Ear


 * Epidemiology: || **Primary cancer of the external auditory canal and the middle ear is rare.6 It has been associated with a long-standing history of chronic infection, and due to the availability of antibiotics and ear tube placement procedures ear cancer is not common. Metastatic lesions and secondary invasion of the temporal bone by tumors from adjacent areas is more common. Temporal bone tumors are often misdiagnosed and caught late, resulting in poor prognosis.7 ****Squamous cell papilloma: rare & benign **
 * Chemoductomas: most common neoplasm of the temporal bone **
 * Squamous cell Ca: external auditory canal **
 * Basal cell skin Ca: also external auditory canal **
 * *malignant melanoma also may occur in the ear6 ** ||
 * Etiology: || **There is no known cause. It is possibly linked to people with a history of otitis externa.8 Individuals who have neglected chronic or long-term drainage and infection in the mastoid or the middle ear.9 **
 * Figure 1. Possible etiology??985 ** ||
 * Signs & Symptoms: || * **pruritus and pain8 **
 * **visible tumor or ulcerating lesion **
 * **swelling or lump **
 * **hearing loss1 **
 * **bloody discharge from the ear **
 * **facial paralysis **
 * **ringing sensation in the ears **
 * **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">dizziness11 ** ||
 * Diagnostic Procedures: || || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Diagnostic workup includes:1 **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Complete history and physical **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Computed Tomography (CT) **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Magnetic Resonance Imaging (MRI) **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Biopsy ** ||
 * Histology: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Tumors of the ear including areas such as the mastoid region, middle ear, and auditory canal, are approximately 85% squamous cell carcinoma.1 ** ||
 * Lymph Node Drainage: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">From our class lecture on the ear, the following possible lymph node involvement was noted for each site: ****<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">External ear=superficial parotid, retroauricular, superficial cervical **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Middle ear=parotid, deep cervical nodes **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Inner ear=No lymph nodes ** ||
 * Metastatic Spread: || || * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Lesions of cartiliginous canal spreads via direct extension to the soft tissue anterior and posterior to the pinna **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Bony canal lesions grow along the canal to involve the mid ear or the external meatus5 **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Lesions of external ear >4 cm with cartilage invasion have a high risk of nodal spread ** ||
 * Grading: || || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">The system of grading tumors classifies the malignant cells according to how abnormal they look under a microscope. Grade 1 tumors resemble normal cells and multiply and grow slowly. Grade 4 tumors tend to grow and spread rapidly and do not look like normal cells. Cancers of the ear follow the American Joint Commission on Cancer (AJCC) guidelines: ** || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Grade: **
 * Grading: || || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">The system of grading tumors classifies the malignant cells according to how abnormal they look under a microscope. Grade 1 tumors resemble normal cells and multiply and grow slowly. Grade 4 tumors tend to grow and spread rapidly and do not look like normal cells. Cancers of the ear follow the American Joint Commission on Cancer (AJCC) guidelines: ** || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Grade: **
 * Grading: || || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">The system of grading tumors classifies the malignant cells according to how abnormal they look under a microscope. Grade 1 tumors resemble normal cells and multiply and grow slowly. Grade 4 tumors tend to grow and spread rapidly and do not look like normal cells. Cancers of the ear follow the American Joint Commission on Cancer (AJCC) guidelines: ** || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Grade: **

**<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">GX Grade cannot be assessed (undetermined grade) ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">G1 Well-differentiated (low grade) ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">G2 Moderately differentiated (intermediate grade) ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">G3 Poorly differentiated (high grade) **


 * <span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">G4 Undifferentiated (high grade) ** ||
 * Staging: || **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Stell and McCormick have **proposed** a staging system using the International Union Against Cancer guidelines: **** T1 ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">: <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Tumor <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">limited to site of origin, <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">with <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">no facial nerve paralysis <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">and <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">no bone destruction <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">detected radiographically. **
 * T2: ****<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Tumor ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">extending beyond site of origin, <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">indicated by <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">facial paralysis <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">or radiographic evidence of <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">bone destruction but no extension beyond organ of origin <span style="color: lime; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">. **
 * T3: ****<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Clinical or radiographic evidence of ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">extension to surrounding structures <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">(e.g. dura, base of skull, parotid gland, temporomandibular joint). **
 * TX: ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Insufficient data for classification, <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">including patient’s previously seen and treated elsewhere.4 ** ||
 * Radiation Side Effects: || **//__<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">RT side effects: __//****<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">[1] **
 * __<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Common __**
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Pain in ears ****<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px;">– late/chronic **
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Earwax or dead skin- ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">tissue build up on ear drum or in canal – late/chronic **
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Poor drainage- ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">of fluids with hearing blockage – late/chronic **
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Recurrent ear infections ****<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px;">– late/chronic **
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Equilibrium and balance problems- ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">caused by inner ear damage – late/chronic **
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Tinnitus- ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Ringing, buzzing sound in head and ears-late/chronic **
 * __<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Rare __**
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Complications with eardrum ****<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px;">– late/chronic **
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">Partial or total hearing loss ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">– late/chronic **
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Damage to the inner ear <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">(vestibular damage) – ** **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">late/chronic4 **
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Possible side effects of radiation include: **
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Damage to the inner ear <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">(vestibular damage) – ** **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">late/chronic4 **
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Possible side effects of radiation include: **


 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">cartilage necrosis ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">of external auditory canal **
 * **<span style="color: windowtext; font-family: 'Times New Roman','serif'; font-size: 16px;">osteoradionecrosis ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">of the temporal bone. **


 * <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Overall ****<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">4% to 10% <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">incidence of bone necrosis can be expected after administration of <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">60 to 65 Gy. <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Risk of necrosis <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">increases for lesions larger than 4 cm **


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Radiation Therapy Oncology Group (RTOG) Acute Radiation Morbity Scoring Criteria for the Ear: **


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Grade 0 <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">- no change over baseline **


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Grade 1 <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">- mild external otitis with erythema; pruritus secondary to desquamation not requiring medication; audiogram unchanged from baseline **


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Grade 2 <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">- Moderate external otitis requiring topical medication; serious otitis media; hypoacusis on testing only **


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Grade 3 <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">-Severe external otitis with discharge or moist desquamation; symptomatic hypoacusis; tinnitus, not drug related **


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Grade 4 <span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">- deafness4 ** ||
 * Prognosis: || * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Tumors of the external ear are more easily controlled so they reflect a better prognosis than tumors of the inner ear or mastoid. External ear tumors are usually visible so they are usually diagnosed earlier. **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Studies show that there doesn’t seem to be a relationship to cell differentiation and survival **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">When the 7th nerve palsy is effected with middle ear tumors this is a poor prognositic indicator **
 * **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Spread of tumor into lymphatics usually is a sign of advanced disease and therefore poorer prognosis.4 ** ||
 * Treatments: || Treatment techniques vary by location of the ear:
 * External Ear
 * The preferred methods of treatment for the external ear are surgery and radiation therapy
 * Surgery can benefit the patient if the lesion has invaded the cartilage of the ear or has advanced towards the auditory canal
 * Large tumors tend to spread to nodes and sometimes require prophylactic nodal irradiation
 * Radical surgery with post-operative radiation therapy are typically used for advanced tumors
 * Middle Ear/Temporal Bone
 * Surgical resection is the preferred method of treatment and post-operative irradiation is crucial for tumor control [1]

Radiation therapy techniques: > > || **<span style="color: #215968; font-family: 'Times New Roman','serif'; font-size: 16px;">Figure 1. Treatment portal for tumor of middle ear.1 ** || These doses should be taken into consideration when treatment planning. Although some of these may not be a concern with orthovoltage/superficial treatment and electrons, it may be when using a wedged pair technique with photons. ||
 * Pinna
 * Smaller lesions are treated with electrons or othovoltage/superficial irradiation
 * Smaller lesions include the volume with a 1 cm margin, while larger lesions include the entire pinna and external auditory canal
 * These tumors are usually treated to 65 Gy
 * External auditory canal
 * Ipsilateral technique with either electrons alone or mixed energy (photons and electrons)
 * Treatment volume should include the entire ear and temporal bone with 3 cm margins
 * Middle ear/temporal bone
 * Post-operative radiation therapy techniques are similar to external auditory canal techniques
 * Post-operative techniques can improve 5-year survival rates by 40-60%
 * Advanced, un-resectable tumors
 * Ipsilateral technique with either electrons alone or mixed energy (photons and electrons)
 * Wedged pair can be used and treated to 60-70 GY
 * <span style="color: #215868; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Figure 2. Isodose distribution for treatment plan of a middle ear tumor using a combination of electrons (16 e’—80%) and photons (4 MV—20%).1 **
 * TD5/5: || The Tolerance Doses of treating and entire organ and seeing 5% of the population experience issues 5 years later that are at risk when treating the ear are:
 * Brain: 45 Gy - necrosis/infarction
 * Eye Lens: 10 Gy - cataract
 * Optic Nerve: 50 Gy - blindness
 * Optic Chiasm: 50 Gy - blindness
 * External/Internal Ear: 30 Gy - acute serious otitis / 50 Gy - chronic serious otitis
 * External/Internal Ear: 30 Gy - acute serious otitis / 50 Gy - chronic serious otitis
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">REFERENCES: **
 * 1) **<span style="color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Chao KSC, Perez CA, Brady LW. Ear. In: Chao KSC, Perez CA, Brady LW, eds. //Radiation Oncology Management Decisions.// Philadelphia, PA: Lippincott Williams & Wilkins; 2002:183-187. **
 * 2) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Tumor Grade: Questions and Answers. National Cancer Institute Web site. []  ****<span style="color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">. Accessed June 1, 2011. **
 * 3) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Simpon, W J, Sutcliffe S B, Gospodarowicz M K. Thyroid Cancer. In: Moss W M, Cox, J D, eds. //Radiation Oncology Rationale, Techniques and Results.// St. Louis, MO: C V Mosby Company; 1989:195-202 **
 * 4) **<span style="color: #00b050; font-family: 'Times New Roman','serif';">Perez and Brady’s Principles and Practice of Radiation Oncology. 5th Edition. PA 2008: 778-796. Lippincott Williams and Wilkin. **
 * 5) **<span style="color: #00b050; font-family: 'Times New Roman','serif';">Washington, C.M & Leaver, D.(Eds.).(2004). //Principles and Practice of Radiation Therapy// (Second ed). Pg.640-641.St. Louis, Missouri; Mosby Inc **
 * 6) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Million. Cassisi. //Management of Head & Neck Cancer; A Multidisciplinary Approach.// Philadelphia PA. J.B. Lippincott Co. 1994: 751-752 **
 * 7) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;"> [|www.dbh.nhs.uk/Library/Patient/Information]  **
 * 8) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Washington & Leaver. //Principles and Practice of Radiation Therapy. 3rd Edition.// St. Louis MO. Mosby Elsevier. 2010: 699, 742 **
 * 9) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;"> [|www.earsurgery.org/site/pages/learn/ear-tumors/tumors-of-the-middle-ear.php]  **
 * 10) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Chao. Perez. Brady. //Radiation Oncology Management Decisions. 2nd Edition.// Philadelphia PA. Lippincott Williams & Wilkins. 2002: 183 **
 * 11) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;"> [|www.buzzle.com/articles/ear-cancer.html]  **