.

Right dominance in the incidence of external auditory canal squamous cell carcinoma in the Japanese population: Does handedness affect carcinogenesis?

Objectives/Hypothesis

To investigate the relationship between handedness and the incidence of squamous cell carcinoma in the external auditory canal (EACSCC).

Materials and Methods

Sixty‐eight cases of EACSCC were enrolled in this study, and their affected side was checked. Handedness and ear‐picking habits were also investigated in 34 EACSCC cases. Handedness was judged based on self‐categorization, and the relationship between handedness and the affected side was investigated.

Results

Fifty‐two cases occurred on the right side, and 16 cases occurred on the left side of patients with EACSCC. The incidence of laterality in EACSCC showed a statistically significant right dominance. Concerning handedness, 29 cases were right‐handed, 4 cases were left‐handed, and 1 case was ambidextrous. Twenty‐seven out of the 29 right‐handed cases and 1 ambidextrous case suffered from carcinoma on the right side, whereas 3 left‐handed cases suffered from carcinoma on the left side. That is, most of the cases suffered from EACSCC on the same side as their handedness, and this tendency showed a statistically significant difference. Most of the patients with EACSCC experienced itching and habitual ear‐picking in the affected side.

Conclusion

Mechanical stimulations to the EAC, such as ear picking, may plausibly cause EACSCC. In Japan, ear picking, also called “mimikaki,” is a popular habit and an established unique culture. Because ear picking requires delicate handling and manipulation, this tends to occur on the same side as the handedness in the Japanese population. This is the first report about the relationship between handedness and carcinogenesis.

Level of Evidence

N/A.

Temporal bone carcinoma: Classical prognostic variables revisited and modern clinico-pathological evidence

AIM

Prognostic factors, rational management, and the ongoing investigations regarding temporal bone squamous cell carcinoma (TBSCC) have been critically reviewed.

BACKGROUND

TBSCC is an uncommon, aggressive malignancy. Although some progress has been made in treating this aggressive tumor, the prognosis in advanced cases remains poor.

MATERIALS AND METHODS

A systematic search of the literature for articles published between 2009 and October 2014 was performed using the PubMed (http://www.pubmed.gov) electronic database.

RESULTS

Given the particular anatomical site of TBSCC, its prognosis is significantly influenced by any direct involvement of nearby structures. The extent of the primary tumor is generally considered one of the most important prognostic factors and it is frequently related to prognosis even more strongly than N stage. For TBSCC, biomarker investigations in surgical specimens are only just beginning to appear in the oncological literature.

CONCLUSION

Given the particular features of TBSCC, the sub-specialty of otologic oncology seems to be emerging as a defined area of practice involving multidisciplinary team comprising oto-neurosurgeons, head and neck surgeons, plastic surgeons, oncologists, radiotherapists, dedicated radiologists, and pathologists.

Malignant tumors of the temporal bone - our experience

Introduction

Malignant tumors of the temporal bone are rare, with an estimated incidence of about 0.8–1.0 per 1,000,000 inhabitants per year. The vast majority of these tumors are squamous cell carcinomas and their treatment is eminently surgical.

Objective

This study is an attempt at systematizing the forms of clinical presentation, the therapeutic possibilities, and oncological outcomes of patients with malignant tumors of the temporal bone in a tertiary hospital in Portugal.

Methods

The authors present a retrospective study of temporal bone tumors treated and followed during otorhinolaryngology consultations between 2004 and 2014. A review of the literature is also included.

Results

Of the 18 patients included in the study, 16 had a primary tumor of the temporal bone, in most cases with squamous cell carcinoma histology. Of these, 13 patients were treated with curative intent that always included the surgical approach. Disease persistence was observed in one patient and local recurrence in five patients, on average 36.8 months after the initial treatment.

Conclusions

The anatomical complexity of the temporal bone and the close associations with vital structures make it difficult to perform tumor resection with margins of safety and thus, tumor relapses are almost always local. A high level of suspicion is crucial for early diagnosis, and stringent and prolonged follow-up after treatment is essential for diagnosis and timely treatment of recurrances.

Occult Temporal Bone Facial Nerve Involvement by Parotid Malignancies with Perineural Spread

Objective

To characterize disease presentation and outcomes following surgical treatment of parotid malignancies with occult temporal bone facial nerve (FN) involvement.

Study Design

Case series with chart review.

Setting

Tertiary academic referral center.

Subjects and Methods

Thirty consecutive patients (mean age 58 years; 77% men) who underwent surgery for parotid malignancies with occult perineural involvement of the intratemporal FN were included. Primary outcome measures included margin status and recurrence.

Results

The mean duration of clinical follow-up was 49 months, and the most common presenting symptom was FN paresis (n = 23; 77%) followed by pain (n = 15; 50%). To obtain a proximal FN margin, 27 patients (90%) underwent mastoidectomy, and 3 patients (10%) had lateral temporal bone resection. The intratemporal FN margin was cleared in 26 patients (87%), most commonly in the mastoid segment (60%). Adjuvant therapy was given in 25 patients (83%). Ten patients (33%) experienced locoregional (4; 13%) and/or distant (8; 27%) recurrence at a median of 19 months (mean 26, 2–54 months) following surgery. Locoregional failure was significantly more common in cases with a positive intratemporal FN margin (66% vs 8%; P = .045). Overall 1-, 3-, and 5-year disease-specific survival rates were 83%, 79%, and 72%, respectively.

Conclusions

Perineural invasion of the intratemporal FN by parotid malignancy is uncommon. Normal preoperative FN function does not preclude histopathologic involvement. Temporal bone FN exploration should be considered when a positive margin is encountered at the stylomastoid foramen, as failure to do so is associated with an increased rate of locoregional recurrence.

Recurrent squamous cell carcinoma of the temporal bone: critical analysis of cases with a poor prognosis

PURPOSE

Temporal bone squamous cell carcinoma (TBSCC) is an uncommon, aggressive malignancy with a significant recurrence rate. We reviewed our experience with recurrent TBSCCs.

MATERIALS AND METHODS

Clinicopathological and therapeutic variables potentially associated with disease-free survival (DFS) and disease-specific survival (DSS) were assessed in 17 TBSCC patients who died of their disease after treatment.

RESULTS

TBSCC recurrences were treated with surgery in 12 cases (palliative in 11, with curative intent in 1) and palliative chemotherapy in 5; the median DFS and DSS were 6 and 16 months, respectively. The mean DFS and DSS were longer in patients who had primary lateral temporal bone resection (LTBR) rather than subtotal temporal bone resection (STBR) (p=0.0173 and p=0.03, respectively). Patients given non-surgical palliative treatment for recurrences had a longer mean DSS than those who underwent surgery (trend toward significance, p=0.09).

CONCLUSIONS

Our results reflect the aggressive nature of TBSCC recurrences. Our findings seem to support the use of non-surgical treatments (chemotherapy, radiotherapy, or specialist palliative care) in patients with loco-regionally advanced recurrent TBSCC. Salvage surgery might be considered for early recurrences when radicality is still achievable. Precise guidelines for the rational follow-up of surgically-treated TBSCCs need to be shared between tertiary centers.

Factors associated with recurrence of squamous cell carcinoma involving the temporal bone

OBJECTIVE

This study aimed to better identify factors associated with recurrence of squamous cell carcinoma (SCC) involving the temporal bone.

METHODS

A retrospective study was conducted at a tertiary hospital. Sixty patients who were diagnosed over a 10-year period with SCC involving the temporal bone and underwent surgical resection were analyzed. All patients were staged based on the University of Pittsburgh staging system. Demographic, intraoperative, and pathologic data were analyzed with respect to recurrence.

RESULTS

Thirteen (21.7%) patients were T1, 8 (13.3%) T2, 7 (11.7%) T3, and 32 (53.3%) T4. Eighteen patients (30.0%) recurred in the study period. The mean time to recurrence was 5.8 months. Tumors originating in the skin overlying the parotid gland and the external auditory canal had higher recurrence rates than those from the auricle/postauricular skin and temporal bone (P = .05). Direct parotid and perineural spread accounted for 15.0% of all routes of temporal invasion but resulted in 22.2% of all recurrences (P = .04). Increased N stage was statistically associated with increased risk of recurrence (P = .01). Cervical, as compared to perifacial and parotid, lymph node involvement was associated with increased risk of recurrence (odds ratio = 6.91; 95% confidence interval, 1.11-42.87).

CONCLUSION

We have identified multiple factors that are associated with increased recurrence of SCC involving the temporal bone.

Survival outcomes of patients with temporal bone squamous cell carcinoma with different invasion patterns

BACKGROUND

The correlation between the survival rate and various invasion patterns of patients with temporal bone squamous cell carcinoma (SCC) is unclear. This study was performed to compare the survival outcomes of these patients to disclose the correlation.

METHODS

The cases of 39 patients with temporal bone SCC who underwent surgery between January 2004 and December 2012 were reviewed.

RESULTS

The 2-year overall survival rate was 56.9%, and it was 22.3% for patients with stage IV disease, and 100% for patients with stage I-III disease. Patients with parotid invasion (n = 11), temporomandibular joint (TMJ) involvement (n = 8), and middle ear surgery (n = 7) before temporal bone malignancies were diagnosed had poor survival with statistical difference.

CONCLUSION

Patients with parotid gland, TMJ involvement, and previous middle ear surgery for chronic otitis media had poor outcomes.

Temporal bone malignancies

Primary temporal bone tumors are rare. Suspicious lesions of the ear canal should be biopsied for diagnosis. Surgical resection to achieve negative margins is the mainstay of treatment. Small tumors can be treated with lateral temporal bone resection. Parotidectomy and neck dissection are added for disease extension and proper staging. Higher staged tumors generally require subtotal temporal bone resection or total temporal bone resection. Adjuvant postoperative radiotherapy has shown improved survival for some patients. Chemotherapy has an emerging role for advanced stage disease. Evaluation and management by a multidisciplinary team are the best approach for patients with these tumors.