SUBTOTAL RESECTION OF THE TEMPORAL BONE FOR CANCER OF THE EAR

HERBERT PARSONS, M.D., AND JOHN s. LEWIS, M.D.

HF. GENERAL PRINCIPLE OF BLOCK RESECTION T of malignant neoplasms in various areas of the body, together with appropriate node excision when indicated, is being applied with increasing frequency. This principle has stimu- lated interest in combined intracranial and ex tracranial procedures for the radical removal of a variety of malignant tumors involving the superficial structures of the head and skull. It has been used with some success in the treat- ment of cancer of the nasal accessory sinuses notably the maxilla and, in a few instances, in cancer involving the frontal sinuses and adja- cent structures. It has seemed reasonable to suppose that the same principle might be ap- plied to malignant tumors arising in, or ex- tending into, the ear.

There has been some hesitancy in employ- ing this method in the past because a number of important anatomical structures are situated in, or in the immediate neighborhood of, the ear and petrous portion of the temporal bone (Fig. 1). The most important of these are the internal carotid artery, the temporal lobe, cer- ebellum, and the base of the brain. Other struc- tures of importance are the lateral and sigmoid venous sinuses draining into the internal jugu- lar vein, the superior petrosal venous sinus, and the cranial nerves-notably the facial and acoustic, the glossopharyngeal, vagus, spinal accessory, and hypoglossal. The basal and lat- eral cerebrospinal-fluid cisterns are also situ- ated in this immediate neighborhood and if inadvertantly entered may lead to the develop- ment of a cerebrospinal-fluid fistula and the resulting danger of meningitis. With the ad- vent of antibiotics this last danger has become much less formidable and for this reason a more vigorous attempt at block excision of tu- mors in this region has seemed more feasible.

The basis for the ensuing discussion is the experience gained and the difficulties encoun-

From the Head and Neck Service, Memorial Center for Cancer and Allied Diseases; and the Department of Neurosurgery, New York Hospital, New York, New York.

Presented at the Seventh Annual Cancer Symposium of the James Ewing Society, March 12, 1954.

Received for publication, April 8, 1954.

tered in thirteen patients who have had malig- nant growths of varying sorts involving the ear canal, middle ear, and mastoid. The ma- jority have consisted of epidermoid carcinomas arising, apparently primarily, in these areas, but, in a few, basal-cell carcinomas have ex- tended from the outer ear into the ear canal and middle ear. One case was a parotid car- cinoma with secondary extension into the ear and two cases were sarcomas, one a spindle-ce:l sarcoma and the other a rhabdomyosarcoma. Although there is none included in this small group, other neoplasms that would be suitably attacked by this method are some of the exten- sive glomus-jugulare tumors that are encoun- tered in this region.

The symptomatology of malignant tumors arising in the deeper portions of the ear has been well recorded by a number of observers who have reviewed the general subject.203. 4 9 6 . 6

Many cases arise in ears from which there has been chronic drainage for many years. This otorrhea, at first purulent, often has become hemorrhagic. Pain deep in the ear has usually been prominent. A peripheral facial paralysis has deveIoped in a large number of cases. Deaf- ness and dizziness are also common symptoms. In the deeper lesions a diagnosis is not estab- lished until a biopsy of polyps or excessive granulation tissue has revealed carcinoma. The superficial lesions are usually obvious.

Formerly a radical mastoidectomy with sub- sequent radiation was the method of dealing with this type of cancer, but it is generally agreed that the results of such therapy were disappointing. In 1951 Ward and his coauthors described a more extensive operation com- bined with radical neck dissection in which the temporal bone containing tumor was re- moved piecemeal, a large area of dura and lat- eral sinus was uncovered, and the internal carotid artery was unroofed. Involved dura was resected. The resulting wound was left open and irradiated. At a later date the granu- lating area was grafted.

In that same year, Campbell described a similar method of excision in which the tumor was also removed in pieces but he suggested

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9% CANCER September 1954 VOl. I

FIC. 1. General anatomy of the temporal bone showing the relationships of the nerves and blood vessels. (Taken from Sobotta, J.: Atlas of Descriptive Human Anatomy, 5th ed. Vol. 111. [Trans]. and ed. by E. Uhlenhuth.] New York. Hafner Publishing Co., Inc. 1954; Fig. 77, p. 95.)

FIG. 2. Types of incision. A and B, Preserving the pinna. C, For excision of the external ear with the specimen.

that it would probably have been possible to remove the petrous portion of the temporal bone en bloc. Recent experience has shown that such a block excision is often possible. In the first two cases in this present series, piece- meal removal of the tumor was performed, but in the last eleven cases a block subtotal excision of the temporal bone was carried out.

OPERATIVE PROCEDURE

At the beginning of the procedure, a malle- able lumbar-puncture needle is inserted into the lumbar spinal canal. Depending on whether the pinna of the ear is involved by tu- mor and, of necessity, is to be sacrificed, an incision is marked out (Fig. 2) in the temporal region, either to permit a soft-tissue flap to be

rn freed

Lateral s i n u s

FIG. 3. Removal of the squamosa of the temporal bone.

reflected upward or to encircle the ear and tu- mor completely, leaving a margin of several centimeters. The incision is carried down onto the neck if it is felt that a neck dissection may be necessary. The incision is then carried down through the skin and subcutaneous tissues to the temporal fascia on the side of the head and through the platysma muscle in the neck. Flaps are dissected upward or anteriorly and poste- riorly i f indicated. The dissection is then car- ried down through the temporal muscle and pericranium to the skull, and the squamous portion of the temporal bone is exposed. A burr hole is made through this thin portion of the skull, and the squamosa is removed with rongeurs (Fig. 3), care being taken to separate the dura from the inner surface of the skull before biting it away. As this is followed down-

No. 5 TEMPORAL-BONE RESECTION IN CANCER OF EAR - Parsons 6. Lewis 997

ward in the posterior aspect of the exposure, the bone behind the mastoid becomes thicker and the lateral sinus is encountered. This ve- nous sinus is gradually uncovered for a dis- tance of several centimeters. The posterior aspect of the mastoid may be rongeured away if it is not invaded by tumor. If it is involved, the tumor is left undisturbed. The mastoid emissary vein is coagulated. The muscles at- taching to the mastoid are freed from their bony attachments. The squamous portion of the temporal bone is then rongeured away above and anterior to the ear canal, while the pinna of the ear is retracted downward. The posterior aspect of the zygoma is fractured. The dissection is then carried deeper in the area below the ear exposing the ascending ramus of the mandible. The periosteum is re- moved from the condyloid process of the man- dible or from a larger portion of the ramus of

the mandible if necessary. This part of the mandible is then cut through with a Gigli saw passed deep to it. The external carotid artery is exposed in the inferior aspect of the dissec- tion and divided. Although it may be desir- able to expose the internal carotid artery and pass a ligature around it, thus far it has not been necessary to ligate it at the primary exci- sion. The temporomandibular joint is usually exposed but left attached to the block to be excised, particularly if there is tumor in the ear canal.

If the tumor is situated entirely within the deeper portion of the ear, it will be possible to preserve the pinna of the ear and leave the ma- jor portion of i t attached to the anterior inferi- or flap of skin. Such being the case, a separate incision is made around the external auditory meatus within the concha (Fig. 4) of the ear and carried through the cartilage. It is then

FIG. 4. A, Freeing the dura from the petrous ridge and, with B, incision for coring out the external audi- tory canal.

FIG. 5. Extent of bone removal of the petrous ridge.

FIG. 6. Plaang of chisels for hacturing the petrous portion of the temporal bone.

Fffi. 7. A, The operative field following removal of the major portion of the temporal bone. B, Extent of bone removal, lateral view.

998 CANCER September 1954 Vol. 7

cut out from the pinna much like the core from an apple and, as the pinna is drawn for- ward and downward with the skin flap, the ear canal and its lining is left behind attached to the block to be excised later.

When this portion of the dissection is com- pleted, fluid is allowed to flow out of the pre- viously inserted spinal needle into a syringe in order to decompress the dura as the dura is separated and retracted medially from the an- terior aspect of the petrous ridge and floor of the middle fossa. The dura is then separated in a similar manner from the posterior aspect of the petrous ridge and from the ridge itself, care being taken not to tear the petrosal ve- nous sinus during its retraction. In this way the lateral two thirds, or three quarters, of the petrous ridge is exposed and bare (Fig. 5). The sigmoid portion of the lateral sinus is also re- tracted posteriorly.

With the ridge thus well exposed, chisels are driven into its medial aspect just lateral to the internal auditory meatus; into its anterior aspect and floor of the middle fossa, being di- rected posteriorly and downward; and into its posterior aspect, being directed anteriorly and downward (Fig. 6). It is also necessary to drive a chisel between the mastoid and occipital bone just above the jugular bulb before one feels the entire block of the lateral petrous bone, mastoid, and ear canal become free from the skull. The styloid process is freed or frac- tured at this time. Then with gentle prying, a t the same time separating the deep muscles at- tached to its inferior surface, the entire block

FIG. 8. A, Closure of the wound. B, Closure with skin graft inserted into the ear-canal defcct.

FIG. 9. Pedicle scalp flap covering ear defect.

FIG. 10. Dural-sinus venogram: small defect in upper sigmoid portion of right lateral sinus.

No. 5 TEMPORAL-BONE RESECTION I N CANCER OF EAR . Parsons 6. Lewis 999

containing the specimen can be lifted out, pro- vided the tumor has not extended outside its bony confines.

After this block removal the internal carotid artery can easily be seen, or felt, lying in the base of the resulting defect (Fig. 7). It is for this reason that the chisels should be driven into the floor of the middle fossa with extreme caution and just through the bone and no fur- ther. When the block is removed a segment of the facial nerve is included with the specimen -it will have been divided by the most medi-

FIG. 1 1 . Operative specimen following block resec- tion of carcinoma of the middle ear.

ally placed chisel and again when the struc- tures inferior to the block are separated or cut from its under surface near the medial aspect of the mastoid process.

The dura is blown up again by reinjecting some of the fluid that was aspirated in the syringe connected to the spinal needle. The soft-tissue flaps are reapproximated as far as possible with a double-layer closure (Fig. 8). A split-thickness graft is then cut with a derma- tome from a suitable donor site, placed over the residual defect, and sutured in place. If the pinna of the ear has been in large part pre- served, the graft is inserted through the open- ing where the canal was cored out, sutured to the margins of the defect, and then packed firmly into the residual recesses with Cornish wool. A firm pressure dressing is applied. The lid margins of the corresponding eye are then warified and sutured together as a lateral canthoplasty to protect the eye.

Should metastatic nodes be palpable in the neck or encountered during the procedure, a

FIG. 13. Operative specimen following block resec l i o i i of embryonal rhahdomyosarcoma of external autli tory canal. FIG. 12. Healed operative defect: casc in Fig. 1 1 .

1000 CANCER September 1954 VOl. 7

FIG. 14. Basal-cell carcinoma involving pinna, extcrnal auditory canal, and middle ear. FIG. 15. Defect following excision of lesion shown in Fig. 14.

radical neck dissection can easily be done at the same sitting. It prolongs the operation but does not greatly add to the risk for the patient. It has seemed preferable, however, to attempt the resection of the tumor first because, if it is found to be inoperable, the neck dissection will not have been wasted effort. There is less venous hemorrhage during the operation if the temporal-bone resection is performed prior to the neck dissection.

If the tumor is found to have invaded the dura, as it occasionally does, that portion of the dura can be resected and patched with a

graft of pericranium or temporal fascia. This grafted area can in turn be covered with a flap of residual temporal muscle so that, when the skin graft is applied over it, it will receive an adequate blood supply. Small tears in the dura or sinuses can usually be closed with a suture or, if very small, will usually be satisfactorily occluded by the skin graft alone. For large dural defects a fascia1 patch will be necessary and, rather than risk a free skin graft over it, a pedicle scalp flap can be used (Fig. 9).

Not infrequently the lateral or sigmoid sinus will be found to have been invaded by tumor.

TABLE 1 SUBTOTAL RESECTION OF TEMPORAL BONE

Case Age, yr. Anatomical Site Patholosy Operability Complications ~ ~~ ~

M. C. 69 Lt. external canal w. c. 65 Lt. external canal K. C. 57 Lt. middle ear B. J. 62 Lt. middle ear A. S. 29 Rt. middle ear W. E. 55 Lt. middle ear v. c. 43 Rt. middle ear F. S. 48 Rt. external canal S. G. 52 Rt. middle ear C. D. 47 Rt. external canal J. B. 5 Rt. external canal

w. 0. 64 Rt. mastoid

L. G. 75 Rt. external canal

Ca. parotid Basal-cell ca. Squamous ca. Squamous ca. Squamous ca. Squamous ca. Spindle-cell sa. Squamous ca. Squamous ca. Basal-cell ca. Embryonal rhabdo-

Squamous ca. myosarcoma

Operable I noperable Inoperable I noperable Operable Operable Operable Operable Inoperable Operable

Operable I noperable

Squamous ca. Operable

None None None Cerebrospinal-fluid fistula None None None None Died on 10th postop. day Segment of graft sloughed

None Cerebral edema with psy-

Died on 14th postop. day chosis, 2 wk.

No. 5 TEMPORAL-BONE RESECTION IN CANCER OF EAR . Parsons 6. Lewis 1001

a cerebrospinal-fluid fistula resulting from a tear in the dura drained intermittently; in an- other, a portion of the graft sloughed; and in still another, there was evidence of some tran- sient postoperative cerebral edema following ligation of the lateral sinus.

It is still too early to evaluate results in this small group of cases. The first case was oper- ated on in 1948, but most of them were done in 1952 and 1953. In five cases we know that residual tumor was left because it extended beyond the limits of the resection, involving the brain, lateral sinus, or structures deep in the neck. Three cases that, at the time of oper- ation, were believed operable have subsequent- ly developed recurrences in the operative site. There are five cases living without evidence of disease and three living with residual disease. A neck dissection was done in three cases, two at the time of the temporal resection and one secondarily. In ten cases neck nodes were not involved. Postoperative radiation has been used only when there has been residual tumor left or evidence of local recurrence (Figs. 11 to 16).

FIG. 16. Roentgenogram of bony defect remaining in case shown in Fig. 14.

This can sometimes be discovered beforehand if a dural-sinus venogram is done as a prelimi- nary procedure (Fig. lo). It would be safe to resect the lateral sinus if one were sure that there was a patent sinus draining out of the torcula from the opposite side. One takes a chance i f this preliminary step is not done and it is found necessary to resect a portion of the sinus.

COMPLICATIONS

Fortunately complications have been few (Table 1) but there were two deaths in the postoperative period. One occurred suddenly on the tenth postoperative day. Autopsy on this patient could not be obtained. The other died on the fourteenth postoperative day of meningitis and cerebral softening. In one case,

CONCLUSIONS

This type of block dissection still leaves much to be desired. We should like to point out, however, that all but two of these cases had had some lesser attempt at excision, plus irradiation, first and that they were recurrent or secondary cases. Our experience has shown us that a block resection of the ear canal, middle ear, and mastoid is practical. If it is used as a primary method of treatment of cancer still con- fined to the temporal bone, it should offer a better opportunity for successful total excision.

SUMMARY

A series of thirteen cases of cancer involving the ear canal, middle ear, and mastoid has been presented. A method of block excision used on eleven of these has been described.

REFERENCES

1. CAMPBELL, E.; VOLK, B. M., and BURKLUND, C. W.: Total resection of temporal bone for malignancy of the middle ear. Ann. Surg. 134: 397-403; disc. 403-404, 1951.

2. F~cr, F. A., and HEMPSTEAD, B. E.: Malignant tu- mors of the middle ear and mastoid process. Arch. Otolaryng. 37: 149-1G8, 1943; also in Tr. A m . Acud. Okhth. 47: 210-227; disc. 225-229, 1942.

3. GROSSMAN, A. A.; DONNELLY, W. A., and SNITMAN, M. F.: Carcinoma of the middle ear and mastoid proc- ess. Ann. Otol., Rhin. 6 L a y n g . 56: 709-721. 1947.

4. MATTICK, W. L.. and MATTICK, J. W.: Some ex- periences in management of cancer of middle ear and mastoid. A . M. A . Arch. Otolaryng. 53: 610-621, 1951.

5. SPENCER, F. R.: Malignant disease of the ear. Arch. Otolaryng. 28: 916-939; disc. 939-940, 1938.

6. TOWSON, C. E., and SHOFSTALL, W. H.: Carcinoma of the ear. Arch. Otolaryng. 51: 724-738, 1950.

7. WARD, G . E.: LOCH. \V. E., and LAWRENCE, W.. JR.: Radical operation for carcinoma of the external audi- tory canal and middle ear. A m . J . Surg. 82: 169-178, 1951.