Paediatric rhabdomyosarcoma of the ear and temporal bone

The objective of the present study was to review the presentation, management, outcome and morbidity of paediatric patients presenting to a single centre with rhabdomyosarcoma of the ear and temporal region. All patients diagnosed with rhabdomyosarcoma of the ear and temporal region between 1980 and 2000 were entered into this retrospective study. Fourteen patients were identified. The median age at presentation was 4.5 years with a mean time of onset of symptoms to diagnosis of 21 weeks. In many patients, the presentation mimicked that of chronic otitis media, delaying diagnosis. Histological subtype was embryonal in 13 patients and alveolar in 1. All patients underwent multimodality treatment. The 5-year disease-free survival rate was 81%. Regional post-treatment morbidity included chronic aural discharge (6/14), facial palsy (8/14), growth disturbance (4/14) and maxillo-facial deformity occurring in four children. From the results, we conclude that these patients should usually present to an ENT surgeon who should keep the diagnosis in mind when dealing with children with chronic otitis media as early diagnosis with referral to a specialist multidisciplinary team will optimize the chance of survival. Discharge, hearing loss and aural polyp, although commonly because of chronic otitis media, should prompt urgent investigation and biopsy, particularly if associated with facial palsy, lymphadenopathy or an obvious mass.

Paragangliomas of the head and neck

Paragangliomas are neuroendocrine tumors derived from the extra-adrenal paraganglia of the autonomic nervous system. Within the head and neck, they are generally defined and named according to their site of origin, and may be found frequently neighboring vascular structures. Physiologic activity is rare in these neoplasms and they may exhibit patterns of inheritance which predispose their occurrence in families, often with multicentricity. These tumors generally exhibit a slow rate of growth, most often presenting asymptomatically as a space occupying mass lesion noted clinically or radiographically. The most common paraganglioma of the head and neck is the carotid body tumor followed by the jugulo-tympanic and vagal varieties. Other rare sites where this tumor may occur include; the larynx, sinonasal chambers and orbit. Diagnosis is generally made through a combination of clinical findings and radiographic studies. Magnetic resonance represents the most important imaging modality for the evaluation and characterization of suspected head and neck paraganglioma. Definitive management for these lesions should be carefully considered in relation to both tumor and patient-oriented factors, especially in regard to the potential morbidity of treatment. Surgery and radiation therapy represent the main treatment modalities for paraganglioma. The selection of treatment depends on the size, location, and biologic activity of the tumor as well as the overall fitness of the patient. Although radiotherapy may be effective in arresting growth of these tumors, rarely is the neoplasm eliminated without surgical resection. Surgery may be associated with significant morbidity, primarily as a consequence of incurring major cranial nerve injury. Patient selection (relative to age and medical condition) should be carefully considered prior to recommending aggressive surgery for paragangliomas of head and neck, especially in those patients at risk for disabling surgical morbidity.

Inflammatory polyps and aural neoplasia

Although aural neoplasia is a relatively uncommon entity in companion animals, it remains a group of heterogeneous conditions that can have a significant negative impact on quality and duration of life of dogs and cats. Chronic ear disease that responds poorly or partially to empiric therapy should raise the suspicion that an underlying condition, such as neoplasia, may be the perpetrator of inflammation. Early diagnosis followed by appropriate therapy improves the likelihood of disease control and prolonged survival.

[Glandular neoplasms of the external auditory canal--clinical and morphologic observations]

In the article cases of glandular neoplasms of the external auditory canal were presented. Ceruminous adenoma was diagnosed in three persons, adenoid cystic carcinoma--in three patients and ceruminous adenocarcinoma in one patient. All of them were treated surgically or by combined method with radiotherapy. Difficulties with exact histopathological diagnosis and with choice of a method of treatment were stressed. Classification of the glandular neoplasms of the external auditory canal was also presented underlying a histopathological and clinical diversity of these tumors, which had previously been incorrectly qualified in one group ceruminoma.

External auditory canal eccrine spiradenocarcinoma: a case report and review of literature

BACKGROUND

Eccrine spiradenocarcinoma is a rare dermal appendage carcinoma believed to arise from transformation of a long-standing benign spiradenoma. This tumor demonstrates highly malignant biologic behavior with a high recurrence rate, frequent lymph node metastases, and overall poor survival.

METHODS

We report the first case of eccrine spiradenocarcinoma arising in the external auditory canal. The management of this tumor, its histopathologic characteristics, and a review of literature are presented.

RESULTS

A literature review identified 17 cases of eccrine spiradenocarcinoma in the head and neck region. Local recurrence occurred in 58.8% of patients, with an average of 23 months from diagnosis. Lymph node metastasis occurred in 35.3%, with an average of 31 months from diagnosis. Other metastatic sites included skin, bone, and lung. Disease-specific mortality was 22.2%.

CONCLUSIONS

Eccrine spiradenocarcinoma is an aggressive tumor with a poor prognosis. Primary treatment should include wide local excision with or without regional lymphadenectomy. Isolated successful treatments have been documented with adjuvant hormonal manipulation, chemotherapy, and radiation therapy.

[CT and MRI of the petrous bone]

Diseases of the petrous bone should now be diagnosed by means of high-resolution multislice spiral computed tomography (MSCT) and/or magnetic resonance imaging (MRI). The first step in the process of diagnosis, however, must be conventional X-ray photographs (according to Schüller, Mayer, Stenvers) for screening purposes, because of the high cost of the other procedures mentioned. Because of the excellent imaging of bone structures with MSCT, this technique is especially suitable for the diagnosis both of acquired pathologies and of congenital abnormalities of the external auditory meatus, the middle ear and the mastoid, of trauma-induced pathologies of the entire petrous bone, and of osteogenic diseases. MRI is the method of choice for examination of the labyrinthine system, the interior auditory meatus and the cerebellopontine angle because it gives much the best depiction of soft tissue. Sometimes when questions remain unsolved after computed tomography (CT) examination of the middle ear MRI can be applied to complement CT, and it can yield additional information. Lesions affecting the apex of the petrous pyramid should be examined by MRI. High-resolution CT through the bone window and thin-layer MRI are both components of the presurgical diagnosis before cochlear implant (CI) surgery. For postoperative monitoring a conventional transorbital X-ray of the petrous bone is sufficient; CT is indicated only in complicated cases, and MRI is absolutely contraindicated after CI.

Squamous carcinoma of the external auditory canal: a different approach

Squamous carcinoma of the external ear canal is a rare disease and a challenge to treat. Some controversy exists regarding the best options for treatment. Reported 5-year survival varies between 35% and 63%. Since 1976, we have adopted a conservative approach to these tumours, with patients undergoing a specific protocol of meticulous tumour debulking followed by a course of repeated topical 5-fluoro-uracil (5-FU) cream application and necrotectomy. Data was collected prospectively. From 1976 to 1998, 23 patients underwent primary treatment according to our protocol. Nine patients had T1 disease whereas six had T2 and eight had T3 disease. The 5- and 10-year overall survivals were 74% and 60% respectively. These results compare very favourably with those in the literature and surgical debulking with topical 5-FU and necrotectomy remains our primary treatment of choice for squamous cell carcinoma of the external auditory canal.

Bilateral squamous cell carcinoma of the external auditory canals

OBJECTIVES

To report a case of bilateral squamous cell carcinoma of the external auditory canals and to present a management algorithm for this difficult clinical scenario.

STUDY DESIGN

Case report and literature review.

METHODS

The study comprises a case report of a 69-year-old man who initially presented with complaints 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 external auditory canals revealed squamous cell carcinoma. A computed tomography scan demonstrated marked abnormal soft tissue in the left external auditory 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 parotidectomy, and postoperative irradiation. The right-sided lesion was more limited and was managed with a lateral temporal bone resection and tympanoplasty for hearing preservation.

CONCLUSIONS

Bilateral squamous cell carcinoma of the external auditory canals is an extremely uncommon but aggressive malignancy that may present with symptoms similar to a case of otitis externa, 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.

Diffuse neonatal hemangiomatosis associated with Simpson-Golabi-Behmel syndrome: a case report

Diffuse neonatal hemangiomatosis (DNH) is a rare disorder characterized by multiple cutaneous and visceral hemangiomas that usually presents in newborns and has a high mortality rate. While previously reported cases of DNH describe multiple cutaneous hemangiomas, we present a patient with a single hemangioma of the ear, who also had DNH of the central nervous system and visceral organs. Furthermore, in this report we present a new constellation of findings, namely, a Simpson-Golabi-Behmel syndrome (SGBS). The practical implication on the basis of the experience with our patient is the need to ensure adequate diagnostics for patients with large hemangiomas as well as for patients with multiple cutaneous hemangiomas, because DNH also can occur in single hemangiomas in rare cases.

Cancer of the external auditory canal and temporal bone

Malignant neoplasms involving the temporal bone are a relatively rare and often misdiagnosed disease. Staging of temporal bone cancer has proven difficult because of the small number of patients with this condition, the various histopathologic and histologic findings reported, and a lack of randomized trials. Of the various staging systems that have been proposed, the Pittsburgh classification appears to be the most widely accepted. A retrospective study of 31 patients with temporal bone malignancy at the University of Arkansas for Medical Sciences has led us to propose a modification of the Pittsburgh classification for early-stage lesions. This modification places more emphasis on the site of disease in the canal and less on the size of the primary tumor or degree of bony invasion. This review discusses this staging system, the management of these tumors in a multidisciplinary team approach, reconstructive options, and auditory rehabilitation.

Temporal bone carcinoma

Squamous cell carcinoma is the most common malignancy of the external auditory canal, middle ear, and mastoid. Surgical resection is the cornerstone of treatment, with T1 lesions of the external auditory canal treated by lateral temporal bone resection and more advanced lesions treated by subtotal or total temporal bone resection. This article summarizes clinical manifestations, differential diagnosis, management, and differences in treatment philosophy.

Improved outcome for patients with middle ear rhabdomyosarcoma: a children's oncology group study

PURPOSE

The goal of this study was to define the clinical features and optimal therapy for children and adolescents with middle ear (ME) rhabdomyosarcoma (RMS).

PATIENTS AND METHODS

We reviewed demographic data, clinical features, therapy (including chemotherapy, surgery, and radiation), and outcome for the 179 eligible patients with ME RMS who were enrolled onto Intergroup Rhabdomyosarcoma Studies (IRS) I through IV or pilot studies between November 1972 and December 1997.

RESULTS

Most patients were younger than 10 years old (90%), and 63% were male. Because of the parameningeal location, most tumors were not resected before chemotherapy (group I, < 1%; group II, 4%; group III, 84%; group IV, 12%). Although most tumors were locally invasive (T2, 89%), the majority were small (< or = 5 cm, 66%), lacked nodal metastases (N0, 86%), and had embryonal histology (85%). The 5-year failure-free survival (FFS) and overall survival (OS) estimates were 67% and 72%, respectively. Both FFS and OS improved significantly over the course of IRS I through IV (3-year FFS and OS: IRS-I, 42% and 42%; IRS-II, 70% and 74%; IRS-III, 65% and 72%; IRS-IV pilot, 81% and 96%; IRS-IV, 88% and 88%, P <.001). Lower clinical group or stage and smaller tumor size were associated with better outcome. Age, sex, tumor invasiveness, and nodal metastases were not predictive of outcome.

CONCLUSION

Patients with ME RMS generally present with small, unresectable, invasive tumors at a site traditionally considered prognostically unfavorable. Nevertheless, such patients have benefited markedly from improvements in multimodal, risk-based therapy during the course of IRS I through IV, and with contemporary therapy, most are cured.

Tumor growth and audiometric change in vestibular schwannomas managed conservatively

OBJECTIVE

To prospectively define the correlation between changes in tumor volume and audiometric function in vestibular schwannomas managed conservatively.

STUDY DESIGN

Prospective longitudinal study.

METHODS

Twenty-one patients (age range, 15-84 y; mean age, 63.3 y) with newly diagnosed vestibular schwannomas were enrolled between 1994 and 1999 in a protocol at The Ohio State University Hospital (Columbus, OH) to evaluate the correlation between tumor volume and audiometric change during a period of observation. Patients were evaluated yearly by clinical examination, a standardized internal auditory canal magnetic resonance imaging scan with gadolinium contrast for volumetric analysis, and audiometric function testing. Demographic data, historical features, neurofibromatosis type 2 (NF2) status, initial testing results, and serial testing results were recorded.

RESULTS

An increase in tumor volume occurred in 14 of the 21 patients (66%). The pattern of volumetric change was found to be extremely variable. Multiple regression analysis revealed significant correlations of changes in tumor volume with changes in pure-tone average and speech discrimination score (P < .0001 and P = .0021, respectively). Change in tumor volume had greater effect on pure-tone average and speech discrimination score in patients initially with class D audiometric function when compared with those initially in class A (P = .0083 and P = .0245, respectively). The presence of NF2 had an independent protective effect against deterioration of the pure-tone average when compared with patients without NF2 (P = .0125).

CONCLUSIONS

This study demonstrated a significant correlation between a change in volume and auditory deterioration in vestibular schwannomas being managed with a trial of observation. A given change in tumor volume appeared to have a greater effect on pure-tone average and speech discrimination score as initial auditory classification declined.

Lymphoma in the ear

BACKGROUND

Malignant tumors of the ear are rare. The most common malignant tumors are squamous cell carcinomas and adenocarcinomas. Lymphoma in the ear is rare.

METHODS

We report 2 cases of a primary presentation of a lymphoma of the ear. The literature since 1947 is reviewed.

RESULTS

An 83-year-old woman with an anaplastic large cell lymphoma of the skin of the external auditory meatus and a 75-year-old man with a B-cell non-Hodgkin's lymphoma of the mastoid process are presented. The literature review shows that only 16 cases of lymphomas of the ear have been reported so far.

CONCLUSIONS

In a case of therapy-resistant otitis and/or peripheral facial paralysis malignancy should be excluded by computer tomography of the mastoid. For histopathological diagnosis unfixed specimens are preferable. Uniform treatment of lymphomas of the ear has not been established.

A case of endolymphatic sac tumor with long-term survival

A 72-year-old man developed left facial palsy at age 14 and left-sided hearing loss at age 20. At the age of 59, he presented with gait disturbance, and a large left cerebellopontine angle tumor was detected, which had markedly destroyed the pyramidal bone. The tumor was subtotally resected, but he required two more operations at the ages of 64 and 69 because of tumor regrowth. At the present time, recurrent tumor has destroyed the occipital bone and is invading the scalp. However, even though he has several cranial nerve palsies and cerebellar ataxia, he remains in stable condition and demonstrates long-term survival. The patient's surgical specimens revealed a papillary adenoma, which was recently thought to be of endolymphatic sac origin, although the origin of this kind of tumor, whether arising from the middle ear or from the endolymphatic sac, has not been established with certainty so far. In this paper, we provide further evidence that this tumor originates from the endolymphatic sac, based on anatomical, histopathological, and embryological evidence.

Malignancy of the Temporal Bone and External Auditory Canal

A retrospective study of 18 patients with malignant tumors of the external auditory canal and temporal bone was undertaken to gain an Asian perspective of this rare disease. Of these patients, 15 (83%) had squamous cell carcinoma (SCC) and 61% had stage T3 tumors at presentation. The mean age was 56 years (range 38-82 years). Seven (39%) of the 18 patients had radiation-associated tumors (RATs), and all had undergone radiotherapy for treatment of nasopharyngeal carcinoma. The 1-year cumulative recurrence for the RAT group was 100%, but there was no recurrence in the non-RAT group ( P = 0.001). In malignancies of the external auditory canal and temporal bone, a different classification and staging system for patients with RATs may be warranted to better guide treatment strategies.

Consequences to hearing during the conservative management of vestibular schwannomas

OBJECTIVE

To estimate the risk of loss of serviceable hearing during the conservative management of vestibular schwannomas.

STUDY DESIGN

Retrospective case review.

METHODS

Twenty-five patients with a radiological diagnosis of unilateral vestibular schwannoma were managed conservatively for a mean duration of 43.8 months (range, 12-194 mo). The pure-tone average (PTA) (0.5, 1, 2, and 3 kHz) and speech discrimination scores (SDS) were measured at regular intervals throughout the entire duration of follow-up. Serviceable hearing was defined using two criteria: 70% SDS/30 dB PTA (the 70/30 rule) and 50% SDS/50 dB PTA (the 50/50 rule). The size and growth rate of tumors were determined according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines (1995). Intervention was recommended if there was evidence of continuous or rapid radiological tumor growth, and/or increasing symptoms or signs suggestive of tumor growth.

RESULTS

The risk of loss of serviceable hearing for the total group was 43% using the 70/30 rule and 42% using the 50/50 rule. Tumor growth was considered significant (> 1 mm) in 8 tumors (32%) and nonsignificant in 17 (68%). The risk of loss of serviceable hearing for the tumor-growth group was 67% using the 70/30 rule and 80% using the 50/50 rule. In contrast, the risk of loss of serviceable hearing for the no tumor-growth group was 25% using the 70/30 rule and 14% using the 50/50 rule. No audiological factors predictive of tumor growth were identified.

CONCLUSIONS

There is a significant risk of loss of serviceable hearing during the conservative management of vestibular schwannomas. This risk appears to be greater in tumors that demonstrate significant growth.

[Rhabdomyosarcoma of the middle ear in childhood]

The authors have described a case of a 2.5-year-old boy who suffered from rhabdomyosarcoma of the middle ear. The clinical course, differential histopathology diagnosis and dynamic growth of the tumor have also been presented. In spite of combined therapy--surgery and chemotherapy--prognosis in rhabdomyosarcoma of the middle ear in childhood is poor.

[Multiple cancer of the external ear]

Neoplasmatic multifocal tumors develop inside the same tissue or organ. They refer to skin, mucosal membrane of gastrointestinal tract or respiratory tract. To diagnose them a histopatological confirmation of their malignancy is needed, there must be macroscopic border line between tumors, the change can not be a metastasis from primary defect. The authors present two cases of external ear squamous cell carcinoma a which appeared bilaterally in different periods of time.

[Angiosarcoma of the outer ear. A case report]

Angiosarcoma (AS) is one of the rarest forms of soft tissue neoplasm. They are considered highly aggressive tumors with a poor prognosis. They range from highly differentiated tumors resembling hemangiomas to anaplastic tumors that are difficult to distinguish from carcinomas. Clinically, the appearance of these lesions varies, so confusion may arise from an initially benign appearance. AS comprise less than 1% of all sarcomas. In these patients, tumor size is an important predictor of survival. In our case, the tumor was located in the outer ear and the patient was treated with surgery, radiotherapy (65 Gy), and chemotherapy (adriamycin). A recurrence one year later was treated with salvage surgery and external carotid artery ligature to control abundant hemorrhage.