Subtotal Temporal Bone Resection Research Articles

Predictors of Survival and Recurrence after Temporal Bone Resection for Cancer

Malignant tumors of the temporal bone and external auditory canal are uncommon, with annual incidence estimated at between 1 and 6 per million.1,2 Cancers of the external auditory canal/temporal bone comprise <0.2% of head and neck cancers.3 The rarity and anatomic complexity of these tumors hampered the development of an en bloc ablative operation until 1954, when Parsons and Lewis4 from Memorial Hospital in New York first described the technique of subtotal temporal bone resection. Conley and Novack5 refined this technique further in 1960 with the description of lateral temporal bone resection. Subsequent developments in imaging, microsurgery, reconstruction, and neuroanesthesia have all contributed to advancements in skull base surgery. As a result, oncologic temporal bone procedures, including lateral, subtotal, and total temporal bone resection, have become the standard of care for malignant disease involving the external auditory canal/temporal bone. Survival and recurrence outcomes in patients with cancer of the external auditory canal/temporal bone have been reported in several single-institution series. Most cohorts have been limited to squamous cell histology, and comprehensive outcomes analyses have been limited.2,6–24 Further complicating analysis, there is no recognized American Joint Committee on Cancer (AJCC) or Union Internationale Contre le Cancer (UICC) staging system for tumors of the external auditory canal/temporal bone, with multiple systems having been proposed.3,16,25,26 To date, the most widely used system is the University of Pittsburgh staging system, first described in 1990 by Arriaga and colleagues25 and modified in 2000 by Moody et al.3 Other than Pittsburgh stage and surgical margin status, no other factors have been consistently demonstrated to be associated with outcome, and multivariable analyses of factors affecting outcome have not been reported.7,16,20,21 Such a comprehensive analysis of patient and tumor characteristics that are predictive of survival outcomes would aid clinical decision making and risk stratification. The objective of this study was to identify factors predictive of survival and recurrence in a contemporary cohort of patients undergoing temporal bone resection for cancer involving the external auditory canal/temporal bone.

Squamous Cell Carcinoma of the Temporal Bone

Evaluation of the management and survival of patients treated for temporal bone squamous cell carcinoma. A retrospective analysis. Tertiary care, academic referral center. Twenty-eight patients underwent primary treatment for squamous cell carcinoma of the temporal bone. The patients were staged using the modified Pittsburgh staging system. Patients underwent a local resection, lateral temporal bone resection, or a subtotal lateral temporal bone resection usually followed by radiotherapy. The survival rate of patients grouped by tumor size was calculated. Staging revealed 12 pT1, 2 pT2, 4 pT3, and 10 pT4 tumors. The mean follow-up was 34 months (2-132 mo). The Kaplan-Meier survival curves showed survival rates at 5 years of 83 and 25% for the stages pT1 and pT4, respectively. The pooled survival curves showed survival rates at 5 years of 85 and 46% for the stages pT1p/T2 and pT3/pT4, respectively. Long-term prognosis of the carcinoma of the external auditory canal mainly depends on the stage and primary treatment. Surgery may consist of a lateral temporal bone or subtotal temporal bone resection; in T3 and T4 tumors, resection may be combined with a superficial parotidectomy. If disease is diagnosed in the neck or parotid, then a neck dissection and total parotidectomy may also be performed. Additional radiotherapy should be provided in incompletely resected T1 and all T2 and T3 tumors and part of the T4 tumors. T4 tumors may be treated according to their subclassification based on the anatomic extension.

外耳道癌の臨床的検討

Carcinoma of the external auditory canal is infrequent and the prognosis is poor, especially in the advanced stage. Over the 15-year period, from 1992 to 2006, 17 patients with carcinoma of the external auditory canal were treated in our hospital. Eight patients (47%) were male, and nine (53%) were female. The mean patient age was 60 years old, ranging from 24 to 82 years. On pathological analysis, 11 patients (65%) showed squamous cell carcinoma, four (24%) adenoid cystic carcinoma, one (6%) basal cell carcinoma, and one (6%) verrucus carcinoma. Thirteen patients underwent external canal resection, lateral temporal bone resection, or subtotal temporal bone resection. Four advanced patients treated with radiation or chemotherapy without surgical treatment died within one year. The 3-year survival rate was 76.5%, and the 5-year survival rate was 68.0% using the Kaplan-Meier method. The main finding of this study was that radical resection is a reasonable approach and postoperative radiotherapy is helpful for carcinoma of the external auditory canal.

Long-Lasting Deviation of the Subjective Visual Horizontal After Complete Unilateral Vestibular Deafferentation by Subtotal Resection of the Temporal Bone

This study examined whether subjective visual horizontal (SVH) could be compensated in patients with complete loss of unilateral vestibular function. Patients comprised two men and three women who underwent subtotal resection of the unilateral temporal bone due to squamous cell carcinoma of the middle or external ear. Mean patient age was 63.2 years (range, 59-69 yr). Diagnostic. Patients were tested postoperatively (mean, 4 yr 5 mo after the surgery; range, 2 yr 9 mo to 8 yr 6 mo). The task for patients involved adjusting a laser projection bar four times to SVH in darkness. All patients displayed marked deviation of SVH toward the operated side-down. Mean deviation from four trials for each subject was 4.5, 2.9, 3.7, 3.0, and 3.4 degrees. Deviation of SVH in patients with definite unilateral vestibular deafferentation can be long term, lasting more than 2 years at least.

Carcinoma of the External Auditory Canal and Middle Ear: Staging and Management Dilemma

Objectives: This study aims to figure out more accurate staging and proper therapeutic strategy for carcinoma of external auditory canal and middle ear. Study Design: Retrospective review of medical records of patients who were diagnosed as squamous cell carcinoma or adenoid cystic carcinoma of external auditory canal and middle ear between 1989 and 2006. Materials and Methods: 34 patients were enrolled in this study. First, treatment outcomes according to pathologies and stages were investigated. Second, surgical outcomes according to different tumor extent and surgical methods in the same stage were investigated . Third, survival rate according to local invasion to adjacent structures such as parotid gland, facial nerve, temporomandibular joint, infratemporal fossa, dura and intracranium, all of which had been frequently used in other staging systems was investigated. Fourth, the effect of adjuvant radiotherapy in advanced stage (stage III, N) was investigated by comparing the survival rate between the patients who underwent radiotherapy with the patients who did not undergo radiotherapy. Results: Patients of stage I and II showed 90% disease control rates with lateral temporal bone resection (LTBR). However, the survival rates were significantly decreased in stage III and IV. In stage III, LTBR was performed in patients whose tumor was confined to the external auditory canal and middle ear and subtotal temporal bone resection was performed in patients with tumor extending into the mastoid. The difference in disease control rates of the two groups were not significant (p > 0.05). The disease control rates were significantly decreased in the patients with ACC where parotid gland invasion was present (p = 0.007) and in the patients with SCC where dural and intracranial invasion was present (p = 0.001). There was no significant survival difference between the patients who underwent adjuvant radiotherapy and the patients who did not (p > 0.05). Conclusions: For the staging system of carcinoma of external auditory canal and middle ear, it can be concluded that staging system needs to be modified. Stage I and II can be put together since the tumors of those stages showed excellent disease control rates . And stage III tumors confined to the external auditory canal and middle ear can be subdivided into two groups, some of which could be included in earlier stage. For the treatment, LTBR seems to be sufficient for stage I, II and limited cases of stage III where tumor is confined to the external auditory canal and middle ear only. In more advanced stages, adjuvant radiotherapy hardly showed any benefit, and therefore initial surgical treatment is more important.

Skull base surgery for removal of temporal bone tumors

Conclusion. When selecting the appropriate surgical approach the pathological type of tumor, the physiological status as well as the functional aspects should be considered. Understanding the strengths and weaknesses of each surgical technique and knowledge of the particular tumor biology facilitates selection of the most appropriate surgical approach and a successful outcome. Objectives. The purpose of this study was to review cases that underwent skull base surgery for a variety of tumors that involved the temporal bone. We reviewed a single center's 25-year experience for epidemiologic characteristics, symptoms, treatment type and outcomes. Patients and Methods. The medical records and radiological images of 91 patients, who underwent skull base surgery, were retrospectively reviewed. Results. Among the 91 patients, 61 cases had benign disease and 30 had malignancies. A facial nerve schwannoma was the most common benign intratemporal tumor and a squamous cell carcinoma was the most common malignant tumor. With the facial nerve schwannoma, facial nerve paralysis and hearing loss were the most common presenting complaints; otalgia was the most common presenting symptom for temporal bone cancer. For patients with a glomus tumor, there was a characteristic pulsating tinnitus. A majority of the facial nerve schwannomas were resectable through the transmastoid approach. The infratemporal fossa approach type A was usually required for lower cranial nerve schwannomas and glomus jugulare tumors. However, the fallopian bridge technique with hypotympanectomy was another surgical option. Partial temporal bone resection and subtotal temporal bone resections were performed in cases with temporal bone cancer. The disease free 5-year survival of the temporal bone cancers was 42% and for the squamous cell carcinomas, it was 44%.

Squamous Cell Carcinoma of the External Auditory Canal and Middle Ear: An Operation Combined with Preoperative Chemoradiotherapy and a Free Surgical Margin

Treatment outcomes for squamous cell carcinoma of the temporal bone were evaluated regarding stage, therapeutic strategy, and prognostic factors. Retrospective case review. University hospital and outpatient clinic. Twenty-five patients with primary squamous cell carcinoma of the external auditory canal and middle ear. Preoperative chemoradiotherapy and radiotherapy were used in 7 of 12 patients. Lateral temporal bone resection was performed for the lesions not beyond the tympanic membrane. Subtotal temporal bone resection was chosen for lesions extending to the middle ear cavity when there was no invasion to the pyramidal apex, carotid canal, or dura or metastasis. Others were conservatively treated by chemoradiotherapy. When the performance status was poor or an agreement regarding the operation could not be reached, the treatment was modified. Estimated survival rates. The 3-year estimated survival for T1 and T2 lesions was 100%. The 5-year estimated survival for T3 and T4 lesions was 80% and 35%, respectively. The 5-year estimated survival improved up to 75% for T4 tumors with operation and 16% for those without operation after 47 months. The tumor-free surgical margin is significantly related to patient survival in T3 and T4 lesions. Multivariate analysis predicted that concomitant chronic otitis media and positive lymph nodes were significantly associated with poorer survival. The tumor-free surgical margin was important to survival. When T4 lesions did not involve the pyramidal apex, carotid canal, dura, or any lymph nodes, the surgical intervention improved the estimated survival rate to a level as good as T3 lesions.

Primary squamous cell carcinoma of the temporal bone

We report the treatment strategy and outcome for squamous cell carcinoma of the temporal bone in Kyushu University. T staging was classified by the Pittsburgh staging system. Lateral temporal bone resection was applied to both Ti and T2 cases (n = 5). When the lesion extended beyond the cartilaginous part, chemoradiotherapy was preoperatively performed. For T3 (n = 6) or the anterior lateral type of T4 cases (n = 4) without an extension to dura, internal carotid artery, and metastasis, either subtotal temporal bone resection or lateral temporal bone resection was done following the preoperative chemoradiotherapy. The medial type of T4 (n = 13) was treated by chemoradiotherapy without surgical intervention. Although the number of cases and observation period were not enough, adequate results have been obtained in both Ti and T2 cases so far. Disease-specific 5-year survival rates of T3 and T4 were 80% and 36%, respectively. Operation significantly improved the survival rate in T4 cases.

Therapeutisches Management von Gehörgangs- und Mittelohrkarzinomen

Carcinomas of the external auditory canal (EAC) and the middle ear are rare and considered to have a poor prognosis. The recommended therapeutic strategy consists of surgical excision and postoperative radiotherapy. However, there are different opinions about the extend of the primary operation. A series of 21 patients with carcinoma of the EAC and middle ear were treated at the ENT-Department of the Hospital Fulda from 1985 to 2003. Their records and radiologic findings were reviewed retrospectively with particular reference to tumor type and size, its relation to surrounding tissues, surgical procedures and radiation techniques. The tumors were staged according to the modified Pittburgh staging system for temporal bone carcinomas. The average follow-up time was 6.2 years (range 0.2 - 18.75). 17 patients suffered from carcinoma of the EAC, 4 carcinomas were primarily located in the middle ear. There were 15 squamous cell carcinomas, 3 adenoidcystic carcinomas, 2 adenocarcinomas and one mucoepidermoid carcinoma. 12 patients came primarily to our institution and were staged as follows: pT1 (n = 2), pT3 (n = 2), pT4 (n = 8). 8 patients showed up with recurrent or residual tumors (all of T3 or T4 stage). One patient could not be classified. In 5 cases the tumor was inoperable. These patients underwent combined chemoradiation therapy. All other 16 patients were operated and most of them received adjuvant radiation therapy. In the group of patients who were primarily operated overall 5-year survival rate was 100 %. In contrast, patients who's recurrent or residual tumors were resected had a 5-year survival rate of only 33 %. Patients who received combined chemoradiation therapy showed a 2-year survival rate of 75 %. Carcinoma of the EAC and middle ear should be treated primarily by a lateral or subtotal temporal bone resection stage dependent combined with a parotidectomy as well as a neck dissection. Local resection of the EAC is not sufficient, not even in T1 tumors. As from stage T2, in cases of recurrent tumor removal and questionable free margins as well as in cases with lymph node metastases an adjuvant radiation therapy should be added. The most important survival factor is removal of the primary tumor with histologically clear margins.

Squamous cell carcinoma of the external auditory canal and middle ear results of treatment with subtotal temporal bone resection and postoperative radiotherapy

Surgical treatment of carcinoma of the ear canal has evolved over the last half century. Several approaches are practiced. Primary radiotherapy is practiced in only a few centres. The small number of patients seen each year in a given centre, the lack of proper staging and the variability of treatment schedules used, make comparisons difficult. Twenty one cases of histologically proven squamous cell carcinoma of the ear canal seen over a period of 20 years were treated with subtotal temporal bone resection and postoperative external beam radiotherapy. Tumors were staged preoperatively according to the classification suggested by Stell. There were 9 Tl. 7 72 and 2 Ti tumors. Three patients had cervical lymph node melastases at presentation. The overall S year disease free survival was 42%. Quality of life as regards speech, swallowing, body image and social contacts was preserved.

極めて稀な両側外耳道癌症例

We report an extremely rare case of bilateral primary carcinoma of the external auditory meatus. A 50-year-old man suffered 1 month from left-ear discharge and otalgia. Examination revealed a tumor of the left ear canal and a biopsy showed well-differentiated squamous cell carcinoma. The patient underwent 60 Gy radiotherapy and left subtotal temporal bone resection. A tumor with irregular swelling of the right external canal was found 8 months after the first diagnosis. Biopsy of the right external canal confirmed the same squamous cell carcinoma. Genetic examination that the carcinoma of the right ear was probably not a metastatic from the carcinoma of the left ear.

Squamous cell carcinoma of temporal bone: reported on 33 patients.

This study assessed the treatment results of a series of 33 patients with squamous cell carcinoma (SCC) of the temporal bone and evaluated the efficacy of mastoidectomy combined with perioperative radiation therapy protocol. Thirty-three patients with biopsy-proven SCC invaded to the temporal bone were reviewed retrospectively and staged into three subgroups according to the University of Pittsburgh TNM Staging System. There were 3 patients with Stage I and II disease(tumor confined to auditory canal), 17 patients with Stage III (tumor involving the middle ear or mastoid), and 13 patients with Stage IV(more extensive disease). Two patients were treated by surgery alone. Eleven patients received irradiation only, and the remaining 20 patients underwent combined surgery and perioperative radiotherapy. The surgical intervention included sleeve resection for patients with Stage I and II lesions and mastoidectomy for all patients with Stage III and IV lesions except 1 who had subtotal temporal bone resection. The radiation dose delivered was in the range of 3500 approximately 10 000 cGy, with an average dose of 6560 cGy. The five-year survival rate for the whole series was 51.7% by the life-table analysis. After being staged into three subgroups (ie, Stage I + II, Stage III, and Stage IV), the estimated five-year survival rates were 100%, 68. 8%, and 19.6%, respectively (p = 0.04). Radiation alone yielded a 28. 7% five-year survival, while combined surgery and irradiation gave a result of 59.6% (p = 0.80). For patients treated with planned combined therapy, the actuarial five-year survival rates were 72.7% (8/11) for Stage III disease and 12.5% (1/8) for Stage IV disease (p = 0.02). Twelve patients who died of disease did so of local recurrence (10 cases), cervical metastases (1 case), and liver metastases (1 case), with 70% of succumbing to their diseases within two years. Complications include osteonecrosis (n = 1), osteitis (n = 3), radiation dermatitis (n = 2), facial nerve palsy (n = 2), and delayed healing (n = 2). Data on clinical presentation and treatment modality were also analyzed. The results of mastoidectomy with removal of all gross tumor, combined with planned perioperative irradiation therapy, seems to be a useful approach for SCC of the temporal bone. This gives at least as good, and possibly better, five-year survival than temporal bone resection. The mastoidectomy procedure creates less operative morbidity and mortality. To facilitate the development of more effective means of treating advanced disease, an accepted staging system and cooperative group investigation is necessary.

Reconstruction After Temporal Bone Resection

Reconstruction of soft tissue defects after temporal bone resection can vary from simple closure of the external auditory canal to complex flap coverage of extensive defects. Between 1987 and 1996, 34 patients underwent lateral skull base resections and reconstruction for invasive carcinoma of the temporal bone. Seven underwent sleeve resection and/or radical mastoidectomy. Sleeve resection was managed with tympanoplasty, canalplasty, or obliteration of the external auditory canal (10). There were 24 lateral temporal bone resections and four subtotal temporal bone resections. Larger defects created by lateral and subtotal temporal bone resections required closure with a combination of temporalis flaps and local rotational cutaneous flaps (13). Lower island trapezius flaps (five), free flaps (four), and pectoralis major flaps (two) were also used. Indications and efficacy of each method are discussed, and treatment outcomes are presented.

Summary Skull Base Surgery for Ear Carcinoma

Multidiciplinary collaboration with otolaryngological, neurosurgical and platic surgical techniques has made it possible to perform safe skull base surgeries. It has also ensured to step up resectable limits for en bloc resection of ear carcinoma. Since 1991, five patients with squamous cell carcinoma of the middle ear or external ear canal underwent skull base surgery for en bloc resection of the pathology in Kobe University Hospital. Among 5 patients, four underwent subtotal temporal bone resections. Out of these patients, two have survived over 6 years without disease. Other two patients died of disease within 6 months after surgery. The reasons for death were distant metastasis to lung in one patient, and accidental bleeding which provided irreversible brain damage in the other. The last patient who underwent lateral temporal bone resection with middle cranial f ossa on the grenoid fossa has survived over 3 years without disease. In this paper, our technique for subtotal temporal bone resection, including the exposure of the pyramidal course of the internal carotid artery and entire resection of the eustachian tube, was precicely reported. And based on above experiences, current problems to perform skull base surgery for ear carcinoma was also discussed.

中耳癌に対する側頭骨亜全摘術

中耳癌に対する側頭骨亜全摘術

Subtotal temporal bone resection for middle ear carcinoma

Subtotal temporal bone resection was done for two patients with squamous cell carcinoma of the middle ear. In the first patient, a 68-year-old man, intracranial resection was performed with the resection of the dura mater of middle and posterior cranial fossa, the sigmoid sinus, and total length of auditory tube. In the second patient, a 48-year-old woman, extradural resection was pertormed. Both patients are free of disease over thirty nine months and thirty two months, respectively. From these experiences, key points of this operation are discussed in this paper. Firstly, for wider resection of the tip of petrous bone, release of the carotid artery from the carotid canal is mandatory. It is achieved by drilling the ventral aspect of the carotid canal. Secondly, total resection of the auditory tube including the pharyngeal orifice is mandatory when the tumor extension into the tube is strongly suggested. Thirdly, the significance of the preservation of the lower cranial nerves at the pars nervosa of the jugular foramen, and that of the vein of Labbe are stressed.

中耳へん平上皮癌例 側頭骨摘出標本の病理組織学的検討

A 48-year-old woman developed middle ear carcinoma after radical mastoidectomy. The left temporal bone was examined after 40Gy of irradiation.A pathological study of the resected temporal bone revealed necrotic tissue and fibrous tissue in 80% of the middle ear. Carcinoma cells were observed in the tympanic sinus, round window niche, anterior wall of the external auditory meatus, and mastoid cells. Carcinoma was still present in the eustachian tube. Six months after surgery, the patient had a local recurrence. Ten months later, she died after cancer had invaded the brain.Radiotherapy for middle ear carcinoma cannot be considered radical treatment. Multi-modal treatment, including subtotal temporal bone resection, is more effective than radiotherapy alone.

Squamous Cell Carcinoma of the External Auditory Meatus (Canal)

A retrospective study of 35 patients with squamous cell carcinoma of the external auditory meatus treated at the Eye and Ear Hospital of the University of Pittsburgh was performed. The standard treatment was a temporal bone resection that corresponded to the extent of the lesion, followed by postoperative radiation therapy. The tumor extensions, symptoms, treatments, survival rates, and prognostic variables were reviewed. Overall, 12 of 35 patients survived. Lesions limited to the external auditory meatus with no erosion had excellent prognoses. Survival in intermediate lesions with bony erosion or middle ear involvement was related to the status of surgical margins after partial or subtotal temporal bone resections. Extensive lesions that involved the surrounding soft tissue or dura had poor prognoses. The survival value of total temporal bone resection remains unproved.

Anatomic considerations of the medial cuts in the subtotal temporal bone resection.

Eighteen temporal bones, 20 sets of polytomograms, and two sets of histologically sectioned temporal bones were studied and the literature was reviewed in order to describe the evolution and anatomic detail of the medial limits of the subtotal temporal bone resection used when malignant neoplasia has invaded the middle ear. An en bloc resection requires incisions medial to the pneumatized spaces involved. The anatomy of the lines of resection through the glenoid fossa, medial to the lateral wall of the carotid canal, through the cochlea, internal auditory canal, and jugular bulb, and just lateral to cranial nerves IX, X, and XI was described in detail. Regardless of the techniques employed, or the feasibility of the task, the concept of en bloc resection must conform to the anatomy of the region.

En bloc subtotal temporal bone resection for cancer of the external ear.

✓ The authors report their technical experience with the en bloc subtotal temporal bone resection of cancer of the external ear involving the temporal bone. With the cooperation of an experienced plastic surgery team, coverage of the large defect with a rotation flap makes this procedure successful by wound healing per primam. Complications such as hemorrhage, vascular thrombosis, and brain abscess can be minimized by strict application of neurosurgical and plastic surgery techniques. Two successful cases are described in detail.