Temporal bone neoplasia and management
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temporal bone benign and malignant neoplasms
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Temporal bone neoplasia and management
- 1. Temporal bone neoplasia & Management DR SAFIKA ZAMAN DEPT OF ENT & HEAD NECK SURGERY VIMS,RKMSP
- 2. contents Introduction Relevant anatomy Etiology & classification Clinical presentation Differential diagnosis Investigations Treatment
- 3. Introduction Origin from all germ layers. Great variety of tumour cell types is possible, both benign and malignant variants. Regional consequences of TB pathology usually occur late. Surgically difficult access Close to brain, important neural and vascular structures
- 5. Cont….
- 6. Lymphatic drainage Lymphatics from the auricle and EAC drain into the parotid and pre- and retro -auricular lymph nodes. Venous is into the jugular vein.
- 7. Presenting symptoms Pulsatile tinnitus Hearing loss Otalgia Aural fullness Hoarseness Dysphagia Pharyngeal fullness Vertigo Facial weakness Headache Dysarthria Aural bleeding Aural discharge Facial palsy Canal mass/lesion Tinnitus auricular swelling Pruritus
- 8. Benign tumours of temporal bone EAC Middle Ear Inner ear 1.Osteoma 2.Exostosis 3.Fibrous dysplasia 4.Langerhans cell histiocytosis 4.Papilloma 5.Nerve sheath neoplasm 6.Haemangioma 1.Adenoma 2.Meningioma 3.Chordoma 4.Paraganglioma 5.Haemangiopericytoma 6.schwanomma 1.Paraganglioma 2.Lipoma 3.Schwanomma 4.Haemangioma 5.Haemangiopericytoma 6.Cholesterol cyst of petrous apex 7.Endolymphatic sac tumour Source- Shambaugh surgery of the ear 6th edition
- 9. Glomus Tumors Benign, slow growing. Spread from site of origin to path of least resistance. Significant mortality and morbidity can occur by virtue of their location . Capacity to produce catecholamines and neuropeptide,neurotransmitters, neurohormones, hormones, and parahormones. STACY RUFUS GUILD {1890-1966} Discovered the glomus jugularie, the site of origin of the most common neoplasm of the middle ear.
- 10. Glomus tumor extension route
- 11. Source- Shambaugh surgery of the ear 6th edition
- 12. Malignant tumours of temporal bone Epidermal Glandular Sarcomas Other 1.SCC 2.BCC 3.Melanoma 1.Adenocarcinoma 2.Adenoid cystic carcinoma 3.Mucoepidermoid 4.Unspecified salivary tumors 1.Rhabdomyosarcoma 2.Osteosarcoma 3.Angiosarcoma 4.Chondrosarcoma 5.Unspecified sarcomas 1.Lymphoma 2.Chordoma 3.Malignant glioma 4.Metastatic renal cell carcinoma Source- Shambaugh surgery of the ear 6th edition
- 13. History of surgery for malignant lesions 1883 • Temporal bone carcinoma was first reported histologically by Politzer in the classic Textbook of Disease of the Ear. 1899 • The first attempted extirpation of a temporal bone malignancy was described by Heyer. 20th century • The concept of en bloc removal of all or a portion of the temporal bone was formalized. Ward, Loch, and Lawrence as well as Campbell, Volk, and Burkland independently.
- 14. Cont… 1954 • Parsons and Lewis who reported the first successful single-stage temporal bone resection with preservation of the petrous apex. 1969 • Hilding and Selker described the technique of resection of the petrous apex with preservation of the ICA. 1984 • Graham & Satalof described temporal bone resection with sacrifice of ICA.
- 15. D/D of temporal bone neoplasm Malignant otitis externa Cholesteatoma Mucocele Aneurysm of artery Eosinophilic granuloma Cholesterol granuloma Osteomyelitis of bone Trapped fluid
- 16. Imaging CT Scan gives an excellent view of soft tissue and bony anatomy. MRI lacks bony detail, its use is reserved as an adjunct especially in cases in which dural involvement or peri-neural invasion is suspected. 4 quadrants of the ear canal, the infratemporal fossa, middle ear, otic capsule, mastoid, jugular foramen, carotid canal, tegmen, middle fossa, and posterior fossa.
- 17. EUM and Biopsy For any temporal bone lesion not responding to conservative therapy Early diagnosis improves disease outcomes.
- 18. Squamous Cell Carcinoma SCC is the most common histopathologic subtype of temporal bone malignancy. 60 to 80% of all malignant lesions. The sites of origin include the EAC, the middle ear space or mastoid, and extensive auricular neoplasms. Squamous cell carcinoma filling the left ear canal. (Fromthe Department ofHead and Neck Surgery, MD Anderson Cancer Center
- 19. Basal Cell Carcinoma BCC accounts for approximately 11 % of tumors of the temporal bone. Basal cell carcinomas rarely metastasize but can be very locally aggressive. better prognosis than SCC. https://www.google.com/url?sa=i&url=http%3A%2F%2Fwww.pcds.org.uk%2Fclinical -guidance%2Fbasal-cell-carcinoma-an- overview&psig=AOvVaw04POXZsqIiOmxVfsxpp- 6U&ust=1610648686462000&source=images&cd=vfe&ved=0CA0QjhxqFwoTCNC8 _pHEme4CFQAAAAAdAAAAABAD
- 20. Melanoma https://www.google.com/url?sa=i&url=htt ps%3A%2F%2Fmedwinpublishers.com%2FI JTPS%2FIJTPS16000114.pdf&psig=AOvVa w02hvTU4e15ExnwW13zVfd8&ust=161064 9040095000&source=images&cd=vfe&ve d=0CA0QjhxqFwoTCIihwNLFme4CFQAAAA AdAAAAABAD Most common in pinna When melanoma does involve the canal or temporal bone, it is typically advanced and caries an exceedingly poor prognosis. Treatment is surgical excision followed by radiation therapy.
- 21. sarcoma Most common temporal bone malignancy in paediatric population. Rhabdomyosarcoma is most common variant. Treated with wide en block resection followed by radiotherapy https://www.google.com/url?sa=i&url=https%3A%2F%2Flink.spring er.com%2Fchapter%2F10.1007%2F978-3-319-74539- 8_13&psig=AOvVaw3pLVL1Dt23593LFjDY2LrZ&ust=161064973439 5000&source=images&cd=vfe&ved=0CA0QjhxqFwoTCIjP3IPIme4C FQAAAAAdAAAAABAD
- 24. Treatment planning Determination of the tumour size, type, and extent Evaluation of histochemical or multi-centric associated lesions Identification and assessment of ICA Assessment of major vasculature involvement Assessment of intracranial collateral circulation
- 25. Treatment Surgical resection has been considered the standard of care. Tailored to the extent of disease. The goal of surgery is to extirpate disease, achieving a negative margin and minimizing morbidity or mortality
- 26. Radiotherapy Inherently poor vascularity of the temporal bone, Existence of an infected tumour bed Low oxygen tension levels Proximity of the brainstem
- 27. Radiotherapy Radiation therapy is Most often used in an adjuvant fashion. Radiation can also be used in a palliative capacity. Lewis et al., in a series of 132 patients, found that postoperative radiation increased the 5-year survival rate from 28.5 to 35.50%. IMRT
- 28. Contraindications to surgery Patients with unresectable disease, distant metastasis, or poor general health status. Tumours that encase the carotid or vertebral artery, that erode into the cervical spine. Significant brain invasion.
- 29. Operative techniques for malignant lesions Sleeve resection Lateral temporal bone resection Modified lateral temporal bone resection Subtotal temporal bone resection Total temporal bone resection
- 30. Sleeve resection For tumours truely confined to EAC. Involved skin and underlying cartilage are removed.
- 31. Lateral Temporal Bone Resection lateral temporal bone resection can be performed for tumours that involve the cartilaginous and bony canal but have not violated the annulus.
- 32. Source- Shambaugh surgery of the ear 6th edition
- 33. Modified Lateral Temporal Bone Resection If the tumour extends into the tympanic cavity or involves the mastoid air cells, The facial nerve, if involved, should be sacrificed piecemeal removal of bone allows complete excision of tumors with less morbidity..
- 34. Subtotal Temporal Bone Resection subtotal temporal bone resection is designed to remove the entire temporal bone lateral to the petrous carotid artery in an en bloc fashion. If necessary, portions of dura, sigmoid sinus, parotid gland, and mandible can be resected with the specimen. It is typically used for tumors that extensively encroach on the tympanic cavity or the mastoid air cells.
- 35. Source- Shambaugh surgery of the ear 6th edition
- 36. Total Temporal Bone Resection total temporal bone resection removes the entirety of the temporal bone and sacrifices the internal carotid artery.
- 37. Reconstruction Regional muscle flaps or a microvascular free tissue transfer. Radial forearm fascio-cutaneous flap Rectus myofasciocutaneous flap Lateral thigh flap.
- 38. THANK YOU