En bloc petrosectomy for malignant tumors involving the external auditory canal and middle ear: surgical methods and long-term outcome

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Object

The aim of this study was to describe a method for resecting malignant tumors originating in the external auditory canal or middle ear and requiring en bloc resection of the petrous bone.

Methods

Between 1995 and 2005, the authors performed en bloc petrosectomy for 18 malignant tumors in 9 male and 9 female patients, ranging in age from 15 to 74 years. Fourteen tumors originated in the external ear, 2 in the middle ear, and 2 in the parotid gland. The pathological entities included 15 squamous cell carcinomas, 2 adenoid cystic carcinomas, and 1 rhabdomyosarcoma. Through an L-shaped temporosuboccipital craniotomy, a medial osteotomy was created through the inner ear for tumors without extension into the inner ear (14 cases) and through the tip of the petrous bone for tumors reaching the inner ear (4 cases). Temporal dura mater in 3 patients and the base of the temporal lobe in 2 patients were included in the en bloc resection.

Results

Surgical complications occurred in 5 patients (28%) with no deaths. During a mean follow-up period of 45 months, 3 patients died of tumor recurrence. Overall, 2- and 5-year survival rates were 86 and 78%, respectively. Two of three patients with dural extension and 1 of 2 with brain invasion remain alive. Two of four patients with tumor extension into the inner ear died.

Conclusions

En bloc petrosectomy is recommended for malignant tumors of the ear. It is safe and effective for lesions limited to the middle ear and may be the procedure of choice for tumors reaching the inner ear and those with dural or brain invasion.

Abbreviations used in this paper:CT = computed tomography; EAC = external auditory canal; GSPN = greater superficial petrosal nerve; MR = magnetic resonance; SCC = squamous cell carcinoma.

Abstract

Object

The aim of this study was to describe a method for resecting malignant tumors originating in the external auditory canal or middle ear and requiring en bloc resection of the petrous bone.

Methods

Between 1995 and 2005, the authors performed en bloc petrosectomy for 18 malignant tumors in 9 male and 9 female patients, ranging in age from 15 to 74 years. Fourteen tumors originated in the external ear, 2 in the middle ear, and 2 in the parotid gland. The pathological entities included 15 squamous cell carcinomas, 2 adenoid cystic carcinomas, and 1 rhabdomyosarcoma. Through an L-shaped temporosuboccipital craniotomy, a medial osteotomy was created through the inner ear for tumors without extension into the inner ear (14 cases) and through the tip of the petrous bone for tumors reaching the inner ear (4 cases). Temporal dura mater in 3 patients and the base of the temporal lobe in 2 patients were included in the en bloc resection.

Results

Surgical complications occurred in 5 patients (28%) with no deaths. During a mean follow-up period of 45 months, 3 patients died of tumor recurrence. Overall, 2- and 5-year survival rates were 86 and 78%, respectively. Two of three patients with dural extension and 1 of 2 with brain invasion remain alive. Two of four patients with tumor extension into the inner ear died.

Conclusions

En bloc petrosectomy is recommended for malignant tumors of the ear. It is safe and effective for lesions limited to the middle ear and may be the procedure of choice for tumors reaching the inner ear and those with dural or brain invasion.

Malignant tumors originating from the EAC or the middle ear are rare, with an incidence of ~ 1 per million persons.7,13 The most common type of malignancy in this region is SCC; however, tumors from adjacent sites, such as the parotid gland or temporomandibular joint, can also extend into structures of the temporal bone. Because the index of suspicion for cancer in this region is low, most of these tumors are advanced by the time a correct diagnosis is made. Reported 5-year survival rates range from 80% for early disease to 10% for advanced disease.5,6,10,15,18 Involvement of the middle ear or petrous bone has been associated with a poor prognosis.5 Surgical procedures described in previously published reports have included conventional mastoidectomy, lateral temporal bone resection, and subtotal temporal bone resection.9,15 Although surgical removal combined with radiotherapy has been recommended for malignant tumors in the ear,1,5,6,10,18,21 lateral temporal bone resection or mastoidectomy with or without radiotherapy does not generate acceptable long-term survival in patients with lesions extending into the middle ear.15

En bloc resection with tumor-free surgical margins is the oncological principle guiding excision of advanced malignant tumors.4,16 Thus, malignant lesions extending into the middle ear require petrous bone resection (classified as subtotal temporal bone resection). Although en bloc resection of the petrous bone is difficult because of the complex anatomical relationships, recent advances in surgery of the skull base and multidisciplinary approaches have made it feasible. In this report, we describe surgical methods for en bloc petrosectomy and report long-term results of this treatment in patients with malignant tumors involving the EAC and middle ear.

Clinical Material and Methods

Patient Population

Between 1995 and 2005, our team of neurosurgeons, otorhinolaryngologists, head and neck surgeons, and plastic surgeons performed en bloc petrosectomy for 18 malignant tumors originating in or around the ear (Table 1). The patients included 9 males and 9 females, ranging in age from 15 to 74 years (mean age 55 years). Fourteen tumors originated in the external ear, 2 in the middle ear, and 2 in the parotid gland. The pathological entities consisted of 15 SCCs, 2 adenoid cystic carcinomas, and 1 rhabdomyosarcoma. Three of the tumors were recurrent. In the waiting period before the scheduled surgery, 2 patients received radiotherapy, 6 received chemotherapy with cisplatin and 5-fluorouracil, and 7 received both radiotherapy and chemotherapy.

TABLE 1

Demographic and clinical characteristics in 18 patients treated with en bloc petrosectomy*

Tumor ExtensionSurgery
Case No.Age (yrs), SexOri ginDiagnosisPreop TreatmentMEIEMastoidCranial SideOsteotomyPositive MarginsComplicationAdditional TreatmentOutcome (at mos FU)
162, MEESCCchemotherapy, radiotherapy+extraduralIEnonenonealive (104)
215, MMErecurrent rhabdochemotherapy, radiotherapy+++w/brainpetrous tip+nonechemotherapyalive (119)
357, FEESCCchemotherapy, radiotherapyextraduralIEnonenonealive (85)
469, FEESCCradiotherapy++w/duraIE+CSF leakradiotherapyalive (38)
564, FEESCCchemotherapy+++extraduralpetrous tipCSF leakradiotherapyalive (81)
661, MMESCCchemotherapy, radiotherapy+++w/brainpetrous tip+nonenonedead (13)
749, FEESCCchemotherapy, radiotherapy++extraduralIEnonenonealive (55)
862, FEErecurrent SCCnone+++w/durapetrous tipnonenonedead (13)
966, FEESCCchemotherapy, radiotherapy++extraduralIEnonenonealive (66)
1048, FPGSCCchemotherapy, radiotherapy+extraduralIEnonenonealive (60)
1127, FEEACCnoneextraduralIEnoneradiotherapydead (33)
1259, MEESCCchemotherapy+extraduralIEnonenonealive (12)
1345, MEESCCchemotherapy++extraduralIEnoneradiotherapyalive (43)
1474, MEESCCradiotherapy+extraduralIEMRSA infectionnonealive (44)
1560, MEESCCchemotherapy++w/duraIEnonenonealive (31)
1663, MPGACCnoneextraduralME+noneradiotherapyalive (8)
1742, FEESCCchemotherapy++extraduralIECSF leak, CN IX & X palsynonealive (5)
1863, MEErecurrent SCCchemotherapy++extraduralIE+CSF leak, flap necrosisradiotherapyalive (4)

* ACC = adenoid cystic carcinoma; CN = cranial nerve; CSF = cerebrospinal fluid; EE = external ear; FU = follow-up; IE = inner ear; ME = middle ear; MRSA = methicillin-resistant Staphylococcus aureus; PG = parotid gland; rhabdo = rhabdomyosarcoma; + = yes; − = no.

† Procedure on cranial side.

‡ Osteotomy on medial side.

Magnetic resonance imaging and thin-slice bone-window CT were performed to define the extent of the tumor. Angiography was performed when the tumor was close to the sigmoid sinus or jugular bulb. All tumors were located in the external ear, 14 occupied the middle ear, 4 extended into the inner ear, and 12 extended into the mastoid bone. In 1 patient (Case 15), tumor in the mastoid bone extended into the jugular bulb. Tumor extension beyond the temporal bone was common: involvement of the temporomandibular joint occurred in 17 patients, and metastases to the cervical lymph nodes occurred in 13 patients. Five tumors were attached to the dura mater through the roof of the tympanic cavity, and 2 of them had invaded the base of the temporal lobe. We excluded from the study patients with tumor extension beyond the limits of en bloc petrosectomy, as in extension to the carotid canal, invasion into the posterior fossa, wide involvement of the dura mater or temporal lobe, or distant metastasis.

Operative Procedure for En Bloc Petrosectomy

Each patient was placed in a supine-lateral position with the head rotated 90° and fixed in a surgical frame. Oto-laryngologists performed neck dissection when lymphatic metastases were suspected and continued facial dissection via a retroauricular -shaped skin incision when the tumor did not involve the skin. The EAC was transected and sutured closed, and the skin flap was reflected forward. In the case of skin invasion, the incision was carried around the involved skin. Distal branches of the facial nerve were cut at the level of the parotid gland. The zygomatic arch was transected, and the mandible also was transected at its neck or body given that the temporomandibular joint usually was included in the resection. The internal carotid artery, jugular vein, and cranial nerves were dissected in the neck and followed close to the base of the skull.

Next, neurosurgeons created an -shaped temporosuboccipital craniotomy. The following procedures were performed via the temporal or the suboccipital side. On the temporal side, the dura mater was elevated to expose the middle cranial base. The middle meningeal artery was coagulated and divided at the foramen spinosum. The foramen ovale, GSPN, arcuate eminence, and petrous tip were exposed. The medial aspect of the osteotomy was carried through the inner ear in cases without tumor extension into the inner ear (14 cases). The GSPN was followed to expose the geniculate ganglion. The proximal facial nerve was cut at the exposed tympanic portion adjacent to the ganglion (12 cases) or at the labyrinthine portion (2 cases). The carotid artery was exposed in the Glasscock triangle, and the eustachian tube was cut lateral to the Glasscock triangle. The carotid artery was followed in the carotid canal by drilling uninvolved petrous bone. Then, using a high-speed drill, an osteotomy was created at the arcuate eminence or the roof of the internal meatus, through the inner ear, toward the top of the jugular bulb and exposed carotid artery (Fig. 1 left). The medial aspect of the osteotomy was carried through the tip of the petrous bone and unroofed internal acoustic meatus (4 cases) in cases of tumor invasion of the inner ear (Fig. 2 left). The facial nerve together with the acoustic nerves was cut at the internal meatus (3 cases) or at the labyrinthine portion (1 case). In the case of temporal dural invasion (3 cases), the dura mater was cut to create a clear surgical margin, and the dura overlying the affected bone was resected en bloc. When the temporal lobe had been invaded (2 cases), involved brain and dura mater were resected en bloc with the petrous bone.

Fig. 1.
Fig. 1.

Schematics depicting left-sided en bloc petrosectomy through the inner ear. Left: Epidural procedures in the middle cranial fossa. The foramen ovale, GSPN, arcuate eminence, and petrous tip are exposed. The GSPN is followed to expose the geniculate ganglion. The proximal facial nerve is cut at the tympanic or labyrinthine portion. The carotid artery is exposed in the Glasscock triangle and followed in the carotid canal by drilling unaffected petrous bone. An osteotomy (A) is made through the inner ear, toward the top of the jugular bulb and exposed carotid artery. The final osteotomy (E) is made from the carotid canal through the lateral side of the foramen ovale to the temporal fossa. Right: Epidural procedures in the posterior fossa. The jugular bulb is exposed by drilling its posterior wall (B) and followed to expose the jugular foramen (C). An osteotomy (D) is made toward the osteotomy (A) in the middle fossa through the inner ear.

Fig. 2.
Fig. 2.

Schematic illustrating left-sided en bloc petrosectomy through the petrous tip. Left: Epidural procedures in the middle cranial fossa. The proximal facial nerve is cut in the internal meatus together with the acoustic nerve, or at the labyrinthine portion. Then an osteotomy (A) is made through the tip of the petrous bone and unroofed internal acoustic meatus. Right: Epidural procedures in the posterior fossa. Drilling of the posterior aspect of the petrous bone (D) is continued through the internal auditory meatus to the petrous tip.

On the suboccipital side, the sigmoid sinus and petrous dura were elevated from the petrous bone. The emissary veins were coagulated carefully and cut to avoid damaging the sigmoid sinus. Then the jugular foramen and jugular bulb were epidurally exposed by drilling the bone of their posterior aspects. The osteotomy was continued toward the osteotomy in the middle fossa through the inner ear (Fig. 1 right). Drilling must preserve a surgical margin of mastoid bone. When medial osteotomy at the petrous tip was required, drilling of the posterior aspect of the petrous bone was continued through the internal auditory meatus to the petrous tip (Fig. 2 right). Again on the temporal side, osteotomy of the middle cranial base was carried from the carotid canal through the lateral side of the foramen ovale to the temporal fossa. Finally, the entire lesion was elevated, remaining soft tissues attached to the base of the external skull were cut, the internal carotid artery and jugular vein were completely separated from the bone, and the lesion was removed en bloc. When tumor had invaded the jugular foramen (1 case), the sigmoid sinus and internal jugular vein were ligated and cut, the lower cranial nerves were dissected, and the jugular bulb and vein in the foramen together with the lesion were resected. In this patient, venous pressure in the transverse sinus did not increase after test occlusion of the sigmoid sinus. If the pressure had increased, a vein graft would have been considered.

Plastic surgeons reconstructed the facial nerve using a nerve graft. The defect was reconstructed with a local flap of temporal muscle for a small defect (2 cases) or a free flap such as a rectus abdominis flap (11 cases), an anterolateral thigh flap (3 cases), or an omentum flap (2 cases). A closed drainage system was set under the flap and left for several days postoperatively.

Data Analysis

Survival was calculated using the Kaplan–Meier method. Relationships between clinical factors (tumor origin, diagnosis, preoperative treatment, tumor extension, surgical procedure on the cranial side, medial osteotomy site, positive tumor in the surgical margin, complication, and additional treatment) and outcome were analyzed using the Fisher exact probability test. A probability value less than 0.05 was considered significant.

Results

Among the 15 tumors treated preoperatively, 2 (Cases 2 and 3) showed a partial response and 13 showed no response. In all patients, en bloc resection was performed as planned. Histopathological tumor extension to the surgical margin, however, was identified intraoperatively in 2 patients and postoperatively in 3. It was difficult to detect tumor extension to the surgical margin through the retrospective analysis of preoperative MR and CT images. We did not use additional postoperative treatments when histopathological examination revealed no tumor extension to the surgical margins. The patient with rhabdomyosarcoma received postoperative chemotherapy. Two patients with adenoid cystic carcinoma and 4 patients with SCC received radiotherapy because of the possibility of extension to the neural region or surgical margin or unexpected lymph node metastasis. The follow-up interval ranged from 4 to 119 months (mean 45 months). Postoperative complications occurred in 5 patients (28%), including cerebrospinal fluid leakage in 4 and lower cranial nerve palsy, flap necrosis, and wound infection in 1 patient each (Table 1). The patient who suffered necrosis of an anterolateral thigh flap required reoperation. The other complications were managed conservatively. No patient died during the perioperative period.

During follow-up, 3 patients died of tumor recurrence, 2 at 13 months and 1 at 33 months after surgery. Fifteen patients were alive without disease. Overall, 2- and 5-year survival rates were 86 and 78%, respectively (Fig. 3). Two of three patients with dural extension and 1 of 2 patients with brain invasion were alive and disease free. Two of four patients with tumor extension into the inner ear died. No clinical factor affecting outcome was identified.

Fig. 3.
Fig. 3.

Graph showing Kaplan–Meier curves of 18 patients after en bloc petrosectomy.

Illustrative Cases

Case 2

This 15-year-old adolescent had presented to another hospital with a left hearing disturbance and tinnitus. Partial removal of the tumor revealed it to be a rhabdomyosarcoma. Computed tomography and MR imaging showed that the lesion filled the middle ear and had invaded the temporal lobe (Fig. 4). The patient was referred to our institute. Chemotherapy with vincristine, actinomycin D, and ifosfamide, and 40 Gy radiation reduced the tumor size. Then, petrosectomy with en bloc resection of involved dura and brain was performed. Medial osteotomy was performed through the petrous tip. The defect was reconstructed with a free anterolateral thigh flap. The patient received additional chemotherapy postoperatively and was alive without tumor 119 months after surgery.

Fig. 4.
Fig. 4.

Case 2. Enhanced MR images (A and B) showing rhabdomyosarcoma involving the inner ear and temporal lobe. Computed tomography scan (C) and enhanced MR image (D) obtained after chemotherapy and radiotherapy, showing reduction in tumor size in the temporal lobe (arrow). Postoperative CT scans (E and F) revealing petrosectomy through the petrous tip and reconstruction with a free anterolateral thigh flap.

Case 13

This 45-year-old man presented with a 2-month history of otorrhea and otalgia. Biopsy sampling of the tumor in the left external ear revealed an SCC. Bone-window CT and MR images showed tumor extension to the middle ear and temporomandibular joint and destruction of the mastoid bone (Fig. 5). The inner ear, carotid canal, and jugular bulb were intact. After chemotherapy with cisplatin and 5-fluorouracil, left-sided neck dissection and en bloc petrosectomy with left parotid gland were performed. The medial side of the osteotomy was created through the inner ear. The facial nerve was reconstructed with a sural nerve graft. The defect was packed with a rectus abdominis free flap. Because pathological examination revealed tumor extension to the parotid lymph nodes, 40 Gy of external radiation was administered postoperatively. The patient was alive and disease free 43 months after surgery.

Fig. 5.
Fig. 5.

Case 13. Preoperative CT scan (A) and enhanced MR image (B) showing SCC in the external ear canal and middle ear, extending to the mastoid bone (arrowhead) and temporomandibular joint (arrow). Tumor does not involve the carotid artery (c), jugular bulb (j), or sigmoid sinus (s). Postoperative CT (C) and enhanced MR image (D) demonstrating petrosectomy through the inner ear and reconstruction with a free rectus abdominis flap.

Discussion

Because of its rarity, lack of an accepted staging system, and wide variety of individualized treatments, it has been difficult to determine and standardize the optimum treatment for malignant tumors originating in the external ear canal or middle ear and involving the temporal bone. Reported 5-year survival rates vary from 14 to 73% with surgery alone, irradiation alone, or surgery and radiotherapy combined.1,5,6,8,14,21 Postoperative irradiation produces no benefit without complete tumor excision.3 Survival rates have been higher when clear surgical margins are achieved (80% compared with 35%).20 Based on these reports, a combination of radical surgery and radiotherapy has been recommended.1,10,18,21 However, critical anatomical structures surround the temporal bone and make resection difficult, leading to high morbidity and mortality rates. Therefore, piecemeal removal of SCCs in the temporal bone via mastoidectomy combined with perioperative irradiation has been recommended to reduce the incidence of complications and death.21

Petrosectomy has been used for both benign and malignant tumors of the temporal bone and retromandibular spaces.11,17 For benign tumors, petrous bone can be removed piece-by-piece or drilled out. En bloc resection of malignant tumors, however, is a demanding procedure because of limited exposure and the need to avoid touching structures containing tumor. Since the proposal of Lewis,8 en bloc resection of the temporal bone has been classified into lateral, subtotal, and total temporal bone resection.9,18,19 Total temporal bone resection is not feasible because radical temporal bone resection usually spares the petrous apex tip.18 Subtotal temporal bone resection has been used for malignant tumors of the external ear canal and the middle ear. Our procedure for en bloc petrosectomy with medial side osteotomy through either the inner ear or petrous tip is similar to the subtotal temporal bone resection described by Lewis and Sasaki.9 We believe medial side osteotomy is crucial for oncological en bloc resection without serious complications. Although Lewis and Sasaki used a chisel, we prefer a high-speed drill and microneurosurgical techniques. The osteotomy in the medial petrous bone was performed through the middle cranial fossa and posterior fossa by a neurosurgeon (K.S.). In the literature, en bloc procedures of the temporal bone are associated with a 5% mortality rate and high complication rates.8,21 The absence of operative death and a 28% complication rate in the present study were achieved by virtue of modern neurosurgical and otorhinolaryngological procedures for excision as well as reconstruction using various local or free flaps.2,11 We hold monthly conferences to decide on surgical indications and approaches and to analyze our results. Preoperatively, we discuss the technical details, such as resection planes, orders, reconstruction methods, and estimated time of operation to refine our technique. We usually need to arrange surgery several weeks ahead due to the busy schedule of the operative theaters. If possible, surgical removal should be performed immediately given that the preoperative radiotherapy and/or chemotherapy induced a partial tumor response in only 2 of 15 patients.

Prasad and Janecka15 reviewed the English literature and found 144 reports of SCCs involving the temporal bone. They concluded that: 1) patients with a carcinoma confined to the EAC had better survival (~ 50% 5-year survival rate) regardless of the treatment; 2) patients with disease extending into the middle ear experienced better survival with subtotal temporal bone resection (42% 5-year survival rate) than with lateral bone resection (29% 5-year survival rate) or mastoidectomy (17% 5-year survival rate); 3) the value of surgical removal when carcinoma extends to the petrous apex is unclear; 4) resection of involved dura mater does not appear to improve survival; and 5) determination of the value of resection of involved brain parenchyma or internal carotid artery requires further study. Our overall 5-year survival rate of 78% suggests that en bloc petrosectomy is the treatment of choice for malignant tumors of the ear. Among our patients, 14 had tumor extension into the middle ear and 4 of them had involvement of the inner ear. All 10 patients with extension limited to the middle ear were alive after en bloc petrosectomy through the inner ear. Among the 4 patients with extension into the inner ear, petrosectomy through the petrous tip resulted in 2 recurrences and deaths (50%). Thus, en bloc petrosectomy is safe and effective for patients with tumors limited to the middle ear and probably is the treatment of choice for lesions reaching the inner ear. Two of three patients with involvement of the dura were alive 31 and 38 months after en bloc resection including dura, and 1 of 2 patients was alive 119 months after en bloc resection including dura and brain. These results suggest that resection is indicated for tumors with dural or brain extension if en bloc resection with tumor-free margins can be performed safely.

No patients in our series had extension into the carotid canal. Graham and colleagues4 reported on 2 patients with malignant tumors of the ear and temporal bone that had been treated with en bloc resection of the temporal bone and carotid artery. Sekhar and associates17 reported that when the carotid artery is invaded by tumor, it should be excised or reconstructed with a saphenous vein graft depending on the results of the balloon occlusion test. Although technically possible, the balloon occlusion test is not entirely reliable, and adding carotid resection to the surgical procedures would increase the risk of postoperative cerebral infarction.16 We agree with Prasad and Janecka15 that the value of internal carotid artery resection in this context has yet to be determined. In the report by Moffat and colleagues,12 extended temporal bone resection for recurrent SCC resulted in a 5-year survival rate of < 50%. Two of three patients in this series were alive after en bloc resection of recurrent tumors; however, 1 had a rhabdomyosarcoma and received adjuvant therapy postoperatively, which may have contributed to survival. Postoperative follow-up in the other patient has not been long enough to draw meaningful conclusions. Further study is required to clarify the indications for extended resection of recurrent carcinomas. Early diagnosis remains the most important variable in long-term survival in patients with malignant tumors involving the EAC and middle ear.

Conclusions

En bloc petrosectomy is recommended for malignant tumors in the ear. Using microsurgical techniques, this procedure can be performed without death or significant surgical morbidity and results in a good long-term outcome. En bloc petrosectomy is safe and effective in patients with tumors extending to the middle ear and may be the procedure of choice for lesions reaching the inner ear. Surgical removal is still indicated for lesions with dural or brain extension if en bloc resection with tumor-free margins can be achieved.

References

Article Information

Address correspondence to: Kiyoshi Saito, M.D., Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya 466-8550, Japan. email: kiyoshis@med.nagoya-u.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

  • View in gallery

    Schematics depicting left-sided en bloc petrosectomy through the inner ear. Left: Epidural procedures in the middle cranial fossa. The foramen ovale, GSPN, arcuate eminence, and petrous tip are exposed. The GSPN is followed to expose the geniculate ganglion. The proximal facial nerve is cut at the tympanic or labyrinthine portion. The carotid artery is exposed in the Glasscock triangle and followed in the carotid canal by drilling unaffected petrous bone. An osteotomy (A) is made through the inner ear, toward the top of the jugular bulb and exposed carotid artery. The final osteotomy (E) is made from the carotid canal through the lateral side of the foramen ovale to the temporal fossa. Right: Epidural procedures in the posterior fossa. The jugular bulb is exposed by drilling its posterior wall (B) and followed to expose the jugular foramen (C). An osteotomy (D) is made toward the osteotomy (A) in the middle fossa through the inner ear.

  • View in gallery

    Schematic illustrating left-sided en bloc petrosectomy through the petrous tip. Left: Epidural procedures in the middle cranial fossa. The proximal facial nerve is cut in the internal meatus together with the acoustic nerve, or at the labyrinthine portion. Then an osteotomy (A) is made through the tip of the petrous bone and unroofed internal acoustic meatus. Right: Epidural procedures in the posterior fossa. Drilling of the posterior aspect of the petrous bone (D) is continued through the internal auditory meatus to the petrous tip.

  • View in gallery

    Graph showing Kaplan–Meier curves of 18 patients after en bloc petrosectomy.

  • View in gallery

    Case 2. Enhanced MR images (A and B) showing rhabdomyosarcoma involving the inner ear and temporal lobe. Computed tomography scan (C) and enhanced MR image (D) obtained after chemotherapy and radiotherapy, showing reduction in tumor size in the temporal lobe (arrow). Postoperative CT scans (E and F) revealing petrosectomy through the petrous tip and reconstruction with a free anterolateral thigh flap.

  • View in gallery

    Case 13. Preoperative CT scan (A) and enhanced MR image (B) showing SCC in the external ear canal and middle ear, extending to the mastoid bone (arrowhead) and temporomandibular joint (arrow). Tumor does not involve the carotid artery (c), jugular bulb (j), or sigmoid sinus (s). Postoperative CT (C) and enhanced MR image (D) demonstrating petrosectomy through the inner ear and reconstruction with a free rectus abdominis flap.

References

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