Unusual Auricular Complications in Cutaneous Oncology BARRY LESHIN, MD SUZANNE P. HESS, MD WAIN L. WHITE, MD BRIAN L. MATTHEWS, MD JAMES A. KOUFMAN, MD

MOHS MICROGRAPHIC SURGERY

The anatomic complexity of the pinna predisposes that structure to a variety of unique, site specific postoperative complications following management of skin cancer. W e describe four unusual auricular complications: I) radiochondronecrosis; 2) autonecrosis of skin during second intention healing; 3) hearing loss secondary to tragal retraction over the external auditory canal; and 4) extension of tumor through fenestrated cartilage. Well-known postoperative auricular complications are reviewed and anticipation and recognition of these unusual complications are emphasized. J Dermatol Surg Oncol 1991; 17~891-896.

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he pinna is a complex anatomic structure of significant cosmetic and functional importance. Malignancies of this area constitute about 7% of all cutaneous cancers, with reported series ranging from 4.6 to 9.7Y0.l-~The architecture of the ear, comprised of a convoluted, delicate cartilaginous skeleton wafered between thin layers of skin and perichondrium, makes management of cancers at this site challenging. Numerous complications following treatment of tumors on the external ear have been described, including chondritis, perichondritis, chondronecrosis, and stenosis of the external auditory The purpose of this paper is to describe four unusual complications we have

From the Departments of Dermatology, Otolaryngology, and Pathology, Bowman Gray School of Medicine of Wake Forest University, WinstonSalem, North Carolina. Reprints are not available. Presented at the Annual Meeting of the American Sociefyfor Dermatologic Surgery, February 16, 1990, Maui, Hawaii.

0 1991 by Elsevier Science Publishing Co., Inc. 0148-0812/91/$3.50

encountered, none of which has been reported previously.

Case Reports Case 1 A 67-year-old man with a several month history of an intermittently tender right ear was evaluated by his dermatologist in January 1988. Examination revealed a 4mm crusted papule with a rolled border on the right anterior helix. A shave biopsy showed ulceration and actinic damage but no tumor. Approximately 5 days after the biopsy the patient began experiencing tenderness at the biopsy site and developed subsequently a red, swollen, diffusely tender ear (Figure 1).Multiple courses of antibiotics, including amoxacillin/clavulinic acid, clindamycin, and cephalexin yielded little improvement. The patient was then referred to the Department of Dermatology at the Bowman Gray School of Medicine of Wake Forest University. The patient’s medical history was significant for a basal cell carcinoma (BCC) of the right posterior helix treated with radiation therapy 15years previously. Physical examination revealed diffuse erythema and edema of the right ear, most pronounced in areas with subjacent cartilage. The patient was hospitalized for intravenous antibiotic therapy. Biopsies obtained from the right anterior helix showed chronic nonspecific inflammatory changes. Special stains and cultures for organisms were negative. The patient had no response to nafcillin and tobramycin. Prednisone, at a dosage of 60 mg per day, was initiated and erythema, swelling, and pain dramatically decreased. The patient was discharged on a 1-month tapering course of prednisone. Subsequent to completing the course of prednisone, he experienced recrudescence of a tender, swollen, erythematous ear. Repeat biopsy revealed a

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the helix (Figure 2) was also noted 2 months after surgery. Despite the marked deformity, the patient has elected to defer reconstruction. An 80-year-old man was referred for Mohs micrographic excision of a large ulcerated basal cell carcinoma on the posterior aspect of the right ear in November 1989. Deep extension of tumor necessitated removal of underlying cartilage (Figure 3A). Immediately postoperatively, cyanosis was noted in the corresponding anterior surface of the ear. At the conclusion of second intention healing 2 months later, the patient had two foci of full-thickness loss of the ear (Figure 3B).

Case 4 A 59-year-old man was referred in October 1988with a 2to 3-month history of a 2.0-cm ulceration in the conchal bowl of the left ear. A shave biopsy revealed both squamous cell carcinoma (SCC)and BCC. Mohs micrographic Figure 2. (Patient 2.) Full-thickness conchal bowl defect following autonecrosis of skin anteriorly and second intention healing.

Figure 1 . (Patient 1.) Diffuse edema and erythema following skin biopsy on a previously irradiated ear.

suppurative chondritis that was histologically consistent with cartilaginousradionecrosis.After removal of devitalized cartilage under general anesthesia (JAK),the patient healed. He has had no recurrence in 3 years.

Cases 2 and 3 In July 1987 a 44-year-old man was referred for Mohs micrographic excision of a twice recurrent BCC in the left postauricular sulcus. This extensivelyinfiltrated skin and muscle posterior to the sulcus and skin and cartilage anteriorly. Removal of the auricular portion of the tumor required excision of skin and underlying cartilage deep to the dermis of the skin on the anterior surface of the ear. The final defect, which measured 4.0 X 8.5 cm, was allowed to heal by second intention. Cyanosis of the anterior helical skin was noted immediately postoperatively. At his follow-up visit 1 week later, a complete throughand-through defect was present at the previously cyanotic site. Retraction and collapse of the mid-portion of

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Figure 3. (Patient 3.) A) Surgical defect following Mohs micrographic excision of a recurrent BCC. B) Full-thickness auricular defect following second intention healing of wound at left.

excision was performed. The surgical defect measured 4.0 X 2.5 cm and, except for a remnant of skin posterior to the tragus, extended circumferentially around the external auditory canal (Figure 4A). The defect was allowed to heal by second intention. Appropriate healing was noted until January 1989, when the patient noted decreased hearing. Physical examination revealed retraction of the tragus over the external auditory meatus (Figure 4B). In two stages the scarred area of the conchal bowl was excised and resurfaced with an island pedicle flap from the postauricular area and the tragal cartilage was excised (BLM). Hearing returned to normal.

Figure 4. (Patient 4.) A) Surgical defect following Mohs micrographic excision of a mixed SCC and BCC of the conchal bowl. B) Retracted tragus occludes meatus of exfernal auditory canal following second intention healing.

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Figure 5. (Patient 5.) 4) The anterior extension of dumbbell shaped SCC. B) The posterior extension of same tumor. C) Diagram illustrates extension of tumor through cartilage.

Case 5 In May 1986 a 79-year-old man underwent initial excision of an SCC on the right posterior pinna. A recurrence of the SCC was excised in June 1987 and the subjacent cartilage was exposed. The cartilage was fenestrated to facilitate healing by second intention. Monsel's solution (ferricsubsulfate)was used for hemostasis after fenestration. In November 1987 a second recurrence was confirmed by biopsy. At that time the patient was referred for Mohs micrographic excision. On physical examination, the patient had a dumbbell-shaped tumor manifested by a 2.0 X 3.0-cm nodule posteriorly and a 1.0-cm nodule anteriorly (Figure 5). Permanent sections of the tumor revealed extension of tumor through cartilage at the site of previous fenestration, which was biologically tagged with iron deposited from Monsel's solution application (Figure 6).

Discussion The anatomic complexity of numerous facial regions leads to region-specific complications. Periorbital complications such as epiphora or ectropion and facial nerve injury are examples of complications in the management of eyelid or temple tumors. Similarly, the ear may be the site of a variety of region-specific complications that result in significant functional and cosmetic morbidity. Well-recognized complicationsfollowingtreatment of auricular tumors include chondronecrosis, perichondritis, chondritis, and stenosis of the external auditory canal. Perichondritis, chrondritis, and frank chondronecrosis (radionecrosis) have been described previously as complications in the managment of external ear malignan-

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Figure 6. (Patient 5.) Photomicrograph showing extension of squamous cell carcinoma (Arrow) through fenestrated cartilage (H&E, X 6). (Inset) Iron staining (white asterisk) at fenestration site (Prussian Blue, X 35).

~ies.~,' They have occurred following radiation therapy as well as surgery and reflect the intimate relationship of cartilage, perichondrium, and the overlying integument. The onset after therapy is frequently within months but can be as long as 25 years, as previously described in an analogous case of laryngeal carcinoma.1° An uncommon late complication of radiotherapy of the head and neck is chondronecrosis.It is unknown how frequently this complication affects the pinna. However, the estimated incidence of laryngeal radionecrosisfollowing doses of 5000-6000 rad ranges from 5 to 12?40.",'~ Radiation changes that contribute to radionecrosis occur primarily in the blood vessels: 1) hyaline degeneration of collagen in vessel walls with fibrosis, 2) proliferation of endothelial cells in small vessels and lymphatics with

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thrombosis, and 3) increased permeability of small vessels with increasing interstitial edema. These combined changes lead to an obliterative endarteritis with a decrease in microcirculationand thence to chronic ischemia and hypoxemia. Variables related to extent of the radionecrosis include amount of radiation delivered to the tissues, the size of the treatment field, and the interval between treatment and the development of the complication. If interruption of the blood supply to the perichondrium progresses, chondronecrosis will result because the cartilage itself contains no blood vessels and receives its nutrition from the perichondrium. Factors contributing to a progression of chondritis to chondronecrosis include: 1) infection, 2) trauma or mechanical injury, 3) infiltration of cartilage by tumor, 4) previous surgery, 5) intercurrent disease (diabetes, alcoholism, etc.), and 6) a "hot spot" resulting from an excessively large dose or from an inappropriate fractionation of the radia'ion therapy."J2 While infectious perichondritis/chondronecrosis usually follows a traumatic laceration or ear surgery, the progression to suppuration with frank subperichondrial abscess is rapid when untreated. Pseudomonas aeruginosa is the most common off ending 0rgani~m.l~ The histologic findings may be nonspecific unless bacteria are seen. In patients who have received radiation therapy the differentiation between infectious and radiation-induced chondronecrosis may be difficult. Stenosis is a well-known complication following surgery or trauma to the external auditory canal. Wounds with involvement of the partial or complete circumference of the auditory canal can result in stenosis as contraction occurs during second intention healing.1,4,5,8 Methods of immediate reconstruction as well as local measures to prevent this complication have been reported.1,4,5,8,14 In this series of five patients, four unusual complications that we have encountered in the management of auricular cutaneous neoplasms are reported. The clinical features, pathogenesis, and methods to help avert these complications are emphasized. The late sequelae of radiation therapy are protean and are usually the result of compromised vascularity. Radiation-relatedvascular insufficiencyis manifestedhistologically by fibrous thickening of vessel walls with partial or complete luminal o c c l ~ s i o nThis . ~ ~probably played a significant pathogenetic role in the patient described in case 1, who had undergone radiation therapy 15 years before the biopsy that precipitated this complication. It is likely that postbiopsy edema and increased metabolic demands at the biopsy site compromised the already attenuated perichondrial blood supply, resulting in chondronecrosis.

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An analogous situation has been reported recently in chondronecrosis of thyroid cartilage following radiation therapy and subsequent surgery (Koufman JA. Subtotal resection of the thyroid cartilage for laryngeal radionecrosis. Presented at the Annual Meeting of the American Laryngological Association, Palm Beach, Florida, April 25,1988). The diagnosis of radiochondronecrosis should be considered when erythema, edema, and warmth suggestive of cellulitis overlie previously irradiated cartilage. In addition, one should recognize that biopsy of sites overlying previously irradiated cartilage may precipitate this complication.16Prophylactic oral corticosteroid therapy may be a reasonable option in this setting. The surgeon should anticipate possible defects and complications following ablation of malignancies of the external ear. Patients 2 and 3, described in cases 2 and 3, experienced autonecrosis of the anterior cutaneous lamella of the ear following removal of underlying perichondrium, cartilage, and posterior cutaneous lamella. The anterior skin leaflet is thin, and when its blood supply is attenuated by loss of underlying perichondrium, autonecrosis may result.” Certainly defect size and the underlying microcirculation are major determinants influencing possible necrosis. Although it is difficult to predict which patients will have necrosis, our experience suggests that early cyanosis is an ominous sign. Generally, it is advantageous to preserve the anterior cutaneous remnant whenever possible because reconstruction of the full-thickness defect is very difficult. Preservation of the anterior perichondrium (if tumor margins permit) would likely permit necrosis to be averted in most instances. If vascular insufficiency appears likely, it may be possible to salvage the skin of the pinna by immediate coverage of the defect with a local flap or by suturing the pinna remnant to a denuded postauricular area with subsequent secondary repair. Wound contracture following removal of skin around the meatus of the external auditory canal can result in hearing loss secondary to canal s t e n o s i ~ . ~The , ~ , ~canal ,~ stenosis may be averted by grafting or placing a flap over such a or, alternatively, by use of a hydroxylated polyvinyl acetyl wick.14Patient 4 described in case 4 had hearing loss as a complication.However, in this case, scar contraction resulted in retraction of the tragus to occlude a nonstenotic canal. This complicationis another reason why immediate reconstruction of this cutaneous defect postoperatively is advisable. The fifth patient in this series had a twice-recurrent SCC that extended through cartilage at a site where fenestration had previously been performed to induce granulation. The perforation in the cartilage served as a conduit for tumor extension to the anterior surface of the

helix. Fenestration of cartilage is an effective means to enhance gran~lation.~J~J* In this patient it provided an iatrogenic portal for tumor spread. We do not recommend that fenestration be performed at a site of carcinoma removal unless the surgeon is very confident of complete tumor removal.

Conclusion Avoidance of auricular complications can be achieved regularly by compliance with prescribed surgical principles and by anticipation of complications in certain settings. The unusual complications encountered and herein reported might have been avoided had they been foreseen. Hopefully, our experience will help others to avoid the same pitfalls.

References 1. Ceilley RI, Bumstead RM, Smith WH. Malignancies on the external ear: methods of ablation and reconstruction of defects. J Dermatol Surg Oncol 1979;5:762-7. 2. Pless J. Carcinoma of the external ear. Scand J Plast Reconstr Surg 1976;10:147- 51. 3. Hansen PB, Jensen MS. Late results following radiotherapy of skin cancer. Acta Radio1 1968;7:307-19. 4. Buecker JW, Phelan JT. Carcinoma of the external auditory canal: removal and prevention of stenosis. J Dermatol Surg Oncol 1986;12:598-600. 5. Byers R, Kesler K, Redmon B, et al. Squamous cell carcinoma of the external ear. Am J Surg 1983;146:44750. 6. Lederman M.Malignant tumors of the ear. J Laryngol Otol 1965;79:85- 119. 7. Avila J, Bosch A, Aristizabal S, Frias Z, Marcia V. Carcinoma of the pinna. Cancer 1977;40:2891-5. 8. Mohs FE. Chemosurgery: microscopically controlled surgery for skin cancer. Springfield, I L Charles C. Thomas, 1978:85- 105. 9. Fredricks S. External ear malignancy. Br J Plast Surg 1956;9:136- 60. 10. Robson FC, Davis JD. A case of perichondritis and necrosis of laryngeal cartilage 25 years after treatment with radium. J Laryngol Otol 1961;75:997-8. 11. Chandler JR. Radiation fibrosis and necrosis of the larynx. Ann Oto Rhino1 Laryngol1979;88:509 - 14. 12. Strauss M. Long-term complications of radiotherapy confronting the head and neck surgeon. Laryngoscope 1983;93:310- 3. 13. Smith PG, Lucente FE. Infections of the external ear. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-head and neck surgery. St Louis: CV Mosby, 1986~2899-909.

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14. Larson PO. Stenosis of the external ear canal: prevention using hydroxylated polyvinyl acetyl wicks. J Dermatol Surg Oncol 1987;13:1121-3. 15. Ackerman LV. The pathology of radiation effect of normal and neoplastic tissue. Am J Roentgenol Rad Therapy & Nuclear Med 1972;114:447-59. 16. Goodrich WA, Lenz M. Laryngeal chondronecrosis fol-

lowing roentgen therapy. Am J Roentgenol 1948;60: 22 - 8. 17. Mohs F, Larson P, Iriondo M. Micrographic surgery for the microscopically controlled excision of carcinoma of the external ear. J Am Acad Dermatol 1988;19:729-37. 18. Smith JD. Auricular and periauricular surgery. J Dermatol Surg Oncol 1978;4:394-6.

Unusual auricular complications in cutaneous oncology.

The anatomic complexity of the pinna predisposes that structure to a variety of unique, site specific postoperative complications following management...
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