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The American Journal of Otology
21:582–588 © 2000, The American Journal of Otology, Inc.
Squamous Cell Carcinoma of the External Auditory
Canal: An Evaluation of a Staging System
Stephanie A. Moody, Barry E. Hirsch, and Eugene N. Myers
Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A.
Objective: The study was conducted to review a staging sys-
tem proposed by the University of Pittsburgh for temporal bone
cancer and to evaluate survival status according to stage, treat-
ment, and certain prognostic factors.
Study Design: The study was a retrospective case review.
Setting: The study was conducted at a tertiary care medical
center and specialty hospital.
Patients: Thirty-two patients with primary squamous cell car-
cinoma of the external auditory canal were studied.
Intervention: All patients underwent surgery of the temporal
bone. Radiotherapy was given depending on tumor stage and
histopathologic findings.
Main Outcome Measures: The 2-year survival rates of pa-
Carcinoma of the temporal bone is a rare tumor that
accounts for <0.2% of all tumors of the head and neck
(1). Developing an appropriate treatment strategy re-
quires the integration of personal and institutional expe-
rience with data gathered from reports published by other
oncology centers. The optimal management of temporal
bone malignancies remains elusive. Controversies high-
lighted in the current literature include the utility of ra-
diographic evaluation of disease extent, the nomencla-
ture of surgical procedures, and the use of adjuvant ra-
diation therapy. Moreover, the lack of a standardized
staging system impedes meaningful interpretation of the
literature. An accurate and universally accepted staging
system is particularly critical in the evaluation of tumors
of the temporal bone because the rarity of the lesion
demands multiinstitutional cooperation to compare treat-
ment protocols and outcome.
Some authors argue that preoperative staging is not
possible because physical examination or radiologic
studies cannot determine the extent of disease within the
temporal bone. They emphasize the unreliability of de-
termining extension to the middle ear, nerves, or fascial
planes (2,3). However, others have found preoperative
computed tomography (CT) helpful in grouping patients
Address correspondence and reprint requests to Dr. Barry E. Hirsch,
Department of Otolaryngology, The Eye and Ear Institute, Suite 500,
200 Lothrop Street, Pittsburgh, PA 15213, U.S.A.
582
tients undergoing surgical resection with or without adjuvant
radiotherapy.
Results: The 2-year survival rates for primary squamous cell
carcinoma of the temporal bone were as follows: T1 lesions
100%, T2 80%, T3 50%, and T4 7%. Survival for T3 tumors
was 75% with postoperative radiotherapy, compared with 0%
with surgery alone.
Conclusions: The 2-year survival data directly correlated
with the staging system. The use of adjuvant radiotherapy
increased survival rate in patients with a T3 lesion. Key
Words: Squamous cell carcinoma—Temporal bone cancer—
External auditory canal—Adjuvant radiotherapy.
Am J Otol 21:582–588, 2000.
(4,5). Arriaga et al. (6) studied the correlation of CT and
pathologic findings and determined that CT can accu-
rately diagnose the pathologic extent of tumor. They
point out the limitations of CT, such as differentiating
fluid and inflamed mucosa from tumor in the middle ear
or mastoid and distinguishing inflammation from tumor
when there is no adjacent bone erosion. In that regard,
these authors advocate clinical evaluation for facial pare-
sis, opacification of the mastoid, and soft tissue indura-
tion to assist in determining the disease extent.
This study is a retrospective review of patients staged
with the Pittsburgh system using CT and clinical infor-
mation. It is a continuation of reviews previously pub-
lished from this institution (5–7). Survival outcome spe-
cific to stage, surgical procedure, adjuvant treatment, and
additional prognostic factors are described to promote
the use of this system, which depends on a systematic
approach to radiologic evaluation and surgical extirpa-
tion of disease.
MATERIALS AND METHODS
Between 1978 and 1998, 61 patients who underwent surgical
treatment for carcinoma of the temporal bone were identified
from a computerized database and previous reports of patients
treated for cancer at the Eye and Ear Institute of the University
of Pittsburgh Medical Center. Forty-six patients had primary
 SQUAMOUS CELL CARCINOMA OF EXTERNAL AUDITORY CANAL 583

cancers of the temporal bone, and 15 had cancer secondary to Statistics

spread from adjacent sites, including the pinna, concha, and
parotid. Of the primary lesions of the temporal bone, there were
35 squamous cell carcinomas (SCCA) of the external auditory
canal (EAC), 2 SCCA of the mastoid cavity, 2 acinic cell
carcinomas, 2 adenocarcinomas, 2 basal cell carcinomas, 1
ceruminous carcinoma, 1 osteosarcoma, and 1 hemangioma.
This report describes 32 patients with primary SCCA of the
EAC who had at least 2 years follow-up. Clinic charts, pathol-
ogy reports, and radiographic studies were retrospectively re-
viewed. Updated follow-up information was obtained by phone
contact with the patients or their families.
The selected 32 patients with primary SCCA of the EAC
were staged according to the Pittsburgh staging system (Table
1). The extent of disease was based on CT findings and con-
firmed by intraoperative and histologic findings. If histologic
criteria suggested more extensive involvement than the CT sug-
gested, the stage was adjusted upward.
All patients were treated surgically by temporal bone resec-
tion. Temporal bone surgical procedures included lateral tem-
poral bone resection (LTBR), modified LTBR, subtotal tem-
poral bone resection (STBR), and total temporal bone resection
(TTBR). Most procedures were performed with an en bloc
technique. Hirsch and Chang have described the operative pro-
cedures in detail, as well as the indications based on the loca-
tion and stage of the tumor (8). Adjunctive procedures, includ-
ing neck dissection, parotidectomy, and craniotomy, were per-
formed when indicated.
A modified LTBR removes the EAC, leaving the uninvolved
tympanic membrane intact. The boundaries of the LTBR in-
clude the middle ear cavity and stapes medially, the mastoid
cavity posteriorly, the epitympanum and zygomatic root supe-
riorly, the temporomandibular joint capsule anteriorly, and the
medial tympanic ring or infratemporal fossa inferiorly. The
lateral margin depends on the extent of spread. The otic capsule
and facial nerve are preserved.
A STBR is performed when there is evidence of invasion
medial to the tympanic membrane or into the mastoid. In this
case, the medial margin may be obtained in a piecemeal fash-
ion, usually with a drill. The specimen includes tissue obtained
by the LTBR with additional dissection of the otic capsule and
the medial bony wall of the middle ear and mastoid. The mar-
gins of resection are the sigmoid sinus and posterior fossa dura
posteriorly, the middle fossa dura superiorly, the internal ca-
rotid artery anteriorly, the jugular bulb inferiorly, and the pe-
trous apex medially. Depending on the extent of tumor spread,
dissection may include the condyle of the mandible, the facial
nerve, the dura, the sigmoid sinus, and the contents of the
infratemporal fossa. The carotid artery is skeletonized and be-
comes the medial margin.
The TTBR proceeds after the STBR to include removal of
the petrous apex. The internal carotid artery may be isolated,
mobilized, and preserved or resected. The dura and cranial
nerves are removed as indicated by the extent of the tumor.
Statistical analysis was performed with the S-PLUS statisti-
cal package (Math Soft, Inc., Cambridge, MA, U.S.A.). Sur-
vival analysis was performed with the Kaplan-Meier method.
The Fisher exact test was used to compare survival outcome
between groups of patients. Statistical comparison of survival
between patients with different stages and between those re-
ceiving adjuvant radiation therapy and those who did not would
not have been meaningful because of the limited number of
patients in each group.
RESULTS
A total of 32 patients were studied (Table 2). The
average age at the time of surgery was 68 years (range
44–92). The average duration of symptoms was 3.9
years. Symptoms included otalgia in 81% of patients,
otorrhea in 75%, decreased hearing in 62%, facial palsy
in 25%, and parotid mass in 19%. Ten patients had pre-
viously been treated at other institutions: 8 had surgery
only, 1 had surgery and radiotherapy, and 1 had chemo-
therapy and radiotherapy. The patients were classified
according to the staging protocol used by our institution
(see Table 1) as follows: T1 (n ⳱ 7), T2 (n ⳱ 5), T3 (n
⳱ 6), and T4 (n ⳱ 14). Three patients underwent modi-
fied LTBR, 18 underwent LTBR, 6 underwent STBR,
and 5 underwent TTBR. Twenty-three patients received
adjuvant radiation therapy. The average follow-up time
for the 32 patients was 49 months. The 2-year survival
for T stages 1 through 4 was 100%, 80%, 50%, and 7%,
respectively (Table 3, Fig. 1).
Patients with T1 cancer underwent either modified
LTBR or LTBR. All patients with T1 cancers were cured
of disease. Of the patients with T1 cancers, one subse-
quently died of lung cancer 17 years after treatment of
his temporal bone cancer. Two other patients in the T1
group were without disease but died of concurrent dis-
ease after 7 years. The remaining four patients with T1
tumors have no evidence of disease, with an average of
8 years at last follow-up.
All five patients with T2 cancers underwent LTBR
and adjuvant radiation therapy. Two patients with T2
cancer survived 4 and 6 years and at last follow-up had
no evidence of disease. Another patient with a T2 cancer
died of renal failure at 4 years. In one patient, the T2
tumor recurred 11 months after LTBR and adjuvant ra-
diation treatment, and STBR and chemotherapy were
given. The tumor recurred again 24 months later at the
petrous apex, and the patient underwent stereotactic ra-
diosurgery but finally succumbed to disease 8 months

TABLE 1. Pittsburgh tumor staging system (modified)

Stage CT or pathologic findings

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) or 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 and/or mastoid
T4 Tumor eroding the cochlea, petrous apex, medial wall of the middle ear, carotid canal, jugular foramen, or dura, or with extensive soft tissue involvement
(>0.5 cm), such as involvement of TMJ or styloid process, or evidence of facial paresis

CT, computed tomography; EAC, external auditory canal; TMJ, temporomandibular joint.

The American Journal of Otology, Vol. 21, No. 4, 2000

584 S. A. MOODY ET AL.

TABLE 2. Patient data

Age Regional
No. (yrs) Previous treatment Stage Specific findings Procedure Adjuvant therapy Margin metastasis Outcome

1 73 Debridement of canal T1 EAC, no erosion MLTBR, P 0 − NED (84 mo)

2 62 T1 Same LTBR, P 6000 − DOC (211 mo)
3 62 T1 Same MLTBR, P 0 − NED (116 mo)
4 42 T1 Same LTBR, P 0 − NED (101 mo)
5 78 T1 Same MLTBR, P 5400 − NED (87 mo)
6 75 T1 Same LTBR, P 5000 − DOC (83 mo)
7 78 T1 Same LTBR, P, ND 0 + DOC (87 mo)
8 76 T2 LE LTBR, P, ND 5600 + DOC (52 mo)
9 45 T2 LE LTBR, P 5829 + DOD (43 mo)
10 73 T2 LE, LST LTBRP 5000 + + DOD (10 mo)
11 85 Excision of skin of EAC T2 LE, LST LTBR, P 6120 − NED (50 mo)
12 63 Excision of lesion of EAC T2 LE LTBR, ND 7500 + + NED (73 mo)
13 48 T3 MA STBR 5440 − NED (112 mo)
14 81 Mastoidectomy T3 MA, ME LTBR 5490 + NED (75 mo)
15 75 T3 MA LTBR 0 + DOC (7 mo)
16 71 T3 MA, ME LTBR, P 6000 + DOC (6 mo)
17 58 T3 MA LTBR, P 5000 − NED (177 mo)
18 66 T3 +/−MA, ME LTBR, P 0 − DOD (14 mo)
19 52 Radical mastoidectomy T4 FP, ST, ME, MA, DU, PA TTBR, C, DR, ND 6120 + DOD (20 mo)
20 57 T4 FP, ST, ME, MA, DU, PA TTBR, C, DR, P 6000 + + DOD (11 mo)
21 79 T4 EST, MA LTBR, P 6600 + DOD (14 mo)
22 63 5FU, Cisplatin (5 cycles) 7,020 T4 EST, ME, MA, DU STBR, P, ND 0 + DOD (8 mo)
cGY
23 67 Mastoidectomy T4 FP, EST, ME, MA, DU, PA TTBR, C, P, DR ?cGy + DOD (10 mo)
24 73 T4 FP, EST, MEMW, MA STBR, CR, DR 5490 + NED (40 mo)
25 66 T4 EST, ME, MA, DU, PA TTBR, DR, ND 0 − DOD (9 mo)
26 64 Mastoidectomy, petrosectomy, T4 FP, EST, MEMW, MA, STBR, C, DR, P, ND 3680+ + DOD (6 mo)
craniotomy, 5,700 cGy DU, PA
27 77 T4 EST, ME LTBR, P 6120 + DOD (20 mo)
28 79 Mastoidectomy T4 ST, ME, MA, DU STBR, DR Unknown + DOD (10 mo)
CGy
29 70 T4 ST, ME, MA, DU LTBR, P, ND 6500 + + DOD (11 mo)
30 76 T4 EST LTBR, P 6000 + DOD (5 mo)
31 92 T4 FP, ST, MEMW, MA STBR 7000 + DOD (12 mo)
32 80 Radical mastoidectomy T4 ST, ME, MA, DU TTBR, C, P 0 − DOD (6 mo)

LE, limited canal erosion; LST, limited soft tissue involvement; ST, soft tissue involvement; ME, middle ear involvement; MA, mastoid involvement; DU, dural
invasion; PA, involvement of petrous apex; EST, extensive (>5 mm) soft tissue involvement; MEMW, invasion of medial wall of middle ear; FP, facial palsy; C,
craniotomy; DR, dural resection; CR, carotid resection; P, parotidectomy; ND, neck dissection; MLTBR, modified lateral temporal bone resection; LTBR, lateral temporal
bone resection; STBR, subtotal temporal bone resection; TTBR, total temporal bone resection; NED, no evidence of disease; DOC, died of other causes; DOD, died of
disease.

later. This patient (surviving 43 months after initial sur-
gery) was the only patient in the study to survive with
disease >2 years after initial surgery but later die of
disease. A second patient treated with LTBR and adju-
vant radiation therapy (5,000 cGy) for a T2 cancer had
tumor recurrence at 9 months postoperatively and died of
disease within 1 month despite an additional 2,000 cGy
radiation. Both of these patients had positive margins.
The 2-year survival for T2 cancers was 80%.
Five patients with T3 cancers were treated with LTBR,
and one underwent STBR. The patient who had STBR
and postoperative radiation therapy was disease free at
her last follow-up at 9 years. Two patients with T3 can-
cer survived free of disease for 6 and 15 years. Two
patients with T3 cancer died in the perioperative period
of medical complications. In another patient with a T3
TABLE 3. Two-year survival by stage
Stage n Survived
T1 7 7
T2 5 4
T3 6 3
T4 14 1 7
cancer treated with LTBR without adjuvant radiation
therapy, the cancer recurred at 8 months and was then
treated with 6,840 cGy. He succumbed of persistent dis-
ease after 14 months. Two-year survival was 50%.
Only one patient with a T4 cancer survived after
STBR that included a resection of the carotid and post-
operative radiation with 5940 cGy for a microscopically
positive margin. She was free of disease after 40 months
on last follow-up. Another patient with a T4 tumor died
of acute leukemia at 14 months but had no evidence of
disease. The remaining patients died of disease between
6 and 20 months (average survival 9.6 months).
The survival outcome based on surgical procedures
was analyzed (Table 4). No survival benefit was seen for
T3 and T4 tumors treated with STBR versus LTBR (33%
vs. 36%). For all stages combined, neck dissection and/or
parotidectomy had no effect on survival (Table 5).
Positive histologic margins were associated with de-
creased survival (75% vs. 32%, p ⳱ 0.029). No patient
% who had involvement of the dura by cancer survived (see
100 Table 5).
80 Radiation therapy seemed to have some benefit.
50
Within the T3 group, those who received adjuvant radia-
tion therapy had improved survival over those who did

The American Journal of Otology, Vol. 21, No. 4, 2000

 SQUAMOUS CELL CARCINOMA OF EXTERNAL AUDITORY CANAL 585

FIG. 1. Percent survival by stage.

not (75% vs. 0%), although the total number of patients leaves the stapes as the medial border), a radical tempo-
in this group was small and prohibitive of statistical ral bone resection (usually sparing the petrous apex tip),
analysis (Table 6). or an infratemporal approach, respectively. The patients
all received adjuvant radiotherapy. The survival was
100% for disease limited to the EAC (n ⳱ 7), 100% for
DISCUSSION
superficial invasion (n ⳱ 3), 70% for deep invasion (n
Staging is of paramount importance in the treatment of ⳱ 10), and 65% for tumors reaching beyond the tempo-
cancer. Physicians can use staging to predict prognosis, ral bone (n ⳱ 14).
evaluate treatment options, and counsel patients. Authors Pensak et al. (9) reported a series of patients with
have used a variety of systems in staging and reporting tumors of multiple histologic types whose staging was
the outcomes in the management of temporal bone can- based on radiologic and intraoperative observations (see
cers (Table 7). Table 7 for staging description). Patients with grade I and
Spector (3) published a prospective treatment plan for II cancers were treated with a sleeve excision or LTBR.
patients with 34 cancers of the EAC staged into four (These procedures were not specifically described).
groups: limited to EAC, superficial invasion, deep inva- Patients with grade III through VI tumors underwent
sion, or beyond the temporal bone. Those with disease modified LTBR or TTBR. The modified LTBR included
limited to the EAC underwent a sleeve resection, which a petrosectomy. All but one patient had adjuvant ra-
included resection of the bony and cartilaginous canal, diotherapy. Three-year survival rates of patients with
the tympanic membrane, the malleus, and the annulus. If grades I through VI tumors were 100% (n ⳱ 3), 78% (n
superficial invasion, deep invasion, or disease beyond ⳱ 14), 67% (n ⳱ 6), 60% (n ⳱ 5), 87% (n ⳱ 8), and
the temporal bone was identified, the treatment included 0% (n ⳱ 3).
a partial superficial temporal bone resection (which
TABLE 5. Two-year survival by adjunctive surgical
TABLE 4. Two-year survival by surgery procedures and histologic findings
Procedure Stage n Survived % Procedure or finding n Survived % p
Modified LTBR T1 3 3 100 No neck dissection 24 12 50
LTBR T1 4 4 100 Neck dissection 8 3 38 0.6911
T2 5 4 80 No parotidectomy 9 4 44
T3 5 2 40 Parotidectomy 23 11 48 1.0
T4 4 0 0 Margins positive 19 6 32
All 18 10 56 Margins negative* 12 9 75 0.029
STBR T3 1 1 100 Regional metastasis 4 1 25
T4 5 1 20 No regional metastasis* 27 14 52 0.5996
All 6 2 33 Invasion of dura 5 0 0
TTBR T4 5 0 0 Dura not involved or not explored 27 15 56 0.0456

LTBR, lateral temporal bone resection; STBR, subtotal temporal *One patient not included because margins and regional disease
bone resection; TTBR, total temporal bone resection. were not documented.

The American Journal of Otology, Vol. 21, No. 4, 2000

586 S. A. MOODY ET AL.

TABLE 6. Two-year survival with and without XRT son of outcomes from these reports because of the vari-
ability of histologic types and sites of origin (such as
Stage XRT n Survived %
secondary temporal bone involvement from primary
T1 yes 3 3 100 tumors of the parotid, pinna, or concha), the small num-
no 4 4 100 ber of patients in each group, the disparity of staging
T2 yes 5 4 80
no 0 criteria, the diversity in management protocols, and the
T3 yes 4 3 75 nonstandardized surgical nomenclature. In addition, spe-
no 2 0 0 cific data such as CT findings, adjunctive surgical pro-
T4 yes 11 1 9 cedures and radiation therapy, and adequacy of margins
no 3 0 0
are often omitted.
XRT, adjuvant radiation. Despite the limitations, review of the studies indicates
certain prognostic factors that can be incorporated into a
unified staging system. Surgeons have observed that
Recently, Manolidis et al. (10) detailed 30 SCCA and bony invasion (3,12), facial paralysis (1,10,11), and ex-
basal cell carcinomas in his extensive review of temporal tension to the middle ear (12), dura (12,13), or soft tis-
bone malignancies. These tumors originating from the sues (temporomandibular joint, infratemporal fossa, pa-
auricle or the EAC were staged as stage 1, 2, or 3 (see rotid) (9,10) are associated with a poor outcome. In the
Table 7 for description). In that series, 22 patients un- Pittsburgh system, these factors differentiate T2, T3, and
derwent LTBR, 6 underwent TTBR, and 1 underwent T4 tumors.
resection via the middle fossa approach. Fourteen pa- We critically reviewed our patient data to confirm the
tients had adjuvant radiation. This author described the staging of patients’ tumors. We determined that two pa-
outcome as overall failure rate rather than the standard tients who previously had been assigned to stage T3
survival rate. The overall failure rate was 20%, 20%, because of paresis of the facial nerve were overstaged.
75%, and 100%, respectively, for stages 1 through 4. One patient had weakness of the marginal mandibular
Although these studies provide useful information, it nerve as a result of previous surgery. The other patient
is difficult to elicit an accurate and meaningful compari- had near resolution of facial paresis after treatment for

TABLE 7. Classification systems with tumor types, outcome, and definition of outcome
Author, date Subjects Staging system Outcome (outcome measure)

Crabtree et al. (15), 1976
Stell and McCormick (11), 1985
Kinney (2), 1989
Shih and Crabtree (4), 1990
Spector (3), 1991
Pensak et al. (9), 1996
Manolidis et al. (10), 1998
35 SCCA, BCCA, ACC,
metastatic renal cell cancer
(25 SCCA of EAC)
47 SCCA, BCCA, ACC, AC
25 SCCA of EAC
18 SCCA, BCCA, ACC, AC,
MM of EAC
I. 17 (1960–1980)
II. 34 (1980–1989)
all SCCA of EAC
46 SCCA, BCCA, ACC,
chondrosarcoma, AC,
endocrine gland,
carcinoma of temporal
bone
30 SCCA, BCCA of EAC
Localized: confined to EAC and mastoid 15/17
Extensive: invades ME or facial nerve 2/8 (free of disease 1–9 yrs)
T1 limited to site of origin Survival for stages T2 and T3 were
T2 extends beyond site of origin, but not beyond significantly poorer than T1
organ of origin
T3 extends to dura, skull base, parotid gland, TMJ
Tx insufficient data to classify
Limited to EAC 85%
Erosion of bone or invasion of ME 83%
Extension to dura, stylomastoid foramen, 40%
or skull base (“control of disease” at
6 months–9 year)
Stage 1 localized to EAC 6/6
Stage 2 extends into temporal bone 1/2
Stage 3 extends to parotid, neck, skull base, dura 6/10
(NED at 1–11 years)
Limited to EAC 7/7 (100%)
Superficial invasion 3/3 (100%)
Deep invasion 6/10 (60%)
Extend beyond temporal bone 9/14 (64%)
for group II
(NED avg. 36.6 months)
Grade I—tumor in a single site, <1 cm 3/3 (100%)
Grade II—tumor in a single site, but >1 cm 11/14 (78%)
Grade III—transannual extension 4/6 (67%)
Grade IV—mastoid or petrous invasion 3/5 (60%)
Grade V—periauricular or contiguous extension 7/8 (87%)
Group VI—neck adenopathy, distant site, or 0/3
infratemporal fossa (3 years alive and NED)
Stage 1 confined to EAC 20%
Stage 2 spread to temporomandibular joint, parotid, or 20%
infratemporal fossa 75%
Stage 3 spread to ME, mastoid, facial nerve 100%
Stage 4 spread to dura, jugular bulb, sigmoid sinus, (overall failure rate)
internal carotid artery, or petrous apex

ACC, adenoid cystic carcinoma; AC, adenocarcinoma; MM, malignant melanoma; TMJ, temporomandibular joint; NED, no evidence of disease; SCCA, squamous cell
carcinoma; BCCA, basal cell carcinoma; EAC, external auditory canal; ME, middle ear.

The American Journal of Otology, Vol. 21, No. 4, 2000

 SQUAMOUS CELL CARCINOMA OF EXTERNAL AUDITORY CANAL
concurrent acute otitis media. The histopathologic results
from both patients confirmed that the tumor was limited
to the EAC without extension into the middle ear or soft
tissue inferior to the tympanic ring. No patients with
limited pathology (staged T1 or T2) had facial nerve
involvement caused by the cancer. For this reason, we
suggest that facial nerve paresis or paralysis is an omi-
nous sign. To adversely affect facial nerve function, a
tumor must involve the facial nerve between the genic-
ulate ganglion and the peripheral branches within the
parotid gland. If cancer causes facial paralysis along the
horizontal segment of the fallopian canal, then by
definition it should be included with T4 tumors eroding
the medial wall of the middle ear. Similarly, if cancer
causes facial paralysis secondary to spread to the area
of the stylomastoid foramen, there is by definition >0.5
cm soft tissue extension. Involvement of the facial nerve
at its vertical portion reflects tumor extension from the
posterior bony canal wall through the annulus and into
the mastoid with the implication of extensive bony
erosion (Fig. 2). We suggest updating the Pittsburgh
staging system by designating carcinoma of the tem-
poral bone and signs of facial paresis or paralysis as a
stage T4 tumor (see Table 1). Our data analysis reflected
this modification.
The Pittsburgh staging system has been used in one
other published study. Austin et al. (14) evaluated 22
patients with SCCA of the EAC and concluded that the
system was reproducible and objective. In that study, the
patients treated surgically were assigned to stages T1 (n
⳱ 8), T2 (n ⳱ 4), T3 (n ⳱ 6), and T4 (n ⳱ 4). The
2-year survival rates were 75%, 100%, 60%, and 75%,
respectively, for those patients undergoing surgery with
or without radiation. Surgical procedures included local
canal resection, partial temporal bone resection, STBR,
and TTBR. Because the pathologic extent was not de-
scribed with regard to adequacy of surgical margins or
invasion of the dura, and because a variety of surgical
587
procedures were used for each T stage, it is difficult to
integrate the two studies. However, the authors of this
study support the Pittsburgh system.
In addition to the disparity of staging systems, a sec-
ond impediment to the development of treatment strate-
gies is the variability in defining surgical procedures and
in choosing the management strategy. Authors list sur-
gical procedures such as en bloc EAC resection, sleeve
resection, local canal resection, wide local excision, radi-
cal resection of the EAC, modified radical mastoidec-
tomy, modified LTBR, LTBR, partial temporal bone re-
section, STBR, and TTBR. This discrepancy precludes
the integration of patient series among institutions. We
suggest using these terms: modified LTBR (resection
lateral to the tympanic membrane), LTBR (the stapes is
the medial limit of resection), STBR, and TTBR as de-
scribed by Hirsch and Chang (8). In addition, a prospec-
tive protocol of surgery and adjuvant radiation therapy
specific to each stage, such as those proposed by other
authors (3,7,10) or as described in this study, is needed.
These steps would permit the assessment of treatment
outcome based on homogeneous groups of patients simi-
larly staged and treated.
One limitation of this retrospective review is the de-
pendence on CT reports and pathologic reports, rather
than having the benefit of a unified and consistent system
for recording findings. In a previous report from this
institution (6), the CT scans and histopathology slides of
13 patients were systematically studied for EAC erosion,
middle ear involvement, otic capsule erosion, mastoid
involvement, jugular fossa erosion, carotid canal erosion,
tegmen erosion, and posterior fossa involvement. The CT
findings were found to correlate well with the histopatho-
logic findings. Magnetic resonance imaging can be useful
to evaluate soft tissue extension and to differentiate the
contents of the middle ear. We suggest that radiologists
and pathologists use this kind of specific format when re-
porting their findings, as suggested by Arriaga et al. (6).
FIG. 2. Coronal anatomy of pathways of spread of
primary cancer of the external auditory canal. Can-
cer can spread (1) anteriorly through the cartilagi-
nous canal into the parotid gland, (2) through the
concha into the postauricular sulcus, (3) through
the tympanic membrane into the middle ear, (4)
posteriorly into the mastoid, (5) into the anterior me-
sotympanum to the carotid artery and Eustachian
tube, (6) into the inner ear through the round win-
dow or otic capsule, (7) along the extratemporal
facial nerve into the infratemporal fossa, and (8)
inferomedially into the jugular fossa, carotid artery
and lower cranial nerves.
The American Journal of Otology, Vol. 21, No. 4, 2000
 588 S. A. MOODY ET AL.
We advocate the addition of adjuvant radiation for
patients with cancer staged T2 and T3. Radiation im-
proved survival in the patients with T3 cancer. Its effect
on T2 cancers cannot be evaluated, because all received
radiation. The prognosis of T4 disease is extremely grim,
but if negative margins are achieved, radiation may be
of benefit.
CONCLUSIONS
The staging system developed and used at our institu-
tion is valid with respect to preoperative assessment of
tumor extent and survival prognosis. Patients having T2
and T3 cancer may be treated with adjuvant radiation
therapy, as it appears to be beneficial. Regardless of the
treatment protocol, a dismal outcome is associated with
T4 cancer, positive margins, and invasion of the dura.
Aggressive surgery for advanced tumors, especially in-
volving the dura, may not be in the patients’ best interest,
because prognosis remains poor.
There should be a multiinstitutional effort to adopt a
staging system and to develop a prospective treatment
protocol so that our understanding of temporal bone can-
cer may be increased. The nomenclature describing sur-
gical procedures should be standardized. We advocate
the definitions described herein. A standard protocol
should be made available to radiologists and pathologists
so that cancers may be staged and multiinstitutional
analyses can be performed. The inclusion of specific pa-
tient information such as disease extent, previous treat-
ment, interventions, adjuvant therapies, and outcome
would allow analysis across publications.
Acknowledgment: The authors thank Jong-Hyeon Jeong,
Ph.D., of the Pittsburgh Cancer Institute and the University of
Pittsburgh Department of Biostatistics for his assistance with
the statistical analysis.
The American Journal of Otology, Vol. 21, No. 4, 2000
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