Primary B-cell lymphoma presenting as bilateral ear lobule swelling

We report a rare case of primary B-cell lymphoma presenting as bilateral ear lobule swelling. A 56-year-old white man presented with a one-year history of painless swelling of both ear lobules. An excision biopsy confirmed B-cell lymphoma. Detailed systemic investigation confirmed the primary nature of the tumour. This tumour is rare in the ear lobule. A review of the English literature revealed no previously reported case of bilateral primary ear lobule involvement. Clinicians should be aware that this tumour can present as a primary in the ear lobules.

Endolymphatic sac tumor demonstrated by intralabyrinthine hemorrhage

✓ Endolymphatic sac tumors (ELSTs) are locally invasive neoplasms that arise in the posterior petrous bone and are associated with von Hippel–Lindau (VHL) disease. These tumors cause symptoms even when microscopic in size (below the threshold for detectability on imaging studies) and can lead to symptoms such as hearing loss, tinnitus, vertigo, and facial nerve dysfunction. While the mechanisms of audiovestibular dysfunction in patients harboring ELSTs are incompletely understood, they have critical implications for management. The authors present the case of a 33-year-old man with VHL disease and a 10-year history of progressive tinnitus, vertigo, and left-sided hearing loss. Serial T1-weighted magnetic resonance (MR) imaging and computed tomography scans revealed no evidence of tumor, but fluid attenuated inversion recovery (FLAIR) MR imaging sequences obtained after hearing loss demonstrated evidence of left intralabyrinthine hemorrhage. On the basis of progressive disabling audiovestibular dysfunction (tinnitus and vertigo), FLAIR imaging findings, and VHL disease status, the patient underwent surgical exploration of the posterior petrous region, and a small (2-mm) ELST was identified and completely resected. Postoperatively, the patient had improvement of the tinnitus and vertigo. Intralabyrinthine hemorrhage may be an early and the only neuroimaging sign of an ELST in patients with VHL disease and audiovestibular dysfunction. These findings support tumor-associated hemorrhage as a mechanism underlying the audiovestibular dysfunction associated with ELSTs.

Treatment and Prognosis of Squamous Cell Carcinoma of the External Auditory Canal and Middle Ear: A Multi-Institutional Retrospective Review of 87 Patients

PURPOSE

To examine the relative roles of surgery, radiotherapy, and chemotherapy in the management of patients with squamous cell carcinomas of the external auditory canal and middle ear.

METHODS AND MATERIALS

The records of 87 patients with histologically confirmed squamous cell carcinoma who were treated between 1984 and 2005 were reviewed. Fifty-three patients (61%) were treated with surgery and radiotherapy (S + RT group) and the remaining 34 patients with radiotherapy alone (RT group). Chemotherapy was administered in 34 patients (39%).

RESULTS

The 5-year actuarial overall and disease-free survival (DFS) rates for all patients were 55% and 54%, respectively. On univariate analysis, T stage (Stell's classification), treatment modality, and Karnofsky performance status had significant impact on DFS. On multivariate analysis, T stage and treatment modality were significant prognostic factors. Chemotherapy did not influence DFS. The 5-year DFS rate in T1, T2, and T3 patients was 83%, 45%, and 0 in the RT group (p < 0.0001) and 75%, 75%, and 46% in the S + RT group (p = 0.13), respectively. The 5-year DFS rate in patients with negative surgical margins, those with positive margins, and those with macroscopic residual disease was 83%, 55%, and 38%, respectively (p = 0.007).

CONCLUSIONS

Radical radiotherapy is the treatment of choice for early-stage (T1) diseases, whereas surgery (negative surgical margins if possible) with radiotherapy is recommended as the standard care for advanced (T2-3) disease. Further clarification on the role of chemotherapy is necessary.

Embryonal rhabdomyosarcoma of the temporal bone

The most common soft-tissue sarcoma in infants and children is rhabdomyosarcoma. The head and neck is the most common site of involvement; temporal bone involvement has been seen in about 7% of reported cases. Multimodality therapy--surgery, multiagent chemotherapy, and radiotherapy-yields sufficiently good results. The author reports a case of embryonal rhabdomyosarcoma of the temporal bone with cranial nerve palsies and extension into the parapharyngeal space in a 4-year-old boy. Despite surgery and chemotherapy, the patient died of his disease within 3 months of presentation.

Squamous cell carcinoma of the external auditory canal and middle ear: an operation combined with preoperative chemoradiotherapy and a free surgical margin

OBJECTIVE

Treatment outcomes for squamous cell carcinoma of the temporal bone were evaluated regarding stage, therapeutic strategy, and prognostic factors.

STUDY DESIGN

Retrospective case review.

SETTING

University hospital and outpatient clinic.

PATIENTS

Twenty-five patients with primary squamous cell carcinoma of the external auditory canal and middle ear.

INTERVENTION

Preoperative chemoradiotherapy and radiotherapy were used in 7 of 12 patients. Lateral temporal bone resection was performed for the lesions not beyond the tympanic membrane. Subtotal temporal bone resection was chosen for lesions extending to the middle ear cavity when there was no invasion to the pyramidal apex, carotid canal, or dura or metastasis. Others were conservatively treated by chemoradiotherapy. When the performance status was poor or an agreement regarding the operation could not be reached, the treatment was modified.

MAIN OUTCOME MEASURE

Estimated survival rates.

RESULTS

The 3-year estimated survival for T1 and T2 lesions was 100%. The 5-year estimated survival for T3 and T4 lesions was 80% and 35%, respectively. The 5-year estimated survival improved up to 75% for T4 tumors with operation and 16% for those without operation after 47 months. The tumor-free surgical margin is significantly related to patient survival in T3 and T4 lesions. Multivariate analysis predicted that concomitant chronic otitis media and positive lymph nodes were significantly associated with poorer survival.

CONCLUSION

The tumor-free surgical margin was important to survival. When T4 lesions did not involve the pyramidal apex, carotid canal, dura, or any lymph nodes, the surgical intervention improved the estimated survival rate to a level as good as T3 lesions.

Endolymphatic sac tumor: a report of 3 cases and discussion of management

Patients with an endolymphatic sac tumor (ELST) typically present with palsy of cranial nerves VII and/or VIII; other presenting symptoms include hearing loss, otalgia, occipital headaches, cranial nerve palsies, vertigo, gait ataxia, tinnitus, and otorrhea. ELSTs are extremely vascular, and they can invade and destroy temporal bone. Because of these characteristics, they are often mistaken for glomus tumors of the skull base. We describe the clinical presentation, evaluation, and management of ELSTs based on our review of the limited literature and our experience with 3 adults who presented to our tertiary care referral center with large ELSTs. Although these patients presented late in the course of their disease, their symptoms were relatively minor. Preoperative tumor embolization was performed, anda near-complete resection was achieved via an extended transotic approach in all 3 patients. The facial nerve was preserved without transposition in the first patient, the second patient underwent a primary nerve anastomosis, and the third required a cable graft of the facial nerve. Postoperative radiation therapy was administered to 2 of these patients. Follow-up by MRI detected no evidence of recurrence in any of the 3 patients.

[Endovascular microembolization of the posterior auricular artery in comprehensive surgical management of capillary angioma of the floor of the auricle]

The article deals with the description of a rare clinical case wherein a 44-year-old female patient presenting with bleeding capillary angioma of the left auricle obstructing the auditory passage was fist subjected to endovascular microembolization of the posterior auricular artery by means of polyvinyl alcohol (PVA-500), followed by a second stage of virtually bloodlessly surgical removal of the tumour carried out five days thereafter. This case report once again points to feasibility of combined, i. e. endovascular and conventional surgical management of capillary angiomas. Preoperative microembolization of a bleeding haemangioma arrests haemorrhage from the tumour, resulting in the decreased size thereof, as well as leading to circumscribing the tumour from healthy tissue. Attention is paid to the fact that embolization of the auricular artery should be performed only after a thorough angiographic evaluation of the pattern of the blood flow in the tumour and adjacent vessels by means of the technique of selective catheterization and using only the officinal emboli.

Primary B cell lymphoma of the external auditory canal

Temporal bone lymphomas are rare and typically metastatic neoplasms. We describe a case of primary B cell lymphoma that originated in the external auditory canal of an elderly woman. The diagnosis was based on histopathologic examination supplemented by immunophenotypic analysis. The patient was treated with external-beam radiation and remained disease-free throughout 9 years of follow-up. We also point out that the presence of non-Hodgkin's lymphoma in an unusual site may be an indication that the patient has an acquired immunodeficiency syndrome.

New-onset facial paralysis and undiagnosed recurrence of cutaneous malignancy: evaluation and management

Perineural invasion of cranial nerves, including the facial nerve by squamous cell carcinoma of the skin, is a poor prognostic factor for recurrent disease and disease-specific mortality. We discuss 2 patients who presented to the Otolaryngology/Head and Neck Surgery service with complete facial nerve paralysis and a history of skin cancer. Based on our experience with these patients, we recommend that patients who present with facial nerve paralysis and a history of cutaneous malignancy undergo aggressive management including early intervention and complete exploration of the facial nerve from the geniculate ganglion out to the periphery. Such rigorous care achieves the best possible oncologic outcomes for a proven aggressive disease.

Rhabdomyosarcoma of the middle ear and mastoid: a case report and review of the literature

We report a case of rhabdomyosarcoma of the middle ear and mastoid in a 3-year-old boy. The patient was treated according to Intergroup Rhabdomyosarcoma Study IV protocol (chemo- and radiotherapy), and he experienced a complete remission. However 7 months after the completion of treatment, he experienced a recurrence at the primary site that spread to the brain. Despite treatment, the patient died of progressive metastasis to the lung 4 months later.

Renal cell carcinoma with cutaneous metastases

An 86-year-old man presented with multiple papules on his face, neck, lips and ears 4 years after a left nephrectomy for renal cell carcinoma. Shave biopsies and excisions of the cutaneous lesions revealed findings consistent with metastatic renal cell carcinoma of clear cell type. The patient continued to present to the clinic over the next 3 years with similar eruptions, and biopsies continued to confirm renal cell carcinoma. During this time, metastases to the bone, lung, soft palate and posterior leg were also diagnosed. This case represents an unusual clinical presentation of metastatic renal cell carcinoma. It shows that a high index of suspicion should be maintained as cutaneous metastases can mimic other skin conditions.

Merkel cell carcinoma of the auricle

Merkel cell carcinoma is a rare malignant tumor of the skin. The face and extremities are the most common locations. We present a case of Merkel cell carcinoma of the auricle in a 93-year-old man subsequently treated with surgery and radiotherapy. The clinical features, prognosis, and treatment of the Merkel cell carcinoma are discussed.

[Main symptom otorrhea: diagnosis and therapy]

Otorrhea is an ambiguous symptom that underlies diverse clinical pictures. Fundamentally, the treatment of uncomplicated acute otitis externa and media can be carried out by the family physician. An ENT specialist should be definitely consulted in cases of complications or development of a chronic condition.

Tumours of the external ear and temporal bone

Symptoms such as hearing impairment, tinnitus, or a disturbance in sense of balance can generally be attributed to non-neoplastic causes, such as otitis media, otosclerosis, or trauma. Less commonly, auricular signs and symptoms are the result of non-neoplastic and neoplastic space-occupying lesions. The external ear can be the site of development of squamous carcinomas and basal-cell carcinomas; the middle ear and inner ear can host metastatic deposits, and primary squamous carcinomas and adenocarcinomas. Most auricular malignant diseases occur in adulthood; only the rhabdomyosarcomas of the middle ear arise in children. Most malignant diseases of the auricular apparatus are treated by a combination of surgery (commonly including radical excision of temporal bone), radiotherapy, and chemotherapy.

[Bilateral auditory canal squamous cell carcinoma]

Only a small number of cases of bilateral carcinomas of the external ear canal have been described in the literature. We present the first case of a 72 year old male patient with a bilateral squamous cell carcinoma of the external ear canal at a very early stage. A computed tomography of the temporal bone revealed a well-pneumatized mastoid on both sides. Both external ear canals were filled with soft tissue without radiological signs of destruction of the adjacent bone. The carcinomas of the external ear canal were surgically removed using a canal-wall down technique and a selective neck dissection of regions II-IV. Histology confirmed a well differentiated squamous cell carcinoma of the external ear canal without lymph node metastasis on both sides (TNM classification: pT1 G2 N0 M0 R0). Bilateral radiation therapy with 59.4 Gy resulted in stenosis of both ear canals. Hearing rehabilitation was achieved with bone conductive hearing glasses. Diagnosis und therapy of bilateral external ear carcinomas are presented and discussed.

[Treatment results in external and middle ear malignant neoplasms of patients treated at the Laryngology Department of Medical University of Silesia between 1991-2001]

The authors present 18 patients with malignant neoplasms of the ear and temporal bone who were treated in the Clinic of Laryngology Medical University of Silesia in Katowice in the years 1991-2001. The most frequent was squamous cell carcinoma (11 patients--61%). The neoplasm was located on the auricle in 7 patients (39%), in the external auditory canal in 4 (22%) patients, in the middle ear in 5 patients (28%) and in 2 cases (11%) it was difficult to establish primary site. Ten patients (55.5%) were treated in stage T4. All patients had surgery and in advanced cases the radiotherapy was added. The best outcomes were in auricular neoplasms. The treatment results were much worse in neoplasms of the external auditory canal and the middle ear. Over 3 year follow-up in 10 patients (55%) with ear and temporal bone neoplasms shows no recurrence.

Middle Ear Carcinoma Originating from a Primary Acquired Cholesteatoma: A Case Report

OBJECTIVES

To describe middle ear carcinoma originating from the matrix of primary acquired cholesteatoma in a 43-year-old man and to discuss the relationship between middle ear carcinoma and cholesteatoma.

STUDY DESIGN

Case report.

SETTING

Department of Otolaryngology, Head and Neck Surgery of Niigata University Medical and Dental Hospital, which is a tertiary care center, Niigata, Japan.

PATIENT

A 43-year-old man demonstrated symptoms resembling those of cholesteatoma: facial palsy, gradually progressive hearing loss, and chronic draining of the right ear. Other objective findings also supported a finding of cholesteatoma, but a computed tomographic scan and magnetic resonance imaging scan showed a well-enhanced mass and extensive bony erosion in the middle ear. At surgery, a granulous tumor in the mastoid cavity was diagnosed as squamous cell carcinoma, and closely coexisting cholesteatoma was found. Surgical specimen demonstrated carcinoma and cholesteatoma in the same field.

INTERVENTION

Radiation and chemotherapy were performed followed-up by mastoidectomy.

CONCLUSION

Because middle ear carcinoma has a poor prognosis, it is important to detect lesions early. It is necessary to consider that middle ear carcinoma arises from not only chronic otitis media or surgical invasion but also from primary acquired cholesteatoma.

Carcinoma of the external auditory canal

Carcinoma of the external auditory canal is one of the most inaccessible areas of the body. It is a rare malignant neoplasm with an aggressive nature and an overall poor prognosis. In a ten year period, 16 patients were treated in King Chulalongkorn Memorial Hospital. From TNM staging proposed by the University of Pittsburgh, the authors found T1 = 1, T2 = 6, T3 = 5, T4 = 4 cases. In 14 patients who were operated on (radical mastoidectomy in 8, lateral temporal bone resection in 5, sleeve resection in 1), 7 had cured (50%), 7 were recurrence. 6 cases of recurrence developed in patients with radical mastoidectomy, 1 case with lateral temporal bone resection. The overall cure rate in stage I-II = 85.71% (6/7) but only 11.11% (1/9) in the advanced stages (III-IV). The present data suggest that in early cancer (stage I-II) the lateral temporal bone resection with postoperative radiation is better than radical mastoidectomy with postoperative radiation.

[Malignant neoplasms of external and middle ear]

INTRODUCTION

Neoplasms of external and middle ear are rare, which cause several problems in diagnosis and therapy. The purpose of the study was to analyze retrospectively patients with malignant neoplasms of the ear.

METHODOLOGY

The study was carried out on 53 patients treated for malignant ear neoplasms in single institution during 25 years (1978-2002).

RESULTS

The most frequent neoplasm was squamous cell carcinoma--36 cases (67.9%), then basal cell carcinoma--9 cases (16.9%). Neoplasm primarily involved auricle in 26 patients (49.1%), external auditory canal in 15 patients (28.3%) and middle ear in 12 patients (22.6%). They were classified according to Stell and McCormick (1985) as follows: stage I--29 tumours (54.7%), stage T2--15 tumours (28.3%), stage T3--9 tumours (17%). Facial nerve paresis occurred in 15 patients (28.3%). The most often treatment modality was surgery--32 persons (60.4%), then surgery followed by radiotherapy--17 persons (32.1%). The characteristics of neoplasms related to the site of location were described. The difficulties in precise histopathologic diagnosis and extent of disease were pointed out.

RESULTS

Neoplasms of external and middle ear constitute a group of various histopathological and clinical tumours, which differ in diagnostic difficulties, treatment and prognosis. A diagnosis was often made in advanced stages of neoplasms, especially for middle ear tumours, that diminished a possibility of effective treatment.

[The outcome of treatments for carcinoma of the external auditory canal]

OBJECTIVE

A retrospective analysis of management and survival of patients treated for temporal bone carcinoma.

PATIENTS AND METHODS

Thirty patients underwent treatment for carcinoma of the temporal bone. Twenty-five squamous cell carcinomas, 1 melanoma, 2 basocellular carcinomas and 2 adenoid cystic carcinomas were treated. Thirteen patients were treated before for the same disease.

RESULTS

Staging revealed 12 T1 and T2, 6 T3 and 12 T4 tumours. The mean follow up was 5 years (2-276 months). The Kaplan Meier survival curves showed survival rates at 2 years of 82%, 67% and 32%, and at 5 years of 82%, 67% and 17%, respectively for the stages T1 or T2, T3 and T4. At the end of follow up at 9 years the survival rates were 66%, 66% and 17% for the stages T1 or T2, T3 and T4 respectively. Overall stages a complete remission was found in 65% and 23%, and deceased was 35% and 77%, respectively for the primary treatment group and the salvage surgery group.

CONCLUSION

Long-term prognosis of the carcinoma of the external auditory canal mainly depends on the stage and primary treatment. Surgery (lateral temporal bone or subtotal temporal bone resection, both in combination with a neck dissection and a parotidectomy) and adjuvant radiotherapy is the treatment of choice for part of stage T1 and all T2 and T3 tumours. The improved survival (65%) of patients treated de novo compared with those treated with salvage surgery (23%) suggests that early referral and aggressive primary surgical treatment with postoperative radiotherapy offer the greatest chance of cure.

Conservative management of vestibular schwannomas - second review of a prospective longitudinal study

Vestibular schwannomas have been traditionally managed with microsurgical removal and in recent years, stereotactic radiotherapy. However, there is a group of patients in whom a conservative management approach might represent a desirable alternative. The aim of this study was to determine the natural history and outcome following the conservative management of 72 patients with unilateral vestibular schwannomas. This is a prospective cohort review of a previously published group of patients [Clin. Otolaryngol. (2000) 25, 28-39] with unilateral vestibular schwannoma that were initially analysed at our institution in 1998 [Walsh R.M., Bath A.P., Bance M.L. et al., Clin. Otolaryngol. (2000) 25, 28]. The mean duration of follow-up was 80 months (range 52-242 months). All the patients in the study underwent serial magnetic resonance imaging (MRI) for assessment of tumour growth. Patients were deemed to have failed conservative management if there was evidence of rapid radiological tumour growth and/or increasing signs and symptoms, which necessitated active intervention. The mean tumour growth rate for the entire group at the second review was 1 mm/year (range -0.84-9.65 mm/year). The mean growth rate for cerebellopontine angle tumours (1.3 mm/year) was significantly greater than that of internal auditory canal (IAC) tumours (0 mm/year) (P = 0.005). The majority of tumours (87.14%) grew <2 mm/year. There was significant tumour growth seen in 38.9%, no or insignificant growth in 41.7%, and negative growth in 19.4%. Twenty-three patients (32%) failed conservative management at the second review. There was no difference in the outcome of these failed patients in comparison with patients who underwent primary treatment without a period of conservative management. The mean growth rate of tumours in patients that failed conservative management (3.1 mm/year) was significantly greater than that in patients who did not fail (0.2 mm/year) (P < 0.001). No factors predictive of tumour growth or failure of conservative management were identified. Hearing deterioration with pure tone averages (0.5, 1, 2, 3 kHz) and speech discrimination scores occurred irrespective of tumour growth. This prospective study further emphasizes the role of conservative management in selected cases of vestibular schwannomas. Tumours in this study confined to the IAC typically demonstrated minimal or no growth on serial MRI scanning. Regular follow-up with interval scanning is mandatory in all patients.

Glomangioma of the middle ear

A 62-year-old female was admitted to our clinic in October 1999 with a 6-year history of hearing loss, tinnitus and otorrhea in the right ear. Physical examination showed a polypoid mass arising from the right middle ear and extending into the external auditory canal. Serohemorrhagic otorrhea was also observed. Serious hemorrhage occurred while taking a biopsy. The histopathologic diagnosis was a glomangioma. MRI demonstrated a hypervascular mass (10 x 15 mm(2)) completely filling the right middle ear. Preoperative embolization of the ascending pharyngeal artery was carried out. The tumor was completely resected via a transmastoid approach. No complications were observed postoperatively. At the most recent follow-up examination, 72 months after the operation, no sign of disease was present. The modified radical mastoidectomy approach used in this case proved to be a safe and efficacious method for removing the glomangioma.

Cystic brain necrosis and temporal bone osteoradionecrosis after radiotherapy and surgery in a patient of ear carcinoma

Brain cyst formation of temporal lobe induced by radionecrosis in ear carcinoma is rare. A 73-year-old man with basosquamous carcinoma of the left external ear canal received excision of tumor and postoperative radiation therapy in 1992. For osteonecrosis of the left temporal bone, a series treatment including oral and intravenous antibiotics and hyperbaric oxygen therapy was given in following years. Encephalomalasia of the left temporal lobe on brain computed tomography (CT) was noted in 1997. The patient suffered from headache, poor concentration, memory impairment, depressed mood, bad temper, and one 8 x 5 x 3.5 cm cystic lesion of the left temporal lobe with tempomandibular joint defect revealed by brain CT in 2001. Symptoms relieved after stereotactic aspiration of cystic fluid and external drainage (Omaya reservoir) insertion under magnetic resonance image by neurosurgeon. We report the progressive radionecrosis of temporal lobe and cyst formation, which caused the neuropsychological symptoms 10 years after radiotherapy.