Ear Cancers, Tumours & Chondrodermatitis

Ear Cancers & Tumours

Cancer of the ear is common and makes up 5–8% of all skin cancer; any non-healing ulcer of the ear should be presumed to be malignant. Many are induced by sun exposure. The decline in the wearing of hats, the adoption of shorter hair styles, the thinning of the ozone layer and the popularity of package holidays all contribute. Even when sunscreens are applied to the face, the ears are often forgotten, allowing harmful rays unsuspected access to the skin of the ear. Patients on immunosuppressive therapy such as steroids, anti-transplant rejection or cancer drugs are especially at risk.

The majority of ear cancer is squamous cell carcinoma (60%), followed by basal cell carcinoma (35%) and melanoma (5%). The distinction between a basal cell carcinoma and a squamous cell carcinoma on the ear may not always be obvious. Cancers derived from sweat glands, hair follicles, wax and sebaceous glands can also occur but are less common. Malignant tumours of the external auditory canal (the ear canal) are, thankfully, rare, as they are difficult to treat.

Most squamous cell tumours begin in areas of solar keratosis and the proper treatment of such minor lesions is therefore important. These discrete crusty lesions frequently develop on the exposed rim of the ear. Lesions of the concha and the back surface of the ear are more worrisome as they are more likely to spread to local lymph nodes.

Basal cell carcinoma can mimic a simple skin infection or a rash, and Any suspicious persistent lesion near the ear should be biopsied. BCC of the ear is unusual in that it tends to occur in the conchal hollow and in the groove behind the ear, areas that do not correspond to those of maximal sun exposure. Basal cell cancers of the ear often extend in a silent manner beyond the visible tumour, and this, combined with a widespread reluctance to potentially increase the postoperative deformity associated with wider margins, may explain a high recurrence rate in some cases.

Larger cancers (basal cell and squamous cell) above 2cm in diameter and recurrent tumours are especially likely to have unrecognized pockets of tumour at a distance from the visible margins. Rather than a spherical growth pattern they may have finger like projections of tumour along tissue planes. As a general rule, the likely extension beyond visible limits is equivalent to the radius of a small primary lesion with a short history but to the diameter of a recurrent longstanding or thicker lesion.

Because there is limited subcutaneous tissue, tumours will become fixed to and invade the deeper tissues, including cartilage at an early stage. Basal cell carcinoma in particular may spread laterally at the level of the perichondrium (the covering of the cartilage) beyond the visual tumour limits although this deep lateral spread rarely exceeds 5–6mm. When perichondrium is involved the underlying cartilage must be excised.

Treatment of Ear Cancers & Tumours

Melanoma of the ear is treated first by a confirmatory excision biopsy. Subsequent treatment depends on the tumour depth, and tumours greater than 1.5mm in thickness will require a radical removal of tissue, but total removal of the ear is not always required. Good long-term results can be achieved with early treatment, wide excision and subsequent reconstruction of the defect.

The majority of tumours are treated with excisional biopsies and immediate reconstruction. With most lesions, only a small margin of normal tissue needs to be removed with the tumour for cure. When a tumour is adherent to the underlying cartilage, then wider margins of skin and cartilage should be taken because of lateral spread. The more aggressive squamous cell tumours of the central and posterior parts of the ear should also be removed with a wider margin. The incidence of spread to the lymph nodes from these sites can be 6–20%, depending on how they are treated, and regular follow-up is recommended.

Reconstruction after tumour excision: simple techniques for smaller tumours

Direct closure

In some patients, the skin of the helical rim is slack enough to permit direct closure when simple lesions such as small basal cell carcinomata and chondrodermatitis nodularis helicis chronica are removed. Incisions along the helical rim margin are particularly easy to close. When the skin is tight then that on the posterior surface can be rotated onto the rim to assist closure. The skin on the posterior ear is less adherent and defects on the postauricular surface can often be closed directly. The scar is hidden in the groove behind the ear. Sometimes the ear is pulled a little closer to the head in the process.

Skin grafts

If the perichondrium can be preserved then a full thickness skin graft is an ideal reconstructive solution (Figure 29.7). Both preauricular and postauricular donor sites are available. For lesions of the conchal hollow, a skin graft is a good form of reconstruction even if cartilage is excised (Figure 29.8). The raw soft tissue behind the conchal cartilage will readily accept a skin graft. Small defects at other sites can be reconstructed with skin grafts but it is important to preserve a round rim of cartilage and skin behind the defect. Without cartilage the helical rim margin will collapse postoperatively.

When large defects of the ear are excised, preserving the underlying perichondrium, then large split thickness skin grafts will give excellent results (Figure B).

Wedge excisions

Defects on the helical margin can be removed as a small wedge. Some elderly patients with skin tumours have oversized ears (7–8cm tall) and a small reduction in overall size is not readily apparent. A simple wedge should always be modified with small lateral extensions to prevent cupping of the ear when the components are joined (Figure 29.9).

In the Antia and Buch technique (a modified wedge), the available circumference of the ear after tumour excision is enhanced by advancing (stretching) the locally available tissues along the helical rim (Figure 29.10).7 Large peripheral flaps of the adjacent helical margin are based on a wide postauricular skin pedicle. The earlobe varies in size but in most patients loose tissue within the lobe can be advanced along the rim of the ear.

This is a useful technique as the flaps are a good match for the missing helical rim. A single flap will suffice for small defects but for larger defects the intact cephalic segment of the helical rim can be advanced into the defect as a second flap. Extension of the flap’s triangular tail into the depth of the concha leaves the ear with a pleasing shape. The chondrocutaneous rim tissue is mobilized on a very wide and highly vascular pedicle and accurately apposed with fine sutures prior to skin closure.

Postauricular pedicle flaps

Defects on the posterior surface of the ear may be repaired by rotation flaps or transposition flaps. In the case of transposition flaps, the donor site is located in the posterior sulcus so that when this is closed, the ear is simply approximated to the side of the head.

Postauricular pedicle flaps to the anterior surface of the ear

A large skin flap from uninvolved postauricular and adjacent mastoid skin can be used to reconstruct defects on the anterior surface of the ear. Such a flap can reach the concha and the scaphal hollow. It is easy to use and the colour match is ideal. A posterior skin flap is outlined and undermined in the postauricular sulcus at a zone corresponding to the defect to be filled. A central pedicle of subcutaneous tissue is preserved. When the ear is pushed back the flap is delivered through to the external defect and secured. The donor site is closed directly.

An alternative to a subcutaneous pedicle is a de-epithelialized pedicle of dermis. Such postauricular flaps are also flipped through the ear to the external surface and used for reconstruction of central ear defects. If both a superior and inferior dermal pedicle are preserved, then the flap is rotated into the central ear defect in the manner of a swinging door (Figure 29.11). It is important to keep the donor defect elliptical in shape to allow easy closure. Wide undermining beneath the epidermis in the corners of the opening will allow substantial pedicles of dermis and subcutaneous tissue to nourish the flap. Small preauricular flaps and flaps from the concha can also be used to reach the external auditory meatus.

Techniques for larger tumours

When large tumours of the ear have been resected, then reconstruction will require some structural support to replace the missing cartilage. Small defects can be replaced by conchal cartilage grafts from either the same or the opposite ear. The curve of these cartilage grafts can be put to good use in mimicking a helical rim. When the missing segment is extensive, a carved costal cartilage framework is required.8 Complex shapes can be tailor-made to fit the defect after tumour excision, and this technique of reconstruction gives excellent results. In the age group that presents with auricular tumours, however, some patients are not keen on the additional discomfort of harvest of costal cartilage, and a number will opt to be fitted with a prosthesis.

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Ear Reconstruction