Full text of DOI:10.1097/00005537-200206000-00012

The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
©
2002 The American Laryngological,
Rhinological and Otological Society, Inc.
Bilateral Squamous Cell Carcinoma of the
External Auditory Canals
Stephen G. Wolfe; Stephen Y. Lai, MD, PhD; Douglas C. Bigelow, MD
Objectives: To report a case of bilateral squamous
cell carcinoma of the external auditory canals and to
present a management algorithm for this difficult clin-
ical scenario. Study Design: Case report and literature
review. Methods: The study comprises a case report of a
proper management of these tumors. The following case
report details the history and management of a patient
with simultaneous bilateral SCC of the external auditory
canals. To our knowledge, only three other cases of bilat-
eral SCC of the external auditory canals have been re-
69-year-old man who initially presented with com-
2–4
ported in the literature.
plaints of bilateral otorrhea, left-sided otalgia, and a
left-sided hearing loss. Following attempted treatment
of a presumed case of otitis externa, biopsy of both ex-
ternal auditory canals revealed squamous cell carci-
noma. A computed tomography scan demonstrated
marked abnormal soft tissue in the left external audi-
tory canal with no bony erosion and thickening of the
soft tissue in the right external auditory canal. Results:
The left-sided lesion required a lateral temporal bone
resection, a partial superficial and deep-lobe parotidec-
tomy, and postoperative irradiation. The right-sided le-
sion was more limited and was managed with a lateral
temporal bone resection and tympanoplasty for hearing
preservation. Conclusions: Bilateral squamous cell car-
cinoma of the external auditory canals is an extremely
uncommon but aggressive malignancy that may
present with symptoms similar to a case of otitis ex-
terna, and this can result in delays in proper diagnosis.
Early recognition is essential because management and
prognosis are determined by the extent of the lesion.
Key Words: Squamous cell carcinoma, external auditory
canal, bilateral.
CASE REPORT
A 69-year-old man initially presented with a 6-month his-
tory of bilateral otorrhea, left-sided otalgia that radiated into the
neck, and bilateral hearing loss with a 10- to 30-dB conductive
component on the left side. The patient had been treated for
bilateral otitis externa with medical therapy and debridement.
When a response to treatment was not obtained, a biopsy of the
more involved left ear revealed SCC and he was referred for
treatment.
On physical examination, the left ear contained a large
amount of squamous debris with irregularity and granulation of
the posterior ear canal down to the tympanic membrane. The
right ear was mildly swollen, erythematous, and moist. A small
amount of squamous debris was present on the right side, but no
gross lesion was identified. A computed tomography (CT) scan
(
Fig. 1) demonstrated abnormal soft tissue in the left EAC with no
bone erosion and thickening of the soft tissue in the right EAC.
Surgery for the left-sided tumor was delayed for 6 weeks
while the patient obtained medical clearance. At the time of
surgery, the left-sided tumor had advanced and grossly involved
the EAC, tympanic membrane, middle ear, and eustachian tube.
This lesion was treated with a lateral temporal bone resection
with gross total removal of the middle ear extension by piecemeal
removal of the surrounding bone extending from the middle fossa
dura to, and including, resection of the bony eustachian tube and
skeletonization of the petrous carotid artery. A superficial and
deep-lobe parotidectomy was also performed. Reconstruction of
the defect was performed with an abdominal fat graft and tem-
poralis musculofascial flap without reconstruction of the ear ca-
nal or middle ear conducting mechanism.
Laryngoscope, 112:1003–1005, 2002
INTRODUCTION
Squamous cell carcinoma (SCC) of the external audi-
tory canal (EAC) is an extremely rare lesion with an
incidence of approximately 1.4 cases per million popula-
1
tion. The low incidence of these lesions, lack of an ac-
cepted staging system, and a variety of individualized
treatment plans have stimulated debate regarding the
Five weeks after surgery on the left-sided lesion, persistent
inflammation and new granulation were seen in the right ear
canal. Biopsy at that time revealed invasive SCC of the right ear
canal. A repeat CT scan was unremarkable except for thickening
of the ear canal skin. The right-sided lesion was managed with an
en bloc lateral temporal bone resection including the tympanic
membrane. There was no gross extension of the tumor outside the
ear canal, and results of frozen-section analysis were negative.
The entire ossicular chain was kept intact in an effort to preserve
hearing because the patient had a severe to profound hearing loss
with a maximal conductive component in the previously operated
Presented as a poster at the Meeting of the Eastern Section of the
Triological Society, Philadelphia, PA, January 25–27, 2002.
From the Department of Otorhinolaryngology—Head and Neck Sur-
gery, University of Pennsylvania Health System, Philadelphia, Pennsyl-
vania, U.S.A.
Editor’s Note: This Manuscript was accepted for publication Febru-
ary 15, 2002.
Send Correspondence to Douglas C. Bigelow, MD, Department of
Otorhinolaryngology—Head and Neck Surgery, 5 Silverstein/Ravdin,
3
400 Spruce Street, Philadelphia, PA 19104, U.S.A. E-mail: douglas.
bigelow@uphs.upenn.edu
Laryngoscope 112: June 2002
Wolfe et al.: Carcinoma of External Auditory Canals
1003

ment challenges. The most common symptoms of these
5
rare lesions, otorrhea (77%) and otalgia (54%), are the
same as symptoms of otitis externa, a common inflamma-
tory process. In fact, the presentation of SCC of the EAC
may be complicated by a concurrent case of otitis externa.
The deceptive presentation of SCC of the EAC and the
extremely low incidence of these lesions often result in
delays in diagnosis while the patient is treated for otitis
externa.
In the present case, only in the more involved left-
sided lesion was biopsy performed after it did not respond
to treatment for an otitis externa. On the right side, which
did not have a gross lesion, biopsy not performed at that
time to evaluate for simultaneous disease. A biopsy of the
right side was only performed after the right-sided symp-
toms persisted despite a second course of treatment and
granulation tissue formed. Thus, a high index of suspicion
for SCC is necessary if the symptoms persist despite ad-
equate treatment for an inflammatory process, even if a
tumor is identified contralaterally.
The early identification of these tumors is essential to
limit tumor extension. These tumors are aggressive, and a
delay in diagnosis and treatment provides these lesions
with an opportunity to spread. In the present case, the
left-sided tumor spread during the 6-week interval be-
tween diagnosis and surgery. This 6-week period was nec-
essary so that the patient could obtain medical clearance
for surgery; however, this time enabled the left-side lesion
to progress from a lesion confined to the EAC without
erosion of the bone to a lesion that grossly involved the
middle ear and eustachian tube and eroded the bone of the
medial anterior and inferior ear canal.
The extent of these aggressive lesions has important
implications for their surgical resection and, ultimately,
patient prognosis. Lesions confined to the EAC facilitate
more complete resections and are associated with higher
5-year survival rates. More extensive lesions are challeng-
ing to resect en bloc because of the proximity of important
anatomic structures within the temporal bone and are
consequently associated with lower 5-year survival rates.
The relationship between the extent of disease and
patient survival is clearly demonstrated in the literature.
In a review of all English-language publications address-
ing the surgical management of SCC of the temporal bone,
Fig. 1. Axial (A), right coronal (B), and left coronal (C) computed
tomographic scans showing minimal soft tissue thickening of the
right external auditory canal and a soft tissue density in the left
external auditory canal but no bone erosion. Scans were performed
approximately 6 weeks before the operation on the left-sided lesion.
The scale is the same for all scans.
6
Prasad and Janecka found that patients with SCC tu-
mors confined to the EAC had an overall 5-year survival
rate of approximately 50%. Patients with lesions that
extended into the middle ear space had an overall 5-year
survival rate of approximately 25%, and patients with
more extensive tumors including those with petrous apex,
internal carotid artery, or dural or temporal lobe involve-
ment had a 5-year survival rate of approximately 6%.
Because patients with positive margins after resec-
contralateral ear. Reconstruction included a tympanoplasty, leav-
ing an open right mastoid bowl. The mastoid and tissues over the
parotid and temporomandibular joint (TMJ) area were skin
grafted. A postoperative audiogram 4 months after resection of
the right lateral temporal bone revealed an air–bone gap of
between 0 and 25 dB (Fig. 2).
The patient received postoperative radiation therapy with a
total dose of 6300 cGy to the primary site for the left-sided lesion.
Pathologic margins were negative on the right side, and no irra-
diation was used for that lesion. The patient was free of disease
bilaterally and doing well 17 months after the resection of the
left-sided temporal bone cancer.
5,7
tion have higher treatment failure rates,
aggressive
treatment of SCC of the EAC is recommended. In a pro-
8
spective study, Spector found improved cure rates with
more aggressive treatments for patients with SCC of the
temporal bone. In the first section of the study, Spector
retrospectively reviewed the management and outcomes
of 17 patients with SCC in four subgroups: external audi-
tory canal, superficial invasion, deep invasion, and tumors
DISCUSSION
Bilateral SCC of the external auditory canals is ex-
tremely rare and presents unique diagnostic and treat-
Laryngoscope 112: June 2002
Wolfe et al.: Carcinoma of External Auditory Canals
1
004

Fig. 2. Postoperative audiogram per-
formed 4 months after the resection of
the right-side lateral temporal bone.
beyond the temporal bone. After treatment with a variety
of surgical and radiotherapeutic combinations, the 5-year
cure rates were 70%, 70%, 50%, and 9%, respectively. In
the second section of the study, Spector prospectively di-
vided 34 new patients into the four previous subgroups
CONCLUSION
Bilateral SCC of the external auditory canals is an
extremely rare lesion that often presents in a manner
similar to an inflammatory process; thus, a high index of
suspicion is required, to make a prompt diagnosis. These
lesions are extremely aggressive and can involve the mid-
dle ear, temporal bone, internal carotid, and dura mater.
Because patient prognosis is directly related to the extent
of the lesion, early diagnosis and aggressive treatment are
essential in the management of these tumors. In limited
lesions it may be possible to preserve the ossicles and
reconstruct the conducting mechanism of the ear. How-
ever, this goal should not circumvent the oncologic sound-
ness of the tumor resection.
(
external auditory canal, superficial invasion, deep inva-
sion, and tumors beyond the temporal bone) and then
placed them into a protocol for treatment. The 5-year cure
rates for these patients were 100%, 100%, 70%, and 65%,
respectively. In this second set of patients, Spector used
more encompassing surgical procedures, as well as higher
doses (6250ϩ cGy) and wider fields of irradiation.
In addition to improved patient survival rates, when
lesions are limited to the EAC, early detection also pro-
vides an opportunity for hearing reconstruction in selected
cases. In the present case, the limited involvement of the
right-sided lesion permitted the preservation of the right
ear’s conducting mechanism. In the absence of tumor in-
vasion of the tympanic membrane, it is possible to care-
fully separate the tympanic membrane from the malleus,
maintaining the tympanic membrane intact as a margin
and preserving the continuity of the ossicles. Skin grafting
of the mastoid and the soft tissues along the parotid and
temporomandibular joint area, which constitutes the new
anterior ear canal, takes well and heals fairly quickly. A
tympanoplasty to reconstruct the tympanic membrane
can be performed in the standard method, but care must
be exercised to preserve a relatively sharp anterior tym-
panic membrane to EAC junction. Blunting of this ante-
rior angle and restricted movement of the new tympanic
membrane can increase the conductive hearing loss. One-
third to half of the posterior temporalis muscle can be
rotated into the mastoid defect to decrease the size of the
open mastoid bowl if it is large. The resulting hearing and
cosmetic defect can be acceptable.
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