Basal cell papilloma
Also known as a seborrhoeic wart, a basal cell papilloma is a common tumour that develops in or around the ear. The development of these increases with age and lesions may differ in colour from yellow to black. The lesions may be flat or have a 'stuck on' appearance with fissures or stippling. There can be concerns of malignant melanoma, so a biopsy should be taken to ensure the correct diagnosis and treatment. The treatment of choice is curettage or excision of the lesion. Alternative approaches are trichloroacetic acid, cryotherapy or electrodessication.
Basal cell carcinoma
This man had been bitten on the ear by his pet cockatiel three years before. When he developed a nodule at the site he had assumed it to be a result of the trauma. However, he sought advice when the lesion ulcerated and failed to heal. The lesion was excised and histology confirmed the diagnosis of BCC. Metastatic spread from a BCC is a rare event but if not removed early there is a risk that it will infiltrate the cartilage and cause local destruction of tissue. Micrographically controlled surgery is the most effective approach if complete removal is to be achieved.
The ears suffer from sun exposure over time. This exposure to ultraviolet light puts individuals at greater risk of sun damage, especially in those with fair skin and blue eyes. Initial signs may show in the form of actinic keratoses. As in this patient, lesions occur on the helical rim with rough textured patches on an erythematous base. Where lesions persist, biopsy should be performed to rule out malignant change. Treatment with curettage, photodynamic therapy, laser, topical 5-fluorouracil, diclofenac, imiquimod or retinoid application, should settle the condition.
Squamous cell carcinoma
This man presented with a large nodule on the ear lobe. The lesion was excised and proved histologically to be a squamous cell carcinoma (SCC). Eighteen months earlier he had undergone a renal transplant and had been taking ciclosporin and azathioprine. It is now recognised that the incidence of malignant tumours following renal transplantation is three to five times higher than those in the general population. The commonest tumours are SCC and lymphoproliferative disorders. It appears that an important factor in their development is the duration and intensity of immunosuppression.
Cutaneous horn occurs in areas that have suffered previous sun damage. The keratotic lesion develops over the surface of a hyperproliferative lesion. This may be a minor lesion, such as a viral or seborrhoeic wart, but nearly half of such lesions are associated with actinic keratoses, basal or squamous cell carcinoma at its base. It is important, therefore, to excise the lesion and examine it histologically to confirm the underlying cause and ensure complete removal.
Ear deformity after excision of squamous cell carcinoma
Wide excision of this large tumour was necessary and the patient was left with a deformity of the ear lobe. SCC of the ear has the highest rate of recurrence and is more likely than BCC to infiltrate cartilage and bone. Therefore an aggressive approach to complete excision of the lesion, with the aid of micrographic surgery, is necessary. Checks should also be made on regional nodes, which may be involved in the event of metastatic spread. If this occurs, excision of nodes and radiotherapy would be recommended.
Basal cell carcinoma
The importance of biopsy is emphasised by this case of a 70-year-old man who presented with a scaling lesion on his ear lobe that had persisted for a few months. Clinically it was thought to be an actinic keratosis, but because it seemed to be increasing in size, surgical excision was recommended. Histology revealed that it was a basal cell carcinoma (BCC) that had been completely removed.
Late presentation of squamous cell carcinoma
Patients not being aware anything is wrong is a common problem with an SCC originating in the external auditory canal. The patient may complain of a bloodstained discharge, which can be mistaken for otitis externa. In this case the patient was referred to the ENT specialist. Biopsy confirmed a differentiated SCC and an MRI scan showed the tumour to be on the pinna. At surgery, it was necessary to remove most of the pinna and conduct a limited parotidectomy, as well as an exploration of the mastoid.