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Malignant Tumors of the Temporal Bone Workup

  • Author: Stephanie A Moody Antonio, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Feb 25, 2016
 

Laboratory Studies

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  • Routine preoperative testing includes CBC counts, electrolyte level tests, renal function tests, liver function tests, and coagulation studies (if warranted based on the patient's history of bleeding and current medications).
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Imaging Studies

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  • CT scanning of the temporal bone and neck: A physical examination alone cannot adequately evaluate the extent of tumor extension beyond the pinna. Specific radiographic information is crucial for accurate preoperative staging. Obtain a fine-cut (1 mm) high-resolution CT scan of the temporal bone. The radiologist should evaluate the study specifically for EAC erosion, middle ear involvement, otic capsule erosion, mastoid involvement, jugular fossa erosion, carotid canal erosion, tegmen erosion, and posterior fossa involvement. The facial nerve, stylomastoid foramen, temporomandibular joint, parotid gland, and infratemporal fossa should also be carefully examined.
  • Magnetic resonance imaging: CT scanning may be unreliable to differentiate fluid and inflamed mucosa from a tumor in the middle ear and mastoid, especially when no bony erosion is present to raise the suspicion for the presence of a tumor. In addition, spread along fascial planes and neurovascular structures can be very difficult to detect. In these situations, MRI with gadolinium enhancement can be helpful because it better delineates soft tissue interfaces.
  • Chest radiography: If the histology indicates squamous cell carcinoma, obtain plain radiographs or CT scans of the chest to rule out metastasis.
  • CT scanning of the chest, abdomen, or pelvis: CT scanning of the chest, abdomen, or pelvis is not necessary unless the biopsy specimen of the temporal bone tumor reveals a tumor with a known propensity for metastasis. This type of tumor includes melanoma, adenocarcinoma, lymphoma, and renal cell carcinoma.
  • Carotid angiography with balloon occlusion Xenon test: If the carotid artery is suspected to be involved, angiography with ipsilateral balloon occlusion Xenon testing is performed to demonstrate the adequacy of cerebral blood flow from the contralateral carotid artery. Special attention is also given to the venous outflow phase to determine the adequacy of the contralateral sigmoid/jugular system in case the surgery requires sacrifice of the sigmoid sinus or internal jugular vein.
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Other Tests

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  • Audiometry: An audiogram is obtained prior to performing any major procedure on the ear or temporal bone. Audiograms provide baseline hearing thresholds for future comparison.
  • Electrocardiography
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Diagnostic Procedures

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  • Biopsy: Obtain a biopsy to determine whether the lesion in the ear is benign or malignant. A needle biopsy can be performed if most of the mass is subcutaneous or in the parenchyma of the parotid gland. A staging mastoidectomy is not appropriate.
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Histologic Findings

Although CT scanning provides important preoperative staging information, systematic pathologic evaluation of the specimen is crucial for staging and treatment. For example, if pathologic evidence of bony invasion or soft tissue spread is found but was not predicted by findings on preoperative imaging studies, the stage may be adjusted and adjuvant therapy considered.

The surgeon should personally orient the surgical tissue for the pathology team. The pathologist should then examine multiple sections of key elements (eg, bony EAC, facial canal, otic capsule, tympanic ring, bony-cartilaginous junction). The soft tissue margins at the stylomastoid foramen, infratemporal fossa, and facial nerve (if resected) should be detailed. Also, mucosal samples of the middle ear and mastoid should be specifically examined.

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Staging

Staging systems are intended to help classify patients preoperatively into groups whereby decisions regarding treatment may be made on the basis of comparison to previously treated patients with similar tumor characteristics (ie, the stage). To date, no staging system for temporal bone malignancies is universally accepted. Several factors impede the process of developing a staging system, including the rarity of the tumors, the impossibility of evaluating disease extent by physical examination alone, and the unreliability of radiographic studies to determine the extent of disease in certain situations.

Many authors have proposed staging systems concurrent with a review of patient series from major institutions; however, the small number of patients per group, the disparity of staging criteria, the diversity in management protocols, and the use of nonstandardized surgical nomenclature prohibits meaningful comparison of outcomes. In addition, some patients are reportedly classified into groups with variability in histology types and sites of tumor origin, which further confounds analysis of outcome by stage.

Numerous staging systems have been proposed; however, to date, no universally accepted staging system for temporal bone cancers exists. A staging system for squamous cell cancers of the EAC proposed by the University of Pittsburgh has been shown useful and has gained support in the literature.[8, 9, 10, 5, 1, 11] This staging system is based on clinical, radiologic, and pathologic findings. In general, tumors that are limited to the EAC are defined as early disease, and those that extend beyond the external canal to invade the surrounding soft tissues, the middle ear, the mastoid, or CNs are recognized as advanced disease.

In the original staging system proposed by Pittsburgh, lesions were defined as follows:[8]

  • T1 - Tumor limited to the EAC without bony erosion or evidence of soft tissue involvement
  • T2 - Tumor with limited EAC bone erosion (not full thickness) with limited (< 0.5 cm) soft tissue involvement
  • T3 - Tumor eroding the osseous EAC (full thickness) with limited (< 0.5 cm) soft tissue involvement or tumor involving the middle ear, mastoid, or both
  • T4 - Tumor eroding the cochlea, petrous apex, medial wall of the middle ear, carotid canal, or jugular foramen of dura; or with extensive soft tissue involvement (>0.5 cm), such as involvement of the temporomandibular joint or stylomastoid foramen; or with evidence of facial paresis

The Pittsburgh staging system has become widely applied in case reports of temporal bone cancer.[1, 12]

The Pittsburgh staging system was modified by the authors after further review of patients from an extended series.[6] In the modified staging system, facial nerve weakness is considered a criterion for a T4 lesion. The authors observed that facial nerve paresis did not occur in lesions otherwise classified as limited T1, T2, or T3 lesions. Involvement of the facial nerve would be otherwise classified as T4 based on the anatomical area of involvement, including the medial wall of the middle ear (horizontal segment), extensive bony erosion within mastoid (vertical segment), or involvement of stylomastoid foramen. In the T4 group, survival was similar between patients with and without facial paralysis (unpublished). A few reports have used the modified staging system.[13]

Nodal involvement and stage can be classified as it is for other cancers of the head and neck.

  • N1 - Single ipsilateral lymph node, size less than 3 cm
  • N2 - Single ipsilateral node, size 3-6 cm
  • N2b - Multiple ipsilateral nodes, all less than 6 cm
  • N2c - Bilateral or contralateral nodes, all less than 6 cm
  • N3 - Nodes involved greater than 6 cm

Cancer is staged as follows:

  • Stage 0 - Tis N0 M0
  • Stage I - T1 N0 M0
  • Stage II - T2 N0 M0
  • Stage III - T3 N0 M0, T1 N1 M0, T2 N1 M0, T3 N1 M0
  • Stage IV - T4 N0 M0, T4 N1 M0, any T N2 M0, any T N3 M0, any T any N M1
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Contributor Information and Disclosures
Author

Stephanie A Moody Antonio, MD Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School

Stephanie A Moody Antonio, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, Virginia Society of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Barry E Hirsch, MD Professor, Department of Otolaryngology, Director, Division of Otology/Neurotology, University of Pittsburgh School of Medicine

Barry E Hirsch, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American College of Surgeons, American Otological Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Erik Kass, MD Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern Virginia

Erik Kass, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Association for Cancer Research, American Rhinologic Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

B Viswanatha, DO, MBBS, PhD, MS, FACS Professor of Otolaryngology (ENT), Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute, India

B Viswanatha, DO, MBBS, PhD, MS, FACS is a member of the following medical societies: Indian Medical Association, Indian Society of Otology, Association of Otolaryngologists of India

Disclosure: Nothing to disclose.

References
  1. Moffat DA, Wagstaff SA, Hardy DG. The outcome of radical surgery and postoperative radiotherapy for squamous carcinoma of the temporal bone. Laryngoscope. 2005 Feb. 115(2):341-7. [Medline].

  2. Keereweer S, Metselaar RM, Dammers R, Hardillo JA. Chronic serous otitis media as a manifestation of temporal meningioma. ORL J Otorhinolaryngol Relat Spec. 2011. 73(5):287-90. [Medline].

  3. Jin YT, Tsai ST, Li C, Chang KC, Yan JJ, Chao WY, et al. Prevalence of human papillomavirus in middle ear carcinoma associated with chronic otitis media. Am J Pathol. 1997 Apr. 150(4):1327-33. [Medline].

  4. Lim LH, Goh YH, Chan YM, Chong VF, Low WK. Malignancy of the temporal bone and external auditory canal. Otolaryngol Head Neck Surg. 2000 Jun. 122(6):882-6. [Medline].

  5. Leonetti JP, Smith PG, Kletzker GR, Izquierdo R. Invasion patterns of advanced temporal bone malignancies. Am J Otol. 1996 May. 17(3):438-42. [Medline].

  6. Moody SA, Hirsch BE, Myers EN. Squamous cell carcinoma of the external auditory canal: an evaluation of a staging system. Am J Otol. 2000 Jul. 21(4):582-8. [Medline].

  7. Choi JY, Choi EC, Lee HK, Yoo JB, Kim SG, Lee WS. Mode of parotid involvement in external auditory canal carcinoma. J Laryngol Otol. 2003 Dec. 117(12):951-4. [Medline].

  8. Arriaga M, Curtin H, Takahashi H, Hirsch BE, Kamerer DB. Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings. Ann Otol Rhinol Laryngol. 1990 Sep. 99(9 Pt 1):714-21. [Medline].

  9. Austin JR, Stewart KL, Fawzi N. Squamous cell carcinoma of the external auditory canal. Therapeutic prognosis based on a proposed staging system. Arch Otolaryngol Head Neck Surg. 1994 Nov. 120(11):1228-32. [Medline].

  10. Zhang B, Tu G, Xu G, Tang P, Hu Y. Squamous cell carcinoma of temporal bone: reported on 33 patients. Head Neck. 1999 Aug. 21(5):461-6. [Medline].

  11. Gillespie MB, Francis HW, Chee N, Eisele DW. Squamous cell carcinoma of the temporal bone: a radiographic-pathologic correlation. Arch Otolaryngol Head Neck Surg. 2001 Jul. 127(7):803-7. [Medline].

  12. Gaudet JE, Walvekar RR, Arriaga MA, Dileo MD, Nuss DW, Pou AM, et al. Applicability of the pittsburgh staging system for advanced cutaneous malignancy of the temporal bone. Skull Base. 2010 Nov. 20(6):409-14. [Medline]. [Full Text].

  13. Nyrop M, Grontved A. Cancer of the external auditory canal. Arch Otolaryngol Head Neck Surg. 2002 Jul. 128(7):834-7. [Medline].

  14. Kunst H, Lavieille JP, Marres H. Squamous cell carcinoma of the temporal bone: results and management. Otol Neurotol. 2008 Jun. 29(4):549-52. [Medline].

  15. Nakagawa T, Kumamoto Y, Natori Y, et al. Squamous cell carcinoma of the external auditory canal and middle ear: an operation combined with preoperative chemoradiotherapy and a free surgical margin. Otol Neurotol. 2006 Feb. 27(2):242-8; discussion 249. [Medline].

  16. Pemberton LS, Swindell R, Sykes AJ. Primary radical radiotherapy for squamous cell carcinoma of the middle ear and external auditory cana--an historical series. Clin Oncol (R Coll Radiol). 2006 Jun. 18(5):390-4. [Medline].

  17. Prasad SC, Mimoune HA, D'Orazio F, et al. The role of wait-and-scan and the efficacy of radiotherapy in the treatment of temporal bone paragangliomas. Otol Neurotol. 2014 Jun. 35(5):922-31. [Medline].

  18. Hirsch BE, Chang CYJ. Carcinoma of the temporal bone. Myers EN, ed. Operative Otolaryngology Head and Neck Surgery. Philadelphia, Pa: WB Saunders; 1997. 1434-1458.

  19. Medina JE, Park AO, Neely JG, Britton BH. Lateral temporal bone resections. Am J Surg. 1990 Oct. 160(4):427-33. [Medline].

  20. Morris LG, Mehra S, Shah JP, Bilsky MH, Selesnick SH, Kraus DH. Predictors of survival and recurrence after temporal bone resection for cancer. Head Neck. 2011 Sep 23. [Medline].

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  23. Hirsch BE, Myers EN, Moody SA. Malignant tumors of the temporal bone. Laercio O, Selaimen S, eds. Otologia Clinia e Cirurgica. Revinter, Tijuca: 2000. 319-329.

  24. Parsons H, Lewis JS. Subtotal resection of the temporal bone for cancer of the ear. Cancer. 1954 Sep. 7(5):995-1001. [Medline].

 
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Coronal image that represents the following potential routes of spread of temporal bone cancer: 1) Anteriorly into the soft tissues of the temporomandibular joint and parotid through the fissures of Santorini. 2) Laterally via the soft tissue and cartilage of the external auditory canal to the concha and pinna. 3) Medially through the tympanic membrane to the middle ear, inner ear, and mastoid. 4) Posteriorly into the mastoid, epitympanum, and middle fossa. 5) Spread can continue through the Eustachian tube to the infratemporal fossa. 6) Spread through the round window, oval window, or facial nerve into the internal auditory canal and cerebellopontine angle. 7) Along the facial nerve through the mastoid and into the stylomastoid foramen and beyond. 8) Via the mastoid into posterior fossa 9) Along structures of the skull base, including the carotid, jugular bulb, and clivus.
Axial image that shows the spread of temporal bone cancer.
Axial T1 MRI with gadolinium of right T4 squamous cell carcinoma.
Axial T1 precontrast image of the same patient from Image 3.
Axial CT scan of the same patient from Image 3 with T4 squamous cell carcinoma.
Axial CT scan of a patient with recurrent basil cell carcinoma of the pinna, spread to the left inferior temporal bone.
 
 
 
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