Temporal Bone Resections for Carcinoma of the Middle Ear and the External Ear Canal R a m m o h a n Tiwari, MD, MS, FRCS, PhD, Louw Feenstra, MD, PhD, A b d u l K a r i m , MD, PhD, Amsterdam,The Netherlands

Petrosectomy has been used in the management of carcinoma of the external ear canal and the middle ear for the last 45 years. In recent years, there have been conflicting reports; some authors advocate a conservative approach, whereas others support an ultraradieal approach. Most retrospective studies report patients who have been treated with radiotherapy or surgery as having undergone the primary modality depending on where the patient first presented. No selection criteria seem to have been employed. Although radiotherapy was used postoperatively, the problems of wound healing were not addressed. This study presents our experience with temporal bone resection as described by Lewis and shows that, in combination with patient selection and proper choice of incision, reconstruetion and timely postoperative radiotherapy can achieve better results, and the patient's quality of life can be preserved.

From the Departments of OtolaryngologyHead and Neck Surgery (RT) and Radiotherapy (AK), Free UniversityHospital,Amsterdam, The Netherlands. Dr. Feenstra is presentlyworkingin the Department of Otolaryngology,l..cuven,Belgium. Requests for reprints should be addressed to Rammohan Tiwari, MD, MS, FRCS, PhD, Departmentof OtolaryngologyHead and Neck Surgery, Free UniversityHospital, de Boelelaan 1117, 1081 HV Amsterdam~The Netherlands. Presentedat the Third InternationalConferenceon Head and Neck Cancer, San Francisco,California,July 26-30, 1992. 64,8

lthough temporal bone resection for malignant tumors of the external ear canal and the middle ear A has been performed for over four decades, the overall 5year survival has not significantly changed [1]. In recent years, both conservative and ultraradical approaches have been described [2,3]. At the same time, reports have appeared in the literature of apparently large series of patients indicating a high complication rate and poor survival figures [4]. These studies have advocated a return to conservatism. Because these tumors are rare, few centers see a significant number over a long period of time. The:purlx~e of this paper is to present our experience in the management of carcinoma of the external ear canal and the middle ear. During the ll-year period from 1980 through 1991, 23 patients with carcinomas located in the external ear canal and the middle ear were seen, which corresponded to 0.5% of all head and neck malignancies. There was one recurrent basalioma and one adenoid cystic carcinoma, and the rest were squamous cell carcinomas. Only one patient was found to be suitable for partial temporal bone excision, the tumor being limited to the external ear canal. Essentially, our approach has been one of planned radical excision as described by Lewis [I], followed by a full course of megavoltage radiotherapy. Two patients were considered poor surgical risks because of their age, poor general health, and the local spread of the disease and were referred back to regional centers for palliative radiotherapy. Standard techniques of excision were used, initially with a preauricular and postauricular incision and a retromandibular extension with a three-point junction under the ear and reconstruction with the temporalis muscle, supported when necessary with split skin grafting as described by Lewis. It was observed that the wound healing was slow and often complicated by a breakdown at the tripartite junction. Postoperative radiotherapy was therefore delayed. We abandoned this policy in 1985 after a period of 5 years from 1980 through 1984. The extended use of these procedures was essentially because of the small number of cases. Since 1985, all patients underwent operation through a vertical incision, and we currently use a modified Blair incision (Figure 1) [5]. Reconstruction was achieved with a sternomastoid myocutaneous or muscle flap [6] (Figure 2). RESULTS The change of approach resulted in an early postoperative recovery, with the average postoperative hospital stay reduced from 5.5 to 3.5 weeks. Timely resumption of postoperative radiotherapy was therefore possible. Despite the initial problems, an overall survival of 41% for all patients was achieved, with a minimum follow-up of 3

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Figure 1. The incision begins 3 to 4 cm above and in front of the helix and enters the concha of the pinna through the fissure between the helix and the tragus. The concha is detached from the external auditory canal, and the incision is extended between the tragus and the antitragus to the preauricular sulcus where it soon turns back under the ear Iobule over the mastoid tip, forward in a round sweep over the stemomastoid muscle toward the hyoid.

years and a maximum of 11 years. For patients with squamous cell carcinoma, this figure was 39%. There was no mortality, and the morbidity was reduced considerably. Cs The appearance of conflicting reports in the literature over the last few years have cast doubts on the value of petrosectomy in the management of malignancies of the middle ear and the external auditory canal. An awareness of the rarity of these lesions and a clear concept on the part of the specialist treating these tumors are essential. We believe that the technique of petrosectomy described by Parson and Lewis [7] is oncologically sound and technically safe. However, it is essential that the patients who are to undergo this surgery be properly selected. It would appear that in the past those who advocated surgery operated on all their patients, and those who propagated the use of radiotherapy encouraged its use in all patients [8]. Undoubtedly, these are rare tumors, which may seldom be seen in an early stage. Modern imaging techniques make a reasonably accurate assessment possible. A preoperative assessment of the state of the general

Figure 2. Posto~ative photograph of a patient after temporal bone resection and reconstruction with the sternomastoid myocutanaous flap. No skin grafting of the donor site was needed. This patient also had a capillary hemangioma of the face and neck.

health of the patient combined with the progress of the local spread of the disease makes prognostic evaluation possible and helps in patient selection [9]. Our experience has shown that the tripartite incision is best avoided. Since the adoption of a single incision, no wound healing problems have been encountered, and the exposure obtained is equal if not better than that found with a tripartite incision. Reconstruction with myocutaneous or muscle flaps that are either pedicled or free vascularized offers the best chance of filling a potentially large cavity while protecting the dura and important vessels and nerves. The sternomastoid muscle is locally available and retains its blood supply from the occipital artery. The accessory nerve seldom needs to be sacrificed. The volume of muscle and skin is sufficient. The temporalis muscle by itself is inadequate for the purpose of reconstruction but serves as a useful adjunct to the other methods. When a neck dissection is indicated, flaps other than the sternomastoid are used. Faciohypoglossal anastomosis remains the method of choice for the restoration of facial innervation, and, although radiotherapy may, to some extent, retard recovery after such a procedure, the ultimate return of facial symmetry and movement is close to

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70%. The period of full recoveryvaries from 6 to 9 months after the completion of the treatment. Besides the early recovery, the quality of life enjoyed by patients treated since 1985 by the modified approach and the reduced complication rate have convinced us of the benefits of the changes in the approach mentioned earlier. Although these changes appear to be minor, their impact on the morbidity and mortality as well as the preservation of the quality of life of our patients has undoubtedly been significant. Lastly, temporal bone resections belong to a special class of surgical expertise that requires highly skilled attention that can ideally be provided when the otologist and the head and neck surgeon perform as a team.

~NCES 1. Lewis JS. Cancer of the external auditory canal, middle car and mastoid. In: Suen, Myers, editors. Cancer of the head and neck. New York: Churchill Livingstone, 1981: 557-75.

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2. Kinney SE, Wood BG. Malignancies of the external car canal and temporal bone. Surgical techniques and results. Laryngoscope 1987: 97; 158-63. 3. Sataloff RT, Myers DL, Lowry LD, Spiegel JR. Total temporal bone resections for squamous cell carcinoma. Otolaryngol Head Neck Surg 1987: 96; 4-14. 4. Goldingwood DG, Quiney RE, Cheesman AD. Carcinoma of the ear. Retrospective analysis of 61 patients. J Laryngol Otol 1979: 103; 653-6. 5. Tiwari RM. Reconstruction after subtotal temporal bone resections. J Laryngol Otol 1985: 99; 143-6. 6, Tiwari RM. Experiences with sternocleidomastoid myocutaneous flaps. J Laryngol Otol 1990: 104; 315-21. 7. Parson H, Lewis JH. Subtotal resection of the temporal bone for cancer of the ear. Cancer 1954: 7; 995-1001. 8. Stell PM. Carcinoma of the external auditory meatus and middle car. Clin Otolaryngol 1984: 9; 281-99. 9. Stell PM, McCormick MS. Carcinoma of the external auditory meatus and middle ear. Prognostic factors and suggested staging system. J Laryngnl Otol 1985: 99; 847-50.

THE AMERICAN JOURNAL OF SURGERY VOLUME 164 DECEMBER 1992

Temporal bone resections for carcinoma of the middle ear and the external ear canal.

Petrosectomy has been used in the management of carcinoma of the external ear canal and the middle ear for the last 45 years. In recent years, there h...
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