HEAD AND NECK

Exostoses are usually detected during clinical examination conducted for another reason. Sensation of ear fullness is the symptom a patient sometimes may present. Between the exostoses and the eardrum, ear wax (cerumen) and cutaneous epithelium may be accumulated thus immobilizing to some extent the tympanic membrane, generating an ear fullness feeling or external otitis. Sharp obstruction of the external auditory canal may cause hearing loss while the removal of secretions behind the exostoses becomes very difficult task.

In such cases, we suggest the surgical removal of the exostoses. It is a rather easy intervention performed from inside the ear canal and also under local anesthesia. The treatment can be performed in both ears simultaneously but the patient must know that after the intervention the ears are filled with absorbable material.

Osteoma: It is a benign tumor of the bones growing in various part of the body. As far as the ear is concerned, it develops in the entrance of the external auditory canal and is likely to obstruct it.

Its surgical removal is the only way of treatment. The incision is done either behind or in the ear. The intervention is not demanding, nevertheless it is absolutely necessary to remove the base of the osteoma very cautiously since osteoma is a tumor. The material is then sent for tissue examination.

Ear cancer: frequent sun exposure in combination with skin sensitivity may lead to carcinoma in the ear pinna. More rarely, melanoma comes from a pre-existing mole, or a carcinoma from the cutaneous sweat glands or from the irritation of the skin caused by purulent otorrhea in cases of chronic otitis.

The patient usually sees the doctor after noticing an intense lesion of the skin which does not heal on its own when receiving usual treatment. More rarely, he /she may visit the doctor when noticing a swelling in the area below the mandible which may prove to be a metastatic lymph node. The skin damage is usually quite recent (only a few months duration) or develops into a chronic alteration, bringing about changes in its aspect, size, color, and hemorrhagic diathesis. A dermatologic examination is also necessary.

During the clinical examination the doctor must evaluate the extent of the damage and look for palpable lymph nodes usually in the angle of the mandible or in front of the ear. In extended damages, an imaging study performed through a computed and magnetic tomography is also necessary in order to find out if there has been infiltration of the adjacent tissues and of the mastoid bone, as well as to study better the regional lymph nodes. If the imaging technique results do not show that the lymph nodes, responsible for the metastatic disease, are swollen, but there is a strong suspicion for a subclinical lymph nodes extension, then the sentinel node must be checked out because it is the first to be affected by the lymphatic spread to the lymph nodes if the lesion is malignant. Pigment or radioactive substances, once injected into the edge of the cutaneous alteration, are then absorbed by the lymph node thus making possible its preoperative and intra-operative detection.

We cannot schedule an extended surgical intervention that possibly entails amputation measures without performing biopsy and tissue examination first. When the damage is small and the removal has no negative aesthetic impact, then we can consider the damage as cancerous and proceed to its direct removal until its reaching the healthy boundaries.

This however is not possible when we deal with cancer types such as melanoma whose extension to the surrounding tissues is quite big, despite the small visible damage, forcing us to proceed to extended surgical removal.

With the results of the histological examination, preoperative control is completed and the patient must be informed about the extent of the surgical intervention required. He/ she must be informed about the part of the ear pinna which is going to be removed and also about the possibility of removing parts of the temporal bone, or adjacent tissues such as parotid gland, or about if a neck dissection must be conducted. In many cases, a plastic surgeon’s help is also necessary.

Surgical removal is the main treatment for ear cancer. However, as an additional help, radiotherapy and interferon administration can also be used.

Tympanic and Jugular paragangliomas: Glomus tympanicum and glomus jugularis are hypervascular tumors of neurogenic origin which rarely have hormone activity when found in the head or neck. There are usually benign tumors, but sometimes, they can also be malignant. They develop in various sites of the head and neck and the same person may present various paragangliomata, especially if there is hereditary predisposition.

Their symptoms result mainly from the pressure they exert as they get bigger. This pressure may lead to the destruction of bone structures, paralysis of cerebral nerves or obstruction of big vessels. Glomus tympanicum and glomus jugularis occupy the same anatomic space thus presenting in the beginning the same symptomatology. Their treatment however is completely different. One of the first symptoms is a unilateral pulsatile tinnitus and a feeling of fullness, or ear congestion. Progressively, hearing loss is also observed and in advanced cases of glomus jugularis there are also symptoms of cerebral nerve paralysis such as voice hoarseness, swallowing difficulties, etc.

During ear examination with a microscope, we can observe a mass occupying a significant part or even the entire tympanic cavity. Upon closer examination, we can also observe pulses in the mass surface. In the case of glomus tympanicum we see a deep red hue whereas glomus jugularis presents a deep blue hue. All the above symptoms take time to develop thus not allowing us to misinterpret them as an acute ear inflammation.

If there is a suspicion of glomus we must perform a computed tomography using a contrast agent. The tomography will helps us confirm the diagnosis and distinguish between glomus tympanicum and glomus jugularis. The presence of free blood flow from the sigmoid sinus to the internal jugular vein and the presence of bone shell between the jugular bulb and the mass in question, make us discard glomus jugularis. Computed tomography may be the only examination required to diagnose glomus tympanicum as there is no large enough feeding artery in order for preoperative angiography and embolism to be necessary.

On suspicion of glomus jugularis, we must proceed with the investigation performing a magnetic tomography with administration of paramagnetic substance, which will render more precisely the tumor’s borders and will trace its possible intracranial expansion. Then, classic angiography and, if necessary, embolism of the tumor will follow, once the patient has consented to its surgical removal. The embolism should be performed only one or two days before the intervention. It will reduce tumor perfusion and therefore its dimensions and its hemorrhagic predilection during surgery.

Main treatment for both types of paraganglioma/glomus is surgical removal. Glomus tympanicum is a rather easy case. We perform the intervention within the limits of the tympanic cavity and very rarely we have to proceed to the mastoid cavity.

Surgeon’s principal care is tumor removal. If even a minuscule element of neoplastic tissue remains this may lead to a relapse. The glomus tympanicum may expand to cells of the tympanic cavity but also inside the cochlea. For this reason the patient should be informed on the possibility of hearing impairment.

Surgery of the glomus jugularis is particularly demanding. The consequences of tumor removal may be important for the patient and surgical complications sometimes may be dangerous. In every case, however, surgical removal is the only radical treatment of a tumor which may become a threat even for the very life of the patient if it keeps growing progressively.

We must inform the patient about the hearing loss, the temporary paralysis of the facial nerve and the others cerebral nerves, about the leakage of cerebro-spinal fluid which are the inevitable or possible complications of the glomus jugularis surgery. Responsibility for this kind of intervention implies sufficient experience in head and neck and cranial base surgery, use of neuromonitoring of the cerebral function and cerebral nerves, use of navigator during the intervention and help of neurosurgeon in particular cases. It is also necessary that the patient remain at least one night in the intensive care unit once the operation is completed.