Tumours of the Ear

Tumours of the ear are uncommon but clinically significant lesions; however, they demand early recognition because delayed diagnosis leads to temporal bone invasion and cranial complications. They may be benign (slow-growing) or malignant (locally aggressive), and although benign lesions often present with obstruction, malignant tumours mimic chronic ear disease; therefore, high suspicion is essential in clinical practice. These tumours may arise from:

• External auditory canal (EAC) – most common site,
• Middle ear cleft,
• Temporal bone structures,

Classification of Ear Tumours

Category	Common Types	Behaviour
Benign Tumours	Papilloma, Exostosis, Osteoma, Adenoma	Slow-growing, localized
Malignant Tumours	Squamous cell carcinoma (most common), Ceruminous adenocarcinoma, Meningioma, Acoustic neuroma, Glomus tumours, Endolymphatic sac tumour.	Locally invasive
Tumour-like Lesions	Cholesteatoma, Paraganglioma	Destructive but not true malignancies

Benign Tumours

Benign tumours primarily arise in the external auditory canal, and although they rarely threaten life, they can cause conductive hearing loss, wax retention, and recurrent infections; therefore, recognition is crucial. However, most require surgery only if symptomatic.

1. Papilloma

• Cause: Papillomas are caused by human papillomavirus (HPV) infection. Infection usually spreads from contaminated fingers.
• Features: It presents like a Cauliflower mass in the outer EAC. Obstruction leads to wax accumulation.
• Treatment: Excise with electrocautery or laser under anaesthesia, and cauterise the base to avoid recurrence.

2. Hyperostosis (Exostosis and Osteoma)

These represent bony overgrowths of EAC; however, students must differentiate them because their aetiology and treatment differ.

Feature	Exostosis	Osteoma
Number	Multiple	Single
Laterality	Bilateral	Unilateral
Site	Deep EAC	Outer EAC
Bone Type	Dense compact bone	Cancellous bone
Cause	Cold water exposure (“Surfer’s ear”). More common in males (3:1)	Idiopathic
Shape	Sessile	Pedunculated
Treatment	Drill if symptomatic	Surgical removal by fracturing through its pedicle or removal with a drill.

Mnemonic: Exostosis = Everywhere (multiple, bilateral); Osteoma = One (single).

3. Adenomas

These tumours arise from glandular structures of the canal; therefore, they usually occur in the cartilaginous portion.

Type	Origin	Key Features	Treatment
Ceruminoma adenoma	Modified sweat glands	Polypoidal may recur	Wide excision
Sebaceous adenoma	Sebaceous glands	Localized	Wide excision

Clinical Pearl: Any “aural polyp not resolving with treatment” must be biopsied, because malignancy may mimic benign disease.

 

Malignant Tumours of the Ear

Malignant tumours invade the temporal bone aggressively; therefore, early staging guides radical surgery. According to WHO 2017, low-grade types include otosclerosis and cholesteatoma.

Squamous Cell Carcinoma (SCC)

• Incidence: ~1 per million/year,
• Represents <0.5% of head and neck cancers,
• Occurs typically in elderly patients,
• Often misdiagnosed as chronic suppurative otitis media.

Aetiology

Risk Factor	Mechanism
Chronic suppurative otitis media	Chronic inflammation → dysplasia
Previous radiotherapy	Latency 5–30 years
UV exposure	Cellular DNA damage
Chemical exposure (chlorinated disinfectants)	Carcinogenic irritation

Pathways of Tumour Spread (Important for Viva)

Squamous cell carcinoma of the ear spreads easily because the temporal bone has many anatomical weak areas; therefore, knowing these pathways helps you understand the symptoms and complications.

How the Tumour Spreads

1. Through the Foramen of Huschke and the Fissures of Santorini. These are small natural deficiencies in the external auditory canal. The tumour passes through them and spreads to the parotid gland and temporomandibular joint (TMJ).
2. Medial Spread to the Middle Ear (Tympanic Cavity). The tumour grows inward into the middle ear. It may involve the facial nerve, causing facial weakness or paralysis. Involvement of the middle ear lining causes blood-stained ear discharge.
3. Upward Spread to the Middle Cranial Fossa. The tumour erodes the thin bone called the tegmen tympani. It can then reach the intracranial cavity.
4. Posterior Spread to Mastoid Cavity. The tumour enters the mastoid air cells and may extend further into the posterior cranial fossa.
5. Medial Spread to Petrous Apex. Deep extension can involve the petrous part of the temporal bone.
6. Anterior spread may surround the internal carotid artery, which is dangerous.
7. Inferior Spread to Jugular Fossa. The tumour can involve the lower cranial nerves (IX, X, XI, XII). This leads to dysphagia, hoarseness, and shoulder weakness.
8. Lymph Node Metastasis. Seen in about 10% of patients. First affected nodes are the Intraparotid nodes and the Postauricular nodes
9. Distant Metastasis (Late Stage). Cancer may spread through the blood to the lungs, Liver, Bones

 Symptoms

Patients usually present with symptoms that look like a chronic ear infection; therefore, always suspect cancer when symptoms do not improve with treatment.

1. Persistent ear pain (Otalgia). Most common symptom. Pain is deep, severe, and continuous.
2. Blood-stained ear discharge. Strong warning sign of malignancy. Discharge may be foul-smelling.
3. Facial nerve weakness (Facial palsy). Indicates advanced disease.
4. Multiple cranial nerve palsies (VII, IX–XII). Suggests spread to the skull base. The patient may develop dysphagia, hoarseness, or shoulder weakness.
5. Non-healing aural polyp. Any polyp that does not improve with treatment must be biopsied.

Examination Findings.

During otoscopic and clinical examination, look carefully for the following:

1. Mass in the External Auditory Canal (EAC). Exophytic mass, subdermal swelling or ulcero-proliferative growth in the external auditory canal. Bleeds on touch.
2. Cranial Nerve Involvement. Facial asymmetry due to facial nerve palsy. Dysphonia and dysphagia if the lower cranial nerves are involved.
3. Neck Examination. Enlarged lymph nodes in Level II and III may indicate metastasis.

Diagnosis.

Early diagnosis is essential; therefore, always investigate suspicious cases.

1. Transcanal Biopsy. Confirms diagnosis. Mandatory before treatment.
2. HRCT Temporal Bone. Shows bone destruction. Helps in staging tumour.
3. MRI. Detects soft tissue and intracranial spread. Evaluates nerve involvement.
4. Neck Imaging (CT/MRI/Ultrasound). Detects lymph node metastasis.

 

TNM Staging of Carcinoma of External Auditory Canal

T – Primary Tumour Classification

Stage	Extent of Tumour
T1	Limited to EAC, no bone erosion, no soft tissue involvement
T2	Limited to EAC with partial bone erosion or soft tissue involvement < 0.5 cm
T3	Full-thickness bony EAC erosion OR involvement of middle ear and/or mastoid
T4	Involves cochlea, petrous apex, medial middle ear wall, carotid canal, jugular foramen, or dura; OR soft tissue involvement > 0.5 cm (TMJ/styloid); OR facial nerve palsy

N – Regional Lymph Node Classification

Stage	Lymph Node Involvement
N0	No regional lymph node metastasis
N1	Single node < 3 cm
N2a	Single ipsilateral node 3–6 cm
N2b	Multiple ipsilateral nodes
N2c	Contralateral lymph node involved
N3	Node > 6 cm

Overall Stage Grouping

Stage	TNM Combination
Stage I	T1 N0
Stage II	T2 N0
Stage III	T3 N0
Stage IV	T4 N0 OR Any T with N1–N3

Important

• Facial nerve palsy automatically suggests T4 disease.
• Middle ear involvement upgrades tumour to T3.
• Intraparotid nodes are first to be involved → assess neck carefully.

Treatment

Treatment depends on the stage of tumour.

1. Lateral Temporal Bone Resection (For T1 and T2 Tumours).

Used when tumour is limited to the external auditory canal. Procedure Includes:

• Removal of EAC, tympanic membrane, and involved bone,
• Extended cortical mastoidectomy,
• Entire middle ear mucosa removed,
• Mastoid cavity obliterated with muscle,
• Eustachian tube closed.

Important Points:

• Facial nerve is preserved,
• Pinna is preserved if tumour margin is more than 5 mm away,
• Surgical limits:
  • Superior → Tegmen plate,
  • Anterior → Zygoma,
  • Inferior → Stylomastoid foramen

2. Extended Temporal Bone Resection (For T3 and T4 Tumours).

Required for advanced disease. More Radical Surgery Includes –  Removal of the middle ear, Mastoid, Inner ear and Head of mandible (if involved). The facial nerve is sacrificed due to tumour involvement.

Surgical Boundaries:

• Superior → Middle cranial fossa dura,
• Inferior → Jugular bulb,
• Anterior → Internal carotid artery,
• Posterior → Posterior cranial fossa dura,
• Medial → Petrous apex.

3. Radical Neck Dissection.

Done when metastatic lymph nodes are present.

4. Postoperative Radiotherapy. Indications are:

• Surgical margins are positive,
• Perineural invasion is present,
• Advanced tumours are treated.

Management Flowchart (Easy to Remember)

Patient with chronic ear disease + persistent pain ↓ Examine ear for suspicious mass ↓ Take biopsy (Do not delay) ↓ HRCT + MRI for staging ↓ Stage tumour ↓ T1/T2 → Lateral Temporal Bone Resection T3/T4 → Extended Temporal Bone Resection ↓ Radiotherapy if indicated

———— End of the chapter ————

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Glasscock-Shambaugh, Textbook of Surgery of the Ear.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Rob and smith, Textbook of Operative surgery.
• Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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