Horizontal Canal Paror

REFERENCES

Positional Vertigo (HCPPV) vs classical BPPV

6.

Schuknecht H. F. (1969) : Cupulolithiasis, Arch. Otolaryngol, 90 :

765-768.

l.

Chalton, R., Mackay, I., Wilson, R. and Cole P. (1985) : Doubleblind placebo controlled trial of betamethasone nasal drops for nasal
polyposis, British Medical Journal, 291 : 788.

7.

2.

Fife, T. D. (1998) : Recognition and Management of horizontal

canal Benign Positional vertigo American J. Otology 19 : 345-35.

Wood, C. D. and Graybzil, A. (1970) : A theory of motion sickness,

based on pharmacological reaction, clinical Pharmacology and
Therapeutics, 11 : 621-629.

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3.

Ghosh P. (2000) : Modified Epley Manoeuvre (How I do it ?), A

domicilliary therapy. Accepted for publication in Indian J.
Otolaryngology and Head and Neck Surgery (in press).

Wood, C. D. and Graybzill, A (1973) : A theory of motion sickness,

Otolaryngologic Clinic of North America, 6:308.

4.

Henry Gray of Gray's Anatomy,

Address for Correspondence :

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Parnes L.S. and Mc Clure J. A. (1992) : Free floating endolymph

particle : a new operative findings during posterior semicircular
canal occlusion, Laryngoscope, 102 : 901-906.

Dr. P. Ghosh
40/60, C. R. Park, New Delhi - 110 019

SQUAMOUS CELL CARCINOMA OF THE EXTERNAL

AUDITORY CANAL AND MIDDLE EAR
RESULTS OF TREATMENT WITH SUBTOTAL TEMPORAL
BONE RESECTION AND POSTOPERATIVE RADIOTHERAPY
Rammohan Tiwari I, Jolijn Brouwer 2, Jasper Quak 3, Hilde Tobi 4,
Henry Winters s, Dinesh Mehta 6

Key Words : E a r C a n a l Middle Ear Squamous C a r c i n o m a Surgery Radiotherapy

INTRODUCTION
Tumors of the external auditory canal (EAC) and middle ear
are uncommon. Ten percent of all tumors involving the ear
are located in the ear canal. The skin of the ear canal is 0.5
to 1 mm thick in the cartilagenous part, but only 0.2 mm
thick in the bony part of the external ear canal. Lesions of
the bony canal therefore have greater propensity to invade
the bone 1,2' Although it is customary to classify tumors into
those located in the middle ear and others localized in the
ear canal, once a tumor in the ear canal grows to occupy the
canal completely, it is difficult to precisely assess its medial
extent. Alternatively a tumor may originate in the middle ear
and grow in the ear canal. Stell's classification of EAC
carcinoma is practicah. Tumor localized in the ear canal

without bone invasion being T 1 and with evidence of bone

invasion being T2. Tumor causing facial paralysis or evidence
of spread beyond the EAC is classified as T3. Various surgical
procedures have been described in the literature. The object
of this article is to present our experience with the long term
results of management of this tumor with surgery and
postoperative radiotherapy.

PATIENTS AND METHODS

Twenty five patients with a diagnosis of carcinoma located
in the EAC were treated with surgery and postoperative
radiotherapy over a 20 year period between 1979 and 1998
at the department ofotolaryngology head neck surgery of the
University Hospital VU, Amsterdam. There were 21 men

~Department of Head and Neck, Surgical Oncology. Reconstructive and Skull Base Surgery, Bangalore Institute of Oncology, 2Dept. of Otolaryngology
Head Neck Surgery, University Hospital VU, Amsterdam, The Netherlands, 3Dept. of Plastic Surgery, University Hospital VU, Amsterdam, The Netherlands,
4Dept. of Epidemiology and Biostatistics, Faculty of Medicine VU, Amsterdam, The Netherlands, 5Dept. of Radiotherapy, University Hospital VU,
Amsterdam, The Netherlands.

180

Fig I :

Squamous Cell Carcinoma of the External Auditoty Canal and Middle Ear

Alternative incision developed by the first author, used since

1985 for temporal bone resections. The incision begins 2 cm
above the level of the pinna in the preauricular area and extends
to the concha through the sulcus between the helix and the tragus.
The concha is detached fi'om the EAC and the incision is extended
back to the preauricular crease via the intertragal notch. It is
continued under the lobule to the mastoid tip and then forwards
to the hyoid.

( 147th kindpermission o/the American Journal o/'Surgeo'. )

and 14 women. Their ages varied between 28 and 90 years,

mean 65 years. The tumor extent was evaluated with the help
of CT scan until 1985 and thereafter with CT scan and MRI
to assess involvement of soft tissues and cervical lymph node
metastases. In 4 patients there was evidence of tumor extension
to the middle ear. Four of the 21 patients, one with a diagnosis
of adenoidcystic carcinoma, one basal cell carcinoma, one
treated for extension of an adenocarcinoma from the parotid
and one who did not receive postoperative radiotherapy, were
excluded from the study.
In the absence of a recognized international classification,
tumors were staged according to the classification proposed
by SteW. There were 9 T1, 9 T2 and 3 T3 tumors. Three
patients (14%), 2 T2 and 1 T3 presented with ipsilateral
cervical lymph node metastases. A subtotal temporal bone
resection was performed in all cases. The internal carotid
artery and IX, X, XI and XII cranial nerves were preserved.
A facial hypoglossal anastomoses was carried out in all cases.
Postoperative radiotherapy was commenced as soon as
possible after the wound was healed and in any case within
6 weeks after surgery. A total of 6500 cGy in 33 fractions
was administered. Until 1985 surgical excision was performed
with a ' Y ' - incision consisting of a pre and postauricular

Fig II :

Fiveyeardiseaseflee cummulativesurvivalof 21 patientstreated

with subtotal temporal bone resection and postoperative
radiotherapy for squamous celt carcinomaof the ear canal and
middle ear.

limb and a downward cervical extension as described by

Ward and modified by Lewiss, in the first 11 patients. Hereafter
a single incision without a threepoint junction was developed
by the first author and has been used since in all patients,,
(Fig.I). The average duration of hospital stay for 11 patients
treated in the period between 1979 and 1985 with the incision
advocated by Lewis was 53 days, as compared to an average
hospital stay of 22.5 days for the 10 patients treated between
1986 and 1998 operated through a single incision. This was
statistically significant (Mann-Whitney p = 0.02).
Patients were followed in our outpatient clinic, the minimum
follow-up being 18 months and the maximum 10 years. No
patient was lost to follow-up.
The presented survival curve is produced using the KaplanMeier estimator (Fig.II). Death is defined as death with or
due to disease. Death due to other causes and patients alive
at the end of follow-up are regarded as censored. Because of
increasing imprecision when few people remain at risk, the
curve stops when less than 6 patients remain at risk.
TECHNIQUE
Details of the technique are well described in the literature.
The highpoints of the dissection are :
1. Retrograde dissection of the facial nerve. The marginal
mandibular nerve is identified and dissected cranially
until the main stem is reached which is then divided.

Indian Journal of Otolaryngology and Head and Neck Surge~ Vol. 54 No. 3, July - September 2002

Squamous Cell Carcinoma of the External Auditory Canal and Middle Ear 181

Fig I11: Clinicalphotographof a patientshowinggood facialmuscletone

and return of nasolabial fold following faciohypoglossal
anastomoses, 6 monthsaftersurgery.

Fig IV : Lateralview of the face 0f patient in figure2 showingresult after

surgery.Notea normalpinnaof the ear and almostimperceptible
scar.

2. The posterior belly of the digastric muscle is identified

and the neurovascular bundle is dissected cranially until
the jugular foramen and the entrance of the internal carotid
artery into the carotid canal. If a subdigastric node is
encountered, it is sent for frozen section, if a diagnosis
has not already been made.
3. The temporalis muscle is dissected free from the temporal
bone anteriorly and left attached posteriorly.
4. Dura is relaxed by the anaesthetist by hyperventilation to
reduce PCO2 level and administration of mannitol.
5. The squama of the temporal bone is removed and the
dura elevated to identify the arcuate eminence. The incision
on the bone is carried from here to the carotid canal.
6. The sigmoid sinus is exposed and obliterated at the
sinodural angle with surgical packing or ligated.
7. The zygoma is divided and the neck of the mandible is
cut.
8. The temporal bone is now removed. During cuts with an
osteotome the internal carotid artery is protected by placing
a finger medial to the styloid process. Care is taken to
avoid injury to the glosopharyngeal nerve which usually
runs lateral to the tip of the styloid process, but may be
close to its base.
9. Faciohypoglossal anastamoses is performed.
10. The defect is reconstructed by a muscle graft or a composite
flap. A free vascularised flap is most suitable.

surviving patients had complete return of function o f

swallowing and speech and were able to carry out their normal
everyday activities without assistance. It took 9 to 12 months
before the recovery of facial movements. At this point the
eye closure was complete, but patients could not squeeze the
eyelids together. Drooling of saliva lasted 10 to 14 weeks. In
2 patients older than 70 years recovery remained incomplete.
Results of facial nerve function were evaluated according to
House Brackman grading system 7. Two patients 80 and 90
years of age were rated as grade V, 19 were rated as grade
III. Patients with lymphnode metastases and previous surgery
had poor prognosis, none surviving 5 years. Bony involvement,
positive margins and age did not affect the outcome adversely.
Postoperative complications were few and are listed in table
1. One patient, operated in 1980, developed cerebrospinal
fluid leak and subsequently developed meningitis 8 weeks
later, which proved fatal. Three patients developed swallowing
difficulty which was attributed to glossopharyngeal neuropathy.
One of these cleared up after 3 days, while the others lasted
several weeks, but cleared up after 21 weeks.

RESULTS
Resection margins were free in 9 o r 43% and positive in the
rest. In one of the 3 neck dissections the margins were dubious.
Extracapsular spread was seen in all 3 neck dissection
specimens. The 5 year disease free survival was 42%. All

DISCUSSION
In the last 25 years there has been a significant change in the
clinical presentation of this disease. With a decline in the
incidence of chronic otitis media secondary to chronic
respiratory infections, carcinoma of the middle ear has become
almost a curiosity in ethnic Western Europeans. The majority
of cases are therefore skin cancers involving the ear canal.
Considerable literature exists on this subject and various
modalities and approaches of treatment have been practised.
In the past, literature often referred to tumors of the external
auditory canal and middle ear as one entity, pi'iinarily because

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July -September 2002

182

Squamous Cell Carcinoma of the External Auditory Canal and Middle Ear

the incidence of the latter was as frequent and once the tumor
grew through the perforated tympanic membrane, the external
auditory canal was involved. Extension of a tumor originating
in the ear canal into the middle ear, though possible through
a preexistent perforation of the tympanic membrane, is less
likely when the tympanic membrane is intact. With the decline
in chronic otitis media secondary to chronic nasal and
pharyngeal infections in the world as a whole and in the
western world in particular, carcinoma of the external ear
canal has assumed increasing importance as a clinical entity.
In this series only 4 of the 21 patients had involvement of
the middle ear and all have had chronic middle ear disease
previously. John and Headington postulated that squamous
carcinoma of the EAC probably develops from a small de
novo focus and infiltrates in a poorly defined pattern. Wide
spread carcinoma in situ or a multifocal field effect was not
apparent in their study8. Four patients in our series were either
being treated or had received treatment for external otitis.
Patients with psoriasis are prone to development of skin
cancer and 2 patients in this series had received treatment
for this condition in the past. Growths occurring on the
anterior canal wall have a higher predisposition for lymphatic
spread. The breach in continuity of the cartilagenous portion
of the ear canal provides ready passage for tumor extension.
Tumors originating in or extending to the middle ear have
ready access to natural passages such as the eustachean tube
and aircells above, below and behind the labyrinth. When
the primary tumor is discovered during surgery for middle
ear disease, the chances of tumor spread via the jugular
foramen and metastases to retropharyngeal lymphnodes of
Rouviere are known3. These patients respond poorly and their
prognosis remains dismal despite secondary radical surgery
and postoperative radiotherapy. Recurrent carcinoma in this
region of the human body has poor prognosis and further
surgical attempt should preferably be deferred. Similar views
have been expressed with respect to salvage surgery by
others9. Radiotherapy has been used extensively as primary
treatment for this tumor in the past, but the overall results
were poor10. With the exception of two centres it has been
abandoned as the sole modality of therapy ",~2. In the long
term high doses of radiotherapy to this region are not without
complications. We e n c o u n t e r e d 2 patients with
osteoradionecrosis leading to severe hemorrhage and death.
Go et al reported radionecrosis of temporal lobe of brain and
celebrovascular occlusion. Both these patients succumbed to
their complicatiom3. The description of several surgical
approaches and modalities of treatment in the literature led
Johns and Headington to draw attention to the lack of
therapeutic guidelines based on controlled trials using as
standardized surgical approach with or without preopeative
or postoperative radiotherapys. In this context our series is

of interest since right from the beginning we have adapted

a standard approach of subtotal temporal bone resection as
described by Lewis,4, followed by postoperative radiotherapy.
The exclusion of all other forms of tumor except squamous
cell carcinoma is also significant since this only confuses the
issue and makes comparisons difficult. Our earlier experience
with the surgical approach however, soon led us to realize
that wound healing was protracted and wound breakdown at
the three point junction using the traditional incision was
frequent, with consequent delay in starting the postoperative
radiotherapy. We therefore designed a new single incision
(Fig I). Following this approach all wounds without exception
healed primarily, the postoperative hospital stay was markedly
reduced by 30 days and more important, the postoperative
radiotherapy could be commenced within six weeks of surgery.
The pinna of the ear could be preserved with good esthetic
result. The temporalis muscle does not provide adequate
tissue for obliteration of the operative defect and protection
of the dura. We have therefore used sternomastoid muscle or
myocutaneous flap and subsequently free vascularised flapsls.
Threepatients in this series presented with cervical lymphnode
metastases and in 1 patient this was the presenting symptom.
Cervical nodal metastases in carcinoma of the EAC and
middle ear is a bad prognostic feature. None of these patients
survived for 5 years.
A faciohypoglossal anastomoses was carried out after tumor
resection and before flap surgery in all cases. The results of
faciohypoglossal anastomoses were assessed 1 year after
surgery according to House Brackman facial nerve grading
system7. The majority of patients (19) were in group III,
and 2 patients, one 80 years and the other 90 years of age,
showed little recovery of their facial nerve functions and
were graded V. Majority of patients had return of the nasolabial
fold and could close their upper eyelid, but were unable to
raise their forehead. This immobility of the forehead was due
primarily to surgery and was not related to the faciohypoglossal
anastomoses. One patient, 80 years, had a gold implant in
the eyelid. There was complete oral competence in all except
those above 80 years of age where the recovery was partial.
A facial sling using palmaris longus tendon was inserted to
restore the angle of the mouth in the 80 year old patient, with
good functional result. Most patients were satisfied with their
esthetics recovery (Fig III & IV). In 2 patients metastases to
cervical 5 vertebra developed 2 years later. Another patient
developed cerebral metastases. Local recurrence, cervical
nodal metastases at presentation and previous surgery had
poor prognostic significance. The 5 year disease free survival
of 42% in this series is comparable with other reported
series 1L16,|7,18,19.The outcome was not influenced by age, bony
involvement or positive surgical margins.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July- September 2002

Squamous Cell Carcinoma of the External Auditory Canal and Middle Ear

Our experience has clearly demonstrated that primary surgery

and p o s t o p e r a t i v e radiotherapy is the appropriate treatment
for squamous cell carcinoma o f the E A C and middle ear. Full
r e s u m p t i o n o f p r e o p e r a t i v e activities after treatment can be
e x p e c t e d . The p r o c e d u r e o f total t e m p o r a l b o n e r e s e c t i o n
c o m p r o m i s e s the quality o f life to such an extent that w e do
not include it in our a r m a m e n t e r i u m 20,21

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R a m m o h a n Tiwari,
R e c o n s t r u c t i v e and Skull B a s e Surgery,
B a n g a l o r e Institute o f O n c o l o g y ,
44-45/2, 2 nd Cross,
R a j a R a m M o h a n R o y Extn.
O f f L a l b a g h D o u b l e Road,
B a n g a l o r e - 560 027

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July - September 2002