Submit Your Article CMED MEACR meeting
Home Print this page Email this page Users Online: 328
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 63-66

Intra-temporal facial nerve abscess due to basal cell carcinoma of external auditory canal: A unique presentation

Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication19-Apr-2013

Correspondence Address:
Sushil Kumar Aggarwal
Department of Neurosurgery, Neurotology Unit, SGPGIMS, Lucknow - 226 014
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-0513.110794

Rights and Permissions

Infranuclear facial palsy following facial nerve abscess in intra-temporal course has not been described in literature as per our knowledge. After extensive search of literature, only one case of facial nerve sheath abscess was found in a case of leprosy, but the abscess was in the intra-parotid course of the nerve. Basal cell carcinoma (BCC) is a rare malignant tumor of external auditory canal (EAC). Facial nerve palsy in BCC occurs only in advance stages when the tumor erodes the floor of EAC to involve the nerve. Contrast enhanced computed tomography of the temporal bone is useful in diagnosing the entity pre-operatively and in planning the management in such cases. This case is being reported as facial nerve sheath abscess in intra-temporal course due to malignancy of the EAC has not been reported as yet.

Keywords: Basal cell carcinoma, external auditory canal, facial nerve abscess

How to cite this article:
Keshri A, Aggarwal SK. Intra-temporal facial nerve abscess due to basal cell carcinoma of external auditory canal: A unique presentation. Clin Cancer Investig J 2013;2:63-6

How to cite this URL:
Keshri A, Aggarwal SK. Intra-temporal facial nerve abscess due to basal cell carcinoma of external auditory canal: A unique presentation. Clin Cancer Investig J [serial online] 2013 [cited 2020 Aug 13];2:63-6. Available from:

  Introduction Top

Non-melanoma skin cancer (NMSC) is the most common cancer in the United States with an incidence 18-20 times greater than that of malignant melanoma. [1] The lifetime risk of developing NMSC were estimated to be 29-55% for basal cell carcinoma (BCC) and 7-11% for squamous cell carcinoma (SCC). [2] About 80% of NMSC are BCC and 20% are SCC. [3]

BCC represents approximately 11% of tumors of the external auditory canal (EAC) and temporal bone. [4],[5],[6] Its actual incidence in population is reported to be one to six patients per million per year. [7],[8] Because of its high frequency and low mortality, BCCs are not routinely registered and incidence estimates have largely come from ad hoc studies. [9] Due to its rarity, it is difficult to develop a proper tumor staging system and treatment for BCC. The American Joint Committee on cancer includes auricular malignancy in their staging system for non-melanomatous lesions of the skin. [10] Facial nerve sheath abscess leading to facial nerve paralysis is an extremely unique presentation in a case of BCC of EAC.

BCC incidence has a strong inverse relationship with latitude. [11] In general, chronically sun exposed parts of the body develop a larger proportion of BCCs than those with less or infrequent exposure. [12] BCC is the predominant skin cancer in Caucasians [13] and its treatment imposes a substantial economic burden. [14],[15] Its incidence in the Indian population is very rare. Our patient was a farm laborer and this segment of population is exposed to excessive sunlight and that can be one of the risk factors in our patient.

  Case Report Top

A 45-year-old female presented to neuro-otology out-patient department of our tertiary care institute with complains of right ear discharge, which was occasionally blood tinged, for about 9 months. Subsequently, she developed right-sided facial weakness which was slowly progressive for last 5 months. Hearing loss was also present but it was not accompanied by any history of tinnitus or giddiness. On examination, her right external ear was filled with pale reddish fleshy polypoidal mass and tympanic membrane landmarks were not visible. Pure tone audiogram showed moderate conductive hearing loss. With the above findings, differential diagnosis of chronic suppurative otitis media, glomus tympanicum or jugulare and SCC of EAC was kept. Biopsy from the EAC was done and sent for histopathology. Meanwhile, contrast enhanced computed tomography (CECT) of temporal bone was also got done. CECT temporal bone showed right-sided facial nerve sheath ballooning with edema of the nerve present. The tympanic membrane was involved by the mass but the middle ear was free of disease in the CECT temporal bone scan [Figure 1] and [Figure 2].
Figure 1: Coronal cut of contrast enhanced computed tomography scan showing right basal cell malignancy with erosion of fl oor of external auditory canal. The middle ear cavity on right side appears normal

Click here to view
Figure 2: Coronal cut of contrast enhanced computed tomography showing ballooning and edema of vertical portion of facial nerve

Click here to view

The patient was then planned for surgery of the right ear canal wall-down mastoidectomy with facial nerve decompression. Intra-operatively, canal wall-down mastoidectomy was done and facial nerve was exposed from geniculate ganglion to stylomastoid foramen. While clearing the disease, we encountered dehiscence of the facial bony canal in its vertical course and the nerve sheath was highly edematous with twice the caliber of the normal size. When facial nerve sheath was incised in its vertical portion, pus was encountered with yellowish-cheesy content coming out of the sheath [Figure 3]. Cheesy content was immediately sent for frozen section along with a portion of sheath of nerve and it was reported to be free of malignant cells. Even though facial nerve sheath was not involved by tumor cells, we resected the edematous portion of the nerve taking 5 mm of margin on both sides and primary grafting of resected facial nerve was done with greater auricular nerve. Malleus and incus were removed from the attic region to ensure complete disease removal from middle ear. Temporalis fascia grafting was done to cover the middle ear and mastoid cavity.
Figure 3: Intra-operative image showing exudation of pus from right facial nerve sheath as pointed by ball-probe

Click here to view

Histopathology of the sent tissue showed a tumor composed of infiltrating solid nest and lobules with peripheral palisading of tumor cells. The tumor cells are small to medium sized with high nucleo-cytoplasmic ratio having hyperchromatic nuclei and small amount of cytoplasm. Mitotic figures are also evident and the tumor is also infilterating surrounding fibrocollagenous tissue. A bit of tissue lined by squamous epithelium along with subepithelial tumor is also seen, suggestive of BCC. Post-operative CECT at 3 months follow-up did not show any recurrence of the disease in the middle ear and EAC, although facial palsy improved from House-Brackmann grade 5 to grade 4.

  Discussion Top

Intra-temporal facial nerve sheath abscess due to malignancy of EAC and middle ear has not been reported in literature so far. Only one case of facial nerve sheath abscess has been reported in a case of leprosy, but it was in the intra-parotid course of facial nerve. [16] Although facial nerve palsy in BCC due to erosion of floor of EAC is a known complication, but development of intra-temporal facial nerve sheath abscess is not documented or reported in the literature till date and hence we are reporting this unique presentation.

Malignant tumors of the EAC and temporal bone are rare in occurrence. [5],[6],[17] They account for less than 0.2% of all head and neck tumors. Out of these, SCC is most common variant followed by BCC. [18],[19],[20] BCCs are slow-growing tumors which spread locally and rarely metastasize. Excessive sun exposure is a risk factor for their occurrence. [21] Temporal bone involvement most often occurs as tumor extends along the EAC toward the tympanic membrane and then it involves the middle ear. However, in our case, the tumor was in deeper EAC, also involving the tympanic membrane, but it was not involving the middle ear. The facial nerve involvement in our case was through the erosion of the floor of EAC.

The incidence of persons affected by BCC is likely to substantially underestimate the true incidence of this cancer due to the common occurrence of multiple primary tumors within individuals synchronously or at different times. [22] It has been observed previously that 43% of people affected by BCC developed a subsequent BCC within 4.5 years of active surveillance in the same population [23] and meta-analysis of seven independent studies showed that mean 3 year risk of BCC is around 44% after an initial diagnosis of BCC in North America. [24]

A study by Buettner and Raasch [25] that included only single lesions per person reported BCC incidence was highest on the combined subsites of lip, orbit, nasolabial, ear, nose, and cheek. Our patient also had BCC of the EAC, which is included in the common sites for BCC. The top five subsites (nose, cheek, eye area, forehead, and ears) correspond closely to the subsites that receive the greatest UV exposure, apart from the forehead which receives the second highest level of UV exposure but had the fourth highest incidence of BCCs. [26] This difference could be explained by the sun protection of the forehead offered by hair cover (which can decrease solar UV exposure by up to 80%). [27] The anatomic site distribution of BCCs on non-facial regions was less predictable and not as directly associated with general UV exposure. [27]

Diagnosis of BCC is mainly based on histopathological examination of the mass either from EAC or from middle ear. Nodular BCC is the most typical, usually arising in head and neck region. It is a slow-growing, fleshy or pearly colored nodule, which is locally invasive. Other varieties like superficial, pigmented and morphiec types are not common in head and neck region. [28] CECT should be done pre-operatively to see extension of disease, to know the stage of the disease and to plan management accordingly.

Extension of BCC from EAC to adjacent surrounding tissues can occur either through natural anatomical fissures or through erosion of bone. Anterior spread occurs through fissures of Santorini, petrosquamous sutures, and foramen of Lushka to temporo-mandibular joint and parotid area causing trismus and pain. Inferior spread through erosion of floor of EAC into the stylomastoid foramen and  Fallopian canal More Details can leads to facial weakness or palsy. Medial spread can involve tympanic membrane and middle ear cleft and can result in facial nerve palsy and conductive deafness. Medial extension with extension into hypotympanum can also lead to jugular foramen syndrome. Superior spread to epitympanic space along with erosion of tegmen tympani causing intracranial extension can be seen in advance cases only. [29]

Due to the rarity of these tumors, there is a lack of a universally accepted staging system, thus making it difficult to analyze data, formulate, and evaluate a treatment strategy. [30] Pre-operative clinical staging is difficult in these tumors because large parts of the temporal bone are not amenable to clinical examination. [31] Treatment of choice for BCC is radical surgery taking a healthy margin of 1-1.5 cm to prevent recurrence followed by risk adapted post-operative radiotherapy. [30],[31] The suggested surgery for complete resection of tumor of the EAC, middle ear, and temporal bone is a lateral temporal bone resection (resection of the bony EAC, the tympanic membrane, the malleus and the incus with the medial limit of the incudostapedial joint), stage dependent, combined with a neck dissection. [32],[33] The most important survival factor is removal of the primary tumor with histologically clear margins. [30],[31] Risk factors for incomplete excision and recurrence includes sensitive locations like ears, eyes, and nose. In these cases, it may be better to perform a more radical excision taking 2 cm healthy margin. Incomplete excision leads to tumor recurrence with 50% occurring in first 2 years and 66% in first 3 years. [34],[35] So, complete resection with a healthy margin during primary surgery is very important, though it is challenging in ear cases due to its complicated anatomy as compared with other skin bearing areas. Moh's microsurgery, which is the gold standard for BCC of the skin, is not applicable in tumors of EAC and temporal bone. The main advantage of Moh's microsurgery (MMS) is the ability to examine 100% of the surgical margins, making incomplete excision less likely. [36] The cure rates reported for primary tumors treated with MMS were 93.3% and 94.8%, respectively. [37],[38]

  References Top

1.Diepgen TL, Mahler VM. The epidemiology of skin cancer. Br J Dermatol 2002;146:1-6.  Back to cited text no. 1
2.Miller DL, Weinstock MA. Nonmelanoma skin cancer in the United States: Incidence. J Am Acad Dermatol 1994;30:774-8.  Back to cited text no. 2
3.Kwa RE, Campana K, Moy RL. Biology of cutaneous squamous cell carcinoma. J Am Acad Dermatol 1992;26:1-26.  Back to cited text no. 3
4.Crabtree JA, Britton BH, Pierce MK. Carcinoma of the external auditory canal. Laryngoscope 1976;86:405-15.  Back to cited text no. 4
5.Conley J, Schuller DE. Malignancies of the ear. Laryngoscope 1976;86:1147-63.  Back to cited text no. 5
6.Gacek RR, Goodman M. Management of malignancy of the temporal bone. Laryngoscope 1977;87:1622-34.  Back to cited text no. 6
7.Morton RP, Stell PM, Derrick PP. Epidemiology of cancer of the middle ear cleft. Cancer 1984;53:1612-7.  Back to cited text no. 7
8.Kinney SE. Clinical evaluation and treatment of ear tumors. In: Thawley SE, Panje WR, Batsakis JG, editors. Comprehensive Management of Head and Neck Tumors. Vol. 1. Philadelphia: WB Saunders; 1999. p. 380-94.  Back to cited text no. 8
9.Green A, MacLennan R. Monitoring and surveillance of skin cancer. Transact Menzies. Found 1989;15:193-9.  Back to cited text no. 9
10.Hayden RC III. Cuteneous squamous carcinoma and related lesions. Otolaryngol Clin North Am 1993;26:37-56.  Back to cited text no. 10
11.Giles GG, Marks R, Foley P. Incidence of non-melanocytic skin cancer treated in Australia. Br Med J (Clin Res Ed) 1988;296:13-7.  Back to cited text no. 11
12.Raasch B, Maclennan R, Wronski I, Robertson I. Body site specific incidence of basal and squamous cell carcinoma in an exposed population, Townsville, Australia. Mutat Res 1998;422:101-6.  Back to cited text no. 12
13.Zedan W, Robinson PA, Markham AF, High AS. Expression of the Sonic Hedgehog receptor "PATCHED" in basal cell carcinomas and odontogenic keratocysts. J Pathol 2001;194:473-7.  Back to cited text no. 13
14.Mathers C, Vos T, Stevenson C. The Burden of Disease and Injury in Australia. AIHW: Canberra; 1999 cat. no. PHE 17.  Back to cited text no. 14
15.Joseph AK, Mark TL, Mueller C. The period prevalence and costs of treating nonmelanoma skin cancers in patients over 65 years of age covered by medicare. Dermatol Surg 2001;27:955-9.  Back to cited text no. 15
16.Thomas M, Emmanuel M. Facial nerve abscess in a case of leprosy. Neurol Asia 2009;14:41-2.  Back to cited text no. 16
17.Arena S, Keen M. Carcinoma of the middle ear and temporal bone. Am J Otol 1988;9:351-6.  Back to cited text no. 17
18.Kuhel WI, Hume CR, Selesnick SH. Cancer of the external auditory canal and temporal bone. Otolaryngol Clin North Am 1996;29:827-52.  Back to cited text no. 18
19.Prasad S, Janecka IP. Efficacy of surgical treatments for squamous cell carcinoma of the temporal bone: A literature review. Otolaryngol Head Neck Surg 1994;110:270-80.  Back to cited text no. 19
20.Moody SA, Hirsch BE, Myers EN. Squamous cell carcinoma of the external auditory canal: An evaluation of a staging system. Am J Otol 2000;21:582-8.  Back to cited text no. 20
21.Shanoff LB, Spira M, Hardy SB. Basal cell carcinoma: A statistical approach to rational management. Plast Reconstr Surg 1967;39:619-24.  Back to cited text no. 21
22.Richmond-Sinclair NM, Pandeya N, Ware RS, Neale RE, Williams GM, van der Pols JC, et al. Incidence of basal cell carcinoma multiplicity and detailed anatomic distribution: Longitudinal study of an Australian population. J Invest Dermatol 2009;129:323-8.  Back to cited text no. 22
23.Pandeya N, Purdie DM, Green A, Williams G. Repeated occurrence of basal cell carcinoma of the skin and multifailure survival analysis: Follow-up data from the Nambour Skin Cancer Prevention Trial. Am J Epidemiol 2005;161:748-54.  Back to cited text no. 23
24.Marcil I, Stern RS. Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: A critical review of the literature and meta-analysis. Arch Dermatol 2000;136:1524-30.  Back to cited text no. 24
25.Buettner PG, Raasch BA. Incidence rates of skin cancer in Townsville, Australia. Int J Cancer 1998;78:587-93.  Back to cited text no. 25
26.Diffey BL, Tate TJ, Davis A. Solar dosimetry of the face: The relationship of natural ultraviolet radiation exposure to basal cell carcinoma localisation. Phys Med Biol 1979;24:931-9.  Back to cited text no. 26
27.Green AC, Kimlin M, Siskind V, Whiteman DC. Hypothesis: Hair cover can protect against invasive melanoma on the head and neck (Australia). Cancer Causes Control 2006;17:1263-6.  Back to cited text no. 27
28.Georgeu GA, Gleeson M. Skin cancer of the head and neck. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery 2008;7:2395-405.  Back to cited text no. 28
29.Moffat D, Wagstaff S. Squamous cell carcinoma of the temporal bone. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery 2008;7:4086-97.  Back to cited text no. 29
30.Ogawa K, Nakamura K, Hatano K, Uno T, Fuwa N, Itami J, et al. Treatment and prognosis of squamous cell carcinoma of the external auditory canal and middle ear: A multi-institutional retrospective review of 87 patients. Int J Radiat Oncol Biol Phys 2007;68:1326-34.  Back to cited text no. 30
31.Pfreundner L, Schwager K, Willner J, Baier K, Bratengeier K, Brunner FX, et al. Carcinoma of the external auditory canal and middle ear. Int J Radiat Oncol Biol Phys 1999;44:777-88.  Back to cited text no. 31
32.Moore MG, Deschler DG, McKenna MJ, Varvares MA, Lin DT. Management outcomes following lateral temporal bone resection for ear and temporal bone malignancies. Otolaryngol Head Neck Surg 2007;137:893-8.  Back to cited text no. 32
33.Kollert M, Draf W, Minovi A, Hofmann E, Bockmühl U. Carcinoma of the external auditory canal and middle ear: Therapeutic strategy and follow up. Laryngorhinootologie 2004;83:818-23.  Back to cited text no. 33
34.Bieley HC, Kirsner RS, Reyes BA, Garland LD. The use of Mohs micrographic surgery for determination of residual tumor in incompletely excised basal cell carcinoma. J Am Acad Dermatol 1992;26:754-6.  Back to cited text no. 34
35.Rowe DE, Carroll RJ, Day CL Jr. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989;15:424-31.  Back to cited text no. 35
36.Mohs FE, Snow SN. Microscopically controlled surgical treatment for squamous cell carcinoma of the lower lip. Surg Gynecol Obstet 1985;160:37-41.  Back to cited text no. 36
37.O'Brien CJ. The parotid gland as a metastatic basin for cutaneous cancer. Arch Otolaryngol Head Neck Surg 2005;131:551-5.  Back to cited text no. 37
38.delCharco JO, Mendenhall WM, Parsons JT, Stringer SP, Cassisi NJ, Mendenhall NP. Carcinoma of the skin metastatic to the parotid area lymph nodes. Head Neck 1998;20:369-73.  Back to cited text no. 38


  [Figure 1], [Figure 2], [Figure 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded73    
    Comments [Add]    

Recommend this journal