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CASE REPORT

Korean J Audiol 2012;16:91-94

pISSN 2092-9862 / eISSN 2093-3797

[Link]

A Case of Basal Cell Carcinoma of External Auditory Canal

Beom-Jun Lee, Seong-Cheon Bae, Jae-Hong Lee and Kyoung-Ho Park
Department of Otolaryngology-Head & Neck Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea

Received June 4, 2012

Revised July 20, 2012
Accepted August 2, 2012

Address for correspondence

Kyoung-Ho Park, MD, PhD

Department of Otolaryngology-Head
& Neck Surgery, The Catholic
University of Korea
College of Medicine,
222 Banpo-daero, Seocho-gu,
Seoul 137-701, Korea
Tel +82-2-2258-6213
Fax +82-2-595-1354
E-mail khpent@[Link]

Malignant tumor originated from external auditory canal (EAC) is very rare with an annual incidence of around 1 per million. Pathologically, squamous cell carcinoma is incidentally most
common, and adenoid cystic carcinoma, basal cell carcinoma, and melanoma follow in decreasing order. Due to the rarity of malignant tumor of EAC, there is no widely accepted treatment modality yet. But basal cell carcinoma, known to be less aggressive tumor, can be removed with a minimal safety margin and have better treatment results. Recently we experienced
a case of basal cell carcinoma in the EAC, confined in the cartilaginous portion of EAC, presenting with intermittent otorrhea for several years. The patient was treated with a sleeve resection of the EAC with a safety margin reconstructed with a split-thickness skin graft. No tumor recurrence or complication was noted in the first postoperative year.

Korean J Audiol 2012;16:91-94
KEY WORDS: Basal cell carcinoma External auditory canal Sleeve resection
Split-thickness skin graft.

Introduction
Carcinomas of external auditory canal (EAC) are very rare
with an annual incidence of around 1 per million people.1) Even
large centers only see few patients. Because of the rarity, consensus regarding the treatment of carcinomas of EAC is inadequate. Although some progress in treating this disease has
been made over the decades, guidelines and treatment protocols are still needed. Among these tumors, basal cell carcinomas are less frequently noted than squamous cell carcinomas.
The authors will describe a case of basal cell carcinoma located in the EAC and the treatment experience with a review of
the literature.

Case Report
A 55-year-old female in otherwise good health presented
with a 10-year history of an intermittent otorrhea in the right ear.
A physical examination revealed a small nodular mass arising from the posterior inferior aspect of the right cartilaginous
portion of the EAC (Fig. 1). Right tympanic membrane was
intact.
Other clinical examinations including the head and neck region, laboratory findings, and audiologic findings were with-

in normal limits. It appeared to be a benign lesion of EAC, an

excisional biopsy was performed under local anesthesia. Contrary to expectation, histologic examination was interpreted as
a basal cell carcinoma (Fig. 2). Fortunately, surgical margin
was negative for malignancy. Further evaluation of the temporal bone by computed tomography (CT) and a magnetic resonance imaging (Fig. 3) of the head and neck showed no involvement of any other temporal bone or of head and neck
structures.
Although less probable, because distant metastasis cannot be
ruled out completely, a full metastatic workup was done. Bone
scan, hepatobilliary sonography, duodenoscopy, chest X-ray,
and CT of the chest, PET-CT were all negative for signs of nodal involvement or metastases to other organs.
According to the Pittsburgh staging system,2) the patient
had tumor limited to the EAC without bony erosion or evidence
of soft tissue involvement (T1), no lymph node metastases
(N0), and no distant metastases (M0).
The patient underwent sleeve resection of the EAC reconstructed with a coverage of the EAC using a left thigh splitthickness skin graft (Fig. 4). Pathologic findings confirmed a
basal cell carcinoma in situ not invading cartilage, all surgical
margins being free of invasion (Fig. 2). No adjuvant chemotherapy or radiation was administered.
Copyright 2012 The Korean Audiological Society 91

Basal Cell Carcinoma in External Ear Canal

After 1 year of surgery, the patient is in good health with no

evidence of complication or recurrence (Fig. 5).

Fig. 1. Photograph of right external auditory canal taken preoperatively. There is a small nodular mass (arrow, 1.51.2 cm) arising
from the posterior inferior aspect of the right cartilaginous portion
of the external auditory canal.

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Korean J Audiol 2012;16:91-94

Discussion
Among carcinomas of EAC, squamous cell carcinoma
(SCC) is the most common, accounting for 80% of tumors
within the temporal bone.3) Basal cell carcinoma, adenoid
cystic carcinoma, adenocarcinoma, melanoma, and various
sarcoma are among the other malignancies within the temporal bone.4)
In 1990, the Pittsburgh group proposed a staging system
for SCCs of the EAC. Arriaga, et al.2) proposed a primary tumor, regional nodes, metastasis (TNM) staging of EAC carcinoma on the basis of clinical examination, and preoperative
CT scan finding.2,5) Other authors have supported the clinical
usefulness of this staging.6,7) The classification method proposed by Arriaga, et al.2) is advantageous with regard to treatment, because it correlates the clinical and radiologic characteristics in patients.
Because of the rarity of malignant tumor of EAC, there are
no randomized clinical trials. Therefore, the management of
these tumors is difficult. In the several studies, authors disagree

Fig. 2. The histopathologic photography of the tumor. A: The tumor cells

typically form lobule extending from
the basal layer (arrow) of epidermis
into more superficial or deep layers
without invading cartilage (arrow
head)(hematoxylin-eosin original
magnification, 100). B: The cells
show little pleomorphism and have
large oval hyperchromatic nuclei with
minimal cytoplasm (hematoxylineosin original magnification, 200).

Fig. 3. Temporal bone computed tomography. This shows narrowing of

the extenal auditory canal and a
small nodule (arrow, 5 mm in diameter) at the posterior wall of the right
external auditory canal. A: Axial view.
B: Coronal view. T1-weighted magnetic resonance imaging enhanced
by Gadolinium. There is about 1.3
cm sized contrast enhancing mass
lesion (arrow) at the lateral aspect
of right external auditory canal and
no definite abnormality in both middle and inner structures. C: Axial view.
D: Coronal view.

Lee BJ, et al.

Fig. 4. Procedure of sleeve resection. A: Transcanal incision was done surrounding mass lesion in the right external auditory canal. B:
Postauricular incision was done posterior 0.5 cm site from post auricular fold. EAC skin elevated to 5 mm site lateral from annulus. C:
Wide excision was made including cartilaginous portion of the EAC with 0.2 cm excision margin. Frozen biopsy of all excision margin
was negative. D: The defect was reconstructed with prepared thigh split thickness skin graft. Lateral margin of thigh skin sutured with
orifice of the ear. E, F: Packing was done tightly with gelform and furacin gauze in the external auditory canal. EAC: external auditory
canal.

Fig. 5. Photograph of external auditory canal taken

1 year postoperatively, showing skin graft on a reconstructed external auditory canal.

about the extent of surgery and the role of radiotherapy and

chemotherapy in managing these tumors. Gidley8) reviewed
several literatures and discussed about treatment strategies focused on the carcinoma of EAC. Early stage tumors can be
managed with a surgery alone reserving radiation as a component of salvage options. Small T1 tumors that are confined
to the soft tissues, cartilaginous ear canal can be removed with
wide local excision, where the skin of the ear canal and the
underlying cartilage are removed with frozen section medial
margins. This operation must be selected for limited tumors
that do not cross medially over the bony-cartilaginous junction.
T1 tumors of the bony ear canal and T2 tumors (i.e., those with

limited bony or soft tissue involvement) are best controlled

with lateral temporal bone resection.
Basal cell carcinoma of the EAC is known to have a locally
aggressive nature and lack of regional lymph node metastasis. Basal cell carcinomas are less lethal because of their slower growth rate and rare metastasis.9,10) Because there is a possibility of distant metastasis, evaluation must be completed
before treatment plan is established. In 2002, Nyrop and
Grntved11) evaluate the result of surgically treated cancer of
EAC in twenty consecutive patients. The authors concluded
that the outcome was related to the stage of disease, suggesting
that the Pittsburgh staging system is also useful in patients
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Basal Cell Carcinoma in External Ear Canal

with non-SCC.
Patients with early cancer benefited from less aggressive surgical approach, while survival was poor in patients with an advanced cancer who went through a more aggressive surgery
despite adjuvant radiotherapy.9,12)
Fortunately, our patient had tumor limited to the EAC without bony erosion or evidence of soft tissue involvement (T1),
no lymph node metastases (N0), and no distant metastases
(M0).
Using the treatment strategies described above on the carcinoma of the EAC, we can remove the tumor with a minimal
safety margin and have better treatment results.
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