Temporal bone malignancy presents a significant clinical challenge for the otolaryngologist. This article provides an overview of squamous cell carcinoma of the temporal bone, including clinical presentation, diagnosis, staging, treatment, and prognosis. As demonstrated in this case study, the prognosis for patients with advanced-stage temporal bone malignancy is poor, even with maximal therapy.
Key points
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Squamous cell carcinoma is the most common primary malignancy of the temporal bone.
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The modified University of Pittsburgh Staging System is the most commonly used system for staging temporal bone malignancies.
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Clear surgical margins improve disease-free survival.
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Postoperative radiotherapy should be offered to all patients with T2, T3, and T4 tumors.
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Multidisciplinary head and neck oncology clinics/institutional tumor boards are invaluable for optimizing the management of patients with these challenging malignancies.
| CRT | Chemoradiation Therapy |
| CT | Computed Tomography |
| DFS | Disease-free Survival |
| EAC | External Auditory Canal |
| LTBR | Lateral Temporal Bone Resection |
| SCC | Squamous Cell Carcinoma |
| STBR | Subtotal Temporal Bone Resection |
| TTBR | Total Temporal Bone Resection |
Case history
A 66-year-old man was referred to the neurotology clinic by head and neck surgery for preoperative planning. He had a 6-month history of left facial paralysis, facial numbness, otalgia, and otorrhea. Three years earlier, a left tragal squamous cell carcinoma (SCC) was resected at another institution, and he received postoperative radiation to the ear and parotid gland.
Cranial nerve examination revealed left V1 through V3 trigeminal nerve sensory deficits and a House-Brackmann grade VI/VI left facial paralysis. An extensive recurrence of the SCC was identified ( Fig. 1 ). Although firmness of the left parotid was noted, no intraparotid or neck lymph nodes were palpable.
An audiogram showed pure tone averages of 5 dB on the right and 57 dB on the left. The left-sided hearing loss was a moderate sloping to profound mixed loss. A PET scan superimposed on computed tomography (CT) revealed hypermetabolic activity of the left parotid gland, external auditory canal and surrounding skin, and left temporal musculature, and a small left cervical level 4/5 lymph node ( Fig. 2 ). No distant metastatic disease was detected on PET. An MRI scan was performed, which revealed the presence of enhancement along the facial nerve at the left stylomastoid foramen, along V3 in the foramen ovale, and along V2 in the foramen rotundum, and enlargement of the trigeminal ganglion in Meckel’s cave ( Fig. 3 ). A biopsy specimen of the ear lesion revealed invasive, poorly differentiated SCC ( Fig. 4 ). The patient was staged as T4N1M0; overall stage IV. His case was discussed at the authors’ institutional tumor board, and the malignancy was deemed resectable. The patient decided to proceed with surgery, and informed surgical consent was obtained.
Surgery involved the head and neck oncologic surgery, neurotology, and neurosurgery teams. The resection included total auriculectomy, ipsilateral selective neck dissection (levels 2–4), parapharyngeal space tumor resection, V1/2/3 resection, temporal dura resection ( Fig. 5 ), resection of involved facial nerve (with frozen section to obtain a negative proximal margin at the second genu of the nerve), lateral temporal bone resection (LTBR), partial mandibulectomy ( Figs. 6 and 7 ), and pectoralis major regional flap reconstruction ( Fig. 8 ).
The patient’s postoperative course was complicated by a cerebrospinal fluid leak at the suture line of the inferior aspect of the pectoralis flap, which was controlled by oversewing of the wound. He subsequently developed an infection deep to the pectoralis flap, which required intravenous antibiotics, local wound care, and finally open debridement and successful reconstruction with a myocutaneous rectus free flap. Unfortunately, on repeat MRI 3 months postoperatively, the patient developed a deep recurrence encasing the left internal carotid artery and vertebral arteries. The case was reviewed at the institutional tumor board, and the decision was made for no further intervention. The patient chose to proceed with hospice care.
Case history
A 66-year-old man was referred to the neurotology clinic by head and neck surgery for preoperative planning. He had a 6-month history of left facial paralysis, facial numbness, otalgia, and otorrhea. Three years earlier, a left tragal squamous cell carcinoma (SCC) was resected at another institution, and he received postoperative radiation to the ear and parotid gland.
Cranial nerve examination revealed left V1 through V3 trigeminal nerve sensory deficits and a House-Brackmann grade VI/VI left facial paralysis. An extensive recurrence of the SCC was identified ( Fig. 1 ). Although firmness of the left parotid was noted, no intraparotid or neck lymph nodes were palpable.
An audiogram showed pure tone averages of 5 dB on the right and 57 dB on the left. The left-sided hearing loss was a moderate sloping to profound mixed loss. A PET scan superimposed on computed tomography (CT) revealed hypermetabolic activity of the left parotid gland, external auditory canal and surrounding skin, and left temporal musculature, and a small left cervical level 4/5 lymph node ( Fig. 2 ). No distant metastatic disease was detected on PET. An MRI scan was performed, which revealed the presence of enhancement along the facial nerve at the left stylomastoid foramen, along V3 in the foramen ovale, and along V2 in the foramen rotundum, and enlargement of the trigeminal ganglion in Meckel’s cave ( Fig. 3 ). A biopsy specimen of the ear lesion revealed invasive, poorly differentiated SCC ( Fig. 4 ). The patient was staged as T4N1M0; overall stage IV. His case was discussed at the authors’ institutional tumor board, and the malignancy was deemed resectable. The patient decided to proceed with surgery, and informed surgical consent was obtained.
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