EAC1
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Carcinoma of external auditory canal

Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
EAC2
Mar. 2002
Carcinoma of external auditory canal
• • Work-up procedure
• • Staging
• • Primary treatment
• • Follow-up
• • Treatment of recurrent and/or metastatic disease
• • References

EAC3
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Clinical evaluation
Complete history of the disease
Performance status (Karnofsky / WHO scale)
Examination of external auditory canal
Audiogram
Examination of the VII th nerve
Neck examination
Drawing of any lesions
Evidence Option
Type C
Type C
Type C
Type C
Type C
Type C
Type C
Std.
Std.
Std.
Std.
Std.
Std.
Std.

EAC4
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Biopsy
Biopsy under local anesthesia of chronic (> 3 months) external lesion
Biopsy under local anesthesia of any new lesion of the external auditory canal
If negative biopsy, then deep biopsy under general anesthesia
Evidence Option
Type C
Type C
Std.
Std.

EAC5
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Advanced clinical evaluation
Dental examination by oral surgeon if RxTh scheduled
Others (if required)
Evidence Option
Type C Std.
Type C Indiv.

EAC6
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Laboratory tests
Hemogram, coagulation tests, liver enzymes, kidney function
Thyroid function if RxTh scheduled: TSH
Evidence Option
Type C Std.
Type C Std.

EAC7
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Loco-regional imaging
CT scan without contrast enhancement (bone window)
1
MRI with gadolinium enhancement 1
1 See guidelines for loco-regional imaging
Evidence Option
Type C Std.
Type C Std.

EAC8
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Pathologic examination
Standards of the British Royal College of
Pathologists (endorsed by EORTC) 1
1 See pathology guidelines
Evidence Option
Type C Std.

EAC9
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Carcinoma of external auditory canal
• • Work-up procedure
• • Staging
• • Primary treatment
• • Follow-up
• • Treatment of recurrent and/or metastatic disease
• • References

EAC10
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Staging
Modified Pittsburgh (revision 2002) classification
Evidence Option
Type C Std.

EAC11
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
T1: Tumor limited to the external auditory canal without bony erosion or evidence of soft tissue extension
T2: Tumor with limited external auditory canal bony erosion (not full thickness) or radiographic finding consistent with limited (< 0.5 cm) soft tissue involvement
T3: Tumor eroding the osseous external auditory canal (full thickness) with limited (< 0.5 cm) soft tissue involvement, or tumor involving middle ear and/or mastoid
T4: Tumor eroding the cochlea, petrous apex, medical wall of the middle ear, carotid canal, jugular foramen or dura, or with extensive (> 0.5 cm) soft tissue involvement; patients presenting with facial paralysis
- T4a: extracranial extension (> 0.5 cm) in soft tissue or skin
- T4b: Tumor eroding the cochlea, petrous apex, medical wall of the middle ear, carotid canal or jugular foramen
- T4c: extension to the dura

Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
EAC12
Mar. 2002

EAC13
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Carcinoma of external auditory canal
• • Work-up procedure
• • Staging
• • Primary treatment
• • Follow-up
• • Treatment of recurrent and/or metastatic disease
• • References

EAC14
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Primary treatment: general strategy
T1–T2, N0
- Lateral temporal bone resection + parotidectomy + selective
ND (level II) ± RxTh
1
pN+ on frozen section examination, dissection of levels III-V
- RxTh if medical status not suitable for surgery : RxTh
T1-T2, N1
- Lateral temporal bone resection + parotidectomy + ND
(selective or radical modified) ± RxTh
1
T3 N0
- no extension to middle ear: Lateral temporal bone resection +
parotidectomy + selective ND (level II) + RxTh
1
- extension to middle ear: subtotal temporal bone resection +
dissection of nerve VII + nerve graft + parotidectomy +
selective ND (level II) + RxTh
1
T3 N1
- no extension to middle ear: Lateral temporal bone resection
+ parotidectomy + ND (selective or radical modified) + RxTh
1
- extension to middle ear: subtotal temporal bone resection
+ dissection of nerve VII + nerve graft + parotidectomy + ND
(selective or radical modified) + RxTh
1
1
see indication of post-operative RxTH (slide 18)
Evidence Option
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Std.
Indiv.
Std.
Std.
Std.
Std.
Std.

EAC15
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Primary treatment: general strategy Evidence Option
T4a, N0
- Subtotal temporal bone resection + parotidectomy + selective
ND (level II) + RxTh
1
pN+ on frozen section examination, dissection of levels III-V
- RxTh if medical status not suitable for surgery : RxTh
T4a, N1
- Subtotal temporal bone resection + parotidectomy + ND
(selectif or radical modified) + RxTh
1
T4b, any N
- Best supportive care
- Chemotherapy
- Local palliative surgery
- Local palliative RxTh
- Temporal bone resection + RxTh
1
T4c, any N
- Best supportive care
- Chemotherapy
- Local palliative surgery
- Local palliative RxTh
1
see indication of post-operative RxTh (slide 18)
Type 3
Type 3
Type 3
Type C
Type C
Type C
Type C
Type C
Type C
Type C
Type C
Type C
Std.
Indiv.
Std.
Std.
Std.
Std.
Std.
Indiv.
Std.
Std.
Std.
Std.

EAC16
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Primary treatment : pathologic examination
Standards of the British Royal College of
Pathalogists ( endorsed by EORTC )
See pathology guidelines
Std .
.

EAC17
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Indication for post-op RxTh
Evidence at the "T" level
-T2-T4
-close margins (< 5mm)
-positive margins: R1
-macroscopic residual disease: R2
-perineural invasion
Evidence at the "N" level
-more than one involved lymph node
-extracapsular rupture/soft tissue invasion
-more than one involved level
-invasion of lymphatic vessels
Evidence Option
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Std.
Std.
Std.
Std.
Std.
Std.
Std.
Std.
Std.

EAC18
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
• Extracapsular extension / soft tissue extension (ECE/STE)
• (Oral cavity tumors)
• R1 surgical margins
• Nerve invasion
• >1 positive neck nodes
• Positive node in > 1 levels
• Node size > 3 cm
• > 6 week interval between surgery and RxTh

EAC19
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
RxTh regimen
Target volumes
- Petrous bone, mastoid, parotid, para-
pharyngeal space and level II (N0) or level
II-V (N1)
Technique
- conformal radiotherapy
- IMRT radiotherapy
Dose
- T and positive neck levels: 70 Gy
- prophylactic dose (undissected neck): 50 Gy
- high risk (ECE or >1 risk factors): 64 Gy
- intermediate risk (1 risk factor other than
(ECE): 60 Gy
Fractionation
- daily 2Gy/fraction
1
See detailled protocol
2
See guidelines for post-operative radiotherapy
Evidence Option
Type C
Type 3
Type 3
Type C
Type C
Type C
Type C
Type 3
Std.
Std.
Invest.
Std.
Std.
Std.
Std.
Std.

EAC20
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Carcinoma of external auditory canal
• • Work-up procedure
• • Staging
• • Primary treatment
• • Follow-up
• • Treatment of recurrent and/or metastatic disease
• • References

EAC21
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Follow-up
Clinical examination
- local examination, audiogram, fiberoptic
examination and neck palpation every 2
months (first 2 years), every 6 months
(3 rd
-5 th
year), then every year (> 5 years)
- dental examination every 6 months, if RxTh
Loco-regional imaging
- NMR at 6, 12 and 24 months
Laboratory tests
-thyroid function (TSH) every year, if RxTh
Evolution of late toxicity (EORTC/RTOG) scale
Evidence Option
Type C
Type C
Type C
Type C
Type C
Std.
Std.
Std.
Std.
Std.

EAC22
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Carcinoma of external auditory canal
• • Work-up procedure
• • Staging
• • Primary treatment
• • Follow-up
• Treatment of recurrent and/or metastatic disease
• References

EAC23
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Evidence Option Salvage treatment for recurrent disease anyT-N0-M0
-Surgery ± RxTh
-Chemotherapy
-Best supportive care
T0-anyN-M0
-ND ± RxTh
-RxTh
-Chemotherapy
-Best supportive care
AnyT-N1-M0/T4 any N
Surgery ± RxTh
Chemotherapy
Best supportive care
Metastasis
Chemotherapy
Surgery
Best supportive care
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Type 3
Std.
Indiv.
Indiv.
Indiv.
Indiv.
Indiv.
Indiv.
Indiv.
Indiv.
Indiv.
Std.
Indiv.
Indiv.

EAC24
Mar. 2002
Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
Carcinoma of external auditory canal
• • Work-up procedure
• • Staging
• • Primary treatment
• • Follow-up
• Treatment of recurrent and/or metastatic disease
• References

Catholic University of Louvain, St - Luc University Hospital
Head and Neck Oncology Programme
EAC25
Mar. 2002
ARRIAGA M., CURTIN H, TAKAHASHI H, HIRSCH B and KAMERER DB : Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings.
Ann Otol Rhinol Laryngol 1990, 99 : 714-721
ARRIAGA M, HIRSCH BE, KAMERER DB and MYERS EN : Squamous carcinoma of the external auditory meatus .
Otolaryngol Head neck Surg 1989, 101 :330-337
AUSTIN J, STEWART K. and FAWZI N. : Squamous cell carcinoma of the external auditory canal. Arch otolaryngol Head Neck Surg 1994, 120 :1228 - 1232
JACKLER R. and DRISCOLL C. , Ed. : Tumors of the ear and temporal bone.Lippincot Williams & Wilkins,
Philadelphia, 2000
KUHEL W., HUME C. and SELESNICK S. : Cancer of the external auditory canal and temporal bone. Otolaryngol
Clin N Am 1996, 29 : 827-852
MANOLIDIS S, PAPPAS D, VON DOERSTEN P, JACKSON G and GLASSCOCK M Temporal bone and lateral skul base malignancy results . Am J Otol, 1998, 19 : S 1 - S 15
MOODY S , HIRSCH B and MYERS E : Squamous cell carcinoma of the external auditory canal : an evaluation of a staging system. Am J Otol 2000, 21 : 582-588
PRASAD S. and JANECKA I. : Efficacy of surgical treatments for squamous cell carcinoma of the temporal bone, a litterature review. Otolaryngol Head Neck Surg 1994, 110 : 270 - 280
SPECTOR JG : Management of temporal bone carcinomas : a therapeutic analysis of two groups of patients and long-term followup. Otolaryngol Head Neck Surg 1991, 104 : 58-66
SHIH L. and CRABTREE J : Carcinoma of the external auditory canal, an update. Laryngoscope 1990, 100: 1215-1218
TRAISSAC L., Ed : Les cancers de l ’oreille, Masson, Paris, 1995
TESTA J , FUKUDA Y and KOWALSKI L. : Prognostic factors in carcinoma of the external auditory canal . Arch
Otolaryngol Head neck Surg, 1997, 123 : 720-724
ZIESKE L. and MYERS E.N. : Squamous cell carcinoma with positive margins Arch otolaryngol Head neck Surg
1986, 112 : 863-866