Temporal Bone His topa thology Update

Metastatic Squamous Cell Carcinoma to the Temporal Bone MITCHELL

S. MARION, MD, AND RAUL HINOJOSA, MD, EDITORS

A 52-year-old female noticed pressure in her right cheek associated with intermittent pain. Intranasal biopsy showed a squamous cell carcinoma of the right antrum. She underwent a right radical maxillectomy. Unfortunately, the tumor recurred locally 8 years later and further surgery was followed by radiation therapy. Four years later, at the age of 64, the patient noticed hearing loss in the right ear, which progressed to profound deafness. Later, the patient became progressively weaker and was admitted to a nursing home where she deteriorated and died. Pathological evaluation of the temporal bone demonstrated metastatic squamous cell carcinoma of the maxilla to the temporal bone [Fig. 1). DISCUSSION As early as 1922, Asail reported in the German literature a patient who developed a temporal bone metastases from carcinoma of the breast. In 1967, Maddox’ reviewed the world’s literature on metastatic tumors of the temporal bone and presented a series of 29 patients. In this series, most patient’s with metastatic temporal bone tumors had their primary tumors identified in either the kidney, lung, or breast. Thirty-four percent of these patients presented with facial paralysis. Two routes of metastatic spread are usually discussed. The first is hematogenous with metastatic cells being trapped in the bone marrow of the apex of the temporal bone. The second is via carcinomatous meningitis from cerebral spinal fluid to the inner ear or petrous portion of the temporal bone. In 1968, Schnuknecht3 had the opportunity to study American

Journal

of Otolaryngology,

10 patients with secondary malignant disease of the temporal bone. Metastatic tumors of the temporal bone often present as an isolated metastatic mass. Although the metastatic lesion usually resembles the primary tumor it may be less well differentiated, and it may not always be possible to localize the primary. Metastatic tumors can be destructive, that is osteolytic or osteoclastic, or provoke new bone formation, that is osteoblastic. The bony otic capsule is quite resistant to invasion by neoplasm, therefore involvement of the inner ear is uncommon. In 1971, Adams and Paparella reviewed 30 cases of malignant temporal bone tumors and discussed the presenting symptoms of patients with both primary and secondary tumors of the temporal bone. Presenting signs were variable and included aural polyps, pain, seventh nerve paralysis, other cranial nerve neuropathy, hemorrhage,

Fig 1. Limited high-powered view of the middle eer (ME). The etaper footplate 6) is identified. There is infiltration of metastatic squamous cell carcinoma (arrows) involving the middle ear mucosa and the tensor tympani tendon. (Original magnification x 17.)

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Fig. 2. Limited view of the temporal bone. The cochlea (Cl and vestibule IV) are identified. The organ of Cotti (ocl is noted along the basilar membrane. In the Internal auditory canal this is metastatic squamous 41 carcinoma involving the eighth nerve (N). (Original magnification x 17.1

hearing loss, vertigo, tinnitus, hemotympanum, acute otitis media, and mastoiditis. Pain, when present, without a draining ear requires a thorough evaluation and the combination of pain and seventh nerve paralysis is ominous. In 1975,5 the Mayo Clinic published a report on 110 malignant lesions of the temporal bone. Of these, 101 were primary tumors and 9 were metastatic. Adenocarcinoma was the most common, arising either in the lung or breast, with hypernephromas occurring in the kidney. Sites of metastasis included the middle ear, the external auditory canal, and the petrous apex. The mean duration of symptoms from onset to diagnosis was approximately 3.8 years. In 1976 Hill and Kohut” re-

MARION AND HINOJOSA

viewed the world literature on metastatic tumors of the temporal bone pointing out that the breast, lung, and hypernephroma were confirmed as the most common primary sites. However, carcinoma of the stomach, larynx, prostate, thyroid gland, nasopharynx, cervix, and uterus had also been observed. In 1978 Igarashi et al7 presented a case of bilateral sudden hearing loss secondary to metastatic pancreatic adenocarcinoma. The histopathology in this case demonstrated a tumor involving the fundus of the internal auditory canal and destruction of the spiral ganglion cells by tumor cell infiltration. Likewise, in our case, there was involvement of the eighth nerve in the internal auditory meatus (Fig 2). However, there was also involvement of the middle ear mucosa and an osteolytic lesion in the otic capsule. REFERENCES 1. Asai: Uker destruktiones des schlafenkeines durch tumoren. F.a.d. Geb. d. Ron&, 1922. 2. Maddox HE III: Metastastic tumors of the temporal bone. Ann Otol Rhino1 Larvnaol 76:149-165. 1967 3. Schuknecht HF, Allam ABF, and Murakami Y: Pathology of secondary malignant tumors of the temporal bone. Ann Otol Rhino1 Laryngol 77:5-22, 1968 4. Adams GL, Paparella MM, El Fiky FM: Primary and metastatic tumors of the temporal bone. Laryngoscope 81:1273-1285, 1971 5. Greer JA, Cody DTR, Weiland LH: Neoplasms of the temporal bone. J Otolaryngol 5:391-398, 1976 6. Hill BA, Kohut RI: Metastatic adenocarcinoma of the temporal bone. Arch Otolaryngol Head Neck Surg 102: 568-571, 1976 7. Igarashi M, Card GG, Johnson PE, et al: Bilateral sudden hearing loss and metastatic pancreatic adenocarcinoma. Arch Otolaryngol Head Neck Surg 105:196-199, 1979