Temporal
Bone Resection
Review of 100 Cases John S. Lewis, MD One hundred cases of temporal bone resection for cancer of the ear were reviewed retrospectively, allowing for a survival five-year follow-up period in all cases. Operative technique previously described varied from case to case but essentially involved subtotal resection of the mastoid, petrous pyramid and squamosa of the temporal bone, temporomandibular joint, base of zygoma, and attached adjacent soft tissues. The procedure sacrifices the facial nerve and hearing in the involved ear. Preoperative radiation or a sandwich technique of preoperative and postoperative radiation was used. Many complications were encountered, but with hypotensive agents, high-speed air drills, and adequate coverage of the defect, the death rate was reduced from 10% in 1954 to 5% in recent years. The overall fiveyear cure rate was 27%, with a 25% cure rate for squamous carcinoma.
Temporal
bone resection has be¬ well-established proce¬ dure for radical extirpation of a can¬ cer of the ear and cancer involving the ear from adjacent structures. Considerable experience has been gained during the past 18 years since Parsons and this author first reported the technique of one-stage subtotal resection of the temporal bone in come
a
Accepted
for publication Feb 13, 1974. From the Head and Neck Service, Memorial Hospital, New York. Read before the first joint meeting of the Society of Head and Neck Surgeons and the American Society for Head and Neck Surgery, Hot Springs, Va, April 30, 1973. Reprint requests to Head and Neck Service, Memorial Hospital, 3 E 71st St, New York, NY 10021 (Dr. Lewis).
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
1954.1 Since then the
use
of modified
incisions, hypotensive anesthesia, di¬ uretic agents, scalp flaps, and high¬ speed air drills have made the pro¬ cedure less formidable. Indeed, the operative mortality has been reduced from 10% in 1954 to 5% at the present time. This report reviews the cases of 100 patients operated on between
1951 and 1967 to allow for a five-year critical review period. The traditional method of dealing with cancer of the ear has been a radical mastoidectomy with subse¬ quent postoperative radiation ther¬ apy. Frequently the diagnosis of can¬ cer is not made until the mastoid and middle ear are uncovered in a formal
operative setting, disclosing granula¬ tion-like tissue that is subsequently reported as cancer after study of fro¬ zen sections and later paraffin sec¬ tions. The patient is then treated by
irradiation. The results of such ther¬ apy are generally disappointing. In 1951 Ward and his co-authors2 de¬ scribed a more extensive operation combined with radical neck dissection in which the temporal bone contain¬ ing tumor was removed piecemeal, a large area of dura and lateral sinus was uncovered, and the internal ca¬ rotid artery was unroofed. Involved dura was resected. The resulting wound was left open and treated by irradiation. At a later date the granu¬ lating area was grafted. In the same year Campbell et al1 described a sim¬ ilar excision in which the tumor was also removed in pieces, but they sug-
gested that it would probably have been possible to remove the petrous portion of the temporal bone en bloc. Although in most of our cases the bone has been resected
en
bloc, with
temporomandibular joint, base of zy¬ goma, and attached muscles, it is not always possible to extirpate the en¬
tire tumor and additional bone in one piece. Dura and lateral sinus may have to be removed secondarily. Re¬ placement of dura with temporal fas¬ cia and coverage of the operative de¬ fect with skin or a scalp flap is
mandatory. During the period of review, 100 patients were operated on. In 20 cases
the cancer arose on the external ear and extended to the mastoid; in 62 cases it appeared to arise in the audi¬ tory canal, and in 18 cases from the middle ear and mastoid. In 4 of the latter cases, it was associated with cholesteatoma.
Etiology Cancer of the external ear is a dis¬ of elderly white men, usually in their seventh decade, who have been exposed to some external irritant, such as frostbite or the actinic rays of the sun being superimposed in kera¬ tosis. About two thirds of these le¬ sions are of the basal cell variety and may form large rodent ulcérations of the pinna, mastoid process, and tem¬ poral region. The remaining third are most often squamous carcinoma or, rarely, melanoma. Neoplasms of the auditory canal ease
prevalent among women. Those tumors arising in the middle are more ear sex
and mastoid process have an even distribution. The median age for
these
cancers
is about 55 years
(Table
1).
Cancer of the auditory canal and middle ear is associated with a chronic otorrhea in about one third of cases. In the remainder, there are re¬ current infections dating back six months to a year. Cholesteatoma have been associated with about a fourth of the middle ear and mastoid carci¬ nomas. Two cases of squamous carci¬ noma of the ear canal have occurred in patients with chronic lymphatic leukemia. A report from the Univer¬ sity of Chicago has indicated that there are eight cases of cancer of the mastoid process which have occurred in radium dial painters.1 Fortunately cancer of the ear is ex¬ tremely rare; the incidence is esti¬ mated at between 1:5,000 to 1:15,000 of all otologie pathological conditions.
Pathological Findings By far the most common type of cancer was squamous carcinoma, com¬ prising 86 of the 100 cases in this
series. Basal cell carcinoma accounted for eight cases, and all arose from the external ear. Two cases of adenocarci¬ noma arising in the auditory canal from ceruminous glands or of pri¬ mary middle ear origin were treated. In addition there were two cases of malignant melanoma, one case of spindle cell sarcoma, and one case of
embryonal rhabdomyosarcoma. Symptoms
and
Diagnosis
The erosion of the external ear by neoplasm is usually obvious, and a biopsy may readily be done on friable bleeding ulcération. The chronically infected auditory canal that fails to
respond to antibiotics and local medi¬
cation may present a more subtle problem. It is estimated in our experi¬ ence that the period of time from the initial symptoms to the diagnosis averages about six months. The onset of bleeding is rather late, and pain oc¬ curs with bone erosion. Hearing loss with otorrhea is the earliest symp¬ tom. Vertigo and facial paralysis in¬ dicate advanced disease. Some pa¬ tients have external swelling due to invasion of the parotid gland and sternomastoid muscle. X-ray films of the mastoid and tomograms will usu¬ ally show the extent of bone destruc¬ tion. The recent use of retrograde jugular venography will demonstrate the possible invasion of the lateral sinus and jugular bulb area. Carotid angiography with the use of subtrac¬ tion technique in the venous phase is useful.
Operative Technique The operation is a combined intracranial-extracranial approach that has been described previously.' Usu¬ ally one or two malleable spinal punc¬ ture needles are inserted in the lum¬ bar spinal canal to withdraw 50 to 100 cc of cerebrospinal fluid. If severe osteoarthritis of the spine precludes their use, furosemide (Lasix) may be used to shrink the brain. The crani¬ otomy flap may be based either above or below, the former being used at the present time. If extensive involve¬ ment of the external ear and auditory canal is present which involves sacri¬ fice of the external ear, a posterior scalp flap or bipedicle scalp flap is used (Fig 1 and 2). High-speed Stry¬ ker air drills facilitate the bony dis-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
section. Bleeding from the lateral sinus is frequent and is controlled with vascular silk and oxidized cellu¬ lose (Surgicel). Segments of dura are replaced with fascia. The temporal muscle is mobilzed and rotated down into the defect to cover the exposed dura. If extensive durai excision and replacement is required, rotation of a scalp flap to cover the defect is necessary.
Operative mortality
duced from this series.
an
has been re¬ initial 10% to 5% in
is usually confined loss from the external jugu¬ lar vein and petrosal sinus. The me¬ dian loss is 1,500 cc. The use of hypo¬ tensive anesthesia has reduced the
1.
Hemorrhage
venous
hemorrhage considerably. 2. The use of preoperative radia¬ tion therapy has led to a high inci¬ dence of postoperative infection to the grafted site. The most common organism is Pseudomonas aeruginosa, which is adequately controlled with colistimethate sodium (Coly-Mycin M Intramuscular) parenterally in combi¬ nation with ampicillin and locally applied acetic acid dressings. Fre¬ quently portions of the skin graft are lost and must be replaced. A perma¬ nent temporal decompression is pres¬ ent, with the result that skin
External
ear
Sex in Advanced Cancer of the Ear Median Age, yr 70
Auditory canal Middle
ear
the dura should always be repaired primarily. If a defect exists, grafting with temporal fascia and skin is man¬ datory. If a cerebrospinal leak per¬ sists for more than ten days, the wound should be reopened and the
repaired. Meningitis and cere¬ bral abscess are hazardous, especially with Gram-negative infections. 5. To avoid facial nerve paralysis, lateral lid fusions are carried out to prevent corneal ulcération. Fascia sling repairs of the affected side with face lift may be carried out at a later date. Facial-hypoglossal anastomoses have been carried out successfully by
cov¬
erage is imperative. 3. If skin coverage of the dura is not intact, cerebral herniation may occur. It will then be necessary to re¬ duce the hernia and cover it by both fascia and scalp flap. 4. To avoid cerebrospinal fistula,
Conley.5
6. Deafness is complete on the op¬ erated side. 7. Vertigo lasts from 5 to 15 days, and there may be a period of un¬ steadiness for several months. 8. Carotid artery thrombosis may occur from trauma or laceration of the internal carotid artery during the operative procedure. In a recent case, thrombosis occurred two days follow¬ ing surgery and resulted in hemi-
plegia.
Role of Radiation
Therapy
In many of our cases, the patients operated on have had a full course of ionizing radiation prior to their refer¬ ral. Preoperative supervoltage radio-
No. of Women
No. of Men 15 22
55 56
and mastoid
tear
Complications to
Age and
40
an established involvement of the Eustachian tube in the middle ear and frequent base-of-skull involve¬ ment. The usual tumor dose is be¬ tween 3,500 and 5,000 rads. In cases in which margins are in doubt, addi¬ tional postoperative radiotherapy is
therapy has become policy because of the
prescribed.
End Results
During the period of 1951 to 1967, a total of 100 cases of temporal bone re¬ section for cancer of the ear have been carried out. The five-year cure rate has been 27% (27 patients). Of the 86 patients with squamous carci¬ noma, the five-year salvage was 25% (22 patients.)
References 1. Parsons
the
temporal
H, Lewis JS: Subtotal resection of bone for
cancer
of the
ear.
Cancer
7:995-1001, 1954. 2. Ward GE, Loch WE, Lawrence W Jr: Radi-
operation for carcinoma of the external auditory canal and middle ear. Am J Surg 82:169-178, cal
1951. 3. Campbell E, Volk BM, Burklund CW: Total resection of the temporal bone for malignancy of the middle ear. Ann Surg 134:397-404, 1951. 4. Beal DD, Lindsay JR, Ward PH: Radiationinduced carcinoma of the mastoid. Arch Otolaryngol 81:9-15, 1965. 5. Conley J: Concepts in Head and Neck Surgery. New York, Grune & Stratton Inc, 1970.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Bone Resection
Review of 100 Cases John S. Lewis, MD One hundred cases of temporal bone resection for cancer of the ear were reviewed retrospectively, allowing for a survival five-year follow-up period in all cases. Operative technique previously described varied from case to case but essentially involved subtotal resection of the mastoid, petrous pyramid and squamosa of the temporal bone, temporomandibular joint, base of zygoma, and attached adjacent soft tissues. The procedure sacrifices the facial nerve and hearing in the involved ear. Preoperative radiation or a sandwich technique of preoperative and postoperative radiation was used. Many complications were encountered, but with hypotensive agents, high-speed air drills, and adequate coverage of the defect, the death rate was reduced from 10% in 1954 to 5% in recent years. The overall fiveyear cure rate was 27%, with a 25% cure rate for squamous carcinoma.
Temporal
bone resection has be¬ well-established proce¬ dure for radical extirpation of a can¬ cer of the ear and cancer involving the ear from adjacent structures. Considerable experience has been gained during the past 18 years since Parsons and this author first reported the technique of one-stage subtotal resection of the temporal bone in come
a
Accepted
for publication Feb 13, 1974. From the Head and Neck Service, Memorial Hospital, New York. Read before the first joint meeting of the Society of Head and Neck Surgeons and the American Society for Head and Neck Surgery, Hot Springs, Va, April 30, 1973. Reprint requests to Head and Neck Service, Memorial Hospital, 3 E 71st St, New York, NY 10021 (Dr. Lewis).
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
1954.1 Since then the
use
of modified
incisions, hypotensive anesthesia, di¬ uretic agents, scalp flaps, and high¬ speed air drills have made the pro¬ cedure less formidable. Indeed, the operative mortality has been reduced from 10% in 1954 to 5% at the present time. This report reviews the cases of 100 patients operated on between
1951 and 1967 to allow for a five-year critical review period. The traditional method of dealing with cancer of the ear has been a radical mastoidectomy with subse¬ quent postoperative radiation ther¬ apy. Frequently the diagnosis of can¬ cer is not made until the mastoid and middle ear are uncovered in a formal
operative setting, disclosing granula¬ tion-like tissue that is subsequently reported as cancer after study of fro¬ zen sections and later paraffin sec¬ tions. The patient is then treated by
irradiation. The results of such ther¬ apy are generally disappointing. In 1951 Ward and his co-authors2 de¬ scribed a more extensive operation combined with radical neck dissection in which the temporal bone contain¬ ing tumor was removed piecemeal, a large area of dura and lateral sinus was uncovered, and the internal ca¬ rotid artery was unroofed. Involved dura was resected. The resulting wound was left open and treated by irradiation. At a later date the granu¬ lating area was grafted. In the same year Campbell et al1 described a sim¬ ilar excision in which the tumor was also removed in pieces, but they sug-
gested that it would probably have been possible to remove the petrous portion of the temporal bone en bloc. Although in most of our cases the bone has been resected
en
bloc, with
temporomandibular joint, base of zy¬ goma, and attached muscles, it is not always possible to extirpate the en¬
tire tumor and additional bone in one piece. Dura and lateral sinus may have to be removed secondarily. Re¬ placement of dura with temporal fas¬ cia and coverage of the operative de¬ fect with skin or a scalp flap is
mandatory. During the period of review, 100 patients were operated on. In 20 cases
the cancer arose on the external ear and extended to the mastoid; in 62 cases it appeared to arise in the audi¬ tory canal, and in 18 cases from the middle ear and mastoid. In 4 of the latter cases, it was associated with cholesteatoma.
Etiology Cancer of the external ear is a dis¬ of elderly white men, usually in their seventh decade, who have been exposed to some external irritant, such as frostbite or the actinic rays of the sun being superimposed in kera¬ tosis. About two thirds of these le¬ sions are of the basal cell variety and may form large rodent ulcérations of the pinna, mastoid process, and tem¬ poral region. The remaining third are most often squamous carcinoma or, rarely, melanoma. Neoplasms of the auditory canal ease
prevalent among women. Those tumors arising in the middle are more ear sex
and mastoid process have an even distribution. The median age for
these
cancers
is about 55 years
(Table
1).
Cancer of the auditory canal and middle ear is associated with a chronic otorrhea in about one third of cases. In the remainder, there are re¬ current infections dating back six months to a year. Cholesteatoma have been associated with about a fourth of the middle ear and mastoid carci¬ nomas. Two cases of squamous carci¬ noma of the ear canal have occurred in patients with chronic lymphatic leukemia. A report from the Univer¬ sity of Chicago has indicated that there are eight cases of cancer of the mastoid process which have occurred in radium dial painters.1 Fortunately cancer of the ear is ex¬ tremely rare; the incidence is esti¬ mated at between 1:5,000 to 1:15,000 of all otologie pathological conditions.
Pathological Findings By far the most common type of cancer was squamous carcinoma, com¬ prising 86 of the 100 cases in this
series. Basal cell carcinoma accounted for eight cases, and all arose from the external ear. Two cases of adenocarci¬ noma arising in the auditory canal from ceruminous glands or of pri¬ mary middle ear origin were treated. In addition there were two cases of malignant melanoma, one case of spindle cell sarcoma, and one case of
embryonal rhabdomyosarcoma. Symptoms
and
Diagnosis
The erosion of the external ear by neoplasm is usually obvious, and a biopsy may readily be done on friable bleeding ulcération. The chronically infected auditory canal that fails to
respond to antibiotics and local medi¬
cation may present a more subtle problem. It is estimated in our experi¬ ence that the period of time from the initial symptoms to the diagnosis averages about six months. The onset of bleeding is rather late, and pain oc¬ curs with bone erosion. Hearing loss with otorrhea is the earliest symp¬ tom. Vertigo and facial paralysis in¬ dicate advanced disease. Some pa¬ tients have external swelling due to invasion of the parotid gland and sternomastoid muscle. X-ray films of the mastoid and tomograms will usu¬ ally show the extent of bone destruc¬ tion. The recent use of retrograde jugular venography will demonstrate the possible invasion of the lateral sinus and jugular bulb area. Carotid angiography with the use of subtrac¬ tion technique in the venous phase is useful.
Operative Technique The operation is a combined intracranial-extracranial approach that has been described previously.' Usu¬ ally one or two malleable spinal punc¬ ture needles are inserted in the lum¬ bar spinal canal to withdraw 50 to 100 cc of cerebrospinal fluid. If severe osteoarthritis of the spine precludes their use, furosemide (Lasix) may be used to shrink the brain. The crani¬ otomy flap may be based either above or below, the former being used at the present time. If extensive involve¬ ment of the external ear and auditory canal is present which involves sacri¬ fice of the external ear, a posterior scalp flap or bipedicle scalp flap is used (Fig 1 and 2). High-speed Stry¬ ker air drills facilitate the bony dis-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
section. Bleeding from the lateral sinus is frequent and is controlled with vascular silk and oxidized cellu¬ lose (Surgicel). Segments of dura are replaced with fascia. The temporal muscle is mobilzed and rotated down into the defect to cover the exposed dura. If extensive durai excision and replacement is required, rotation of a scalp flap to cover the defect is necessary.
Operative mortality
duced from this series.
an
has been re¬ initial 10% to 5% in
is usually confined loss from the external jugu¬ lar vein and petrosal sinus. The me¬ dian loss is 1,500 cc. The use of hypo¬ tensive anesthesia has reduced the
1.
Hemorrhage
venous
hemorrhage considerably. 2. The use of preoperative radia¬ tion therapy has led to a high inci¬ dence of postoperative infection to the grafted site. The most common organism is Pseudomonas aeruginosa, which is adequately controlled with colistimethate sodium (Coly-Mycin M Intramuscular) parenterally in combi¬ nation with ampicillin and locally applied acetic acid dressings. Fre¬ quently portions of the skin graft are lost and must be replaced. A perma¬ nent temporal decompression is pres¬ ent, with the result that skin
External
ear
Sex in Advanced Cancer of the Ear Median Age, yr 70
Auditory canal Middle
ear
the dura should always be repaired primarily. If a defect exists, grafting with temporal fascia and skin is man¬ datory. If a cerebrospinal leak per¬ sists for more than ten days, the wound should be reopened and the
repaired. Meningitis and cere¬ bral abscess are hazardous, especially with Gram-negative infections. 5. To avoid facial nerve paralysis, lateral lid fusions are carried out to prevent corneal ulcération. Fascia sling repairs of the affected side with face lift may be carried out at a later date. Facial-hypoglossal anastomoses have been carried out successfully by
cov¬
erage is imperative. 3. If skin coverage of the dura is not intact, cerebral herniation may occur. It will then be necessary to re¬ duce the hernia and cover it by both fascia and scalp flap. 4. To avoid cerebrospinal fistula,
Conley.5
6. Deafness is complete on the op¬ erated side. 7. Vertigo lasts from 5 to 15 days, and there may be a period of un¬ steadiness for several months. 8. Carotid artery thrombosis may occur from trauma or laceration of the internal carotid artery during the operative procedure. In a recent case, thrombosis occurred two days follow¬ ing surgery and resulted in hemi-
plegia.
Role of Radiation
Therapy
In many of our cases, the patients operated on have had a full course of ionizing radiation prior to their refer¬ ral. Preoperative supervoltage radio-
No. of Women
No. of Men 15 22
55 56
and mastoid
tear
Complications to
Age and
40
an established involvement of the Eustachian tube in the middle ear and frequent base-of-skull involve¬ ment. The usual tumor dose is be¬ tween 3,500 and 5,000 rads. In cases in which margins are in doubt, addi¬ tional postoperative radiotherapy is
therapy has become policy because of the
prescribed.
End Results
During the period of 1951 to 1967, a total of 100 cases of temporal bone re¬ section for cancer of the ear have been carried out. The five-year cure rate has been 27% (27 patients). Of the 86 patients with squamous carci¬ noma, the five-year salvage was 25% (22 patients.)
References 1. Parsons
the
temporal
H, Lewis JS: Subtotal resection of bone for
cancer
of the
ear.
Cancer
7:995-1001, 1954. 2. Ward GE, Loch WE, Lawrence W Jr: Radi-
operation for carcinoma of the external auditory canal and middle ear. Am J Surg 82:169-178, cal
1951. 3. Campbell E, Volk BM, Burklund CW: Total resection of the temporal bone for malignancy of the middle ear. Ann Surg 134:397-404, 1951. 4. Beal DD, Lindsay JR, Ward PH: Radiationinduced carcinoma of the mastoid. Arch Otolaryngol 81:9-15, 1965. 5. Conley J: Concepts in Head and Neck Surgery. New York, Grune & Stratton Inc, 1970.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
