Malignant tumors of the external ear

From the report of J. Leroux-Robert and A. Ennuyer, who analyzed statistical data from many oncological clinics in Europe, it is known that by 1957, malignant tumors of the outer ear accounted for 1.35-2.25% of all malignant tumors and 5-8% of all similar skin tumors. According to the same authors, malignant tumors of the outer ear are localized in the auricle in 93-98% and only 3.3-16.6% in the external auditory canal.

In 1957, the IV International Congress under the auspices of the French Society of Otolaryngologists on the problem of "Malignant Tumors of the Ear" was held in Paris, where world-famous otolaryngologists J. Leroux-Robert and A. Ennuyer made a keynote speech. It would seem that malignant tumors of the ear are a very rare disease, not deserving such high attention from leading specialists, but from the reports of the aforementioned scientists it became known that the problem lies not in the frequency of the disease, but in its early diagnosis, since, for example, middle ear cancer in the overwhelming majority of cases first proceeds "under the flag" of chronic, complicated by caries, granulation and cholesteatoma, purulent otitis media, and only when the process goes beyond the middle ear into the posterior or middle cranial fossa, and the patient acquires the "status" of a hopeless patient, the true diagnosis of this insidious disease is recognized. Most inoperable cases fall into the above example.

Classifications of ear tumors can be based on the same principles as those of tumors of any other ENT organs: by localization, by prevalence, by morphological structure, by nature of growth and degree of malignancy. Each of these principles plays a certain role in the overall chain of events of the holistic treatment process, in the center of which is the sick person. This process is subject to a certain algorithm of the sequence of actions, according to which a diagnosis is made, the method of treatment is determined and the prognosis is made. To implement the specified principles of classification and their use in practice, there is a set of structurally interconnected methods, which constitute the toolkit of the holistic treatment and diagnostic process. From the following, all the above provisions will become obvious in the context of specific clinical material.

According to A. Lewis, out of 150 cases of ear cancer, 60% involved the auricle and 28% involved the external auditory canal. Men get cancer of the auricle four times more often than women, while cancer of the external auditory canal occurs equally often in both males and females. The disease most often occurs at the age of 60-70 years.

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What causes malignant tumors of the outer ear?

Factors that contribute to the development of malignant tumors of the outer ear include prolonged insolation, exposure to ionizing radiation, trauma, etc. According to foreign authors (Rozengans), in 77.7% of cases these tumors arise as a consequence of various diseases of the auricle (chronic eczema, psoriasis, lupus, old scars, benign tumors).

Pathological anatomy of malignant tumors of the external ear

Macroscopically, malignant tumors of the auricle can be presented in three forms: solitary vegetative form (20%), ulcerative form (20%), ulcerative-infiltrative form (60%). Each of these forms, especially ulcerative, can become secondarily infected, complicated by perichondritis of the cartilages of the outer ear.

According to their spread, malignant tumors are divided into degrees:

• Grade I - a tumor or ulcer no larger than 5 mm, affecting only the skin without growing into the cartilage tissue;
• Grade II - a tumor penetrating the cartilage with signs of its destruction;
• Grade III - a tumor that has affected the entire outer ear with regional adenopathy;
• Stage IV - the tumor has extended beyond the outer ear and metastasized to the cervical lymph nodes.

Histologically, the vast majority of malignant tumors of the outer ear are epitheliomas. Sarcomas in their various forms occur rarely and only in the auricle. Melanomas are also rare, and neurinomas, glomus tumors, and malignant lymphangiomas are extremely rare in the outer ear.

Symptoms of malignant tumors of the outer ear

Symptoms of malignant tumors of the outer ear are largely determined by the histological type of the tumor.

Spinocellular epidermoid epitheliomas, the most common, evolve very quickly and are localized most often on the auricle, appearing as a warty-looking formation, grown into the underlying tissue with its entire base, often bleeding when rubbed against a pillow during sleep or carelessly touching the auricle. J. Leroux-Robert and A. Ennuyer describe three forms of epithelioma of the auricle:

1. a limited keratinized node located on an inflamed base and developing over a long period of time (several years);
2. ulcerative-proliferative formation with raised edges, villous bottom covered with crusts;
3. The infiltrative form is a deep ulcer with jagged edges and a bleeding bottom.

Most often (50%) the helix is affected, then, in decreasing frequency, the antihelix, the posterior surface of the auricle, the lobe, the tragus and the antitragus. Sometimes epithelioma of the auricle spreads to the external auditory canal.

Epithelioma of the external auditory canal can take the form of external otitis (furuncle) with an unusually long course without a tendency to heal, or in the form of a single kidney-shaped formation that bleeds when touched, or in the form of a long-term non-healing ulcer.

Symptoms of malignant tumors of the outer ear are typical: in addition to the above-described objective picture, one should pay attention to such complaints of the patient as constant pain in the auricle, more reminiscent of a sensation of a burn, irradiation of pain to the temporal region. At the onset of the disease, the pain occurs periodically, mainly at night, then it becomes constant and increasing in intensity, then painful paroxysms occur. When the tumor is localized in the external auditory canal, patients complain of bloody-purulent discharge from the ear, followed by the pain syndrome described above (difference from a furuncle of the external auditory canal). With total obstruction of the external auditory canal, hearing loss appears in the corresponding ear.

In spinocellular epidermoid epithelioma, a dark red erosion resembling stagnant granulation is detected in the external auditory canal, either limited in size or spreading throughout the external auditory canal both in width and depth; when palpating the bottom of the ulcer with a button probe, either loosened cartilaginous tissue or dense bone with a rough surface (scraper symptom) is felt. After careful and gentle scraping with a curette or a sharp spoon of all pathological contents, the extent of the tumor is determined, and whether it originates from the epitympanic space, in which granulation tissue often becomes malignant in chronic purulent epitympanitis. Often, in malignant tumors of the external auditory canal, the process, whether metastatic or inflammatory, involves regional lymph nodes and the parotid salivary gland, which is manifested by swelling and compaction of the corresponding areas.

Basal cell non-epidermoid epitheliomas of the external auditory canal occur less frequently than spinocellular ones, are characterized by slower development and later metastasis. When the auricle is affected, this tumor takes the form of ulcus rodens or a flat cicatricial tumor in the pretragal and posterior surface of the auricle; when the tumor is localized at the base of the auricle, at the place of its attachment to the skull, its partial or complete amputation may occur.

Sarcoma of the auricle occurs infrequently and is characterized by slow development, dense adhesion to the underlying tissue, late ulceration and absence of adenopathy. Sarcoma of the external auditory canal is characterized by proliferative growth, early grows into the middle ear and manifests itself in functional disorders, often occurring in childhood.

Diagnosis of malignant tumors of the outer ear

The diagnosis of "malignant tumors of the outer ear" is usually established by the appearance of the tumor, but often for some time this disease passes under the guise of complicated granulation eczema of the external auditory canal or even chronic purulent otitis media. Tumors of the auricle are more easily recognized. The final diagnosis is established by histological examination. Differential diagnostics of malignant tumors of the outer ear is of great importance, since there are many different diseases of the outer ear, which in their appearance are very similar to the initial forms of malignant tumors of the outer ear. Thus, when a tumor occurs in the area of the auricle, differential diagnostics should be carried out with the following diseases:

• dyskeratosis of the elderly, which manifests itself as multiple yellowish or brown crusts localized in various areas of the face and head;
• frostbite complicated by painful cracks, ulcers, granulations;
• eczema, manifested by oozing or scaling, infiltration of the underlying tissue, but not the phenomenon of growth into it;
• psoriasis, which manifests itself as characteristic psoriatic erythroderma spread throughout the body and mucous membranes;
• various specific granulomas (lupus, syphilis, etc.);
• various benign tumors.

In case of malignant tumors of the external auditory canal, they should be differentiated:

• from an ear polyp complicating chronic purulent otitis media;
• from Gelle's fistula, which occurs with chronic epitympanitis with bone caries and destruction of the upper posterior bone sections of the external auditory canal;
• from diffuse eczema of the external auditory canal, manifested by itching, periods of remission and exacerbation;
• from a furuncle of the external auditory canal, characterized by sudden onset, acute pain and other symptoms typical of this disease;
• from purulent mumps, which manifests itself as a fistula in the external auditory canal and other symptoms characteristic of this disease;
• from benign tumors of the external auditory canal.

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Treatment of malignant tumors of the outer ear

Treatment of malignant tumors of the outer ear depends on the nature of the tumor and its prevalence. In each individual case, one or another method is selected depending on the experience available in a given medical institution, technological means and on the basis of indications for one or another method. The methods of choice are diathermocoagulation, laser surgery, radiation and corpuscular ionizing therapy (radio- and cobalt therapy). Common tumors of the external auditory canal, the posterior surface of the auricle, and the auriculomastoid fossa are difficult to treat. Usually, in advanced cases, death occurs from secondary intracranial complications, metastases to the perivascular cervical lymph nodes with their subsequent disintegration and erosive bleeding, cancer cachexia.

What is the prognosis for malignant tumors of the outer ear?

Malignant tumors of the outer ear, even in the initial stages of this disease, always have a cautious prognosis, serious for widespread tumors within the tissues of the external auditory canal and pessimistic when the tumor grows into the middle ear, posterior or anterior cranial fossa.