[Undifferentiated carcinoma of the ear: apropos of a case]

A case report of ear undifferentiated squamous cell carcinoma is presented. The patient complained pain and suppurative ear, which lead to us to practise an exploratory atticotomy, and therefore the tumor was detected on its early stages. It is a very interesting case report due to its unusual localization, and to the early diagnosis to improve the prognosis of these patients.

Malignant tumours of the middle ear

The authors present 15 patients with middle ear malignant tumours, of which 13 were squamous cell carcinomas, one was a rhabdomyosarcoma and one a malignant lymphoma. In 11 of 13 patients with squamous cell carcinoma, long-standing chronic otitis media preceded the malignant process and only in 2 patients did the tumour develop without previous chronic infection. Most of the patients presented at an advanced stage of the disease: in 6 the tumour had destroyed surrounding bone, commonly involving the endocranium; in 7 the facial nerve was paralysed and in 8 patients there was total hearing loss. The diagnosis of malignant tumour was established before surgery in 5 patients, but 8 patients were operated upon for suspected chronic otitis. Three patients died without treatment and 10 were treated: 3 with radiotherapy because the tumour was inoperable, 3 had surgery only and 4 patients had surgery and received radiotherapy post-operatively. Of 7 operated patients only 2 are alive without signs of tumour. Our findings suggest that otologists should bear in mind this disease in patients with chronic suppurative otitis and accompanying suspected symptoms. In 2 patients with rare types of sarcoma of the middle ear the diagnosis of tumour was established at an advanced stage and they could not be treated.

[Malignant skin neoplasms]

Malignant skin neoplasms of the auricle and peri-auricular region constitute only 6% of all skin cancers. However, rates of recurrence and metastasis are higher than for other cutaneous malignancies. Of 81 patients with malignant skin neoplasms of the auricle, 53.1% had basal cell carcinoma, 39.5% squamous cell carcinoma and 7.4% malignant melanoma. The neoplasms were 4 times more common in men (more than in other series), and more common in those of Ashkenazi origin (75% of the patients) and in the elderly (peak incidence in the 7th decade). All patients were treated surgically, and 21 were also irradiated. In 4 with cervical metastases neck dissection was performed. The recurrence rate for all neoplasms was 12.4% and the rate of metastases to regional lymph nodes from squamous cell carcinoma, 12.5%. There was a marked correlation between positive margins after surgical excision and rates of recurrence and regional metastases. Malignant skin neoplasms of the auricle should be regarded as high risk lesions which often recur and/or metastasize. Therefore, it is recommended to excise the tumors adequately so as to get negative margins, and to follow-up with careful, frequent evaluation.

Adenoid cystic carcinoma of the salivary glands. Management of recurrent, advanced, or persistent disease with hyperthermia and radiation therapy

Adenoid cystic carcinomas (ACC) of the salivary glands are aggressive tumors characterized by multiple late local recurrences and distant metastases. Current therapy includes wide local excision and high-dose postoperative radiation therapy (XRT) (5400 to 7000 cGy). Despite early aggressive treatment, local recurrence remains a major problem with limited safe and effective therapeutic options available. The excellent local responses obtained in four patients (six sites) with ACC of the head and neck treated either with additional low-dose irradiation (2160 to 3420 cGy) in conjunction with two to five hyperthermia (HT) treatments or with full dose XRT and HT as part of the overall treatment plan are reported. All HT treatments were for 45 minutes once steady state conditions were obtained. Monitored intratumoral temperatures for all treatments achieved average maximum (Tmax), average mean (Tave), and average minimum (Tmin) temperatures of 44.2 degrees C, 41.2 degrees C, and 38.9 degrees C, respectively. A complete response was obtained for all six fields with no significant long-term complications. Two patients remain alive and free of local disease at 42 and 63 months of follow-up. Two patients died--one with metastases (with persistent local control) and one with a local recurrence at 9 and 30 months, respectively, after XRT and HT. This is the first report of HT and low-dose XRT in the management of previously irradiated ACC and suggests a potential role for the use of this modality in the treatment of ACC.

Cancer of the auricle

Thirty-five patients with carcinoma of the auricle seen in Veterans General Hospitals, Taipei and Taichung from January 1970 to December 1988 were reviewed retrospectively. There were 28 men and 7 women. More cases occurred in the 7th and 8th decades with an average of 64 years (median 67) and ranged from 29 to 91 years. The most common manifestations at diagnosis were exophytic mass (86%) and/or ulcerative lesion (29%). Histologically, basal cell carcinoma outnumbered squamous cell carcinoma 17 to 14. The remaining 4 cases consisted of 2 melanomas, 1 sweat gland adenocarcinoma and 1 unclassified sarcoma. Eighty-eight percent (15/17) of basal cell carcinoma presented at early stage without regional lymph node or distant metastasis. They were mainly treated by surgery. One patient with multifocal lesions suffered from marginal recurrence. The 2 and 5-year survival rates were 94% and 86% respectively. Half of our 14 patients with squamous cell carcinoma had local extensive tumor but no lymph node or distant metastasis was found at the time of diagnosis. Local recurrence occurred in 4 patients, one case associated with lung metastasis. The local control rate of combined surgery and irradiation in squamous cell carcinoma was 100% (4/4), superior than that of operation alone 67% (6/9) or radiotherapy alone (0/1). The actual 2 and 5-year survival rates were 85% and 64% respectively. Our 4 patients with different pathology other than basal cell or squamous cell carcinoma had high rate of regional lymph nodes or distant metastases, presenting poor prognosis. The overall treatment failure for carcinoma of the auricle was 23% (8/35) but reduced to 14% after salvage treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Embryonal rhabdomyosarcoma of the middle ear: description of a case with long-term survival]

A case is described of embryonal rhabdomyosarcoma (E.R.) of the middle ear in a 4-year-old child; survival has been over 9 years. R.E. is the most common malignant tumor of the auricular region in children and is most often fatal due to locoregional extensions or secondary metastases carried through the bloodstream and lymphatic systems. The basis for treatment is a multidisciplinary approach to the disease: surgery with as broad an exeresis as possible; radiotherapy with tumor-killing doses of 5,500/6,000 rads; and polychemotherapy (Vincristina, Endoxan, Methotrexate). Such "aggressive" treatment often results in a high rate of morbidity with complications involving the blood, bones, eyes and meninx often requiring temporary suspension of treatment and prolonged hospitalization.

Facial nerve paralysis caused by tumor-forming chronic lymphatic leukemia: a case report

A 60-year-old female with chronic lymphatic leukemia developed a complete facial paralysis. Clinical examination revealed a tumor protruding through the cranial part of the eardrum. A CT scan and biopsy specimens showed a leukemic infiltrate in the middle ear with extension to the facial canal. She was successfully treated with radiotherapy.

Rhabdomyosarcoma of the ear and temporal bone

Rhabdomyosarcoma, the most common soft tissue sarcoma of childhood, involves the temporal bone in approximately 7% of reported cases. Until recently, the outcome of this disease was always fatal. The recent Intergroup Rhabdomyosarcoma Study Group (IRS-I) reported on the efficacy of multimodality therapy consisting of multiagent chemotherapy, radiation, and surgical resection when indicated. Twelve patients with rhabdomyosarcoma involving the temporal bone were treated between 1966 and 1988. Three patients were treated according to the IRS-I protocols and the remaining nine patients received various combinations of treatment modalities. Ten patients succumbed to their disease, most with distant metastases or intracranial extension. Two patients are alive; one at 5 1/2 years and one at 19 years. It is apparent that, although survival for rhabdomyosarcoma in general has improved with the use of IRS-I protocols, prognosis remains poor for disease involving the temporal bone and other parameningeal sites.

[Clinical features and results in the treatment of malignant neoplasms of the external auditory canal and middle ear]

Carcinoma of the external auditory canal and middle ear is extremely rare. The total number of patients referred to the Department of Radiology, School of Medicine, Chiba Univ. during the period of 13 years from January 1975 to July 1987 is only 8 cases. Mean age is 63.8 years old. Four of 7 pts., who were evaluable, had a history of chronic otitis media. Mean period between the first visit to physicians for the symptom and the diagnosis of malignant neoplasm was 8.4 Mo. Six pts. had operation and radiotherapy, 2 pts. radiotherapy alone. Three of 8 pts. failed in local site, and one patient also had submandibular lymph node metastasis during follow-up period.

Carcinoma of the ear: retrospective analysis of 61 patients

Malignant tumours of the ear canal and middle ear retain a poor prognosis despite the development of increasingly radical procedures. We report the combined experience of 61 patients presenting to our hospital over the past 30 years with this condition. Radiotherapy was the preferred initial treatment in almost all patients. Early surgical treatment by local resection just before or just after radiotherapy and radical mastoidectomy produced disease free survival for two to 20 years in 59 per cent (16 of 27) patients. Long term survival was achieved in 50 per cent of patients with carcinoma of the external auditory meatus and only 24 per cent of those with middle ear carcinoma. Salvage surgery produced a variable degree and duration of palliation but few survivors. Little was gained in the quality of life by petrosectomy.

[The diagnosis, evolution and treatment of cavum conchae neoplasms based on cases from the Colţea Radiology and ENT Clinics]

The authors report on the result of a study carried out on a group of 73 patients with neoplasm of the cavum, admitted and followed up in the "Colţea" clinics of radiology and O.R.L. for 5 years (1984-1988). The paper shows the incidence on groups of age and sex, the risk factors, the time elapsed between the onset and the first examination, till the diagnosis is established, the elements of positive diagnosis and also the onset characteristics. The histologic types of the cavum neoplasm followed, the therapeutic measures, and the results obtained are presented, with emphasis on the factors able to improve them.

[Cholesteatoma of the ear]

Cholesteatoma of the ear is characterized by the presence of a keratinizing squamous epithelium in the cavities of the middle ear. The epithelium invades the ear either by direct migration or by retraction of the eardrum. Owing to is potentials for migration, desquamation, bone erosion and infection, it is for most of the complications of chronic otitis and fully justifies the adjective "dangerous" applied to chronic cholesteatomatous otitis. The clinical diagnosis rests on microscope otoscopy. Audiometry informs on the degree of hearing loss and on the state of the contralateral ear. Standard radiography and computerized tomography of the petrous bone evaluate the extent of the lesion. Treatment is purely surgical: it consists of excision of the entire epithelium that has entered the middle ear and, secondarily, conservation or improvement of hearing. Whatever the surgical technique used, the frequency of recurrences calls for long-term follow-up.

Rhabdomyosarcoma of the middle ear and mastoid in children

Three cases of embryonal rhabdomyosarcoma in the middle ear and mastoid in children are presented. Diagnosis was confirmed by histopathology. A multidisciplinary approach employing surgery, chemotherapy and radiation therapy is the method of choice in the management of this rare and highly lethal condition.

The wet ear

Management of the wet ear is a frustrating problem. Essential to the management of the draining ear is the ability to determine the site of origin and the underlying cause of this drainage. Management of these problems frequently requires acute medical or surgical management followed by long-term therapy to keep the ear dry.

Squamous cell carcinoma of the middle ear. A 25-year retrospective study

Squamous cell carcinomas of the middle ear cleft are highly unpleasant tumors which pose many problems for the otologist. We have retrospectively reviewed the hospital notes of 21 patients (22 ears) who presented with this disease in order to try to clarify those features which are of prognostic significance. We confirmed that a history of chronic suppuration with or without cholesteatoma predisposes the patient to tumor development and that, in the presence of continuing otorrhea, patients are not protected by mastoid surgery. These patients have been treated with conservative surgery and radiotherapy without en bloc resection of the temporal bone and, in these circumstances, the histological grade of the tumor at presentation appears to bear a direct relationship to survival.

Embryonal rhabdomyosarcoma of the ear: a review of the literature and case history

Approximately 50 per cent of all rhabdomyosarcomas in children occur in the head and neck region with the orbit, nasopharynx and ear in order of descending frequency. Embryonal rhabdomyosarcoma is the commonest malignant tumour of the aural region in childhood and its clinical course is usually rapidly fatal, with extensive local disease and or distant metastases (Dehner and Chen, 1978). Other malignant tumours that can occur in children include melanoma and other mesenchymal tumours, including undifferentiated sarcoma, fibrosarcoma, osteogenic sarcomas and Ewing sarcoma. Secondary extension may occur from a meningioma. Osseous disorders of the temporal bone, such as eosinophilic granuloma and Hand-Schüller-Christian disease, should be included as a differential diagnosis (Lewis, 1979).

Obliteration of the mastoid in the treatment of tumors of the temporal bone

A retrospective analysis of 29 cases of squamous cell carcinoma of the external and middle ear and 15 cases of glomus jugulare tumors of the middle ear was performed to evaluate the incidence of osteoradionecrosis of the temporal bone following surgery and/or radiotherapy. Osteoradionecrosis occurred in 42% (8/19) of cases of squamous cell carcinoma which were treated with radical mastoidectomy, lateral or subtotal temporal bone resection leaving an open cavity and followed by an average of 5,840 rad postoperatively. No osteoradionecrosis, wound breakdown or otorrhea occurred in another group of six patients who were treated by surgical exenteration, total cavity obliteration, and an average of 5,700 rad of postoperative radiotherapy. Thus, cavity obliteration significantly decreased the incidence of these complications (p less than 0.05). In contrast, in 15 patients treated by surgery and postoperative irradiation (average dose = 4,610 rad) for glomus jugulare tumors, no osteoradionecrosis occurred despite use of an open cavity technique.

Significance of apparent intratympanic meningiomas

Meningioma is the most common tumor of the central nervous system, but it has only been reported in 79 patients to involve the temporal bone. The 4 cases presented here show striking clinical similarity to a subgroup of 20 meningiomas reported to be entirely intratympanic; however, in each instance the extent, origin, and potential of the disease was not initially evident. Precise histopathologic diagnosis may be aided by electron microscopy. Current concepts of embryology lend credence to the possible role of arachnoid endothelial cells in the pathogenesis of intratympanic meningioma. An advanced intracranial meningioma may be overshadowed by the hearing loss, tinnitus, and otalgia calling attention to an intratympanic component. The clinician should remain suspicious of intracranial disease even after excision of an apparently well circumscribed intratemporal lesion. Progressive sensorineural hearing loss and persistent otalgia portend recurrent or intracranial disease. Follow-up for at least 10 years with judicious use of CT scans is suggested.

Life endangering tumors in the ENT region in children

Forty children with life-endangering tumors localized in the ENT region were treated during the last 10 years at two clinics in Poland: the Oncological Clinic in Warsaw and the Otolaryngological Children's Clinic in Lódź. In this group there were 29 malignant tumors at different pathology, and 11 non-malignant tumors that became life-endangering because of their size and localization. These children were treated, dependent on the nature of the tumor, with surgery, chemotherapy and X-ray therapy.

Carcinoma of the middle ear and external auditory canal

Thirty-one patients with malignant tumors of the middle ear and external auditory canal (EAC) were observed at the University of Virginia Hospital from 1956 through 1980. Of 27 patients with carcinoma, 21 had squamous cell carcinoma, 4 had basal cell carcinoma and 2 had adenoid cystic carcinoma. One Ewing's sarcoma and 3 rhabdomyosarcomas occurred in an age group of one to 10 years. The 27 patients with carcinoma are reviewed with regard to clinical presentation, treatment modality, results and complications. The majority (67%) of patients had a history of chronic ear drainage, 22% had a previous mastoidectomy or polypectomy and 7% had an associated cholesteatoma. The treatment modalities employed depended on the extent of disease and the patient's general condition. Eighty percent of patients with carcinoma limited to EAC were alive and well at 5 years, compared to 43% of patients with involvement of the middle ear. Fifty-six percent of patients without invasion of the petrous bone were alive at 5 years compared to only 20% of patients with petrous bone involvement. The data strongly suggest that survival depends on the extent of disease. The corrected disease free 5 year survival rates were 14% for patients who had surgery alone and 50% for those who had surgery and radiotherapy. Of the three patients with advanced disease who received radiotherapy alone, none survived five years. Surgery or radiotherapy alone is not sufficient for most of the cases of carcinoma of the middle ear, since these patients often present with advanced disease. We recommend combined therapy, especially postoperative radiotherapy, except for early lesions that do not involve the mastoid or petrous bone. Other series suggest radiotherapy would be adequate and more effective than surgery for early lesions. Surgery will provide the diagnosis, determine the extent of disease, offer adequate drainage of infected material and relieve most pain before radiation therapy.

Primary adenocarcinoma of the middle ear

Adenocarcinoma arising from the mucosa of the middle ear is a rare tumor. This report adds four new cases to the 13 cases that have been previously reported in the literature. These neoplasms tend to have a rather slow growth pattern and have an infrequent incidence of distant metastases. The observations that local recurrence is the major problem with adenocarcinoma of the middle ear suggest that aggressive locoregional treatment should be strongly considered.