comprehensive overview of squamous cell carcinoma of temporal bone and its management (temporal bone resections; lateral and total)

1. Carcinoma Temporal Bone
Dr Tabeer Arif

2. Layout
 Introduction
 Relevant Anatomy
 Etiology
 Clinical Presentation
 Differential diagnosis
 Investigations
 Treatment
 Complications
 Outcome

3. Introduction
 Rare, rapidly progressive disease with limited
therapeutic success
 Female predominance
 Malignant temporal bone tumors < 0.2% of all
head and neck tumors
 Most common (80%) of all primary Temporal bone
tumors – SCC

4. Anatomy

6. Spread of tumour

7. Aetiology
 Chronic Suppurative Otitis Media
 Radiation
 Familial disposition for skin SCC
 HPV – (jin et all – 1997)
 Ultraviolet radiation, chlorinated disinfectants

8. Clinical
Presentation
 Otorrhea (bloody, offensive)
 Otalgia
 Hearing loss
 Facial palsy
 External Auditory Canal lesion
 Tinnitus
 Headache
 Vertigo

9. Examination
 Ulcerated lesion or granular
mass or polypoid mass
 Cranial nerve examination
 Neck examination including
parotid gland

10. Differential
Diagnosis
 Skull base osteomyelitis
 CSOM
 Other tumors of temporal bone
 Melanoma
 Adenocarcinoma
 Adenoid cystic carcinoma
 Lymphoma
 Metastsis

11. Investigations
 Deep biopsy – CT guided biopsy
 CT
 MRI
 PTA
 Angiography & Balloon Occlusion Test
 Systemic workup (for GA fitness)

14. Staging
(Pittsburgh
Classification)
Stage Description
T1 Tumour limited to EAC
T2 Tumour with limited erosion of EAC or <0.5cm
involvement of soft tissue on radiological
assessment
T3 Tumour eroding the osseous EAC (full
thickness) with limited (<0.5cm) soft tissue
involvement or middle ear and/or mastoid
T4 Tumour eroding the cochlear, petrous apex,
medial wall of middle ear, carotid canal, jugular
foramen or dura or extensive soft tissue
involvement (>0.5cm). Facial paralysis at
presentation

15. N Status
N0 No nodal metastasis
N1 Metastasis to regional lymph nodes
M Status
M0 No distant metastasis
M1 Distance metastasis present
Stage
Stage I T1,N0,M0
Stage II T2,N0,M0
Stage III T3,N0,M0 T1,N1,M0
Stage IV T4,N0,M0 T2-4, N1,M0 any T, any N M1

16. Treatment
 Lateral Temporal bone resection
 T1, T2
 Lesion lateral to Tympanic membrane
 Extended temporal bone resection
 T3, T4
 Adjuvant therapy

17. Lateral
temporalbone
resection
 Incision
 Pinna excised partially or completely
 Cortical Mastoidectomy
 Posterior Tympanotomy – extended facial recess
 Anterosuperior extension into
Temporomandibular Joint (TMJ)
 Resection of TMJ and Mandible (condyle)
 Superficial Parotidectomy
 Neck dissection
 Reconstruction

18. Incision

19. Cortical Mastoidectomy and posterior tympanotomy

21. Surgical specimen after lateral temporal bone resection. (A) Lateral surface showing large
periauricular tumor. (B) Medial surface of specimen showing intact ear canal and eardrum.

22. Extended
temporalbone
resection
 Removal of pinna
 Posterior and middle craniotomy
 Sigmoid sinus and jugular bulb delineated
 Labyrinth removed, IAC transected
 Neck dissection continued inferiorly
 Upper 2/3rds of vertical ramus of mandible
excised
 Petrous tip (medial to internal Carotid) excised
separately

23. Incisions
Petrous apex,
ICA and IJV left
intact
Osteotomies
Bird’s eye view

24. Sleeve resection of the external auditory canal (solid line) - small lesions of the EAC.
Lateral temporal bone resection (dotted line)
Total temporal bone resection (dashed line)

25. Managementof
Neck
 Clinically N0 – Supraomohyoid Neck dissections
 Frozen section of suspicious node +ve for tumour
– Modified Radical Neck Dissection
 Clinically palpable lymph nodes at presentation –
Radical Neck dissection
 Parotidectomy

26. Reconstruction
• Temporal fascia
• Fibrin glue, Fat graft
• Temporalis muscle flap
• Myocutaneous (pectoralis, trapezius)
• Free Flap

27. Adjuvant
therapy
 Radiotherapy
 Primary treatment – Lesion limited to pinna,
limited EAC tumour by Silva et all
 Post- op radiotherapy (60-70 Gy)
 Chemotherapy
 Debulking and chemotherapy (5FU) by knegt et all

28. Intracranial
extension
 Poor prognostic factor
 Dura and brain involved – resected
 Frozen section of resection margins
 Dural defect repair with Fascia Lata

29. Carotid
involvement
 Poor prognosis
 Adventitia involvement – tumor dissected of
artery
 Gross involvement – ligation and resection of
artery
 Neurological consequences

30. Palliativecare
o Distant metastasis
o ICA involvement, petrous apex involvement and
extensive Dural or brain parenchymal
involvement
 Palliative surgical resection + post op
Radiotherapy

31. Complications
 Cranial nerve deficit
 Facial paralysis
 Dysphagia
 Aspiration
 Speech problems
 Nutritional deficiency
 Flap failure
 CSF leak
 Meningitis
 Hearing loss

32. Post Op Care
 Hearing Aids – BAHA
 Facial reanimation
 Feeding tube
 Speech therapy
 Follow UP –
 2 monthly – first 2 years
 6 monthly – 3rd-5th years
 Yearly – after 5 years
 CT & MRI – 6monthly (first 2 years) and then yearly

33. Recurrence
 Recurrence without distant metastasis – surgical
resection and post op radiotherapy
 Recurrent disease with metastasis – palliative
care

34. Outcome
 80-100% 5 year survival rates in stage I & II
 50% - stage III
 15-42% - stage IV

35. Thank You