Conclusion

1. The most important prognostic factor in the treatment of malignancy of the temporal bone is early diagnosis. Any lesion of the external auditory canal not responding to medical treatment, with bleeding, forming granulation tissue, or persistent pain, must be biopsied.

2. An appropriate head and neck examination should also be performed, including cranial nerves and areas of potential lymphatic spread.

3. Imaging studies are performed, including high-resolution CT scans with bone algorithm and possible MRI scan. These studies are reviewed with the temporal bone neuroradiologist and other members of the treating team (i.e., head and neck surgeon, neurosurgeon, and neurotologist).

4. The tumor is staged according to the TNM classification of Arriaga et al.3 The literature and experience will show that there often will be intraoperative findings that will change the TNM classification.

5. T1 and T2 lesions will be treated with a lateral temporal bone resection in continuity with superficial lobe of the parotid gland, possible resection of the deep lobe of the parotid gland, sampling of level 2 and 3 neck nodes, and neck dissection as needed. The area will be covered with vascularized tissue and skin, sacrificing the middle ear transformer. Postoperative full-therapy irradiation will be given.

6. T3 and T4 lesions will begin with the lateral temporal bone resection, followed by piecemeal removal of all tumor and adjacent normal structures based on frozen-section control. Parotidectomy and neck evaluation will be as with T1 and T2 lesions. Those T1 and T2 lesions that experience violation of tumor by the resection, will be treated as a T3 or T4 lesion. The surgical field will be covered by vascularized tissue and skin. Appropriate steps to protect the exposed eye, airway, and swallowing will be taken. Full-therapy postoperative irradiation will be given.

7. Cases of squamous cell carcinoma in a previous mastoid cavity, or when radiotherapy has been given with persistence, will be treated with attempted en bloc resection based on the imaging studies. This approach may be used for palliation in those patients with severe pain.

REFERENCES

Kinney—CHAPTER S2

1. Conley J. Cancer of the middle ear. Ann Otol Rhinol Laryngol 1965;74:555-572

2. Manolidis S, Pappas D, Von Doersten P, et al. Temporal bone and lateral skull base malignancy: experience and results with 81 patients. Am J Otol 1998;19:S1-S15

3. Arriaga M, Curtin H, Takahashi H, et al. Staging proposal for external auditory meatus carcinoma based on preoperative

clinical examination and computed tomography findings. Ann Otol Rhinol Laryngol 1990;90:714-721

Boland J. The management of carcinoma of the middle ear. Radiology 1963;80:285

Wang CL. Radiation therapy in the management of carcinoma of the external canal, middle ear, or mastoid. Radiology 1975;116:713-715

6. Wang CL, Doppke K. Osteoradionecrosis of the temporal bone—considerations of nominal standard dose. Int J Radiat Oncol Biol Phys 1976;1:881-883

7. Lewis JS. Surgical management of tumors of the middle ear and mastoid. JLaryngol Otol 1983;97:299-311

8. Arena S. Tumor surgery of the temporal bone. Laryngoscope 1974;84:615-670

9. Neely JG, Forrester M. Anatomic considerations of the medial cuts in subtotal temporal bone resection. Otolaryngol Head Neck Surg 1982;90:641-645

10. Goodwin WJ, Jesse RH. Malignant neoplasms of the external auditory canal and temporal bone. Arch Otolaryngol 1980;106:675-679

11. Go KG, Annyas AA, Vermey A, et al. Evaluation of results of temporal bone resection. Acta Neurochir 1991;110:110-115

12. Graham MD, Sataloff RT, Kemink JL, et al. Total en bloc resection of the temporal bone and carotid artery for maligant tumors of the ear and temporal bone. Laryngoscope 1984;94: 528-533

13. Sataloff RT, Myers DL, Lowry LD, et al. Total temporal bone resection for squamous cell carcinoma. Otolaryngol Head Neck Surg 1987;96:4-14

14. Willging JP, Pensak ML. Temporal bone resection. Ear Nose Throat J 1991;70:612-617

15. Kinney SE, Wood BG. Malignancies of the external ear canal and temporal bone: surgical techniques and results. Laryngoscope 1987;97:158-164

16. Kinney SE, Wood BG. Surgical treatment of skull base malignancy. Otolaryngol Head Neck Surg 1984;92:94-99

17. Kinney SE. Squamous cell carcinoma of the external auditory canal. Am J Otol 1989;10:111-116

18. Crabtree JA, Britton BH, Pierce MK. Carcinoma of the external auditory canal. Laryngoscope 1976;86:405-415

19. Batsakis JG. Adenomatous tumors of the middle ear. Ann Otol Rhinol Laryngol 1989;98:749-752

20. Li JC, Brackmann DE, Lo WWM, Carberry JN, House JW. The reclassification of aggressive adenomatous mastoid neoplasms as endolymphatic sac tumors. Laryngoscope 1993;103:1342-1348

Temporal Bone Malignancies

Sam J. Marzo and John P. Leonetti

CHAPTER 53

The human temporal bone occupies the inferolateral skull base. Although osseous, it also possesses an epithelialized ear canal, mastoid, and middle ear, as well as other foramina and canals. Cranial nerves VII to IX, the carotid artery, and the sigmoid sinus all traverse the temporal bone. Almost every type of tissue, from cartilaginous to glandular, can be found within it. Athough any of these structures can give rise to a malignancy, most temporal bone cancers arise from the external auditory canal, and of these, squamous cell carcinoma (SCCA) is the most common.1 Table 53-1 lists a classification of temporal bone malignancies.

It is often difficult to determine the tissue of origin in patients with temporal bone malignancy. Patients with a biopsy-proven ear canal SCCA and an otherwise normal head and neck examination most likely have primary SCCA of the temporal bone. Patients with a prior history of head and neck SCCA who present with a lesion in the temporal bone may

TABLE 53-1

Differential Diagnosis of Temporal Bone Malignancies

TABLE 53-1

Differential Diagnosis of Temporal Bone Malignancies

Origin

Type

Ear canal

Squamous cell carcinoma

Basal cell carcinoma

Adenoid cystic carcinoma

Ceruminal gland adenocarcinoma

Malignant melanoma

Kaposi's sarcoma

Middle ear

Squamous cell carcinoma

Adenocarcinoma

Rhabdomyosarcoma

Malignant lymphoma

Plasmacytoma

Metastatic

Breast carcinoma

Squamous cell carcinoma from other head

and neck site

Pulmonary adenocarcinoma

Malignant melanoma

Renal cell carcinoma

Prostate adenocarcinoma

Thyroid papillary adenocarcinoma

SOURCE: Wenig B, ed. Pathology of the Head and Neck. New York: McGraw-Hill; 1990.

SOURCE: Wenig B, ed. Pathology of the Head and Neck. New York: McGraw-Hill; 1990.

have metastatic disease. A diligent search for other evidence of metastases should be sought before embarking on surgical therapy. This might include a contrast computed tomography (CT) scan of the head, neck, and chest. Uncommon lesions such as adenocarcinoma may require a search for metastatic disease, including a thorough breast examination with or without mammography, and a contrast CT scan of the chest, abdomen, and pelvis. Primary tumors metastatic to the temporal bone include carcinoma of the breast, lung, stomach, prostate, and kidney. Of these, most are from the breast.2 This chapter focuses primarily on the management of SCCA of the temporal bone. Principles apply to other isolated less common lesions as well, with the exception of pediatric rhabdomyosarcoma, which is treated with limited surgical resection, chemotherapy, and radiotherapy.3

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