TUMOURS

OF
EXTERNAL AND MIDDLE EAR

Dr Kaushik Sarangi
MS ( ENT )
 Tumors of the Auricle
BENIGN TUMORS MALIGNANT
 Hemangioma TUMORS
•Squamous cell carcinoma
 Sebaceous cyst
•Basal cell carcinoma
 Dermoid cyst •Melanoma
 Papilloma
 Keratoacanthoma
 Neurofibroma
 Keloid
 Cutaneous Horn
Hemangioma
 Benign tumors of blood
vessels(capillary/ cavernous)
 Congenital tumor
 commonly seen in children
 Bleeds frequently
 May get infected
Dermoid cyst
 Developmental cyst

 Presents as round mass over the upper part of

mastoid behind the pinna

 Treatment: surgical excision

Sebaceous cyst

 Cysts of sebaceous glands

 Contains cheesy materials

 Common site is
postauricular sulcus or
below and behind the ear
lobule

 Treatment: total surgical

excision
Papilloma (Wart)

 May present as a
tufted growth or flat
grey plaque and is
rough to feel

 Viral in origin

 Treatment: surgical
excision or curettage
with cauterization of
its base.
Keratoacanthoma

 benign tumour of hair

follicles

 rapidly growing and

painless

 biopsy done to
distinguish from
neoplastic lesions
Keloid

 benign overgrowths of dermal scar

tissue in response to local trauma

 commonly on the ear as a result of

ear piercing

 Treatment of keloids
includes
surgical excision,
laser therapy,
intradermal steroid injection,
cryotherapy,
occlusive Silastic sheeting,
pressure earrings, or
even radiation therapy (reserved for
severe, refractory cases)
Squamous cell carcinoma
 It can arise anywhere in the external ear, commonly
helix.
 May present as a painless nodule or an ulcer with
raised everted edges and indurated base.
 Grows rapidly, invades the surrounding bone and
spreads through lymphatics
Treatment:
 Small lesions with no nodal metastasis- local excision
with 1 cm of external auditory canal
 Lesions with nodal metastasis- total amputation of the
pinna, often with en bloc removal of parotid gland and
cervical lymph nodes.
Squamous cell carcinoma
Basal cell carcinoma
 Commonly seen over helix and tragus
 More common in men beyond 50 yrs
 Presents as nodule with central crust, removal of which
results in bleeding.
 Ulcer has a raised or beaded edge
 Lesion often extends circumferentially into the skin,
may penetrate deeper to cartilage or bone
Treatment:
 Superficial lesion not involving cartilage- irradiation and
avoidance of cosmetic deformity
 Lesions involving cartilage- surgical excision as in SCC
Basal Cell Carcinoma
Tumors of Ear Canal
 Benign
Osteoma
Exostosis
Ceruminoma
Sebaceous adenoma

 Malignant
Squamous Cell Carcinoma
Basal Cell Carcinoma
Adenocarcinoma
Malignant Carcinoma
Melanoma
Exostosis
 Smooth, Sessile, Bony Swellings In the Deeper Part of the Meatus
 Multiple and Bilateral
 Arise From Compact Bone
 Exostosis - Exposed to Entry of Cold Water
Divers
Swimmers
 Males are affected Three Times More
Exotosis - Treatment
 No Treatment
Small and asymptomatic

 Larger Ones
Impair Hearing
Retention of Debris

 Surgical Treatment
High Speed Drill to Restore Normal Sized Meatus
Use of Gouge and Hammer Should Be avoided
Osteomas
 Arises From Cancellous Bone
 Single, Smooth, Bony, Hard, Pedunculated Tumour
 Often Arising From the Posterior Wall of the
Osseous Meatus
 Treatment is Surgical Removal By
Fracturing Through its Pedicle
Removal With a Drill.
Adenoma
 Benign tumours may arise from both the types of glandular
tissues in the external canal.
 So, the adenoma could be of following types:
i. Sebaceous adenoma
ii. Ceruminoma.
 Sebaceous adenoma
The tumour arises from sebaceous glands and is usually seen as smooth,
skin covered swelling in the outer part of the meatus.
Treatment is surgical excision.
 Ceruminoma (Hidradenoma)
This tumour arises from the ceruminous glands of the meatal skin.
The lesion presents as a firm skin covered mass which may be sessile or
pedunculated.
Treatment is wide local excision because chances of its recurrence and
turning malignant are marked.
Sebaceous adenoma
 Arises From Sebaceous Glands

 Smooth, Skin Covered, Swelling In the

Outer Meatus.

 Treatment
Surgical Excision.
Ceruminoma (Hidradenoma)
 Tumour of Modified Sweat Glands(Cerumenous)

 Smooth, Firm, Skin-covered Polypoid Swelling

 Usually attached to the Posterior or Inferior wall

 Obstructs the Meatus Leading to Retention of Wax and Debris.

 Malignant : Benign = 2: 1

 Treatment.
Wide Surgical Excision
Tendency to Recur
Regular Followed Up
Malignant Tumours of the (EAC)
1. SCC
 The external auditory meatus is not a common site for
squamous cell carcinoma.
 The disease is usually seen in cases having long-standing
suppurative disease.
 The patient presents with blood-stained discharge and pain in
the ear and on examination, a malignant ulcer or a bleeding
mass is seen in the canal.
 The adjacent auricular lymph nodes may be involved.
 Wide surgical excision is done which may mean an extended
radical mastoidectomy followed by postoperative radiotherapy.
2.Adenocarcinoma

 The tumour may primarily arise from the glands of the

external auditory canal and its differentiation from
squamous cell carcinoma is difficult on clinical
grounds.

 Diagnosis – by Biopsy which is confirmatory.

 Treatment - Surgery followed by radiotherapy (RT) is

the treatment of choice.
Depending upon the extent of involvement, surgery may be
○ radical mastoidectomy or
○ subtotal resection of the temporal bone.
TUMOURS OF THE MIDDLE EAR
CLASSIFICATION
 Tumours of middle ear and mastoid can be
divided into:
1. Primary tumours
(a) Benign: Glomus tumour
(b) Malignant: Carcinoma, sarcoma

2. Secondary tumours
(a) From adjacent areas, e.g. nasopharynx, external
meatus and the parotid.
(b) Metastatic, e.g. from carcinoma of bronchus, breast,
kidney, thyroid, prostate and gastrointestinal tract.
 GLOMUS TUMOUR
 Most common benign neoplasm of middle ear.
 It is so-named because of its origin from the
glomus bodies.
 The tumour consists of paraganglionic cells
derived from the neural crest.
 Tumors of these paraganglia are divided into 2
groups:
(1)adrenal paragangliomas (90%)known as
pheochromocytomas and
(2) extra-adrenal paragangliomas(10%) located in the
abdomen, chest,head and neck regions
 Head and neck
paragangliomas are
classified based on
anatomic location and
include the carotid
body, jugulotympanic,
vagal,laryngeal,nasal
and orbital
paragangliomas.

 Histologically, they
resemble carotid
body.
 In middle ear paraganglia
are distributed over –

1. Promontory – Along the

branches of tympanic
branch of
glossopharyngeal Nerve
(jacobson’s nerve). or
auricular br. Of
vagus(Arnold’s Nerve)

2. Dome of jugular bulb –

Adventitial layer
AETIOLOGY AND
PATHOLOGY
 The tumour is often seen in the middle age
(40–50 years).
 Females to male ratio is 5:1.
 It is a benign, but locally invasive
 extremely vascular
 very slow growing.
 According to their location they are named as
Glomus Jugulare, - arising from the jugular bulb,
Glomus Vagale,- arising from the vagus
Glomus tympanum, - arising from the promontory.
Clinical Features
 Depending upon the origin and spread
of the tumour, symptoms may be
aural,
neurological, or
combination of the two groups.
Symptoms
1. Aural symptoms:
Earliest symptoms are hearing loss and tinnitus.
Hearing loss is conductive and slowly progressive.
Tinnitus is pulsatile and of swishing character, synchronous with
pulse and can be temporarily stopped by carotid pressure.

2. Neurological symptoms: The tumour which primarily

arises from the jugular bulb subsequently involves the
adjacent cranial nerves in the jugular foramen and produces
symptoms of their involvement.
The seventh and eighth cranial nerve involvement produces
asymmetry of the face, dizziness and perceptive deafness.
Pain is not the usual feature unless infection is present.
Signs
 Rising sun sign - Otoscopically a reddish blue
mass may be seen behind the tympanic
membrane when tumour arises from the floor of
middle ear. - a.
 Brown (Pulsation sign)sign – positive
Increasing the pressure in the external auditory canal
by the Siegle’s speculum makes the tumour mass
more prominent and red, with increased pulsations.
As the pressure is increased above systolic pressure,
blanching occurs and pulsations disappear to
reappear again on release of the pressure.
 Once the tumour perforates the drum-head it
presents as a bleeding vascular polypoidal mass
in the canal.
 A bruit may be heard over the ear.
 Evidence of cranial nerve paralysis may be
present and mostly the seventh, eighth, ninth,
tenth and eleventh cranial nerves are involved.
 Rule of 10s
 10% are familial,
 10% multicentric (occurring in more than one site)
 10% functional, i.e. they secrete catecholamines.
DIAGNOSIS
 thorough History
 Physical examination, to find out the
extent of tumour, other associated
glomus tumours and
 Serum levels of catecholamines or their
breakdown products in urine
(vanillylmandelic acid, metanephrine,
etc.).
Investigations
1. Computed Tomography (CT) Scan Head.
 It helps to distinguish glomus tympanicum from the glomus jugulare
tumour by identification of caroticojugular spine which is eroded in the
latter.
 CT scan also helps to differentiate it from the aberrant carotid artery, high
or dehiscent jugular bulb.
2. MRI. tissue extent of tumour
3. Four-Vessel Angiography
 delineate any other glomus tumour (as they may be multiple), find the feeding vessels or
embolization of tumour if required.
4. Brain Perfusion and Flow Studies
5. Embolization –
 embolization of feeding vessels 1–2 days before operation helps to reduce blood loss.

6. Biopsy –
 Preoperative biopsy of the tumour for diagnosis is never done.
TREATMENT
 It consists of:
1. Surgical removal.
2. Radiation.
3. Embolization.
4. Combination of the above techniques.
 Small tumours are excised.
 Larger lesions may be treated by
radiotherapy followed by surgery.
 Radiotherapy
Preoperatively - to reduce the size and
vascularity of the tumour.
Postoperatively - for recurrent tumours or
for those cases which cannot
withstand surgery.
Malignant Tumours of
Middle Ear Cleft
 CARCINOMA
 SARCOMAS
 SECONDARY TUMOURS
 Carcinoma
 Rare, but it is the commonest primary middle
ear malignancy.
 AETIOLOGY
40–60 years and is slightly more common in
females.
Most cases (75%) have associated long-standing
ear discharge
 PATHOLOGY
Squamous cell variety is by far the most common.
Adenocarcinoma may occasionally be seen
CLINICAL FEATURES
 Patient often presents with clinical picture
simulating chronic suppurative otitis media.
 However, the following features in age group of
40–60 years may arouse suspicion of
malignancy:
1. Chronic foul-smelling discharge especially when
blood stained.
2. Pain which is usually severe and comes at night.
3. Facial palsy.
4. Friable, haemorrhagic granulations or polyp.
5. Appearance of or increase in hearing loss or vertigo.
DIAGNOSIS
 Definitive diagnosis is made only on biopsy.
 Extent of disease is judged by clinical and radiological
examination.
CT scan and angiography are useful in the assessment of
disease.

TREATMENT
 A combination of surgery and radiotherapy gives
better results.
 Surgery consists of radical mastoidectomy, subtotal
or total petrosectomy depending on the extent of
tumour.
SARCOMAS
Rhabdomyosarcoma.
 It is a rare tumour, mostly affecting children.
 In early stages, it mimics chronic suppurative otitis media with ear
discharge, polyp or granulations.
 Facial palsy occurs early
 Diagnosis is made only on biopsy.
 Prognosis is poor.
 A combination of radiation and chemotherapy is the treatment of
choice. Surgery is done in selected localized lesions.

Other Sarcomas. Osteosarcoma, lymphoma, fibrosarcoma and

chondrosarcoma are rare.
 Distant metastases are seen in the lungs or bone. Prognosis is
poor.
SECONDARY TUMOURS
 Tumours of external auditory meatus,
parotid gland or nasopharynx may
invade middle ear cleft either through
the preformed pathways or bone
erosion.
Th a n k You