Image SW Review the anatomy of the EAC and how this plays a role in the spread of tumors.

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1 Neoplasms of the Ear and Lateral Skull Base Image SW What are the three most common neoplasms of the auricle? SW What are the four most common neoplasms of the external auditory canal (EAC) and temporal bone? SW Review the anatomy of the EAC and how this plays a role in the spread of tumors.

2 Discuss the staging of temporal bone carcinoma and survival rates using this system. Arriaga M, Curtin H, Takahashi H, Hirsch BE, Kamerer DB. Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings. Ann Otol Rhinol Laryngol Sep;99(9 Pt 1): PMID: An accepted staging system for squamous cell carcinoma of the external auditory meatus is currently lacking and would permit accurate comparison of treatment strategies and results for patients with this unusual neoplasm. In order to develop such a staging system we reviewed the prognostic variables and the accuracy of radiographic diagnosis in 39 patients undergoing temporal bone resection for squamous carcinoma of the external auditory meatus. Predictors of poor survival were extensive tumor involvement, facial nerve paralysis, middle ear involvement, and cervical or periparotid lymphadenopathy. In a comparison of 12 specific anatomic sites, computed tomography was found to be an accurate indicator of histopathologically proven tumor invasion. On the basis of this clinical radiographic-histopathologic analysis, we propose a TNM staging system for external auditory meatus carcinoma utilizing preoperative computed tomography and physical examination. This system fulfills the requirements of the American Joint Committee on Cancer that a staging system should provide a sound basis for therapeutic planning for cancer patients by describing the survival and resultant treatment of different patient groups in comparable form AL Previously proposed categories: A: Lesion was limited to the EAM without erosion B: Tumor eroding the osseous EAM or involving the middle ear and/or mastoid C: Involvement of the cochlea, dura, medial wall of the middle ear, petrous apex, or surrounding soft tissue -PreOp staging is difficult because of inaccessibility of direct examination - new CT accurately assesses extent of disease - Radiographic-clinical-histopathologic correlation - Retrospective review of 39 patient charts -Radiography-Pathology Correlations: 13 Pts received CT preop -CT scans reviewed: 12 anatomic areas -Survival: A 100%, B 50%, C 18%, clear margins 63%, + margins 25%, +LN 29% - Avg interval from local recurrence to death ~ 3.6 months -Perioperative mortality 5% - Proposed TNM Staging: T1-tumor limited to the EAM without bony erosion or evidence of soft tissue extension T2-Tumor with limited EAM bone erosion (not full thickness), or radiographic findings consistent with limited (<0.5cm) soft tissue involvement T3-Tumor eroding the EAM (full thickness) with limited (<0.5cm) soft tissue involvement, or tumor involving the middle ear and/or mastoid, or patients presenting with facial paralysis T4- Tumor eroding the cochlea, petrous apex, medial wall of the middle ear, carotid canal jugular foramen or dura, or with extensive soft tissue involvement (>0.5cm) -Nodal Status: Use AJCC guidelines. Nodal involvement automatically is considered advanced disease - Recommend en bloc tumor resection since +margins are associated with poorer outcomes

3 Iowa H&N Protocols: Staging 1. T1: tumor limited to the EAC without bony erosion or soft tissue extension 2. T2: tumor with limited EAC bony erosion (not full thickness) or limited (<0.5 cm) soft tissue involvement 3. T3: tumor eroding the osseous EAC (full thickness) with limited (<0.5 cm) soft tissue involvement or tumor involving the middle ear and/or mastoid, or facial paralysis 4. T4: tumor eroding the cochlea, petrous apex, medial wall of the middle ear, carotid canal, jugular foramen or dura or with extensive (>0.5 cm) soft tissue involvement Arriaga M, Hirsch BE, Kamerer DB, Myers EN. Squamous cell carcinoma of the external auditory meatus (canal). Otolaryngol Head Neck Surg Sep;101(3): PMID: A retrospective study of 35 patients with squamous cell carcinoma of the external auditory meatus treated at the Eye and Ear Hospital of the University of Pittsburgh was performed. The standard treatment was a temporal bone resection that corresponded to the extent of the lesion, followed by postoperative radiation therapy. The tumor extensions, symptoms, treatments, survival rates, and prognostic variables were reviewed. Overall, 12 of 35 patients survived. Lesions limited to the external auditory meatus with no erosion had excellent prognoses. Survival in intermediate lesions with bony erosion or middle ear involvement was related to the status of surgical margins after partial or subtotal temporal bone resections. Extensive lesions that involved the surrounding soft tissue or dura had poor prognoses. The survival value of total temporal bone resection remains unproved CB What is the most common true neoplasm of the middle ear? Review the pathophysiology, presentation and work-up CB Discuss the classification and management of the above neoplasm. What are the surgical approaches for resection of this neoplasm? AL What other tumors affect the middle ear?

4 CB What tumors commonly metastasize to the temporal bone?

5 TT What are the known complications of temporal bone and lateral skull base surgery? Who should get a pre-op balloon occlusion test? TT Discuss the role of radiation therapy in the treatment of glomus tumors TT What are jugular foramen tumors? What is jugular foramen syndrome?

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