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CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 4  |  Page : 283-288

Lateral temporal bone resection for carcinoma external auditory canal with hearing preservation – Our approach


Department of ENT, Dr. Baba Saheb Ambedkar Central Railway Hospital, Mumbai, Maharashtra, India

Date of Submission02-Apr-2020
Date of Acceptance18-May-2020
Date of Web Publication23-Apr-2021

Correspondence Address:
Dr. Deepak Dalmia
Department of ENT, Dr. Baba Saheb Ambedkar Central Railway Hospital, Byculla, Mumbai - 400 027, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_53_20

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  Abstract 


The case series is regarding effective management of carcinoma external auditory canal (EAC). Patients were assessed clinically and radiologically preoperatively, and an operative plan was decided. Patients were operated for carcinoma EAC, and lateral temporal bone resection along with ancillary procedures such as superficial parotidectomy and selective neck dissection were performed. With the help of frozen section, adjacent clinically suspicious tissue involvement was ruled out for malignancy. Hearing mechanism reconstruction was performed using autologous cartilage and instead of cul-de-sac closure of EAC, canal was kept open by doing wide conchomeatoplasty to aid in postoperative assessment and can avoid repeated imaging.

Keywords: Carcinoma external auditory canal, carcinoma ear, lateral temporal bone resection, tumors of external auditory canal, wide conchomeatoplasty, selective neck dissection


How to cite this article:
Dalmia D, Davange N, Patni P, Katakdhond HN, Bhagavan K. Lateral temporal bone resection for carcinoma external auditory canal with hearing preservation – Our approach. Indian J Otol 2020;26:283-8

How to cite this URL:
Dalmia D, Davange N, Patni P, Katakdhond HN, Bhagavan K. Lateral temporal bone resection for carcinoma external auditory canal with hearing preservation – Our approach. Indian J Otol [serial online] 2020 [cited 2021 Jun 16];26:283-8. Available from: https://www.indianjotol.org/text.asp?2020/26/4/283/314350




  Introduction Top


Tumors of external auditory canal (EAC) are very rare with an incidence rate of 0.3% of all cancers within head-and-neck region worldwide.[1] The complex anatomy of the region and proximity to vital structures presents a great challenge to the surgeon in achieving oncosurgical clearance while at the same time keeping morbidity to the minimum. A combination of surgery and radiation is now used to treat this condition.[2] The aim of treatment should be to achieve complete oncologically safe resection with preservation of function. In this three-patient case series, we emphasize on complete tumor excision with preservation of hearing and avoiding Cul-de-sac closure to give better functional outcome.


  Case Reports Top


Case 1

A 67-year-old male patient came to the ENT outpatient department (OPD) with the complaints of discharge from the right ear for 6 years associated with reduced hearing in the right ear which started along with the complaints of discharge. Discharge from the right ear was blood stained, purulent, and foul smelling in nature. The patient did not have any complaints regarding imbalance, giddiness, tinnitus, facial weakness, and pain.

There is no history of recent trauma, previous ear surgery. There were no nasal or oral complaints.

On examination, there was no obvious facial asymmetry. Bilateral pinna appeared normal. On otoscopic examination, proliferative, nonpulsatile pinkinsh-red growth was visualized occluding lumen of cartilaginous EAC which was friable and bleeds on touch [Figure 1]. There was no palpable neck swelling. Left ear examination was normal. Rest ENT examination was unremarkable. Cranial nerve functions were normal.
Figure 1: Proliferative growth in the external auditory canal

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On audiological examination, tuning fork test showed Rinne's negative at 256 and 512 kHz and Weber's lateralized to right. ABC test was reduced in the right ear. Audiogram confirmed moderate-to-moderately severe conductive to mixed hearing loss in the right ear.

On radiological evaluation, high-resolution computed tomography (HRCT) temporal bone revealed soft-tissue densities within the middle, external ear canal as well as mastoid air cells and mastoid antrum on right side [Figure 2]. The right cochlea, semicircular canal, internal auditory canal were normal. There is subtle bony erosion in the anterior part of bony EAC.
Figure 2: Imaging showing soft-tissue mass in the external auditory canal without bony erosion, middle and inner ear are free

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Punch biopsy was taken from the lesion suggestive of squamous cell carcinoma.

As per Modified Pittsburgh TNM staging, it was T3N0M0.[3],[4]

The patient was subsequently operated for lateral temporal bone resection with superficial parotidectomy (as subtle erosion of anterior wall of EAC) with selective neck dissection with EAC reconstruction under general anesthesia [Figure 3] and [Figure 4].
Figure 3: Extended posterior tympanotomy with intact posterior and superior bony canal wall

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Figure 4: Osteotome used anterosuperiorly

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Case 2

A 67-year-old male patient came to the ENT OPD with the complaints of discharge and decreased hearing from the right ear for 6 months. The discharge from the right ear was blood stained, purulent, and foul smelling in nature. The patient did not have any complaints regarding imbalance, giddiness, tinnitus, facial weakness, and pain.

There is no history of recent trauma, previous ear surgery. There were no nasal or oral complaints.

On examination, there was no facial asymmetry. Bilateral pinna appeared normal. On otoscopic examination, proliferative, nonpulsatile pinkish-red growth was visualized in the lumen of cartilaginous EAC, which was friable and bleeds on touch. There was no palpable neck swelling. Left ear examination was normal. Rest ENT examination and cranial nerve functions were normal.

On audiological examination, Tuning Fork Test showed Rinne's negative at 256 and 512 KHz and Weber's lateralized to right. ABC test was reduced in the right ear. Audiogram confirmed moderately severe-to-severe mixed hearing loss in the right ear.

On radiological evaluation, HRCT temporal bone revealed soft-tissue and mucosal thickening in external ear canal along bony and cartilaginous portion, causing moderate to significant luminal narrowing with no underlying bony involvement.

Punch biopsy was taken from the lesion suggestive of squamous cell carcinoma [Figure 5].
Figure 5: Poorly differentiated invasive nonkeratinizing squamous cell carcinoma

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As per Modified Pittsburgh TNM staging, it was T3N0M0.[3],[4]

The patient was subsequently operated for lateral temporal bone resection with cartilagenous reconstruction under general anesthesia [Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10].
Figure 6: After placement of Temporalis fascia graft

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Figure 7: Incision visible through meatus in Anterior Canal Wall

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Figure 8: Partial thickness skin graft harvested from postaural region

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Figure 9: Wide conchomeatoplasty

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Figure 10: Excised lateral temporal bone resection including bony meatus, skin of external auditory canal, tympanic membrane, and malleus

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Case 3

A 33-year-old male patient came to the ENT OPD with the complaints of discharge from the right ear for 1 year which was blood stained for 6 months associated with decreased hearing. The patient did not have any complaints regarding imbalance, giddiness, pain, tinnitus, and facial weakness.

There was no history of recent trauma, previous ear surgery. There were no nasal or oral complaints.

On examination, there was no obvious facial asymmetry. Bilateral pinna appeared normal. On otoscopic examination, proliferative, nonpulsatile pinkinsh-red polypoidal growth was visualized in the lumen of cartilaginous EAC which was friable and bleeds on touch. There was no palpable neck swelling. Left ear examination was normal. Rest ENT examination and cranial nerve functions were umremarkable.

On audiological examination, Tuning Fork Test showed Rinne's negative at 256 and 512 kHz and Weber's lateralized to right. ABC test was normal in the right ear. Audiogram confirmed mild to moderate conductive hearing loss in the right ear [Figure 13].

On radiological evaluation, HRCT temporal bone revealed soft-tissue opacification of the EAC with no bony erosion. The ossicles were intact; inner ear structures were normal.

Punch biopsy was taken from the lesion suggestive of poorly differentiated invasive nonkeratinizing squamous cell carcinoma.

As per Modified Pittsburgh TNM staging, it was T2N0M0.[3],[4]

The patient was subsequently operated for lateral temporal bone resection with cartilaginous reconstruction under general anesthesia [Figure 11], [Figure 12] and [Figure 14].
Figure 11: Piece of conchal cartilge kept on the head of stapes

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Figure 12: Incudostapedial joint visualized

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Figure 13: Pre- and post-surgery right ear hearing comparison (case 3)

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Figure 14: Postoperative picture after 3 months (case 3)

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  Discussion Top


C-shaped postauricular incision was placed more posteriorly for better exposure of structures. Skin flap was raised anteriorly and cartilaginous EAC was divided with adequate margin and flap extended till root of zygoma; superficial temporal artery should be preserved anteriorly to maintain the blood supply to the ear if the pinna is being preserved.

Anterior musculoperiosteal flaps raised and was included in the excised specimen and McEvan's triangle exposed. Cortical mastoidectomy done; posterior bony ear canal should be kept relatively thick for adequate margin

Incus was visualized; extended posterior tympanotomy was done [Figure 3]. Drilling continued inferiorly till TMJ. During this, mastoid segment of facial canal was preserved and bony meatal wall was kept intact for en bloc resection (with adequate margin).

Incudo-stapedial joint was dislocated and the incus was removed to avoid causing sensorineural hearing loss. The incus was removed and sent for evaluation. Clinically suspicious tissue from middle ear over promontory region in the first case was sent for frozen section – suggestive of negative for malignancy. Frozen section report helped to preserve inner ear and hence preserve hearing.

Stapes' suprastructure was preserved; round window reflex was present.

Drilling using a diamond burr continued superiorly between tegmen and superior Bony EAC till TMJ keeping the tegmen plate intact using progressively smaller burrs; if needed, it is better to remove the bone of tegmen and expose dura rather than to overthin the ear canal and risk of spillage.[5]

Use of cutting burr should be avoided as it may cause injury to Tegmen plate, facial nerve, jugular bulb, and carotid artery while drilling adjacent to these structures.[5]

Using osteotome, En-bloc resection was completed by applying gentle anterior pressure to the bone encasing the EAC to fracture the medial part of the anterior wall of the EAC.

Adjuvant/ancillary procedures

Margin clearance

To confirm adequate margin clearance anteriorly, adjacent tissue from the capsule of TMJ in the first case and superficial parotid excised and sent separately.

Superficial parotidectomy

In the first case, postauricular incision was extended along the upper neck crease and SMAS flap raised anteriorly. Trunk of facial nerve and its branches was delineated, and superficial parotidectomy was done, leaving a sleeve of parotid tissue anteriorly and sent for histopathology.

Neck dissection

In the first case, accessory spinal nerve was identified and Level IIa and IIb lymph nodes were excised and sent for histopathology.

Reconstruction

Conchal cartilage and temporalis fascia were harvested for reconstruction. Conchal cartilage gives an added advantage as it is curved, pliable, and gives anatomical shape as natural posterior wall of TMJ. Hearing is preserved in all cases by performing type III tympanoplasty, keeping a piece of cartilage over head of stapes. Refashioned piece of cartilage was kept over the head of stapes to reconstruct the hearing mechanism and anterior wall of EAC (posterior wall of TMJ). Pieces of Conchal cartilage can be used to obliterate mastoid cavity. Harvested piece of temporalis fascia should be kept over the assembly. Raw areas, if present, can be covered with Split thickness skin graft for epithelialisation and better healing [Figure 8]. Incision can be taken over the conchal skin for wide meatoplasty and anchoring of skin flaps with bony edges of mastoid cavity (using fine burr, holes are made in superior and posterior bony edges of mastoidectomy). Wide meatoplasty was kept for postoperative follow-up examination instead of Cul-de-sac closure [Figure 9],[Figure 14] and [Figure 15].
Figure 15: Postoperative picture day 10 (case 2)

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Canal was packed with medicated gel foam. Negative pressure drain was placed in the neck as selective neck dissection was performed in the first case along with pressure dressing. Immediate Postoperative facial nerve function was intact.


  Conclusion Top


In our approach, we follow all traditional steps of lateral temporal bone resection as given in current literature, and we modify it to reconstruct the anterior wall of EAC (posterior wall of TMJ) and hearing mechanism wherever possible. This gives patient a better postoperative quality of life. Reconstructed and obliterated mastoid cavity with wide meatoplasty like cholesteatoma cases allows us for better clinical assessment on follow-up and recurrences if any can be picked up early. This reduces the cost of repeated imaging and radiation exposure and improves patient compliance. Reconstruction of hearing mechanism gives patient better hearing quality and helps in use of hearing aid, if needed. Costly hearing rehabilitation procedures such as bone anchored hearing aids can be avoided. With preoperative planning, radiological assessment, and frozen section, carcinoma EAC can be managed successfully with hearing preservation without Cul-de-sac closure and by reconstructing the hearing mechanism.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Scott-Brown W, Watkinson J, Clarke R. Scott-Brown's Otorhinolaryngology. 8th ed. London: Hodder Arnold; 2018. p. 1425-6.  Back to cited text no. 1
    
2.
Venkatesh M, Nilakantan A, Raghavan D, Datta R, Dwivedi G. Lateral temporal bone resection for malignancy of external auditory meatus: Our approach. Indian J Otolaryngol Head Neck Surg 2008;60:202-6.  Back to cited text no. 2
    
3.
Moody SA, Hirsch BE, Myers EN. Squamous cell carcinoma of the external auditory canal: An evaluation of a staging system. Am J Otol 2000;21:582-8.  Back to cited text no. 3
    
4.
Arriaga M, Curtin H, Hirsch B, Takahashi H, Kamerer D. Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings. Ann Otol Rhinol Laryngol 1990;99:714-21.  Back to cited text no. 4
    
5.
Mathew R, Harris T, Patel P. [Internet]. Vula.uct.ac.za. Available from: https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Lateral%20temporal%20bone%20resection%20surgical%20technique.pdf. [Last accessed on 2020 Sep 25].  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]



 

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