645
BASAL CELL CARCINOMA OF THE TEMPORAL BONE JAMES l. PARKIN, MD MICHAEL H. STEVENS, MD SALT lAkE CITY, UTAH
A case of a 57-year-old man with a 25-year history of untreated basal cell carcinoma of the ear Is presented. The lesion resulted in auricular destruction and temporal bone Invasion. This case emphasizes the potential destructive ilbillty of bilsa' cell carclnoma, Extensive resection and reconstruction were required for control.
BASAL cell carcinoma is the most common and usually the most easily treated of the cutaneous malignancies. This tumor most frequently remains superficial with minimal invasion and no evidence of distant metastases. A variety of treatment modalities are successfully used, including surgical treatment, irradiation, chemotherapy, cryosurgery, cautery, and curettage.' Basal cell carcinoma also has the potential for deep local tissue invasion as well as for distant metastases.>' Early appropriate treatment is important in preventing later disease extension. The auricle is less commonly involved with basal cell carcinoma than the central area of the face. s In fair-skinned men with a long history of sunlight exposure, the occurrence of facial basal cell carcinoma is increased. In a large series of ear malignancies reported by Conley and Schuller,s basal cell carcinoma was the most frequent auricular malignancy (ex-
Submitted for publication Sept 12, 1978. From the Division of Otolaryngology, University of Utah College of Medicine, Salt lake City. Presented in combination with the Committee on Surgery of the Head and Neck at the 1978 Annual Meeting of the American Academy of Otolaryngology, las Vegas, Sept 10-13.
cept for the unusually large number of melanomas in their report). Untreated or poorly treated basal cell carcinoma has the potential of becoming a highly invasive destructive lesion with the potential for distant metastases.
CASE REPORT In the fall of 1973, a 57-year-old white man was admitted to the emergency room with chief complaints of dyspnea and ankle swelling. He was diagnosed as having congestive heart failure, and appropriate therapy was initiated. The patient was also noted to have a bandage over his left ear. Bandage removal revealed an absent auricle with a SX7-cm ulcer crater over the temporal bone region. Multiple maggots were found throughout the lesion. The ear canal was identified with difficulty. The ulcer was surrounded by granulation tissue with central bone exposure. On further questioning, the patient stated he had been told by a physician in 1948 that he had a skin cancer on his auricle. This had frightened the patient, and he decided not to return for any therapy. Over the subsequent 25 years, the lesion gradually increased in size, with loss of the total auricle. The patient was hospitalized on the medical service for treatment of his congestive heart failure. This was controlled, and he was transferred to the otolaryngology service for additional treatment of the temporal bone lesion. Biopsy specimens revealed infiltrating basal cell carcinoma. Mastoid roentgenograms revealed some clouding of the mastoid air cell system with hypopneumatization of the left mastoid air cells but a normal middle ear cleft and inner ear. Surgical treatment was planned to use a laterally based deltopectoral flap. This flap was delayed prior to tumor resection to avoid flap shrinkage and to assure tip viability. The patient also had a small mass behind the opposite ear; this was excised and covered with a free
Otolaryngol Head Neck Surg 87:645-647 (Sept-Oct) 1979 Downloaded from oto.sagepub.com at The University of Iowa Libraries on June 5, 2016
PARKIN AND STEVENS
646
Fig 3.-Splint devised to reduce deltopecloral flap tension. Fig 1.-Surgical defect with pointer at inferior facial canal.
skin graft. The pathology of th is tumor was superficially invasive squamous cell carcinoma with adequate margins. Definitive surgery of the left temporal bone lesion was then undertaken . This consisted of a parotidectomy, partial temporal bone resection down to the jugula r bulb, fadal nerve resection , and wide field removal of skin and soft tissues . Resect ion continued until frozen sections were free of tumor . Biopsy specimens in the facial canal showed carcinoma necess itat ing facial nerve resection until clean margins were achieved. A free facial nerve graft was placed lollowing tumor resection . The large resultant surgical defect was partially co vered with the previously delayed chest flap (Fig 1). In addition, an anteriorly based scalping flap was used to allow tension -free coverage of the superior portion of the operat ive defect (Fig 2l. A special splint was des igned to m in imize ten sion on the chest flap pedicle (Fig 3). Five weeks later, a tourn iquet was applied to the chest flap pedicle, and atropine was injected into the distal flap with resultant oral dryness. The chest flap was then released and remodeled. The patient has subsequently had tarsorraph y, blepharoplasty, and re vision of the chest flap. FiK 2.-Combined deltopectoral flap and ~urKiral defect .
covI'raKf' 01
~(al~inK
flap
The patient was last seen 2'/1 years after resection without evidence of carcinoma re-
Oto/aryngol Head Neck SurK 87:645-647 (Sept-Get) 1979 Downloaded from oto.sagepub.com at The University of Iowa Libraries on June 5, 2016
BASAL CELL CARCINOMA
647
currence. He had minimal facial nerve function. Auricular reconstruction was planned, but the patient has failed to return for further follow-up.
nize the invasive and the metastatic potential of this lesion. Patients with basal cell carcinoma require adequate early treatment and continued follow-up.
CONCLUSION
REFERENCES
A case of extensive, destructive basal cell carcinoma of the ear and temporal bone is presented. This patient allowed 25 years to pass without any treatment of the lesion. The case demonstrates the aggressive potential of the natural history of this lesion. Radiation therapy is not as effective when bony invasion has occurred.' Extensive resection and reconstruction was required to control this malignancy. Appropriate early diagnosis and treatment could have prevented the morbidity of wide field resection.
1.. Jansen GT: Treatment of basal cell epitheliomas and actinic keratoses. lAMA 235: 1152-1154, 1976.
5. Batsakis JG: Tumors of the Head and Neck. Baltimore, Williams & Wilkins Co 1974 p 324. ' ,
The surgeon treating basal cell carcinoma of the head and neck must recog-
6. Conley), Schuller DE: Malignancies of the ear. Laryngoscope 86:1147-1163, 1976.
2. White H: Two cases of metastasizing basal cell carcinoma. Clin Oncol 1:149-155, 1975. 3. Wermuth BM, Fajardo IF: Metastatic basal cell carcinoma, a review. Arch Pathol 90:458462, 1970. 4. Lidholdt T, Sogaard H: Metastasizing basal cell carcinoma. Scand 1 Plsst Reconstr Surg 9:170-173, 1975.
Oto/aryngol Head Neck Surg 87:645-647 (Sept-Oct) 1979 Downloaded from oto.sagepub.com at The University of Iowa Libraries on June 5, 2016
BASAL CELL CARCINOMA OF THE TEMPORAL BONE JAMES l. PARKIN, MD MICHAEL H. STEVENS, MD SALT lAkE CITY, UTAH
A case of a 57-year-old man with a 25-year history of untreated basal cell carcinoma of the ear Is presented. The lesion resulted in auricular destruction and temporal bone Invasion. This case emphasizes the potential destructive ilbillty of bilsa' cell carclnoma, Extensive resection and reconstruction were required for control.
BASAL cell carcinoma is the most common and usually the most easily treated of the cutaneous malignancies. This tumor most frequently remains superficial with minimal invasion and no evidence of distant metastases. A variety of treatment modalities are successfully used, including surgical treatment, irradiation, chemotherapy, cryosurgery, cautery, and curettage.' Basal cell carcinoma also has the potential for deep local tissue invasion as well as for distant metastases.>' Early appropriate treatment is important in preventing later disease extension. The auricle is less commonly involved with basal cell carcinoma than the central area of the face. s In fair-skinned men with a long history of sunlight exposure, the occurrence of facial basal cell carcinoma is increased. In a large series of ear malignancies reported by Conley and Schuller,s basal cell carcinoma was the most frequent auricular malignancy (ex-
Submitted for publication Sept 12, 1978. From the Division of Otolaryngology, University of Utah College of Medicine, Salt lake City. Presented in combination with the Committee on Surgery of the Head and Neck at the 1978 Annual Meeting of the American Academy of Otolaryngology, las Vegas, Sept 10-13.
cept for the unusually large number of melanomas in their report). Untreated or poorly treated basal cell carcinoma has the potential of becoming a highly invasive destructive lesion with the potential for distant metastases.
CASE REPORT In the fall of 1973, a 57-year-old white man was admitted to the emergency room with chief complaints of dyspnea and ankle swelling. He was diagnosed as having congestive heart failure, and appropriate therapy was initiated. The patient was also noted to have a bandage over his left ear. Bandage removal revealed an absent auricle with a SX7-cm ulcer crater over the temporal bone region. Multiple maggots were found throughout the lesion. The ear canal was identified with difficulty. The ulcer was surrounded by granulation tissue with central bone exposure. On further questioning, the patient stated he had been told by a physician in 1948 that he had a skin cancer on his auricle. This had frightened the patient, and he decided not to return for any therapy. Over the subsequent 25 years, the lesion gradually increased in size, with loss of the total auricle. The patient was hospitalized on the medical service for treatment of his congestive heart failure. This was controlled, and he was transferred to the otolaryngology service for additional treatment of the temporal bone lesion. Biopsy specimens revealed infiltrating basal cell carcinoma. Mastoid roentgenograms revealed some clouding of the mastoid air cell system with hypopneumatization of the left mastoid air cells but a normal middle ear cleft and inner ear. Surgical treatment was planned to use a laterally based deltopectoral flap. This flap was delayed prior to tumor resection to avoid flap shrinkage and to assure tip viability. The patient also had a small mass behind the opposite ear; this was excised and covered with a free
Otolaryngol Head Neck Surg 87:645-647 (Sept-Oct) 1979 Downloaded from oto.sagepub.com at The University of Iowa Libraries on June 5, 2016
PARKIN AND STEVENS
646
Fig 3.-Splint devised to reduce deltopecloral flap tension. Fig 1.-Surgical defect with pointer at inferior facial canal.
skin graft. The pathology of th is tumor was superficially invasive squamous cell carcinoma with adequate margins. Definitive surgery of the left temporal bone lesion was then undertaken . This consisted of a parotidectomy, partial temporal bone resection down to the jugula r bulb, fadal nerve resection , and wide field removal of skin and soft tissues . Resect ion continued until frozen sections were free of tumor . Biopsy specimens in the facial canal showed carcinoma necess itat ing facial nerve resection until clean margins were achieved. A free facial nerve graft was placed lollowing tumor resection . The large resultant surgical defect was partially co vered with the previously delayed chest flap (Fig 1). In addition, an anteriorly based scalping flap was used to allow tension -free coverage of the superior portion of the operat ive defect (Fig 2l. A special splint was des igned to m in imize ten sion on the chest flap pedicle (Fig 3). Five weeks later, a tourn iquet was applied to the chest flap pedicle, and atropine was injected into the distal flap with resultant oral dryness. The chest flap was then released and remodeled. The patient has subsequently had tarsorraph y, blepharoplasty, and re vision of the chest flap. FiK 2.-Combined deltopectoral flap and ~urKiral defect .
covI'raKf' 01
~(al~inK
flap
The patient was last seen 2'/1 years after resection without evidence of carcinoma re-
Oto/aryngol Head Neck SurK 87:645-647 (Sept-Get) 1979 Downloaded from oto.sagepub.com at The University of Iowa Libraries on June 5, 2016
BASAL CELL CARCINOMA
647
currence. He had minimal facial nerve function. Auricular reconstruction was planned, but the patient has failed to return for further follow-up.
nize the invasive and the metastatic potential of this lesion. Patients with basal cell carcinoma require adequate early treatment and continued follow-up.
CONCLUSION
REFERENCES
A case of extensive, destructive basal cell carcinoma of the ear and temporal bone is presented. This patient allowed 25 years to pass without any treatment of the lesion. The case demonstrates the aggressive potential of the natural history of this lesion. Radiation therapy is not as effective when bony invasion has occurred.' Extensive resection and reconstruction was required to control this malignancy. Appropriate early diagnosis and treatment could have prevented the morbidity of wide field resection.
1.. Jansen GT: Treatment of basal cell epitheliomas and actinic keratoses. lAMA 235: 1152-1154, 1976.
5. Batsakis JG: Tumors of the Head and Neck. Baltimore, Williams & Wilkins Co 1974 p 324. ' ,
The surgeon treating basal cell carcinoma of the head and neck must recog-
6. Conley), Schuller DE: Malignancies of the ear. Laryngoscope 86:1147-1163, 1976.
2. White H: Two cases of metastasizing basal cell carcinoma. Clin Oncol 1:149-155, 1975. 3. Wermuth BM, Fajardo IF: Metastatic basal cell carcinoma, a review. Arch Pathol 90:458462, 1970. 4. Lidholdt T, Sogaard H: Metastasizing basal cell carcinoma. Scand 1 Plsst Reconstr Surg 9:170-173, 1975.
Oto/aryngol Head Neck Surg 87:645-647 (Sept-Oct) 1979 Downloaded from oto.sagepub.com at The University of Iowa Libraries on June 5, 2016
