A 60-year-old South Indian male patient presented to the Head and Neck Surgical Oncology OPD with a chief complaint of swelling and pain inside the left ear of 3 months duration. Medical history revealed that the patient was hypertensive and diabetic with a history of angioplasty. Patient also recalled recurrent ear infection in the past. He is a chronic smoker (40 years), with a habit of tobacco chewing (for the past 1 year) and was taking alcohol in the past, which he quit around 12 years ago. Past family history revealed that patient's mother died of tongue SCC. On examination, a polypoidal growth was noticed involving the posterior and inferior walls almost filling the canal, with no clinically enlarged intra- or peri-parotid gland, pre/postauricular or neck nodes.
He had already consulted a surgeon who had taken biopsy of the tumor located in the left EAC, for histopathological diagnosis. The hematoxylin and eosin slides and paraffin blocks of tissue were submitted for review at onco-pathology division of our institution. The slide was reviewed and reported as well-differentiated SCC.
Radiological examination displayed an irregular enhancing lesion in the left EAC without bony invasion. There was no middle ear extension. The right EAC was normal [Figure 1]. Since the tumor was confined to left EAC without bony erosion or evidence of soft-tissue extension, the patient was categorized in Pittsburg stage I. After discussion in the multi-speciality board, lateral temporal bone resection (LTBR) with superficial parotidectomy, and selective neck dissection was done with preservation of facial nerve.
Postauricular incision was placed extending anteriorly and approaching into the neck. Posterior-based flap was raised followed by cortical mastoidectomy. Antrum, facial nerve canal, and incus were identified. Using drill lateral temporal bone was delineated all around till ear ossicles, and the malleus and incus were removed. LTBR was completed using chisel and hammer. The facial flap was used to fill in the middle ear. Superficial parotidectomy was done with the preservation of branches of the facial nerve. Level II and III lymph nodes were dissected out, and the wound was primarily closed.
Radical specimen received in our department constituted of left LTBR with left superficial parotidectomy and left level II to III cervical lymph nodes. The specimen was cut open, which revealed an ulceroproliferative growth of size 1.4 cm x 1.3 cm x 0.4 cm situated 1.1 cm from superior resected margin, 0.7 cm from posterior resected margin, 0.8 cm inferior resected margin, and 0.6 cm from the anterior margin. Sections from EAC lesion showed an invasive epithelial neoplasm composed of islands of tumor cells showing increased nucleo-cytoplasmic ratio, moderate nuclear pleomorphism, vesicular nuclei with prominent nucleoli, and abundant keratin pearl formation. Stroma showed dense inflammatory reaction [Figure 2a]. The temporal bone was free of tumor microscopically. All resected soft tissue, and bony margins and parotid gland were free of tumor. No perineural or lymphovascular invasion was seen. Two intraparotid lymph nodes were identified, larger node measured 9 mm. Smaller node showed reactive changes, while the larger node showed double-layered oncocytic epithelium arranged in complex papillary architecture and thin core composed of lymphoid tissue [Figure 2b-d]. Adjacent nodal tissue was unremarkable. Eight neck nodes showed reactive changes. A final diagnosis of pT1 N0 well-differentiated SCC of the left EAC (AJCC 8th edition) with incipient intraparotid lymphnodal WT was made. Figure 3a shows the gross specimen of LTBR specimen. The operated site healed uneventfully with no evidence of recurrence 1 year and 11 months after surgery [Figure 3b]. The patient is under close follow-up.