Tumours of the external ear and temporal bone

A case report of otoendoscopic radiofrequency resection of squamous cell carcinoma of the external auditory canal

Squamous cell carcinoma is the most common pathological type of external and middle ear malignancy. Squamous cell carcinoma of the external auditory canal and middle ear is closely associated with long-term chronic inflammatory irritation. The patient was admitted with a major complaint of a "stuffy feeling in the left ear for more than three months." The results of the otoendoscopic examination were as follows: The left external auditory canal was filled with a granuloma-shaped mass with an unsmooth surface that showed obvious oozing of blood. The tympanic membrane was not visible. After the completion of the relevant examinations, radiofrequency resection of the external auditory canal mass was performed under otoendoscopy and the wound healed well with postoperative dressing changes. Pathological results revealed a well-differentiated keratinizing cutaneous squamous cell carcinoma and there was no recurrence throughout the next 5 years after the operation. Proper preoperative evaluation and the correct selection of surgical approaches can be of great importance. The primary complication of ear squamous cell carcinoma was local recurrence with a low incidence of metastasis. Early and complete resection was determined to be the optimal course of treatment.

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.

Malignant tumors of the external auditory canal: diagnosis, treatment, genetic landscape, biomarkers, and clinical outcome

Malignant tumors of the external auditory canal (EAC) are rare neoplasms that appear in the head and neck area. A common feature of these malignancies is their rarity, as well as their delayed diagnosis due to the appearance of non-specific symptoms that mimic various benign otologic conditions. The reported histological types of cancer of the external ear are: squamous cell carcinoma, basal cell carcinoma, malignant melanoma, Merkel cell carcinoma, angiosarcoma, adnexal carcinoma (including ceruminous adenocarcinoma and adenoid cystic carcinoma), and lymphoma (Lancet Oncol. 2005;6:411-20. doi: 10.1016/S1470-2045(05)70208-4). Several therapeutic interventions have been proposed, primarily orientated towards the cure of the patient, placing the surgical excision of the lesions at the tip of the spear. Subsequently and depending on the clinical stage and the pathological characteristics of the tumor, radiation, chemotherapy, a combination thereof, or some form of palliative treatment for particularly advanced cases, may be recommended. The aim of all the above-mentioned approaches is the complete resection of the mass with negative surgical margins along with lymph node dissection, the elimination of any residual disease or metastasis, and the improvement of survival. The anatomical complexity of the region will always remain a demanding challenge. Nevertheless, advances in the fields of ear microsurgery, imaging, radiation, molecular biology, and genomics have led to remarkable outcomes compared to the past, with a view to the patient's quality of life. Large, well-organized, and prospective studies with the participation of multiple centers in contrast to existing retrospective studies with a limited number of patients will help to establish universally accepted guidelines. The exploration of the molecular and genetic background of these cancers in conjunction with the search for new biomarkers and target molecules seems promising for providing upgraded and more personalized treatment modalities for the future.

99mTechnetium-Ubiquicidin Scan with Single-Photon Emission Computed Tomography/Computed Tomography in Skull Base Osteomyelitis

Malignant otitis externa (MOE) with skull base osteomyelitis (SBO) is an aggressive infection that predominantly affects elderly, diabetic, or immunocompromised patients, and is associated with high disease-specific mortality. Pseudomonas aeruginosa is the most isolated microorganism. External otitis associated with granulation tissue and pain is the most common presenting feature; a biopsy is obtained to rule out malignancy. A proper consensus is lacking regarding the best imaging modality for early initial diagnosis and follow-up. 99mTechnetium (99mTc)-labeled ubiquicidin (UBI) 29-41 is a bacterial attaching peptide that does not bind to activated leukocytes. We report a case of SBO initially misdiagnosed as a chronic otitis media, but later proved to be a case of MOE. 99mTc methylene diphosphonate bone scan and 99mTc-UBI 29-41 scan with single-photon emission computed tomography/computed tomography scans were performed to corroborate the clinical diagnosis. SBO remains a great challenge due to its increasing prevalence and high morbidity are difficult to diagnose and are often confused with cholesteatoma and neoplastic process. The UBI scan could be an auxiliary noninvasive diagnostic alternative in early diagnosis.

Syringocystadenocarcinoma Papilliferum of External Auditory Canal: First Case Report in English Literature

Malignant tumors of external auditory canal (EAC) constitute less than 0.2% of all head and neck cancers. The incidence of carcinoma of the EAC is estimated to be between one in six per million populations. Majority of cancers of EAC are squamous cell carcinomas and basal cell carcinomas. Some rare and unusual tumors do occur within the ear canal including malignant melanoma, merkel cell carcinoma, angiosarcoma, lymphoma and adnexal carcinomas like ceruminous adenocaricinoma and adenoid cystic carcinoma. Ceruminous glands tumors constitute about 5% of all external auditory canal tumors. Carcinoma of the external auditory canal is a difficult diagnosis unless the tumors presents as a fungating mass protruding from the external auditory canal. Syringocystadenocarcinoma Papilliferum (SCACP) is an extremely rare cutaneous adnexal neoplasm. Syringocystadenoma papilliferum (SCAP) is thought to be precursor of SCACP. About 50 cases of SCACP have been reported in literature all over the body. The diagnosis is difficult and excisional biopsy becomes mandatory for diagnosis and treatment. We present a case of SCACP in the external auditory canal in a middle-aged female. To the best of our knowledge and belief, this is the first case of SCACP in the external auditory canal in the English literature. This prompted us to report this case.

Classification of Ear Imagery Database using Bayesian Optimization based on CNN-LSTM Architecture

The external and middle ear conditions are diagnosed using a digital otoscope. The clinical diagnosis of ear conditions is suffered from restricted accuracy due to the increased dependency on otolaryngologist expertise, patient complaint, blurring of the otoscopic images, and complexity of lesions definition. There is a high requirement for improved diagnosis algorithms based on otoscopic image processing. This paper presented an ear diagnosis approach based on a convolutional neural network (CNN) as feature extraction and long short-term memory (LSTM) as a classifier algorithm. However, the suggested LSTM model accuracy may be decreased by the omission of a hyperparameter tuning process. Therefore, Bayesian optimization is used for selecting the hyperparameters to improve the results of the LSTM network to obtain a good classification. This study is based on an ear imagery database that consists of four categories: normal, myringosclerosis, earwax plug, and chronic otitis media (COM). This study used 880 otoscopic images divided into 792 training images and 88 testing images to evaluate the approach performance. In this paper, the evaluation metrics of ear condition classification are based on a percentage of accuracy, sensitivity, specificity, and positive predictive value (PPV). The findings yielded a classification accuracy of 100%, a sensitivity of 100%, a specificity of 100%, and a PPV of 100% for the testing database. Finally, the proposed approach shows how to find the best hyperparameters concerning the Bayesian optimization for reliable diagnosis of ear conditions under the consideration of LSTM architecture. This approach demonstrates that CNN-LSTM has higher performance and lower training time than CNN, which has not been used in previous studies for classifying ear diseases. Consequently, the usefulness and reliability of the proposed approach will create an automatic tool for improving the classification and prediction of various ear pathologies.

Ear canal and middle-ear tumors: a single-institution series of 87 patients

BACKGROUND

Ear canal and middle ear tumors are rare and exhibit variability in histology and clinical manifestation. Surgical resection remains the treatment of choice, but individualized approach is needed to preserve function when possible.

AIMS/OBJECTIVES

To review the management and outcome of ear canal and middle ear tumors at an academic referral center.

MATERIALS AND METHODS

Helsinki University Hospital (HUS) patient files were searched for clinically and histologically confirmed ear canal and middle ear tumors over a 14-year period. The minimum follow-up time was 2 years.

RESULTS

Eighty-seven patients with 88 tumors were identified. There were 20 (23%) benign external auditory canal (EAC), 36 (41%) benign middle ear space (MES), 29 (33%) malignant EAC, and 3 (3%) malignant MES tumors. Most (92%) tumors were managed with primary resection. Thirty-five percent of the operatively managed patients had a residual or a recurrent tumor.

CONCLUSIONS AND SIGNIFICANCE

EAC and MES tumors show great diagnostic and histologic heterogeneity with need for individualized investigative and treatment approaches. In benign tumors, we advocate aggressive local surgical control without sacrificing vital structures. In malignant tumors, we recommend local surgical control with or without adjunct RT.

A Rare Presentation of Primary Cutaneous Low-Grade Neuroendocrine Tumor of the External Auditory Canal

OBJECTIVE

To describe the first case of a primary cutaneous low-grade neuroendocrine tumor (cLGNET) originating from the external auditory canal as well as our team's surgical management.

PATIENT

A healthy 34-year-old female presented with a low-grade neuroendocrine tumor of her right external auditory canal (EAC) which extended from the posterior-superior aspect of the EAC into the middle ear.

INTERVENTION

A complete otological examination was performed in addition to CT and MRI imaging. The low-grade neuroendocrine tumor was surgically biopsied and further surgery was recommended for complete resection.

RESULTS

Audiogram revealed profound right sensorineural hearing loss. CT scan demonstrated complete opacification of the right EAC, middle ear, and mastoid air cells, dystrophic calcification in the mesotympanum overlying the cochlear promontory, and no associated osseous erosion. MRI revealed abnormal FLAIR hyperintensity and enhancement of the labyrinthine segment of the right facial nerve, cochlea, and horizontal and posterior semicircular canals. An enhancing mass opacifying the right EAC demonstrating restricted diffusion on diffusion-weighted image was also evident. Pathologic examination and immunohistochemical staining confirmed a diagnosis of primary cLGNET of the EAC.

CONCLUSION

Primary cLGNETs of the external ear are exceedingly rare but should be considered if an adult patient presents with a mass in the EAC. Management should include early biopsy and surgical excision followed by histological and immunohistochemical confirmation.

Evaluating the prognostic contributions of TNM classifications and building novel staging schemes for middle ear squamous cell carcinoma

Background

A universally acknowledged cancer staging system considering all aspects of the T‐, N‐, and M‐classifications for middle ear squamous cell carcinoma (MESCC) remains absent, limiting the clinical management of MESCC patients.

Materials and Methods

A total of 214 MESCC patients were extracted from the SEER (the Surveillance, Epidemiology, and End Results) database between 1973 and 2016. The relationships between patient’s characteristics and prognoses were analyzed by Kaplan–Meier and Cox proportional hazards regression models. Novel staging schemes for MESCC were designed by adjusted hazard ratio (AHR) modeling method according to the combinations of Stell’s T‐classification and the eighth AJCC N‐ and M‐classifications, of which performances were evaluated based on five criteria: hazard consistency, hazard discrimination, explained variation, likelihood difference, and balance.

Results

T‐classification was the most significant prognostic factor for MESCC patients in multivariable analysis (p = 0.021). The N‐ and M‐classifications also had obvious prognostic effect but were not statistically significant by multivariate analysis due to the limited metastasis events. Three novel staging schemes (AHR‐Ⅰ–Ⅲ models, different combination of T‐ and N‐classifications) and ST (solely derived from Stell’s T‐classification) were developed, among which the AHR‐Ⅰ staging scheme performed best.

Conclusions

Tumor extension, quantified by Stell’s T‐classification, is the most significant prognostic factor for MESCC patients. However, our AHR‐Ⅰ staging scheme, a comprehensive staging scheme that integrating T‐, N‐, and M‐classifications, might be an optimal option for clinical practitioners to predict MESCC patients’ prognosis and make proper clinical decisions.

A systematic review of the primary squamous cell carcinoma of the external auditory canal: survival outcome based on T-staging and proposal of a new classification

OBJECTIVE

This study aimed to provide a systematic review on survival outcome based on Pittsburgh T-staging for patients with primary external auditory canal squamous cell carcinoma.

METHOD

This study was a systematic review in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines performed until January 2018; pertinent studies were screened. Quality of evidence was assessed using the grading of recommendation, assessment, development and evaluation working group system.

RESULTS

Eight articles were chosen that reported on 437 patients with external auditory carcinoma. The 5-year overall survival rate was 53.0 per cent. The pooled proportion of survivors at 5 years for T1 tumours was 88.4 per cent and for T2 tumours was 88.6 per cent. For the combined population of T1 and T2 cancer patients, it was 84.5 per cent. For T3 and T4 tumours, it was 53.3 per cent and 26.8 per cent, respectively, whereas for T3 and T4 tumours combined, it was 40.4 per cent. Individual analysis of 61 patients with presence of cervical nodes showed a poor survival rate.

CONCLUSION

From this review, there was not any significant difference found in the survival outcome between T1 and T2 tumours. A practical classification incorporating nodal status that accurately stratifies patients was proposed.

A retrospective analysis of radiotherapy in the treatment of external auditory canal carcinoma

External auditory canal carcinoma (EACC) is a rare disease. The current study aimed to evaluate the clinical outcomes of patients treated with external beam radiotherapy (EBRT) for EACC. The present study retrospectively reviewed 34 consecutive patients treated for EACC with EBRT between February 2001 and January 2019 at the University of Tokyo Hospital. Clinical staging was performed according to the modified Pittsburgh classification. Of all the included patients, seven patients were in the early stages (I or II) and 27 in the advanced stages (III or IV) of EACC. A total of 16 patients underwent EBRT and surgery (S+RT) pre- and/or postoperatively, while 18 patients underwent definitive radiotherapy (dRT). The median prescribed doses for the S+RT and dRT groups were 66 and 70 Gy, respectively. The median follow-up period for all patients was 22.4 months (range, 2-205 months). The 5-year overall survival rates of the S+RT and dRT groups were 66.7 and 45.1%, respectively. The progression-free survival rate at 5-year was 55.6% (95% confidence interval: 36.5-71.1%) for the entire cohort. A total of 14 patients experienced disease relapse after treatment, consisting of 11 locoregional recurrences and three distant metastases. The current study revealed the clinical outcomes of EBRT for EACC.

External Ear Diseases: A Comprehensive Review of the Pathologies With Neuroradiological Considerations

The peripheral auditory system is subdivided into 3 compartments: the external, middle, and inner ear. Historically, the middle and inner ear have garnered more attention in the imaging literature, due to their intricate anatomy and complexity of pathologies. The external ear, however, has attained less recognition given its relatively straightforward anatomy and convenience of direct visual examination. The continued advancement in computed tomography and magnetic resonance imaging has expanded the role of radiology in the evaluation of the external ear lesions. The purpose of this article is to offer a comprehensive review of external ear pathologies, including congenital, inflammatory, infectious, traumatic, neoplastic, and rare disease entities and their imaging findings.

A Window Into the Whole Story: Temporal Bone Plasmacytoma Presenting With a Mobile Third Window

A 63-year-old man presented with imbalance when coughing due to a respiratory tract infection. He had a history of multiple myeloma with a plasmacytoma of the left temporal bone. Examination revealed a positive leftward head impulse test, no spontaneous nystagmus, left-beating positional nystagmus, and left-beating Valsalva-induced nystagmus. Videonystagmography, audiology, and comprehensive vestibular function tests revealed a subtotal left peripheral audio-vestibular loss. Temporal bone computed tomography showed an unchanged bony erosion of the left labyrinth from 2 years prior. Vertigo subsided after treatment of the respiratory tract infection. Although no tumor progression was evident, coughing had triggered a preexisting third mobile window to declare itself. Laryngoscope, 131:E966-E969, 2021.

Respiratory Epithelial Adenomatoid Hamartoma: A Very Rare Entity Originating from the External Auditory Canal

Respiratory epithelial adenomatoid hamartoma (REAH) is an uncommon lesion of the upper aerodigestive tract. It is characterized by abnormal glandular formations with ciliated epithelium arising from the nasal cavity, paranasal sinuses and nasopharynx, but other locations have also been described. We did not find any other cases of this hamartomas in the external auditory canal in the literature. A 40-year-old man was referred to the otorhinolaryngology department due to otorrhea and decreased hearing from 1 year ago. Otoscopic examination showed a reddish hemorrhagic mass in the left external auditory canal. Intraoperatively, the tumor was completely resected. The pathologic findings were consistent with REAH.

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.

Epidermal Carcinoma of the Conchal Bowl: Creation of a Multidisciplinary Pathway Approach

BACKGROUND

Malignant neoplasms of the auricle make up 6% of all skin cancers. Management of cutaneous neoplasms of the conchal bowl presents a unique challenge in visualizing and defining margins that may extend into the external auditory canal (EAC).

OBJECTIVES

The objective of this study was to create a multidisciplinary pathway for cutaneous carcinoma of the conchal bowl extending into the EAC.

METHODS

We present a series of patients that were referred to dermatology or otolaryngology, with cutaneous neoplasms arising in the conchal bowl. A consensus approach from otolaryngology and dermatology, for evaluation and treatment, was created based on evaluation of these cases, and review of the otolaryngology and dermatology literature, in collaboration between the two specialties.

RESULTS

Initial evaluation should be done by both dermatology and otolaryngology, with otomicroscopic evaluation of the canal. Imaging is recommended for lesions that approach the EAC, for bony and soft tissue spread. Excision of the tumor with Mohs micrographic surgery to achieve clearance in the conchal bowl should be performed initially. If extension into the external auditory meatus is present, otolaryngology would proceed with en bloc resection. Repair is dictated by the defect, with both specialties involved in follow-up.

CONCLUSIONS

In collaboration between dermatology and otolaryngology, and following review of the literature, a pathway was created to manage skin cancer of the conchal bowl. This resulted in a stepwise approach for evaluation and management, ensuring that patients have a streamlined pathway for the treatment of these lesions.

Case Report: Case report: A rare case of middle-ear Rhabdomyosarcoma in a 4-year-old boy

We present a rare case of a four-year-old boy with a botyroid embryonal rhabdomyosarcoma of the right middle ear. Rhabdomyosarcoma is a soft tissue malignancy which is thought to originate from embryonic mesenchymal cells of striated skeletal muscle.  It is a disease primarily of children and is exceptionally rare in parameningeal regions.  The diagnosis is often delayed and easily misdiagnosed as aural polyp. Therefore, advanced disease is common at the time of diagnosis.  A four-year-old boy presented with a four-month history of recurrent left ear blood and pus discharge, otalgia and fevers. He attended his GP three times and paediatric A&E 13 times where he received antibiotics for presumed otitis media and externa. He was eventually referred to the otolaryngology department and underwent an examination under anaesthesia of ear and excisional biopsy of a suspicious aural polyp.  Staging chest CT and PET scan showed no loco-regional spread or distal metastasis. Magnetic resonance imaging demonstrated absence of invasion into adjacent organs.  Histology confirmed embryonal rhabdomyosarcoma, botryoid subtype.  Subsequent to the initial excision of the polyp, he was started on an ifosfamine, vincristine and actinomycin (IVA) chemotherapy regime in three weekly cycles for nine cycles with concomitant radiotherapy. Two weeks subsequent to his first chemotherapy dose he presented with a House-Brackmann II-III facial nerve palsy but no other middle ear complications. He was started on intravenous antibiotics and dexamethasone. The facial nerve palsy incompletely resolved with treatment.

Additive value of 99mTechnetium methylene diphosphonate hybrid single-photon emission computed tomography/computed tomography in the diagnosis of skull base osteomyelitis in otitis externa patients compared to planar bone scintigraphy

The aim of this study was to evaluate the additive value of ^99mtechnetium methylene diphosphonate (^99mTc-MDP) hybrid single-photon emission computed tomography/computed tomography (SPECT-CT) in the diagnosis of skull base osteomyelitis (SBO) compared to planar bone scintigraphy (PBS). This was a single institution; prospective study included 23 patients with otitis externa, clinically suspected of SBO, all of them were diabetic. Three-phase bone scintigraphy and SPECT/CT were performed to all patients. The imaging modalities which had the most equivocal results were PBS (9/23) followed by SPECT (3/23). No equivocal results were detected with CT or SPECT-CT. SPECT-CT had the highest sensitivity (100%) and highest accuracy (95.7%) in diagnosis of SBO, whereas, PBS showed the lowest sensitivity (50%) and lowest accuracy (52.2%). In this study, SPECT-CT considered the best modality for accurate localization of the site of SBO involvement, followed by CT. SPECT and planar BS were less accurate in this consideration. When comparing the sensitivity of planar BS, CT, SPECT and SPECT/CT, statistical significance difference was detected between planar BS and SPECT (P = 0.057), planar BS and SPECT/CT (P = 0.001), and between CT and SPECT/CT (P = 0.031). No statistically significant difference was detected between SPECT and SPECT/CT (P = 0.250), CT and planar BS (P = 0.125), and between CT and SPECT (P = 0.508) In conclusion, ⁹⁹Tc-MDP SPECT/CT has high sensitivity in the diagnosis of SBO and also provide accurate localization of the site of SBO.

The Clinical Characteristics and Surgical Outcomes of Carcinoma of the External Auditory Canal: A Multicenter Study

OBJECTIVE

To analyze the clinical characteristics and evaluate the surgical outcomes of carcinoma of the external auditory canal (CEAC).

MATERIALS AND METHODS

Overall, 31 patients from four multicenter hospitals, who were diagnosed and surgically treated for CEAC in 2009-2014, were enrolled for this retrospective study. Medical records were reviewed to determine cancer stage according to the Pittsburgh classification. Clinical data of age, sex, site, initial symptoms, surgery extent, postoperative complications including recurrence, follow-up period, and current patient status were collected for analysis. Five-year cumulative survival rate was obtained using Kaplan-Meier method.

RESULTS

At initial diagnosis, 22 patients were in the early stages (stage I: 15; stage II: 7) and 9 patients were in the advanced stages (stage III: 1; stage IV: 8). Lymph node metastasis was present in 5 patients and distant metastasis in 2. Of the 31 patients, 4 patients died (stage II: 1, stage IV: 3) during the follow-up period. Early-stage patients showed 100% 5-year estimated cumulative survival rate, whereas the advanced-stage patients showed 5-year estimated survival rate of 53.6% (p=.006). The overall survival rate of all enrolled patients was 90.3%. Although 5-year estimated disease-free survival rate of stage I was 100.0%, that for stage II was low at 30.0% because of considerable recurrences.

CONCLUSION

The results of this multicenter study suggest that more aggressive treatment modality, including adjuvant therapy, is necessary for patients with CEAC with Pittsburgh stage II or more.

Current Treatment of Endolymphatic Sac Tumor of the Temporal Bone

An endolymphatic sac tumor (ELST) is a rare, indolent but locally aggressive tumor arising in the posterior petrous ridge. Patients present with sensorineural hearing loss and tinnitus. As the tumor progresses, patients may experience vertigo, ataxia, facial nerve paresis, pain and otorrhea. Most patients present in their 4th or 5th decade with a wide age range. Patients with von Hippel-Lindau disease have an increased likelihood of developing ELST. Histologically, ELST is a low-grade adenocarcinoma. As it progresses, it destroys bone and extends into adjacent tissues. The likelihood of regional or distant metastases is remote. The optimal treatment is resection with negative margins. Patients with positive margins, gross residual disease, or unresectable tumor are treated with radiotherapy or radiosurgery. Late recurrences are common, so long follow-up is necessary to assess efficacy. The likelihood of cure depends on tumor extent and is probably in the range of 50-75%.

Outlook and future of inner ear therapy

Drug delivery to the inner ear is an ideal method to treat a wide variety of otologic conditions. A broad range of potential applications is just beginning to be explored. New approaches combine principles of inner ear pharmacokinetics with emerging technologies of drug delivery including novel delivery systems, drug-device combinations, and new categories of drugs. Strategies include cell-specific targeting, manipulation of gene expression, local activation following systemic delivery, and use of stem cells, viral vectors, and gene editing systems. Translation of these therapies to the clinic remains challenging given the potential risks of intracochlear and intralabyrinthine trauma, our limited understanding of the etiologies of particular inner ear disorders, and paucity of accurate diagnostic tools at the cellular level. This review provides an overview of future methods, delivery systems, disease targets, and clinical considerations required for translation to clinical medicine.

Malignant lymphoma with middle ear involvement in a Sprague-Dawley rat

Sprague-Dawley rats are amongst the most widely used animals in biomedical research and malignant lymphoma has long been known to be a frequent neoplasm in these animals. A 9-month-old male control Sprague-Dawley rat from a toxicity study showed gelatinous material in the cranial cavity and dark, thickened cerebral meninges at necropsy. At microscopic evaluation of the temporal bone, neoplastic lymphocytes were seen invading several structures of the middle ear. The neoplastic cells appeared to extend from the marrow of the temporal bone, covered the dorsal part of the tympanic cavity wall, and surrounded and infiltrated the base of the tensor tympani muscle as well as the chorda tympani branch of the facial nerve. The lymphoma was generalized; neoplastic lymphocytes were also noted in numerous other tissues. Literature regarding neoplasms of the middle and inner ear in animals is scarce and, to our knowledge, this is the first report of a lymphoma involving the middle ear of a rat.

Expression profiling of long noncoding RNA identifies lnc-MMP3-1 as a prognostic biomarker in external auditory canal squamous cell carcinoma

Our previous studies suggested external auditory canal squamous cell carcinoma (EACSCC) is a rare malignancy with heterogeneous outcomes. This study aimed to identify lncRNA profile of EACSCC and determine the clinical application. Differential expression genes (DEGs) were investigated in EACSCC by whole transcriptome lncRNA arrays (GPL23178). RT‐PCR was used to quantify the microarray data. Bioinformatics analyses were performed to evaluate DEGs regulations in gene ontology and cellular pathways. Fluorescence in situ hybridization (FISH) was utilized to validate lncRNA expression. The overall survival was determined by Kaplan–Meier and log‐rank analyses. Our microarrays data had been submitted to Gene Expression Omnibus (GSE98912). We identified 5621 DEGs (3185 mRNAs, 2436 lncRNAs) in EACSCC. Lnc‐MMP3‐1 was the top one upregulated lncRNA in EACSCC with fold change of 237.2 (P < 0.001). RT‐PCR results showed similar expression levels as microarrays data. Bioinformatics analyses indicated development of EACSCC was involved in aberrant alternations of multiple biological processes and cellular pathways. FSIH assays also found lnc‐MMP3‐1 was significantly differentially overexpressed in EACSCC (P < 0.001). Tumor lnc‐MMP3‐1 levels were closely associated with differentiation degree (P = 0.016), tumor invasion (P = 0.015) and TNM stage (P = 0.015). Moreover, lnc‐MMP3‐1 expression was a significant prognostic factor in EACSCC (χ² = 4.276, P = 0.039). The study is the first screening and analysis of lncRNAs profile in EACSCC and provides new insights into pathogenesis of this rare disease. Our findings offered convincing evidences that lnc‐MMP3‐1 is a novel survival predictor of EACSCC patients.

Metastasis of Breast Carcinoma to the External Auditory Canal: Report of an Unusual Case and Literature Review

We present a case of metastasis of the external auditory canal (EAC) from a primary breast carcinoma in a 53-year-old female with a review of the literature. The patient had been diagnosed with a primary carcinoma 4 years previously. The metastasis had developed recently in her left EAC and presented as a bulky, fleshy, bleeding mass. The mass was causing hearing loss on the left due to complete obstruction in the left EAC. The mass was incompletely removed with a surgical operation and histopathologically metastasis was proven. Although there are few case reports in the literature of various cancers metastasizing to the EAC, metastasis in the EAC from the breast carcinoma is exceedingly rare and only one case has been reported in the literature so far.

Lesions involving the jugular foramen: clinical characteristics and surgical management

CONCLUSION

Lesions involving the jugular foramen (JF) present as various diagnoses. Pulsatile tinnitus is more common in glomus jugulare (GJ) tumors, whereas otalgia and facial nerve paresis are more prevalent in temporal bone malignancies (TBMs). Preoperative facial nerve electroneurography (ENoG) was significantly correlated with postoperative facial nerve function.

OBJECTIVE

To describe the diagnosis and surgical management of lesions involving the JF.

METHODS

The charts were reviewed for 38 patients who had lesions involving the JF, including 14 patients with TBMs, 11 with GJ tumors, 7 with cholesteatomas, 2 with facial nerve schwannomas, 2 with JF schwannomas, and 2 with cholesterol granulomas. The follow-up data were recorded.

RESULTS

The most frequent symptoms included hearing loss (89.47%), followed by otorrhea (47.37%) and pulsatile tinnitus (39.47%). With respect to TBMs, 57.14% of patients complained of otorrhea and otalgia, and 50.00% presented with facial nerve paresis. Among the 13 patients with facial nerve paresis, 53.85% were diagnosed with TBMs. Regarding GJ tumors, 81.82% had pulsatile tinnitus and hearing loss. Among the 25 patients with normal preoperative facial nerve function, the mean facial nerve ENoG reduction was 29.48 ± 29.15%, and the mean postoperative facial nerve score was 77.48 ± 33.13. The correlation coefficient was -0.973 (p = 0.000).

Microsurgical anatomy of subtotal temporal bone resection en bloc with the parotid gland and temporomandibular joint

BACKGROUND

Subtotal temporal bone resection (STBR) has been used for half a century to remove temporal bone malignancies. However, there are few reports on the detailed anatomy involved in the resection.

OBJECTIVE

To describe the microsurgical anatomy of STBR combined en bloc with the resection of the parotid gland and temporomandibular joint (TMJ).

METHODS

Cadaveric specimens were dissected in a stepwise manner using 3× to 40× magnification.

RESULTS

STBR can be combined with the total parotidectomy and the resection of the TMJ if the tumor extends into the parotid gland, TMJ, or facial nerve. In this study, we describe the step-by-step microsurgical anatomy of STBR en bloc with the parotid gland and TMJ. The surgical technique described combines 3 approaches: the high cervical, subtemporal-infratemporal fossa, and retromastoid-paracondylar approaches. Combining these 3 approaches aided in efficiently completing this modified approach.

CONCLUSION

STBR is a complicated and technically challenging procedure. This study highlights the importance of understanding the surgical anatomy of STBR and will serve as a catalyst for improvement of the surgical technique for temporal bone resection.

Rare embryonal rhabdomyosarcoma of external acoustic canal: a case report and literature review

Embryonal rhabdomyosarcoma of external ear canal is very rare, even in the pediatric population. We report an embryonal rhabdomyosarcoma of external acoustic canal, occurring in a 12-year-old Chinese girl who presented with left ear canal mass. Wide local excision of the mass was done under local anesthesia. Histopathological examination revealed the diagnosis. She then underwent 20 cycles of radiotherapy. CECT scan post treatment showed clearance of tumor cell. Now, patient is disease free for 5 years. We believe that early diagnosis followed by complete resection of the tumor with clear margin and radiotherapy improves the prognosis of the disease.

Skull base osteomyelitis in otitis externa: The utility of triphasic and single photon emission computed tomography/computed tomography bone scintigraphy

Background:

Skull base osteomyelitis (SBO) refers to infection that has spread beyond the external auditory canal to the base of the skull in advanced stages of otitis externa. Clinically, it may be difficult to differentiate SBO from severe otitis externa without bony involvement. This study was performed to determine the role of three phase bone scintigraphy (TPBS) and single photon emission tomography/computed tomography (SPECT/CT) in detecting SBO.

Materials and Methods:

We retrospectively analyzed records of 20 patients (14 M, 6 F) with otitis externa and suspected SBO. TPBS and SPECT/CT of the skull were performed. Findings were correlated with clinical, laboratory and diagnostic CT scan findings.

Results:

All patients were diabetic with elevated erythrocyte sedimentation rate. A total of 18 patients had bilateral and two unilateral symptoms. Cranial nerves were involved in eight patients and microbiological culture of ear discharge fluid positive in seven. Early images showed increased temporal vascularity in nine patients and increased soft-tissue uptake in 10, while delayed images showed increased bone uptake in 19/20 patients. Localized abnormal tracer uptake was shown by SPECT/CT in the mastoid temporal (15), petrous (11), sphenoid (3) and zygomatic (1) and showed destructive changes in five. Thus, TPBS was found positive for SBO in 10/20 patients and changed the management in four.

Conclusion:

Our study suggests that TPBS with SPECT/CT is a useful non-invasive investigation for detection of SBO in otitis externa.

Post-aural ache: an unusual presentation of a metastatic temporal bone lesion from a primary adenocarcinoma of the lung

OBJECTIVE

We report a rare case of temporal bone metastasis from a lung primary, presenting only as post-aural tenderness.

CASE REPORT

A 57-year-old man presented to our out-patient department with left post-aural pain of four months' duration. Clinical examination revealed tenderness in the left post-aural region; the ear, nose and throat examination was otherwise unremarkable. Computed tomography and contrast-enhanced magnetic resonance imaging showed erosion of the left petrous temporal bone. Incisional biopsy was carried out. Histopathological and immunohistochemical analysis showed infiltrative metastatic adenocarcinoma of the lung. Further imaging with positron emission tomography confirmed increased uptake from the right lower lobe of the lung, suggesting the site of the primary lesion. The patient was treated with chemo-radiotherapy.

CONCLUSION

Post-aural pain is a non-specific symptom, and, with normal clinical and audiometric test results, rare lesions such as the one presented could be easily missed. A thorough clinical examination must be performed to identify genuine signs, and appropriate imaging undertaken to exclude rare causes, such as this metastatic lesion of the temporal bone.

Cancer of the external auditory canal

INTRODUCTION

Cancer of the external auditory canal is a rare tumour with an annual incidence of one per one million inhabitants. The objective of this study was to evaluate the 5-year overall survival and disease-free survival rates in a series of patients with carcinoma of the external auditory canal and to compare our results concerning the clinical presentation, management and survival with those of the literature.

PATIENTS AND METHOD

Ten patients were included in this retrospective, single-centre study over a 20-year period. Data concerning age, symptoms, imaging, TNM stage according to the Pittsburgh classification, histology, management, sequelae, recurrences and survival were recorded.

RESULTS

The mean age of the patients of this series was 60.7 years. Seven patients had a squamous cell carcinoma. The other histological types were undifferentiated carcinoma, adenoid cystic carcinoma and neuroendocrine carcinoma. Staging was based on the Pittsburgh classification with one stage I, one stage III and eight stage IV tumours. Five-year overall survival rates were 100%, 50% and 0%, respectively. The mean 5-year overall survival rate was 35% and the mean 5-year disease-free survival rate was 24%.

CONCLUSION

Carcinoma of the external auditory canal is a difficult diagnosis when the tumour does not present as a fungating mass protruding from the external auditory canal. The Pittsburgh classification was used for TNM staging of these tumours, allowing comparison of our results with those of the literature. The clinical findings and survival rates observed in this study are comparable to those reported in the literature. These tumours are associated with a poor prognosis on the basis of our results and published data.

External Auditory Canal Mass as the First Manifestation of a Bronchogenic Carcinoma: Report of a Rare Case

Objectives:

Metastatic tumors in the external auditory canal (EAC) are exceptionally rare. These metastases almost always occur in the latter stages of the disease process. Ten cases of metastatic tumors of the EAC have been reported in the literature. We report the first case of a metastatic bronchogenic adenocarcinoma that presented initially as an EAC mass.

Methods:

We present a case report and a literature review.

Results:

Although bronchogenic adenocarcinoma not uncommonly metastasizes to the temporal bone, metastasis to the EAC is extremely rare. We report the case of a 62-year-old woman who presented with a 6-week history of swelling in her right EAC and sudden onset of hearing loss. Physical examination revealed a small, polypoid, friable mass originating from the superior-posterior wall of the right EAC. Incision biopsy was performed, and the histopathologic examination of specimens revealed a moderately to poorly differentiated adenocarcinoma compatible with a bronchogenic origin.

Conclusions:

A patient with an aural mass presents a diagnostic dilemma. Metastatic tumors in the EAC are extremely rare, but they should be included in the differential diagnosis of a mass in this location.

A case of Basal cell carcinoma of external auditory canal

Malignant tumor originated from external auditory canal (EAC) is very rare with an annual incidence of around 1 per million. Pathologically, squamous cell carcinoma is incidentally most common, and adenoid cystic carcinoma, basal cell carcinoma, and melanoma follow in decreasing order. Due to the rarity of malignant tumor of EAC, there is no widely accepted treatment modality yet. But basal cell carcinoma, known to be less aggressive tumor, can be removed with a minimal safety margin and have better treatment results. Recently we experienced a case of basal cell carcinoma in the EAC, confined in the cartilaginous portion of EAC, presenting with intermittent otorrhea for several years. The patient was treated with a sleeve resection of the EAC with a safety margin reconstructed with a split-thickness skin graft. No tumor recurrence or complication was noted in the first postoperative year.

External and middle ear diseases: radiological diagnosis based on clinical signs and symptoms

Objective

Pathology of the external and middle ear is the most frequent reason to prescribe antibiotics and perform surgery in children and young adults. In the majority of cases imaging studies are not performed; the need for imaging comes when complications are suspected or when treatment is not effective. This paper discusses indications for temporal bone imaging studies and presents the most frequent pathological conditions, together with differential diagnosis, clinical symptoms and methods of treatment.

Methods and Results

This pictorial review describes major external and middle ear diseases, with special regard to clinical findings and appropriate reporting.

Conclusions

Apprehension of the complete clinical picture, together with imaging clues, narrows differential diagnosis and helps avoid mistakes. Evaluation of temporal bone pathologies requires close cooperation between the clinician and radiologist.

Squamous cell carcinoma of the external auditory canal

OBJECTIVES

This study aims to analyze the treatments, prognostic variables, and outcomes of patients with squamous cell carcinomas (SCC) of the external auditory canal (EAC) and middle ear treated in our department over a 15-year period.

DESIGN

A retrospective analysis of 19 patients treated in our department between 1990 and 2006. The patients were staged according to the Pittsburgh classification. Patients were treated with either a lateral (LTBR) or an extended temporal bone resection (total or subtotal). Parotidectomy was performed in patients with suspected clinical or radiological invasion and postoperative radiotherapy was the adjuvant treatment in most patients in advanced stages.

RESULTS

The overall 5-year survival was 37%. There were no patients in stage I. The survival rates were 100%, 25%, and 16% for stages II, III, and IV, respectively. Facial nerve paralysis (p = 0.007) and lymph node involvement (p = 0.006) were associated with decreased survival rates.

CONCLUSION

SCC of the temporal bone are rare but have a poor prognosis. Lymph node involvement and facial nerve palsy are associated with a poorer outcome. These tumors must initially be treated radically, for which an early diagnosis is important.

Temporal bone myeloid sarcoma

Myeloid sarcoma is a rare condition that's caused by the aggregation of immature myeloid cells in leukemic patients. Myeloid sarcoma occurring in the temporal bone more frequently involves the mastoid bone than is the case for metastatic lesions arising from non-systemic malignancies. The disease is difficult to diagnose when it presents with symptoms that mimic otomastoiditis. However, an early diagnosis is important in order to achieve complete remission of the disease. Magnetic resonance imaging of the temporal bone is useful for making the diagnosis of myeloid sarcoma, and especially to evaluate the extent of disease. High-dose radio- or chemotherapies are the first-line approaches and possibly the only approaches to achieve complete remission and to cure the disease. With the aim of improving our understanding of myeloid sarcoma in the temporal bone, the present report describes our experience with 5 such cases and we compare the clinical features of these 5 patients with those clinical features of patients who have metastatic lesions.

Necrotizing otitis externa: 19 cases' report

Necrotizing otitis externa is an uncommon but severe infectious disease of the external auditory canal. Patients at risk are those immunodepressed or having diabetes. The causal germ is often Pseudomonas aeruginosa. Over a period of 10 years (1997-2006), we treated 19 patients: 94.7% had diabetes (insulin dependent in 6 cases). The causal germ was P. aeruginosa in 59% of cases. The pretherapeutic work-up included a computed tomography and a scintigraphy practiced in order to confirm diagnosis and assess the extension. Medical treatment was based on a parenteral antibiotic therapy using a third-generation cephalosporin and a fluoroquinolones. Local treatment of the auditory canal including cleaning and application of antimicrobial agents was performed in all the cases. Surgical debridement of soft tissue and infected bone was performed in one patient who did not respond to medical management. Repeated scintigraphies with gallium were used to follow the course under treatment in only three cases. We had a 89.4% cure rate with only three cases of recurrence. We reviewed the data in the literature on necrotizing otitis externa and present the important diagnostic, imaging, and therapeutic aspects of the disease.

Primary middle ear Epstein-Barr virus-related lymphoepithelial carcinoma: case reports and systematic review

OBJECTIVES/HYPOTHESIS

To report two cases of primary lymphoepithelial carcinoma in the middle ear and to determine the optimal treatment for such lesions.

STUDY DESIGN/METHODS

Case reports and a systematic review of the literature.

RESULTS

Primary lymphoepithelial carcinoma in the middle ear is an exceptionally rare condition with only two other cases reported in the literature. There appears to be an association with Epstein-Barr virus infection and in those patients originating from the Guangdong province of China, much as is the case for similar lesions found in the nasopharynx. Piecemeal rather than en bloc excision, in combination with adjuvant radiotherapy, appears to adequately control the disease.

CONCLUSIONS

Primary lymphoepithelial carcinoma of the middle ear is a rare lesion, which when treated has a good prognosis.

[Malignant tumors of auricula and periauricular area]

BACKGROUND/AIM

Malignant tumors of auricula and periauricular area represent seven percent of all cutaneous tumors. They appear mostly in the sixth and seventh decade. According to histological type they are basocellular and planocellular carcinomas. The most frequent etiology is the sun exposition. The aim of this study was to analyze clinical and histological characteristics and therapy of malignant tumors of auricular and periauricular area.

METHODS

Totally 155 patients were treated in ORL Clinic, Clinical Center Nis during the period 1990-2006. The patients were treated surgically (59.35%), by radiotherapy (1.94%) and by combination of the two methods (38.71%).

RESULTS

Since the majority of tumors were small and presented on the helix, wedge excision and primary reconstruction were performed (136), while total (9) or partial (10) auriculectomy were done in a small number of the patients. For larger lesions (T4--when lesion is greater than 4.0 cm) and neck metastasis invading cartilage or bone, parotidectomy (15), radical neck dissection (25) and temporal bone resection (9) were performed.

CONCLUSION

Carcinoma of auricular and periauricular area should be confirmed by biopsy and histopathologic evaluation. In all cases an adequate excision, margin examination and observation of appropriate lymph node draining regions should be provided.

Managing malignancies of the external auditory canal

The ear canal, middle ear and temporal bone are rare sites of primary cancer. However, given its central location within the skull base, the tumors from these sites often extend to involve the parotid, overlying skin and even the dura or carotid artery. Squamous cell carcinoma is the most common histology for both primary and secondary tumors. The rarity of temporal bone cancers and the complexity of the region's anatomy make treating temporal bone malignancies difficult. While early-stage cancers can be effectively treated by complete resection, multimodal therapy is imperative for most of these tumors. A contemporary review of the literature is presented with present-day controversies outlined.

Cancer of the external auditory canal and middle ear in Denmark from 1992 to 2001

BACKGROUND

In the context of the Danish Head and Neck Cancer Group, nationwide material from 1992-2001 was analyzed to study the extent and nature of the disease, evaluate treatment, compare staging systems, and examine prognosis and survival.

METHODS

Review of 68 consecutive cases: 47 squamous cell carcinoma, 10 basal cell carcinoma, and 11 other histologies. Moody (modified Pittsburgh) stages were T1 (26), T2 (9), T3 (8), T4 (23), Tx (2). Sixty-four patients were treated with curative intent: 24 primary radiotherapy, 18 primary surgery, and 22 combined. Surgery was limited to tumor excision and mastoidectomy and in 1 case temporal bone excision.

RESULTS

Twenty-seven of 28 recurrences involved primary site. Kaplan-Meier analysis showed 5-year locoregional control of 48%, disease-specific survival 57%, and overall survival 44%.

CONCLUSION

This nationwide study confirmed that local failure is the main problem, and future improvements should focus on more aggressive local treatment.

Malignancies of the ear in irradiated patients of nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

To report on the clinical profiles and treatment experiences of patients with second primary ear malignancy after treatment of nasopharyngeal carcinoma (NPC).

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective review of the clinical outcomes and pathology of 11 irradiated NPC patients who subsequently had second primary malignancies of the ear at a single institution.

RESULTS

Ten tumors were squamous cell carcinoma and one tumor was chondrosarcoma occurring within the radiation field of previous treatment for NPC. The interval between previous radiotherapy and diagnosis of ear malignancy was 3 to 27 years with a median time of 17 years. Six tumors were located in the external auditory canal, two in the middle ear cavity, two in the periauricular region and one in the mastoid cavity. Four patients underwent surgery, and the other seven patients underwent surgery plus adjuvant radiotherapy. The 3-year disease-free and overall survival rates were 30.3% and 20%, respectively.

CONCLUSIONS

Postirradiated malignancy of the ear is extremely rare, but is one of the causes of death for NPC long-term survivors despite curative-intended treatment with surgery plus adjuvant radiotherapy is instituted.

Primary temporal bone secretory meningioma presenting as chronic otitis media

We report an extremely rare case of a secretory meningioma primarily involving the temporal bone. A 56-year old female patient presented to us with a history of a chronic otitis media and unilateral hearing loss. Diagnostic investigations revealed a tumor arising from the temporal bone without signs of intracranial involvement. Histopathological examination showed a meningioma of the secretory type. The tumor was partially resected and serial imaging at follow-up revealed no extension of the tumor. No new symptoms developed 1 year after surgery. Secretory meningioma is a rare meningioma subtype and extracranial presentation in the temporal bone is very unusual. We present the first case of a primary temporal bone secretory meningioma in the otorhinolaryngological literature. As radical as possible surgical excision with serial imaging at follow-up is recommended.