Squamous cell carcinoma of the temporal bone

Survival Outcomes of Temporal Bone Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

Temporal bone squamous cell carcinoma (TBSCC) is a rare malignancy with poor prognosis, and optimal treatment for advanced cases is uncertain. Our systematic literature review aimed to assess 5-year survival outcomes for advanced TBSCC across different treatment modalities.

DATA SOURCES

EMBASE, Medline, PubMed, and Web of Science.

REVIEW METHODS

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for articles published between January 1989 and June 2023.

RESULTS

The review yielded 1229 citations of which 31 provided 5-year survival data for TBSCC. The final analysis included 1289 patients. T classification data was available for 1269 patients and overall stage for 1033 patients. Data for 5-year overall survival (OS) was 59.6%. Five-year OS was 81.9% for T1/2 and 47.5% for T3/4 (P < .0001). OS for T1/T2 cancers did not significantly differ between surgery and radiation (100% vs 81.3%, P  = .103). For advanced-stage disease (T3/T4), there was no statistical difference in OS when comparing surgery with postoperative chemoradiotherapy (CRT) (OS 50.0%) versus surgery with postoperative radiotherapy (XRT) (OS 53.3%) versus definitive CRT (OS 58.1%, P  = .767-1.000). There was not enough data to assess the role of neoadjuvant CRT.

CONCLUSION

Most patients will present with advanced-stage disease, and nodal metastasis is seen in nearly 22% of patients. This study confirms the prognostic correlation of the current T classification system. Our results suggest that OS did not differ significantly between surgery and XRT for early stage disease, and combined treatment modalities yield similar 5-year OS for advanced cancers.

Melanoma of the external auditory canal: case report and systematic literature review

Melanoma of the external auditory canal (EAC) is particularly rare and poorly understood, with limited available data on management and survival. This systematic review aims to analyze existing data and provide insights into the management and prognosis the beginning of EAC melanoma. It is conducted using Pubmed and Scopus databases from the beginning to July 2023 and it follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. Searches are performed using the search string "(melanoma) AND (external auditory canal)".

The review includes a total of 30 patients diagnosed with EAC melanoma, supplemented by an additional case from the authors' clinical experience. The role of Breslow thickness as a determining factor for the choice of surgery remains inconclusive due to limited available data. Sentinel lymph node biopsy and adjuvant therapy are sparingly employed, indicating the need for standardized guidelines. Patients in the study demonstrate a 50% overall survival rate at 5 years.

EAC Melanoma is a rare and aggressive malignancy with limited therapeutic guidelines. Surgical interventions, including wide local excision and lateral temporal bone resection, are the primary treatment options for patients without distant metastases.

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.

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.

Pattern of nodal metastasis of cutaneous squamous cell carcinoma involving the temporal bone

Objective

The objective of this study was to explore the pattern of lymph-node spread of SCCs involving the temporal bone.

Methods

We retrospectively reviewed all cutaneous SCCs involving the temporal bone over a 20-year time-period. Forty-one patients were eligible.

Results

Mean age was 72.8 years. The diagnosis was cutaneous SCC in all cases.All patients underwent a temporal bone resection, 70.7% had a neck-dissection and 78.0% a parotidectomy.Level 2 was the most common area of neck metastasis, and occurred in 12.2%. The parotid had disease in 34.1%. 51.2% of patients underwent free-flap reconstruction.Mean overall survival of the cohort was 4.2 years.

Conclusions

Overall, the rate of cervical nodal metastasis was 22.0% and 13.5% in the occult setting. The parotid was involved in 34.1% and 10.0% in the occult setting. Results from the present study support consideration for performing a parotidectomy at the time of temporal bone resection, while a neck dissection can be performed for adequate staging of the nodal basin.

Level of Evidence

3.

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.

Necrotizing Otitis Concealing Carcinomas of the External Auditory Canal

External auditory canal Carcinomas are rare and aggressive tumors and their prognosis depends on early diagnosis. Their clinical similarity to necrotizing otitis is a source of error and therefore of diagnostic delay. Hence the interest of our study which consists in providing ENT specialists and all practitioners with the necessary clinical, evolutionary, radiological, biological and histological elements to avoid diagnostic errors. This is a retrospective study of all patients who were hospitalized for necrotizing otitis in the department of otolaryngology of the hospital of specialties of Rabat spread over a period of 5 years. All patients received an admission CT scan, biological tests, bacteriological sampling and biopsy. As well as initial parenteral antibiotic therapy and surgery for incidentally discovered EAC carcinomas. Clinically, all patients had otalgia and granulation tissue on otoscopic examination under the microscope. 50% had otorrhea. Pseudomonas aeruginosa was isolated in 50% of the cases, staphylococcus aureus in 25% and sterile culture in 25%. From the first biopsy, the diagnosis of tumor was retained in 6/10 patients. A second biopsy was performed in patients who did not show improvement and had a sterile culture. This one allowed the diagnosis in 4 other patients. All our patients had a surgical indication and were operated and then irradiated. The survival at 5 years was 50%. Biopsy must be systematic for every patient hospitalize for necrotizing otitis. Without hesitating to do it again each time the evolution is not good and the culture is sterile.

Treatment of advanced squamous cell carcinoma of the external auditory canal: Critical analysis of persistent failures in diagnosis and surgery with a competing-risk model

BACKGROUND

A series of temporal bone squamous cell carcinomas (TBSCCs) was analyzed with the aim of (i) better understanding the causes for the persistent high failure rate in advanced SCCs and (ii) discussing a possible way out from this stalemate in treatment.

METHODS

Forty-five TBSCCs consecutively treated surgically were reviewed.

RESULTS

The 5-year cumulative incidence for postoperative local recurrence was 41.8%. At multivariable analysis, pT3-4 stages were associated with eightfold relative incidence of developing local recurrence during follow-up (sHR = 9.06, 95% confidence interval [CI] = 1.18-69.46, p = 0.034) and cause-specific death (sHR = 7.95, 95%CI = 1.01-62.27, p = 0.048).

CONCLUSIONS

The poor outcome in advanced TBSCC occurred because of local recurrence due to defective resection. The fundamental pitfall of surgery on advanced TBSCC appeared to be the insufficient knowledge of microscopic tumor growth in the different sites and subsites of the temporal bone. The serial histopathological study of the en bloc surgical specimen and autopsy temporal bones seems to represent a way to enhance our understanding of these tumors.

Evaluation of subclasses for T4-classified squamous cell carcinoma of the external auditory canal

Background

T4‐classified squamous cell carcinoma (SCC) of external auditory canal (EAC) can potentially involve different anatomical structures, which could translate into different treatment strategies and survival outcomes within one classification. Our aim is to evaluate the clinical added value of T4‐subclasses proposed by Lavieille and by Zanoletti.

Methods

Retrospective data, including patients with primary operated cT4‐classified EAC SCC, was obtained from 12 international hospitals. We subclassified according to the T4‐subclasses. The treatment strategies, disease‐free survival (DFS) and overall survival per subclass were calculated.

Results

A total of 130 T4‐classified EAC SCC were included. We found commonly used treatment strategies per subclass according to Lavieille and the DFS seems also to differ per subclass. Subclass according to Zanoletti showed comparable treatment strategies and survival outcomes per subclass.

Conclusion

Our study suggests that the subclass according Lavieille might have added value in clinical practice to improve care of T4‐classified EAC SCC.

Treatment Outcome of External Auditory Canal Carcinoma: The Utility of Lateral Temporal Bone Resection

We examined the role of lateral temporal bone resection (LTBR) in the treatment of external ear canal (EAC) carcinoma between 2007 and 2018. The estimated 3-year disease-free survival (DFS) and disease-specific survival (DSS) according to the tumor stage and treatments were investigated in 36 patients with EAC squamous cell carcinoma. T stage classification according to the University of Pittsburgh staging system was as follows: 14 patients in T1, four patients in T2, nine patients in T3, and nine patients in T4. The 3-year DFS rate was 77.4% for T1 tumors, 100% for T2, 44.4% for T3 tumors, and 11.1% for T4 tumors (p < 001). The 3-year DSS rate was 100% for T1/T2 tumors, 87.5% for T3 tumors, and 11.1% for T4 tumors (p < 0.01). T1/T2 patients received mostly LTBR. Among nine T3 tumors, five patients (56%) received LTBR combined with preoperative chemotherapy and/or postoperative radiation (RT). Four of them had negative surgical margin and survived with no evidence of disease. The DFS of T3 patients who underwent concurrent chemoradiotherapy and LTBR was 0 and 80%, respectively (p = 0.048). For T1/T2 tumors, surgery achieved an excellent outcome. For T3 tumors, LTBR achieved negative surgical margin and showed good survival when combined with preoperative chemotherapy and/or postoperative RT. In contrast, the prognosis of T3 patients who could not undergo surgery was as poor as that of T4 patients. Therefore, in addition to subtotal temporal bone resection, LTBR-based treatment strategy may be a treatment option for limited cases of T3 patients.

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.

Occult parotid involvement in early-stage squamous cell carcinoma of the external auditory canal

BACKGROUND

The importance of elective parotidectomy in early-stage squamous cell carcinoma (SCC) of the external auditory canal (EAC) is not well established.

METHODS

A retrospective study of 43 patients with early-stage SCC of the EAC who underwent parotidectomy in conjunction with lateral temporal bone resection at three centers.

RESULTS

Overall occult parotid involvement (OPI) rate in early-stage SCC of the EAC was 13.9% (6/43). When considering both the anteroposterior position and the bony-cartilaginous position, patients with SCC in both the anterior wall and cartilaginous portion exhibited significantly higher OPI than other locations (37.5% vs. 0%, p = 0.001), with an increase in the OPI predictive value.

CONCLUSION

SCC located in either the anterior wall of the EAC or the cartilaginous portion of the EAC or both simultaneously showed a high prevalence of OPI, and elective parotidectomy should be considered in those patients.

Aural Polyp or Temporal Bone Carcinoma: Lesson to Learn

Temporal bone carcinoma is a rare malignant tumor of the head and neck region. Its clinical presentations can mimic benign ear diseases, leading to inaccurate diagnosis and substandard management. We present the case of a 53-year-old female with a three-month history of progressive right otalgia, otorrhea, and hearing loss. Otoscopic examination revealed a mass occupying the right external auditory canal. However, the lesion was presumed to be an aural polyp by several clinicians previously. Multiple courses of oral antibiotics had been prescribed before she was referred to our clinic for the non-resolving aural polyp. Imaging studies showed an external auditory canal soft tissue mass with extradural and parotid extension. The mass was biopsied, and the result was reported as squamous cell carcinoma of the temporal bone. The patient was advised for a total temporal bone resection and parotidectomy; however, she declined the surgical intervention. Within a month, the tumor had metastasized to her lung, liver, and vertebral bodies. She was referred to the Oncology team for palliative chemo-radiotherapy. Temporal bone malignancy must be considered as a differential diagnosis in a middle-aged or elderly patient with a non-resolving aural polyp without a chronic discharging ear. Imaging studies and histopathological evaluation should be prompted to ascertain the diagnosis. Repeated course of oral antibiotic will delay treatment and subsequently may lead to poor prognosis.

Invasion Patterns of External Auditory Canal Squamous Cell Carcinoma: A Histopathology Study

OBJECTIVES/HYPOTHESIS

To describe the histopathology of the invasion patterns of advanced-stage external auditory canal (EAC) squamous cell carcinoma (SCC). Study Design Retrospective cohort study.

METHODS

Retrospective analysis of medical records of patients diagnosed with EAC SCC available at the Massachusetts Eye and Ear temporal bone (TB) collection. TBs underwent processing for histologic examination. Hematoxylin and eosin-stained slides were examined. Histologic findings were compared to premortem clinical data.

RESULTS

Nine TBs were identified. Male:female ratio was 6:3. The average age of diagnosis and duration of survival was 64 (46-80 years) and 2.3 years (1-50 months), respectively. All presented with T4 disease, most commonly due to petrous apex (PA) invasion and facial nerve (FN) weakness. The mastoid air cells system served as a tumor conduit to the tegmen mastoideum and overlying dura in four patients, posterior fossa dura in one patient, vertical segment of FN in four patients, and middle ear (ME) and lateral semicircular canal in five patients. The tumor did not penetrate the tympanic membrane, oval window membrane (fenestra vestibule), or round window (RW) membrane. Supra- and infralabyrinthine pneumatization patterns allowed direct routes to the PA. Translabyrinthine PA invasion was seen in two patients. The most common locus of otic capsule invasion was the cochlea. One patient had FN paralysis due to compression rather than invasion.

CONCLUSIONS

SCC does not tend to extend from the ME to the inner ear through the RW and vestibule-stapedial ligament. Tumors tend to spread along the preexisting TB air-tract routes. Well-aerated TB, may facilitate extension to the PA.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E590-E597, 2021.

Squamous cell cancer of the temporal bone: a review of the literature

Background and aims

Squamous cell carcinoma (SCC) of the temporal bone is a rare malignancy accounting for only 0.2% of head and neck cancers. There is currently no clear consensus on staging or common approach to management. It is the aim of this work to provide the readers with a review of the current literature on this malignancy.

Methods

A literature review was performed identifying 16 case series with patient numbers ranging from 12 to 124. A total of 708 patients were included in this review, 67% presented with advanced disease. 578 cases were managed operatively with lateral temporal bone resection, some underwent local resection alone in early stage disease. In all studies radiation therapy was used as an adjunct to some degree.

Results

More than half of studies reported 100% either 2-, 3- or 5-year survival for T1 and T2 disease with no nodal involvement. Survival correlated with disease stage and in five studies SCC differentiation was found to be a significant prognostic factor. Post-operative radiotherapy was found to improve survival in only one study.

Conclusions

Temporal bone SCC is a readily treatable malignancy in early stage disease, however late stage disease has a poor prognosis. Differentiation of the SCC and stage of disease at presentation appear to have the greatest influence on 5-year survival rates. Further work is required in both the identification of early stage disease and in the treatment of later T3 and T4 lesions.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06281-4) contains supplementary material, which is available to authorized users.

Evaluation of the modified Pittsburgh classification for predicting the disease-free survival outcome of squamous cell carcinoma of the external auditory canal

Background

Squamous cell carcinoma (SCC) of the external auditory canal (EAC) is a rare disease, which is commonly classified with the modified Pittsburgh classification. Our aim was to evaluate the predictive performance of this classification in relation to disease‐free survival (DFS).

Methods

We examined retrospective data from a nationwide Dutch cohort study including patients with primary EAC SCC. These data were combined with individual patient data from the literature. Using the combined data, the predictive performances were calculated using the c‐index.

Results

A total of 381 patients were included, 294 for clinical and 281 for the pathological classification analyses. The c‐indices of the clinical and the pathological modified Pittsburgh classification predicting DFS were 0.725 (0.668‐0.782) and 0.729 (0.672‐0.786), respectively.

Conclusion

The predictive performance of the modified Pittsburgh classification system as such appears to be acceptable to predict the DFS of EAC SCC. Other factors need to be added to a future model to improve the predicted performance.

Primary Advanced Squamous Cell Carcinoma of the Temporal Bone: A Single-Center Clinical Study

OBJECTIVES/HYPOTHESIS

The extreme rarity of temporal bone squamous cell carcinoma (TB-SCC) has delayed the accumulation of high-quality clinical evidence. For the purposes of retrospective meta-analysis in the future, a large dataset with information from various institutions would be ideal. Our objective here was to retrospectively review cases of TB-SCC encountered at a single tertiary referral center and explore survival outcomes and prognostic factors.

STUDY DESIGN

Retrospective chart review.

METHODS

The medical records of all TB-SCC cases were retrospectively reviewed. The resulting dataset contained 71 cases of primary cancer eligible for initial definitive (curative) treatment.

RESULTS

T4 status was associated with lower disease-specific 5-year survival than T1 to T3 staging (T1: 100%, T2: 92%, T3: 86%, T4: 51%). Survival was significantly higher in operable than in inoperable cases, even when restricted to advanced (T3/T4) cancers. The tumor extension to the middle ear cavity was observed in 13/17 of T3 cases, but it was not associated with poor survival. In addition, among operable cases, negative surgical margins were associated with significantly higher survival than positive margins.

CONCLUSIONS

Definitive treatments can offer disease-specific 5-year survival of over 85% in T1 to T3 cases of TB-SCC. The tumor extension to the middle ear cavity is not associated with poor survival. T4 status, inoperability, nodal invasion, and positive surgical margin are identified as a predictor of poor prognosis. Still, the matter of how to deal with unresectable tumors remains an outstanding issue in the treatment of TB-SCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E583-E589, 2021.

High Human Papillomavirus DNA loads in Inflammatory Middle Ear Diseases

Background. Previous studies reported human papillomaviruses (HPVs) in middle ear tumors, whereas these viruses have been poorly investigated in chronic inflammatory middle ear diseases. We investigated HPVs in non-tumor middle ear diseases, including chronic otitis media (COM). Methods. COM specimens (n = 52), including chronic suppurative otitis media (CSOM) (n =38) and cholesteatoma (COMC) (n = 14), as well as normal middle ear (NME) specimens (n = 56) were analyzed. HPV sequences and DNA loads were analyzed by quantitative-PCR. HPV genotyping was performed by direct sequencing. Results. HPV DNA was detected in 23% (12/52) of COM and in 30.4% (17/56) of NME (p > 0.05). Specifically, HPV DNA sequences were found in 26.3% (10/38) of CSOM and in 14.3% (2/14) of COMC (p > 0.05). Interestingly, the HPV DNA load was higher in COMC (mean 7.47 copy/cell) than in CSOM (mean 1.02 copy/cell) and NME (mean 1.18 copy/cell) (P = 0.03 and P = 0.017 versus CSOM and NME, respectively). HPV16 and HPV18 were the main genotypes detected in COMC, CSOM and NME. Conclusions. These data suggest that HPV may infect the middle ear mucosa, whereas HPV-positive COMCs are associated with higher viral DNA loads as compared to NME.

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.

Melanoma of the External Auditory Canal: A Review of Seven Cases at a Tertiary Care Referral Center

OBJECTIVES/HYPOTHESIS

Examine the presentation and management characteristics of seven patients with melanoma of the external auditory canal (EAC).

STUDY DESIGN

Retrospective case series and review of the relevant literature.

METHODS

Records of seven patients from 2003 to 2017 with melanoma of the EAC were reviewed for characteristics of presentation, subsequent management, and outcomes. A thorough review of relevant literature is presented.

RESULTS

The median age is 52 years, with four females. The average Breslow depth was 3.6 mm, with five patients having a Clark level IV or greater on presentation. Six patients underwent lateral temporal bone resection, and one patient underwent wide local excision of the cartilaginous canal. Sentinel lymph node biopsy (SLNB) was performed in three patients. Three patients experienced distant recurrence an average of 20 months following primary therapy. Median follow-up was 21 months. At last follow-up, four were free of disease, one had active disease, and two were deceased from melanoma.

CONCLUSIONS

This is the largest series and the first to report the use of SLNB for patients with EAC melanoma in the peer-reviewed literature. Patients with external auditory canal melanoma present with higher Breslow thickness and stage relative to all external ear melanomas. Management should include wide local excision, which entails lateral temporal bone resection when the bony ear canal is involved. SLNB has a critical role in identifying patients with early metastatic disease. Postoperative radiation therapy should be considered for patients with high-risk features to reduce the risk of locoregional relapse. Chemotherapy, and especially immunotherapy, has an emerging role for this disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:165-172, 2021.

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.

Clear cell variant squamous cell carcinoma of temporal bone: Case report and literature review

•

Squamous cell carcinomas of the temporal bone are rare malignancies.

•

This is a case of clear cell squamous cell carcinoma.

•

Otalgia, otorrhea, and hearing loss are the usual presenting symptoms.

•

This case of temporal bone SCC was aggressive in nature and presentation.

Introduction

Squamous cell carcinoma (SCC) of the temporal bone is a rare malignancy. Clear cell SCC is a rare variant of SCC of temporal bone in which no clear risk factor has been suggested as possible etiology. Otalgia, otorrhea, and hearing loss are the usual presenting symptoms of SCC of the temporal bone.

Presentation of case

This is a case is of a 62-year-old female who presented with a 6 months’ history of experiencing intermittent left hearing disturbance, loss of balance, persistent left tinnitus, left otalgia radiating to the lateral neck and post auricular swelling. Histology showed clear cell variant, well differentiated SCC. The patient’s tumor was found to be non-resectable due to the extensive invasion. The patient was referred for palliative therapy by medical and radiation oncology, however, the patient couldn't tolerate it. One month later she passed away.

Discussion

SCC of the temporal bone is a challenging clinical entity. It is diagnosed mainly by clinical and radiological assessment, and deep biopsies are used to confirm the diagnosis. Temporal bone SCC is usually diagnosed late due to delayed presentation. This case of temporal bone SCC was aggressive in nature and presentation. The presentation was different from the known triad of symptoms of temporal bone SCC which is offensive otorrhea, pain, and bleeding.

Conclusion

This case showed a very destructive and bizarre clinical presentation but more report of cases is needed to have a better characterization of the clinical presentation and prognosis of this variant of SCC of temporal bone.

Evidence Based Tailored Parotidectomy in Treating External Auditory Canal Carcinoma

Carcinoma of the external auditory canal (EAC) is a rare tumor and little information is available regarding parotid gland in surgically treating EAC carcinomas. This study aimed to investigate the mode of parotid involvement in EAC carcinoma through staging and histopathological analysis, and to establish surgical guidelines for the parotid gland management when there is no clinical evidence of parotid involvement. Sixty-five patients with EAC carcinoma who underwent temporal bone resection and any type of parotidectomy simultaneously were retrospectively reviewed. The rate of direct parotid invasion and parotid nodal involvement was analyzed according to the stage and histopathological findings. Among the 65 patients, 39 were confirmed to have squamous cell carcinoma (SCC) and 26 were confirmed to have adenoid cystic carcinoma (ACC). Direct parotid invasion occurred in 7 of 39 patients with SCC, only in the advanced stages, and in 15 of 26 patients with ACC, regardless of stage. Metastasis to the parotid node was noted in 6 patients with advanced-stage SCC, whereas no patient with ACC showed parotid nodal metastasis. For adequate tumor control with low risk of surgical complications, evidence based tailored parotidectomy should be applied. With no evidence of parotid involvement, an elective parotidectomy can be excluded in early SCC, whereas a total parotidectomy is recommended for advanced SCC. In ACC, basal resection of the parotid gland rather than a superficial or total parotidectomy should be performed at all disease stages.

Treatment and Outcomes of Carcinoma of the External and Middle Ear: The Validity of En Bloc Resection for Advanced Tumor

Carcinoma of the external and middle ear is a very rare disease. Despite the various treatment modalities available, its prognosis is still poor. We aimed to analyze the treatment modalities, outcomes, and validity of surgical approaches, especially in advanced tumors in the ear. Twenty-five patients with carcinoma of the external and middle ear were retrospectively analyzed. The modified Pittsburgh staging system was used for staging of the patients. Overall and disease-free survival was estimated using of Kaplan-Meier method. In our cohort of 25 patients, the majority (76%) had tumor located in external auditory meatus. The most common histologic subtype was squamous cell carcinoma (80%). More than half of patients (56%) had tumor stage IV. In the stage IV group, five patients underwent subtotal temporal bone resection and ipsilateral neck dissection. Seven patients underwent definitive radiotherapy. The remaining two patients underwent palliative chemotherapy. The 2-year overall and disease-free survival for patients with tumor stage IV was 67.7% and 57.8%, respectively. In patients with tumor stage IV, the 2-year overall survival for patients who underwent surgery was 80.0% versus 53.6% for those who underwent radiotherapy (P = 0.16). The 2-year disease-free survival for patients who underwent surgery was 80.0% versus 28.6% for those who underwent radiotherapy (P = 0.15). In the present study, the outcome of patients who received surgical treatment tended to be better than that of patients who received radiation therapy. Our results suggest that en bloc resection could be the first choice even in the advanced disease stage.

Basal cell carcinoma of the temporal bone and external auditory canal

OBJECTIVES/HYPOTHESIS

To review the presenting features, treatment, and outcomes for patients with basal cell carcinoma (BCC) involving the temporal bone or external auditory canal (EAC).

STUDY DESIGN

Retrospective case series.

METHODS

Presenting characteristics, treatment strategies, and outcomes for patients with BCC involving the temporal bone or EAC were reviewed. Main outcome measures included rates of overall and disease-free survival at 5 years.

RESULTS

Forty-two patients met the inclusion criteria (mean age, 67 years). The most common presenting symptoms were hearing loss (15 patients, 36%) and otorrhea (11 patients, 26%). The 5-year overall survival rate was 78%, and the 5-year disease-free survival rate was 77%. Patients who had undergone surgery elsewhere and presented with facial weakness had significantly worse overall survival (P = .004). Ten patients (24%) underwent sacrifice of at least a portion of the facial nerve at the time of their initial procedure at our institution. Two patients (5%) developed regional nodal disease. There was a trend toward better disease-free survival for patients who received adjuvant radiation therapy after surgery at our institution (P = .06).

CONCLUSIONS

BCC originating from or extending to the temporal bone can exhibit a wide range of behavior, ranging from superficial lesions readily managed with surgery to extensive locally invasive tumors with propensity for recurrence, treated with multimodality therapy. BCC may be associated with better prognosis than other temporal bone malignancies.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1425-1430, 2018.

Osteoradionecrosis of the Temporal Bone Leading to Cerebellar Abscess

Squamous cell carcinoma of the temporal bone is a rare and destructive malignancy and represents both diagnostic and therapeutic challenge. The complex regional anatomy of the temporal bone requires equally intricate surgical techniques to adequately resect the tumour mass during surgical excision. Adjuvant radiotherapy is offered to patients with advanced disease and has been showed to confer a survival benefit in carefully selected patients. One feared complication of radiotherapy is osteoradionecrosis and is a major obstacle faced in the treatment of head and neck cancers. The case presented here is a rare example of a patient who was successfully treated for SCC of the temporal with both surgical resection and adjuvant radiotherapy who subsequently developed two major complications: first, osteoradionecrosis of the temporal bone that leads to penetrating osteomyelitis; second, the formation of a large cerebellar abscess that required surgical drainage. This case is a rare example of the complications that are possible following radiotherapy to the head and the close follow-up that is required in patients.

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.

Primary definitive radiotherapy with or without chemotherapy for squamous cell carcinoma of the temporal bone

We aimed to evaluate the impact of concurrent chemoradiotherapy (CCRT) on the survival of patients with squamous cell carcinoma of the temporal bone. We retrospectively analyzed the data of 13 consecutive patients who were treated by definitive radiation therapy (RT) or CCRT as the initial treatment between 1999 and 2012. There were 5 patients with stage II disease, 5 with stage III, and 3 with stage IV, as classified according to the University of Pittsburgh system. Among these, 2, 4, and 3 patients, respectively, were treated by CCRT; whereas the remaining (3 patients with stage II and 1 with stage III) were treated by RT alone. Median follow-up duration was 39 months (12-106 months) in all cases, and 61.5 months (17-70 months) in censored cases. The 5-year overall survival (OS) rates were 51 % in all patients, and 40, 100, and 0 % in patients with stage II, stage III, and stage IV disease, respectively. In patients with stage II and III disease, the 5-year OS rates were 80 % in the CCRT group and 50 % in the RT-alone group. We found better prognosis in patients with stage II and III disease who were treated by CCRT. Only 2 patients treated by CCRT experienced adverse events more than grade 3, which were neutropenia and dermatitis. There was no late adverse event of bony necrosis. Our study results indicate that CCRT is safe and very effective as a first-line treatment for stage II and III squamous cell carcinoma of the temporal bone.

Reconstruction of Lateral Skull Base Defects with Radial Forearm Free Flaps: The Double-Layer Technique

Introduction The radial forearm flap has fallen out of favor in lateral skull base reconstruction in recent literature. However, especially when used in a double layer, a radial forearm may be able to provide the thickness of a large flap while taking advantage of the pliability for which the flap is renowned. Objective To report the results of the double-layer technique of radial forearm free flap reconstruction of lateral temporal bone defects. Design A retrospective chart review. Setting A tertiary care institution. Participants All consecutive patients who underwent lateral temporal bone resections and were reconstructed with free flaps from 2006 to 2012. Major Outcome Measures Flap success rate, complications, and rate of revision surgery. Results A total of 17 patients were identified with free flap reconstruction of the lateral skull base. Seven received reconstruction with a double-layer radial forearm flap. Reconstruction-related complications in this group included one case of facial cellulitis. The flap success rate was 100%. These results were comparable with patients who had other flaps. Conclusions The radial forearm free flap may be an effective reconstruction option for lateral temporal bone defects especially when used in the double-layer technique.

Lateral temporal bone resection in advanced cutaneous squamous cell carcinoma: report of 35 patients

Objective To evaluate lateral temporal bone resection (LTBR) in the management of advanced cutaneous squamous cell carcinoma (SCC) with temporal bone invasion and patterns of failure. Methods This is a retrospective study of 35 patients undergoing lateral temporal bone resection for advanced cutaneous SCC at a tertiary care center between 1995 and 2006. Results The Pittsburgh tumor stage was T4 in 18 patients (51%), T3 in 5 (14%), T2 in 9 (26%), and T1 in 3 (9%). Clear margins were reported in 22 (63%) patients. Resection of the mandible and/or temporomandibular joint (TMJ) was required in 11 (31%) patients. Facial nerve involvement was seen in 10 (29%) patients. Survival outcomes at 2 and 5 years for overall survival were 72% and 49%; disease-free survival, 68% and 59%; and disease-specific survival, 79% and 62%, respectively. Pittsburgh T stage correlated significantly with disease-specific survival (p = 0.015) and margin status was significant for both disease-free survival (p = 0.0015) and disease-specific survival (p < 0.001). Conclusions Surgery with curative intent is justified for cutaneous SCC invading the temporal bone with extended LTBR. Margin status was a significant predictor of outcome. Surgeons should plan preoperatively to achieve clear margins by extending the LTBR with possible nerve resection.

Predictors of survival and recurrence after temporal bone resection for cancer

BACKGROUND

The purpose of this study was to identify factors predictive of outcome in patients undergoing temporal bone resection (TBR) for head and neck cancer.

METHODS

This was a retrospective study of 72 patients undergoing TBR. Factors associated with survival and recurrence were identified on multivariable regression.

RESULTS

Most tumors were epithelial (81%), commonly (69%) involving critical structures. Cervical metastases were uncommon (6%). Squamous cell carcinoma (SCC) of the external auditory canal carried a high rate of parotid invasion (25%) and parotid nodal metastases (43%). The 5-year rate of overall survival (OS) was 62%; disease-specific survival (DSS), 70%; recurrence-free survival (RFS), 46%. Factors independently associated with outcome on multivariable analysis were margin status and extratemporal spread of disease to the parotid, mandible, or regional nodes. Recurrence was common (72%) in cT3-4 tumors.

CONCLUSIONS

Margin status and extratemporal disease spread are the strongest independent predictors of survival and recurrence. In SCC of the external auditory canal, high rates of parotid involvement support adjunctive parotidectomy. Risk of recurrence in T3-T4 tumors may support a role for adjuvant therapy.