The Laryngoscope
C 2010 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Squamous Cell Carcinoma of the
Temporal Bone
Paul W. Gidley, MD; Dianna B. Roberts, PhD; Erich M. Sturgis, MD
Objectives/Hypothesis: To study the survival
outcomes of patients with squamous cell carcinoma
(SCC) of the temporal bone. A secondary purpose was
to evaluate the University of Pittsburgh staging sys-
tem as a predictor of survival.
Study Design: Retrospective review.
Methods: We performed a single-institution ret-
rospective review of the medical charts of patients
diagnosed with SCC of the temporal bone between
1945 and 2005. We identified the patients’ demo-
graphic characteristics, presenting symptoms, physi-
cal examination findings, tumor histology, disease
extent, treatment course, and clinical outcomes. We
used the Pittsburgh staging system (2000) to deter-
mine the patients’ tumor classification and disease
state. We then compared the overall and disease-free
survival rates between patients with early-stage ver-
sus late-stage disease.
Results: We identified 124 patients with SCC of
the temporal bone. Of these, 71 had incident
(untreated) SCC, 26 had recurrent SCC, and 27 had
persistent SCC after treatment elsewhere. The 5-year
overall survival rate for patients with incident SCC
was 38%, and the disease-free survival rate was 60%.
The overall survival rate for patients with incident
SCC was similar to that for patients with persistent
disease and was significantly better than that for
patients with recurrent SCC (P ¼ .008). Patients with
early-stage tumors (T1 or T2) had longer overall sur-
vival than those with late-stage tumors (T3 or T4;
P ¼ .004, log-rank). The 5-year overall survival rate
was 48% for patients with early-stage disease and
28% for patients with late-stage disease. Further-
more, patients with T1 tumors had significantly lon-
ger overall survival than patients with T2 tumors
From the Department of Head and Neck Surgery, University of
Texas M. D. Anderson Cancer Center, Houston, Texas, U.S.A.
Editor’s Note: This Manuscript was accepted for publication on
March 10, 2010.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Paul W. Gidley, MD, Department of Head
and Neck Surgery, U. T. M. D. Anderson Cancer Center, 1515 Holcombe
Blvd, Unit 1445, Houston, Texas 77030. E-mail: pwgidley@mdanderson.
org
DOI: 10.1002/lary.20937
Laryngoscope 120: June 2010
1144
TRIOLOGICAL SOCIETY
CANDIDATE THESIS
(P ¼ .039) and patients with T3 and T4 tumors (P ¼
.0008). Overall survival (OS) and disease-free interval
(DFI) were improved for T2 tumors when radiother-
apy was combined with surgery (OS, P ¼ .011; DFI, P
¼ .02). T1 tumors did not benefit in a statistically sig-
nificant way with combined therapy. T3 and T4
tumors had relatively poor outcomes in spite of com-
bined therapy. Twenty-two patients (31%) experienced
a recurrence within 1 year of treatment, whereas
only one patient developed recurrence after 1 year.
Lymph node metastasis, facial paralysis, or involve-
ment of the carotid artery, jugular foramen, or infra-
temporal fossa were not significantly associated with
overall or disease-free survival.
Conclusions: Patients with recurrent SCC of
the temporal bone had significantly shorter overall
survival and disease-free interval than patients with
incident SCC. In addition, patients with early-stage
disease (T1 and T2) had significantly longer overall
survival and disease-free survival than patients with
late-stage tumors.
Key Words: Temporal bone carcinoma,
squamous cell carcinoma, external auditory canal,
Pittsburgh staging system.
Level of Evidence: 2b
Laryngoscope, 120:1144–1151, 2010
INTRODUCTION
Malignancies in the temporal bone are extremely
rare in the United States, with only one to five cases
diagnosed per 1 million people annually.1–4 Squamous
cell carcinoma (SCC) is the most common tumor type to
occur in the temporal bone, though other histologic sub-
types of tumors of the skin, skin appendage structures,
parotid, other soft tissues, or bone/cartilage can invade
or arise within the temporal bone; basal cell carcinoma,
adenoid cystic carcinoma, adenocarcinoma, melanoma,
and various forms of sarcoma have all been described as
arising within the temporal bone.
The current literature on temporal bone malignan-
cies is limited by the rarity of these tumors, with only
nine studies reporting more than 35 cases of any single
histology.5–13 In addition, some studies have included
multiple histologic subtypes or primary tumor sites to
enhance the sample size.8,13–24 However, temporal bone
Gidley et al.: SCC of the Temporal Bone
malignancies have widely varying clinical courses, and
treatment decisions must be based on a sound under-
standing of their clinical behavior. In this study, we
excluded nonsquamous histologies and tumors arising in
the parotid or outer ear from our analysis to eliminate
confounding issues due to inclusion of other primary tu-
mor sites or non-SCC histologic subtypes. Instead, we
focused our study on SCC of the temporal bone at a sin-
gle multidisciplinary cancer center and sought to
determine the overall and disease-free survival rates for
patients with SCC of the temporal bone.
A reliable staging system is paramount for treat-
ment planning for this rare disease. The staging system
for temporal bone cancer has undergone many revisions,
with many surgeons offering their own systems.9,19,25–27
Since 1990, the Pittsburgh staging system has become
the most commonly utilized system, and the latest revi-
sion of this system28 was used in this retrospective
review.
MATERIALS AND METHODS
After institutional review board approval, a patient data-
base at a single institution was used to identify patients who
were diagnosed with a malignancy of the temporal bone or a
subsite of the temporal bone (external auditory canal, middle
ear, or mastoid) between 1945 and 2005. A total of 330 patients
were identified, and of these 124 had histologically identified
SCC. These patients’ medical charts were reviewed for the
patients’ demographic data and tumor site. Seventy-one
patients with incident (newly diagnosed or previously
untreated) SCC of the temporal bone were then selected for fur-
ther review of their presenting symptoms, physical examination
findings, tumor histology, disease extent, treatment, and clinical
outcome. Patients who had undergone previous treatment and
had a disease-free interval were considered to have recurrent
tumors. Patients who had undergone previous treatment but
did not have a disease-free interval (i.e., they were referred for
a tumor that was perhaps more extensive than originally
planned or surgical removal was incomplete) were considered to
have persistent disease.
The most recent version (2000) of the Pittsburgh staging
system (summarized in Table I)28 was used to stage all incident
tumors based on the available clinical descriptions, radiologic
descriptions, operative findings, and final pathologic reports.
Positive lymph nodes are considered signs of aggressive disease,
and so patients with T1 through T3 tumors with positive neck
nodes and all patients with T4 tumors were considered to have
stage IV disease.9 Patient records were reviewed for the extent
of the tumor, status of the resection margins, lymph node me-
tastasis status, treatment received, and final outcomes were
used for tumor staging. Findings from the physical examina-
tion, operative, and pathologic findings were used for tumor
staging.29 Plain films, polytomography, computed tomography,
and magnetic resonance imaging findings were also taken into
account when available. We also reviewed treatment received
and final outcome for each patient.
We calculated descriptive statistics for scaled values and
number of patients in the categories for each parameter of in-
terest. The correlations between the parameters and endpoints
were assessed using Pearson x2 test or Fisher exact 2-tailed
test if there were fewer than 10 patients in any cell of a 2
2
grid. Curves describing overall and disease-specific survival
were generated using the Kaplan-Meier product limit method.
The log-rank test was used to test the statistical significance of
Laryngoscope 120: June 2010
TABLE I.
Pittsburgh 2000 Staging System.28
Staging System Description
T classification
T1 Limited to the EAC without bony erosion or
evidence of soft tissue involvement
T2 Limited to the EAC with bone erosion (not full
thickness) or limited soft tissue involvement
(<0.5 cm)
T3 Erosion through the osseous EAC (full thick-
ness) with limited soft tissue involvement
(<0.5 cm), or tumor involvement in the mid-
dle ear and/or mastoid
T4 Erosion of the cochlea, petrous apex, medial
wall of the middle ear, carotid canal, jugular
foramen, or dura; with extensive soft tissue
involvement (>0.5 cm, such as involvement
of the TMJ or styloid process); or evidence
of facial paresis
N classification
N0 No regional nodes involved
N1 Single metastatic regional node <3 cm in size
N2
N2a Single ipsilateral metastatic node 3–6 cm in
size
N2b Multiple ipsilateral metastatic lymph nodes
N2c Contralateral metastatic lymph node
N3 Metastatic lymph node >6 cm in size
Overall stage
I T1N0
II T2N0
III T3N0
IV T4N0 and T1-4N1-3
EAC ¼ external auditory canal; TMJ ¼ temporomandibular joint.
the differences between the actuarial curves. Overall survival
was defined as the time from a patient’s first appointment for
the primary tumor of concern until the date of last contact or
death. Disease-free survival was defined as the time from the
end of treatment for the original disease to the patient’s first re-
currence. Results were considered statistically significant if the
probability that the null hypothesis was true was <.05. All sta-
tistical tests were performed using Statistica (StatSoft, Inc.,
Tulsa, OK) and SPSS (SPSS for Windows; SPSS Inc., Chicago,
IL).
RESULTS
Patient Demographics and
Presenting Symptoms
In our cohort of 124 patients with SCC of the tem-
poral bone, 66 (53%) were men, and 115 (93%) were
white, three (2%) were black, and five (4%) were His-
panic. Sixty-nine patients (56%) had tumors of the left
temporal bone. The mean patient age was 60 years (me-
dian, 61.5 years; range, 21–89 years). Seventy-one
patients (57%) had incident SCC. The remaining 53
patients had persistent SCC (n ¼ 27) or recurrent SCC
(n ¼ 26).
Of the 71 patients with incident SCC, 37 (52%)
were men and 66 (93%) were white. The mean patient
age was 62 years (median, 63 years; range 21–89 years).
Gidley et al.: SCC of the Temporal Bone
1145
 TABLE II. TABLE III.
Symptoms Reported by Patients With Incident Squamous TNM Classification and Disease Stage of Patients With Incident
Cell Carcinoma of the Temporal Bone and Squamous Cell Carcinoma of the Temporal Bone.
Disease Extent on Presentation.
TNM Classification Disease Stage No. of Patients %
Disease Characteristics No. of Patients (n ¼ 71) %
T1N0 I 20 28.2
Presenting symptoms T2N0 II 14 19.7
Otorrhea 44 62.0 T3N0 III 2 2.8
Otalgia 37 52.1 T4N0 IV 22 31.0
Hearing loss 31 43.7 T1-3N1 IV 4 5.6
Facial nerve dysfunction 11 15.5 T4N1 IV 4 5.6
Trismus 9 12.7 T4N2 IV 2 2.8
Ear canal mass 9 12.7 T4NX IV 3 4.2
Itching 6 8.5
TNM ¼ tumor, node, metastasis.
Ulcer in ear 5 7.0
Tinnitus 4 5.6
had tumor involvement with the posterior quadrant of
Vertigo 4 5.6
the ear canal most commonly involved (n ¼ 48). The
Dysphagia 4 5.6
tumor was circumferential or filled the ear canal in 32
Bleeding from ear 4 5.6
patients. In 22 patients, the SCC involved the tympanic
Chronic otitis media 3 4.2 membrane (TM); however, TM involvement could not be
Hoarseness 1 1.4 determined in patients with disease filling the ear canal.
Tongue dysfunction 1 1.4 In 40 patients (56%), the tumor extended beyond the ear
Neck mass 1 1.4 canal, and the most common site of extension was the
Location of primary tumor N % anterior to the tragus (n ¼ 25, 63%). Operative and radi-
Bony ear canal 63 88.7 ographic findings showed specific tumor extension to the
Membranous ear canal 5 7.0 jugular foramen (n ¼ 16), the carotid artery (n ¼ 8), the
Middle ear 3 4.2 infratemporal fossa (n ¼ 8), and the temporomandibular
joint (n ¼ 3). Overwhelmingly, patients had either T1 or
Total 71 99.9
T4 tumors and lacked metastatic adenopathy (Table III).
Tumor extending beyond ear canal 40 56.3
At presentation, nodes in the neck were palpable in 10
Anterior 25 35.2
patients, seven of whom had pathologically negative
Inferior 10 14.1 lymph nodes. The most common site of neck disease was
Posterior 9 12.7 level II, and no patient had contralateral nodal disease.
Superior 8 11.3
Two or more sites of extension 8 11.3
Tumor limited to ear canal 29 40.8 Treatment
Tumor extent not reported 2 2.8 Fifty-five patients (77%) underwent surgery, and 23
of them (32%) underwent surgery and then postopera-
tive radiotherapy (Table IV). The mean postoperative
Thirty-nine patients (55%) had tumors of the left tempo- adjuvant radiotherapy dose was 58.0 Gy (range, 29.6–
ral bone. The most common presenting symptoms were 75.0 Gy) to the primary tumor site and 49.5 Gy (range,
otorrhea, otalgia, and hearing loss (Table II). Otorrhea 10.5–75.0 Gy) to the neck. Ten patients underwent
was present for a mean of 9 months (range, 1–120
months), otalgia was present for a mean of 5 months
TABLE IV.
(range, 1–30 months), and hearing loss was present for a
Treatment of Patients With Incident Squamous Cell Carcinoma of
mean of 37 months (range, 1–480 months). Facial nerve the Temporal Bone.
dysfunction was reported as a symptom by 11 (15.5%)
No. of
patients, and this symptom was present for a mean of 6 Treatment Patients (n ¼ 71) %
months (range, 1–12 months). Facial paralysis (House-
Brackmann30 VI/VI) was documented in physical exami- Surgery 31 43.7
nation in eight patients. Surgery and radiotherapy 23 32.4
Surgery and radiotherapy 1 1.4
and chemotherapy
Definitive radiotherapy 9 12.8
Disease Extent
Tumors typically arose in the bony ear canal (89%), Definitive radiotherapy 1 1.4
and chemotherapy
with lateral extension to the external auditory meatus
Palliative care 4 5.6
in 20 patients, and medial extension to the middle ear in
Palliative radiotherapy 1 1.4
19 patients (Table II). Only 11% of patients had tumors and chemotherapy
confined to either the membranous ear canal (n ¼ 5) or Palliative chemotherapy 1 1.4
the middle ear (n ¼ 3). All quadrants of the ear canal

Laryngoscope 120: June 2010 Gidley et al.: SCC of the Temporal Bone
1146
 TABLE V.
Surgical Procedures on the Ear Canal or Temporal Bone
for Primary Squamous Cell Cancer.
Procedure
Biopsy only
Sleeve resection (n ¼ 18)
Sleeve resection only
Sleeve resection and superficial parotidectomy
Sleeve resection and mastoidectomy
Sleeve resection, tympanoplasty, and superficial
parotidectomy
Mastoidectomy (n ¼ 7)
Mastoidectomy only
Mastoidectomy and total parotidectomy
Mastoidectomy and TMJ resection
Lateral TB resection (n ¼ 19)
LTBR only
LTBR and superficial parotidectomy
LTBR and total parotidectomy
LTBR, mandibulectomy, and superficial parotidectomy
LTBR, mandibulectomy, and total parotidectomy
Subtotal TB resection (n ¼ 6)
STBR only
STBR and superficial parotidectomy
STBR and mandibulectomy
STBR, mandibulectomy, and superficial parotidectomy
Total TB resection (n ¼ 5)
TTBR only
TTBR and total parotidectomy
TTBR, mandibulectomy, and total parotidectomy
No surgery
TMJ ¼ temporomandibular joint; TB ¼ temporal bone; LTBR ¼ lateral
temporal bone resection; STBR ¼ subtotal temporal bone resection; TTBR
¼ total temporal bone resection.
definitive radiotherapy. The mean definitive radiother-
apy dose was 61.2 Gy (range, 13.5–94.0 Gy) to the
primary tumor site and 53.8 Gy (range, 25–94 Gy) to the
neck. Six patients received palliative radiotherapy or
chemotherapy or palliative care.
The surgical procedures performed are summarized
in Table V. We found that sleeve resections were more
often performed in the earlier years of this review, and
lateral temporal bone resections became the standard in
the 1980s. Even though anterior extension was common,
parotidectomy was performed in only one half of the
patients who underwent surgery. Eighteen patients
underwent a superficial parotidectomy (direct parotid
involvement in two patients), and nine patients under-
went a total parotidectomy (direct parotid involvement
in three patients). An ipsilateral neck dissection was
performed in 26 patients. Ten patients had positive
lymph nodes on physical examination, whereas only
three patients had positive lymph nodes on pathologic
examination. All three patients had pathologically posi-
tive level II nodes of the neck, and one of these three
patients also had a positive level III node. Extracapsular
spread was found in one patient who also had multilevel
Laryngoscope 120: June 2010
lymphadenopathy. None of the patients had a positive
level I, IV, or V node.
Earlier in this series, the standard reconstruction
No. technique was a split-thickness skin graft, regardless of
whether patients had undergone a sleeve resection or a
1
lateral temporal bone resection. For patients with larger
defects, especially patients with exposed dura or those
11 who had undergone a dural resection, a temporalis mus-
4 cle flap (n ¼ 15), a scalp rotational flap (n ¼ 2), or a free
2 flap (n ¼ 2) was utilized. The reconstruction technique
1 was not documented in six patients.
When cranial nerve deficits were included as a post-
operative complication, 30 patients (55%) experienced at
5 least one surgical complication. The most common surgi-
1 cal complication was facial nerve dysfunction (n ¼ 27),
1 followed by wound complications, including wound
breakdown in eight patients, spinal fluid leak in three
4 patients, wound infection in two patients, and meningi-
10
tis in one patient. Other complications could all be
classified as nonfacial cranial neuropathies (spinal acces-
2
sory neuropathy in two, vagal neuropathy in one,
1
hypoglossal neuropathy in one, and dizziness in one).
2
3 Pathologic Findings and Recurrence
A positive margin was reported in 13 of 55 patients
1
(24%) who underwent surgery; 35 patients who under-
1
went surgery had negative margins, and in the other
1
seven patients margin status was either not stated or
could not be determined. Tumor differentiation was
1 recorded in 51 patients and was as follows: well differen-
3 tiated in 17 patients, moderately differentiated in 28,
1 and poorly differentiated in six. Perineural invasion was
15 reported in four patients, and vascular invasion was
reported in two patients.
Twenty-three patients experienced tumor recur-
rence after completion of primary treatment, and 22
patients had recurrences within 1 year of completion of
initial treatment. Most of these recurrences were local
(n ¼ 12), eight patients had isolated regional recur-
rences, two patients had simultaneous local and regional
recurrences, and one patient had a solitary metastatic
lung lesion. Of the eight patients who had an isolated
neck recurrence, four (50%) did not undergo a neck dis-
section as part of their original surgery, and two (25%)
did not receive adjuvant postoperative radiotherapy.
Overall and Disease-Free Survival
The 5-year overall survival for patients with incident
SCC of the temporal bone was 38% (Fig. 1A). The overall
survival for patients with incident tumors was similar to
that for patients with persistent disease and was signifi-
cantly better than for the patients with recurrent tumors
(P ¼ .008; Fig. 1B). The 5-year disease-free survival rate
for patients with incident SCC was 60% (Fig. 2A), and the
disease-free interval for patients with incident tumors
was similar to the interval for patients with persistent
disease and was significantly better than the interval for
patients with recurrent tumors (P ¼ .001; Fig. 2B).
Patients with early-stage tumors (T1 or T2) had bet-
ter overall survival than those with late-stage tumors (T3
Gidley et al.: SCC of the Temporal Bone
1147
 ment types (data not shown). When patients were
stratified according to the presence of cervical metastases,
year of treatment (pre- or post-1990), or evidence of facial
paralysis, we found no significant differences in overall
survival (data not shown), which could have been due to
our small sample size. The numbers of patients with ca-
rotid artery, jugular foramen, or infratemporal fossa
involvement were also too small to demonstrate a signifi-
cant association with survival. However, none of the
patients with carotid artery involvement, intracranial
extension, or direct extension to the parotid gland were
alive at 5 years. Only one of the seven patients with jugular
foramen involvement and only two of the eight patients
with facial paralysis were alive at 5 years.

DISCUSSION
We evaluated the disease-free and overall survival
of patients with SCC of the temporal bone and found
that disease stage at presentation was significantly asso-
ciated with the overall and disease-free survival.
Patients with recurrent disease had significantly worse
overall survival and disease-free survival than patients

Fig. 1. (A) Overall survival of patients with squamous cell carci-

noma of the temporal bone who had not received prior treatment.
(B) Overall survival of patients with squamous cell carcinoma of
the temporal bone according to disease status at presentation.

or T4; P ¼ 0.004, log-rank; Fig. 3A). The 5-year overall

survival rate was 48% for patients with early-stage (T1
or T2) disease and 28% for patients with late-stage (T3 or
T4) disease. When patients with early-stage tumors were
subdivided according to T classification, patients with T1
tumors had significantly better 5-year overall survival
than patients with T2 tumors (P ¼ .039) and patients
with T3 and T4 tumors (P ¼ .0008; Fig. 3B).
The disease-free interval was longer in patients with
early-stage (T1 or T2) tumors than in patients with late-
stage (T3 and T4) tumors, although this did not reach
statistical significance (P ¼ .053; log-rank; Fig. 4A). Fur-
ther stratification of the patients into three groups
(patients with T1, T2, or T3 and T4 disease) showed a
trend of worse survival and disease-free intervals with
progressive T stage, but these differences were significant
only between T1 versus T3-T4 tumors (Fig. 4B).
Patients were stratified by treatment type (surgery
only, surgery and radiotherapy, or radiotherapy alone). We
found a significant difference in the overall survival or dis-
Fig. 2. (A) Disease-free interval in patients with squamous cell car-
ease-free interval in T2 patients comparing surgery alone cinoma of the temporal bone. (B) Disease-free interval of patients
to surgery with radiotherapy (Fig. 5A and 5B). For other T with squamous cell carcinoma of the temporal bone according to
stages, we did not find a significant difference among treat- disease status at presentation.

Laryngoscope 120: June 2010 Gidley et al.: SCC of the Temporal Bone
1148
 physical examination, and assessment of disease extent
by physical examination alone is often inadequate. Mod-
ern imaging now allows accurate assessment of temporal
bone cancer extension to the surrounding areas, such as
the dura, brain, carotid artery, jugular foramen, and tem-
poromandibular joint.31–34
In our patient cohort, patients with early-stage
tumors (T1 and T2) and those with late-stage tumors (T3
and T4) were clearly separate in terms of overall survival
and disease-free survival. However, further stratification
by the current staging system was limited because of the
small number of patients with stage III disease. As a sin-
gle factor, the extent of facial paralysis moved some of
our patients from T3 to T4, meaning that in these
patients, facial paralysis was the only T4 feature present.
Facial nerve paralysis was not a significant prognostic in-
dicator in our study; however, our analysis of this factor
was of limited power (only eight patients presented with
facial paralysis). Our ability to confirm the adverse
effects of other indicators of local extension (e.g., to ca-
rotid artery, jugular foramen, temporomandibular joint,
parotid, and infratemporal fossa) was also limited by our
small sample size.

Fig. 3. (A) Overall survival of patients with squamous cell carci-

noma of the temporal bone based on Pittsburgh staging system.
(B) Overall survival of patients with squamous cell carcinoma of
the temporal bone based on Pittsburgh T classification.

with incident tumors. In addition, patients with incident

tumors in the ear canal or with minimal tumor extension
and without middle ear or mastoid involvement (i.e.,
Pittsburgh stage T1 and T2 tumors) had significantly
better overall survival and disease-free survival than
patients with higher-staged tumors. The Pittsburgh
staging scheme used in this study appears to provide
adequate prognostic stratification between early- and
late-stage tumors.
In this study, we only included patients with SCC of
the temporal bone. Other studies have included patients
with nonsquamous histologies and/or sites outside of the
temporal bone. To our knowledge, there has only been
one multi-institutional report of patients with SCC of the
temporal bone (n ¼ 95).12 Thus, we have described the
largest series to date (n ¼ 124), a series that included 71
patients with incident SCC of the temporal bone
Four major developments have emerged in the con-
temporary management of SCC of the temporal bone:
multiplanar imaging, a reliable staging system, skull base
Fig. 4. (A) Disease-free interval in patients with squamous cell car-
surgery, and microvascular free flap reconstruction. Mul- cinoma of the temporal bone based on Pittsburgh staging system.
tiplanar imaging is important because as was the case in (B) Disease-free interval in patients with squamous cell carcinoma
our study, many patients have very limited findings on of the temporal bone based on Pittsburgh T classification.

Laryngoscope 120: June 2010 Gidley et al.: SCC of the Temporal Bone
1149

Fig. 5. (A) Overall survival for T2 tumors comparing surgery alone
to surgery combined with radiotherapy. (B) Disease free interval in
stage II tumor with surgery alone versus surgery with
radiotherapy.
Modern skull base and reconstructive surgery tech-
niques have advanced the treatment of SCC of the
temporal bone. The goal of these techniques is to achieve
a negative surgical margin while preserving unaffected
structures and to close large open surgical wounds.
Although surgical margin status is often very hard to
assess in temporal bone cancers, we did not find positive
margins associated with poorer survival rates. However,
only 13 patients with positive margins and 35 patients
with negative margins were identified, as no assessment
can be made for tumors without margins (such as
tumors treated with definitive radiotherapy) or tumors
for which margins were not reported (a drawback of ret-
rospective review).
Currently, there is no widely accepted strategy for
managing temporal bone tumors. Our past experience
has been limited largely to surgery and radiotherapy, ei-
ther alone or in combination, and these choices have
been applied haphazardly or on an ad hoc basis. We
were disappointed in the high local-regional recurrence
rate in this study; however, given the limited sophistica-
tion in evaluation, resection, reconstruction, and
radiotherapy for patients diagnosed during the early
Laryngoscope 120: June 2010
1150
years identified in this study, we were not surprised.
Surgical approaches have evolved over the period of this
review, and since 2005, when a neurotologist formally
joined the multidisciplinary team, we have standardized
our resection and reconstruction techniques.
In part because of common extension anteriorly and
to the TM, the current treatment strategy at our institu-
tion for early-stage disease (stage I or II) is lateral
temporal bone resection with superficial parotidectomy.
Many recent studies have shown excellent results with
this approach for patients with localized disease.4,10,12,35
The 5-year overall survival rates for patients with T1 and
T2 (or stage I and II) disease were reported to be between
80% and 100% in these modern studies. We also com-
monly perform limited, selective neck dissection (level
IIA, IIB, and III) in these patients not because of the fre-
quency of cervical metastases but rather to appropriately
stage and select patients for adjuvant radiotherapy.
Patients with preoperatively staged I disease will receive
postoperative radiotherapy if a final pathology examina-
tion reveals bone invasion/erosion, a positive or close
margin, perineural or vascular invasion, and/or cervical
nodal metastasis. T2 patients are given post-operative
radiotherapy. Patients with early-stage disease might do
well with radiotherapy alone; however, the current study
included only a few patients who received definitive radio-
therapy, and thus we were unable to discern a survival
advantage or disadvantage with single-modality radio-
therapy. Select patients with intermediate-stage disease
(stage III [T3N0] or stage IV [T1-3N1-3]) typically
undergo lateral temporal bone resection (sometimes
extended for T3 disease) with parotidectomy and neck dis-
section and postoperative adjuvant radiotherapy. Patients
with advanced primary disease (T4) are usually evaluated
for induction chemotherapy or targeted therapy,
approaches that need further study.36 Subtotal or total
temporal bone resection is performed if patients have sta-
ble or responding disease. Patients are then treated with
postoperative concurrent chemotherapy and radiotherapy.
As a result of our institution’s experience with relatively
common wound complications, our team’s standard is to
use flap reconstruction with a temporalis muscle flap for
smaller defects in which the deep temporal vessels were
undisturbed and free-flap reconstruction for larger defects
and most recurrent cancers.
Future studies of SCC of the temporal bone should
include either multi-institutional trials or studies from
identified regional cancer centers to treat and study
these cancers. This is especially important for patients
who will require multimodality treatment. The prospect
for large tumors is still dismal. Currently, surgery and
radiotherapy are not sufficient for achieving durable sur-
vival rates for patients with advanced stage SCC of the
temporal bone. Thus, chemotherapy as induction ther-
apy and as a postoperative radiosensitizer should be
explored as a means of achieving higher survival rates.
CONCLUSION
Though temporal bone malignancies are extremely
rare, SCC is the most common tumor type to arise in the
temporal bone and is more commonly found in the left
Gidley et al.: SCC of the Temporal Bone
ear of middle-aged to elderly men. The Pittsburgh staging
system provides important prognostic stratification for
patients with SCC of the temporal bone, but few patients
in our study fell into the stage III category, which could
have been a result of facial paralysis being included as a
descriptor of T4 disease. Owing to the retrospective na-
ture of this report, limited data here would support
specific treatment recommendations. Our current treat-
ment strategy for most patients with SCC of the temporal
bone is lateral temporal bone resection with parotidec-
tomy and neck dissection. In addition, adjuvant
postoperative radiotherapy is given to patients with T2
and larger tumors, perineural or vascular invasion, posi-
tive or close margins, and cervical metastases. Currently,
vascularized reconstruction methods with either tempo-
ralis muscle flap or microvascular free flap are the best
options to provide adequate coverage and ensure that the
wound can tolerate adjuvant postoperative radiotherapy.
Patients with incident tumors had higher disease-free
and overall survival rates than patients with recurrent
disease. This is important to keep in mind, as treatment
planning must ensure complete eradication of disease on
the first attempt, since treatment efficacy for recurrent
tumors is very poor. Finally, the high local-regional recur-
rence rate in this study has led us to focus our efforts on
a consistent approach to oncologic resection, reconstruc-
tion, and adjuvant radiotherapy.
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