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Surgery of the

Temporal Bone
Carcinoma

1
Introduction

Temporal bone carcinoma is a rare disease


Very aggressive course
If diagnosis is delayedBad prognosis
Rapid progression and limited therapeutic success
Squamous cell carcinoma (SCC) : Most common
primary (80%)
0.2% of all head and neck tumours

Ishak LN, Goh SB, Saim L, 2014; Beyea AJ, Moberly CA, 2015

2
Lecture Goals

Temporal bone anatomy

Malignant tumors
SCC and other primary
tumors
Metastatic tumors

Surgical technic

3
Temporal Bone Anatomy : identifying
pathways
of the spread of cancer

4
5 6
1 2 3
3
7 1 5
6 4 2
7 9

Axial Coronal
Hirsch EB, Chang JY, Antonio
4
MS, 2009
Cancer can spread :
1. Anteriorly : cartilaginous ear canal parotid
gland
2. Concha postauricular sulcus
3. Tympanic membrane middle ear
4. Posteriorly mastoid
5. Anterior mesotympanum carotid artery &
eustachian tube
6. Inner ear round window or otic capsule
7. Along the facial nerve infratemporal fossa
8. Through the mastoid, posterior fossa dura, &
sigmoid sinus
Hirsch EB, Chang JY, Antonio
9. Beneath the skull base jugular fossa, carotid
MS, 2009
artery & lower cranial nerves 5
PRIMARY MALIGNANCIES OF THE
TEMPORAL BONE

Gustafson LM, Pensak LM, 2003

6
Metastasis to Temporal Bone:

Breast carcinoma
Prostatic carcinoma
Renal cell
carcinoma
Bronchogenic
carcinoma
Lymphoma
Histiocytosis X
Marsh M, Jenkins A, 2010; Beyea AJ, Moberly
ColonCA, carcinoma
2015

7
SIGNS AND SYMPTOMS
OF TEMPORAL BONE MALIGNANCIES

Gustafson LM, Pensak LM, 2003


8
The differential diagnosis of temporal bone
malignancies

Leonetti PJ, Marzo JS, 2002


9
Squamous cell carcinoma (SCC)

Most common
No sex prevalence
Most patients have H/O chronic
inflammation of some kind
S/S are otorrhea, HL and deep seated
otalgia. 40% have a ME mass.
Direct labyrinthine invasion is rare
due to otic capsule
Gustafson LM, Pensak LM, 2003; Noorizan Y, Asma A, 2010; Beyea AJ,
Moberly CA, 2015
10
Extensive
recurrence of a
tragal SCC of the
left ear

Beyea AJ, Moberly CA, 2015


11
Squamous cell carcinoma

Facial nerve involvement = advanced


Dz
CN VII paresis = 30-50% recurrence rate
Paralysis = >60% recurrence
Involvement of other CN = dismal
prognosis
CT and MRI are complimentary
Noorizan Y, Asma A, 2010; Beyea AJ, Moberly CA,
Consider angio with embo 2015
if surgery
is feasible
12
Pittsburgh Staging System:
T classification

T1 : Tumor limited to the EAC; no bone


erosion or soft tissue extension
T2 : Tumor with limited bone erosion to the EAC or
<0.5 cm of soft tissue involvement
T3 : Tumor with full-thickness EAC bone erosion,
<0.5-cm soft tissue involvement, or tumor in the
middle ear or mastoid
T4 : Tumor eroding the cochlea, petrous apex,
medial wall of the middle ear, carotid canal,
jugular foramen, or dura; or >0.5-cm soft tissue
involvement; or facial nerve paresis
Hirsch EB, Chang JY, Antonio
MS, 2009 13
N classification
N0 : No regional nodes identified
N1 : Single ipsilateral regional node
<3 cm
N2a : Single ipsilateral regional node
36 cm
N2b : Multiple ipsilateral regional
nodes 6 cm
N2c : Bilateral or contralateral
Hirsch EB, Chang JY, Antonio MS, 2009; Beyea AJ,
regional nodes 6 Moberly
cm CA, 2015
N3 : Regional node >6 cm
14
M classification
M0 : Absence of distant metastatic
disease
M1 : Presence of distant metastatic
disease
Overall stage
I : T1N0M0
II : T2N0M0
III : T3N0M0
IV : T4N0M0, T14N1M0, T14N0
3M1 Hirsch EB, Chang JY, Antonio MS, 2009; Beyea AJ,
Moberly CA, 2015 15
Algorithm Temporal Bone
Carcinoma Therapy high grade
type

Marsh M, Jenkins A, 16
2010
Surgical Technic
Therapeutic guidelines by stage
T1 : LTBR or primary radiation, consider SP
T2 : LTBR plus postoperative radiation, consider SP
T3 : STBR or TTBR plus postoperative radiation,
consider SP
T4 : STBR or TTBR plus postoperative radiation,
consider SP
N+ : Add radical parotidectomy and SND to the
above
M1: Palliation
Hirsch EB, Chang JY, Antonio MS, 2009; Beyea AJ,
Moberly CA, 2015
17
Margins of resection

3.TT
BR

3.TTB
R
1.LTB 2.STBR
R
2.STBR

1.LTBR
Axial

2.STBR 3.TTB
R
1.LTB
R Hirsch EB, Chang JY, Antonio MS,
2009;
Beyea AJ, Moberly CA, 2015

Coronal 18
Carotid Management

T bone resection requires carotid


control as vessel passes thru medial
to the Eustachian tube before
entering the cavernous sinus
CT will show if the tumor is near the
carotid canal.
4 vessel angiography will show if
vessel is involved with
Hirsch EB, Chang tumor
JY, Antonio MS, 2009; Marsh M,
Jenkins A, 2010
19
Carotid BTO

Balloon occlusion testing with


Xenon/CT
Investigate the collateral blood flow to
ipsilateral hemisphere
80% will tolerate ICA sacrifice
10% will not necessitates prior bypass
grafting (ECA to MCA bypass) before T bone
resection
10% grey zone
Hirsch intraoperative
EB, or2009; Marsh M,
Chang JY, Antonio MS,
Jenkins A, 2010
preoperative revascularization
20
Lateral T Bone Resection

En bloc removal of the entire EAC


and TM
Utilizes the extended facial recess
approach
May also include parotidectomy, ND
and mandibular condylectomy
Hirsch
Involves resection of concha, may
EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ,
include variable parts of the pinna
Moberly CA, 2015

and tragus PRN 21


Lateral T Bone Resection

Postauricular and
meatal incisions for
resection of the
temporal bone.
This illustration
demonstrates
inclusion of the
tragus with the
specimen
Hirsch EB, Chang JY, Antonio MS,
2009 22
Lateral T Bone Resection
Closure of the EAC
Complete
mastoidectomy
Hypotympanic Extended facial
dissection
recess (sacrifice the
chorda)
Disarticulate the IS
joint
Fracture the anterior
Specimen fractured
with osteotome
Specimen
separated EAC just lateral to the
from soft tissue
Eustachian tube
Marsh with
M, Jenkins A,
2010
osteotome 23
The anteriorly
based skin flap
containing the
pinna is separated
from the core of
the external
auditory meatus.
The meatus has
been oversewn to
prevent tumor
Hirsch EB, Chang JY, Antonio MS,
spillage. 2009
24
Subtotal T Bone Resection

Used with CA has penetrated into the ME


space or mastoid cavities
Requires resection of the otic capsule
Can be extended toward the ITF, jugular
bulb or dura as prescribed by tumor extent
Should include monitoring of CN 7, 9, 10,
11
If possible spare CN 7 by complete
mobilization from geniculate to foramen
and transpose the nerve posteriorly.
Hirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ,
Moberly CA, 2015
25
Subtotal T Bone
Resection
The tegmen and posterior fossa plates are
thinned and then removed.
A translab drill out of the IAC and jug bulb
then done
Allows further mobilization of the FN from the
porus if needed.
The transected end of CN VIII should be sent
for frozen section
Entire tympanic ring drilled out but leaving
periostium over ICA and lower CNs.
Hirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ,
Moberly CA, 2015

26
C-shaped incision or Y-shaped incision
Incisions include a central
external auditory canal core,
which is sutured closed
Tragus can be preserved for
better cosmesis
Temporal craniotomy for
subtotal temporal bone
resection is smaller than for a
total temporal bone resection
Parotid gland with main trunk
of facial nerve has been
elevated from masseter
muscle.
Marsh M, Jenkins A,
2010 27
Subtotal T Bone Resection
Neck dissection
preformed for
vascular control of IJ
and ICA
Involvement of jugular
foramen necessitates
IJ sacrifice and ligation
of the sigmoid
Avoid injury to vein of
Labbe drainage of
the temporal lobe and
can result in venous
infarction of temporal
lobeBad!!
28
Marsh M, Jenkins A,
Subtotal T Bone Resection

Dural extension can


be resected with
help of
neurosurgeon to
close the dural
defect.
Extension into the
ITF accomplished
by including a Fisch
A ITF approach
Marsh M, Jenkins A,
29
2010
Total Temporal Bone
Resection

Marsh M, Jenkins A,
2010 30
Total T Bone Resection

Used if tumor involves the petrous


apex
Mandates proximal and DISTAL
control of the ICA
Distal control accomplished with middle
cranial fossa approach
Requires division of CN 7, 8, 9, 10
andEB,11
Hirsch Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ,

Done through Moberly CA, 2015


a suboccipital crani
31
The ICA is completely mobilized or
resected if involved with tumor
Osteotomy completed posterior to the
foramen ovale

Marsh M, Jenkins A,
32
2010
N. VII through XI have
been transected
The underlying dura
incised as the posterior
border of the en bloc
resection of the petrous
bone

The temporal and


retrosigmoid portions of
the dura have been Marsh M, Jenkins A,
33
Postoperative

Left Ear, Reconstruction has been performed


with a pectoralis major flap (PM)
Beyea AJ, Moberly CA, 2015
34
Complication

Vascular
Cerebrospinal fluid leak
Infection
Intracranial hemmorrhage and
hypertension
Wound
Hirsch EB, Chang JY, Antonio MS,
2009

35
Outcomes
Tumors limited to the EAC have 50-80%
cure rate after LTBR
Tumor extending beyond the ME 0-15%
survival >2yrs
Survival increases with dual modality
therapy
University of Pittsburg staging system
Increasing T stage is inversely proportional to
survival
T1 and T2 have reported 100% 2 yr survival
T3 lesions have 2 yr of 56%
2 yr survival of T4 tumorsHirsch
at 17%EB, Chang JY, Antonio MS,
2009 36
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