NEOPLASMS OF THE EAR. 
BY 
EDWARD BRADFORD DENCH, M.D. 
PROFESSOR OF OTOLOGY, BELLEVUE HOSPITAL MEDICAL COLLEGE ; 
Surgeon to n. y. eye and far infirmary. 
Reprinted from the N. Y. Eye and Ear Infirmary Reports, Jan., 1896. NEOPLASMS OF THE EAR. 
By Edward Bradford Dench, M.D. 
T N the present paper the author does not propose to give 
A more than a brief history of those cases of neoplasms 
affecting the organ of hearing which have come under his 
observation within the past few years, and most of which have 
been seen during the last twelve months. For a more full 
account of neoplasms of the ear he begs to refer to his own 
previous contributions to medical literature upon this subject:1 
Case I.-The patient was a male, about 35 years of age. 
About one and a half years before he presented himself at the 
New York Eye and Ear Infirmary, he had noticed a small 
swelling in front of the left ear just above the tragus. During 
the few months prior to his admission to the hospital this 
growth had rapidly increased in size, until at the time when I 
first saw him it was as large as an English walnut. 
Examination revealed a tumor occupying the region before 
named ; the surface of the growth was smooth ; there was no 
superficial ulceration, and upon palpation the tumefaction 
appeared dense and hard. The integument covering it was 
dark, almost black. Upon manipulation the growth seemed 
to be firmly attached to the tragus and appeared to extend for 
a short distance into the external auditory canal, otherwise 
the growth was movable. The cervical glands were not 
enlarged and the general condition of the patient was excellent. 
Immediate operation was advised. The growth and the neigh- 
boring parts were thoroughly scrubbed with soap and water, 
then washed with ether, and subsequently with a solution of 
bichloride of mercury 1 :iooo. The external auditory meatus 
was syringed with a similar solution, after which the canal was 
1 A System of Diseases of the Ear, Nose, and Throat, edited by Charles 
H. Burnett, Philadelphia, 1893, vol. i., p. 156 et seq. Archives of Otology, 
vol. xxii., p. 166, Dench, Diseases of the Ear, D. Appleton & Co., New 
York, 1894, p. 206 et seq., p. 285. 
Reprinted from the N. Y. Eye and Ear Infirmary Reports, Jan., 1896. 88 
DENCH 
plugged with a strip of iodoform gauze. A moist bichloride 
dressing was then applied over the field of operation. 
Under anaesthesia the growth was circumscribed by two 
curved incisions ; one being made below and the other above 
the tumor. The hemorrhage was free but was easily controlled 
by hemostatic forceps. The entire mass, together with the 
tragus to which it was attached, and a small portion of the 
anterior wall of the cartilaginous meatus, was dissected out. 
The skin was then dissected up along the lines of the elliptical 
incision and at the angle of junction anteriorly, so that the 
margins could be approximated by sutures throughout a con- 
siderable portion of their length. Considerable traction upon 
the sutures was necessary to effect this approximation, and 
after the parts had been adjusted a denuded area about the 
size of a ten-cent piece remained. This surface was allowed 
to heal by granulation. The subsequent history of the case 
was uneventful. Union by first intention took place where the 
edges of the wound had been approximated, and the granu- 
lating surface healed rapidly. The patient was under obser- 
vation at intervals for a period of about eight or nine months, 
and when last seen there was no evidence of recurrence. 
An examination of the growth showed it to be a round-cell 
sarcoma, richly supplied by blood-vessels. 
The following cases have occurred during the last twelve 
months of my service at the Infirmary. 
Case II.-The patient was a male about 20 years of age. 
When first seen he complained of gradually increasing impair- 
ment of hearing in the left ear. He stated that during the 
past two or three years the ear seemed to be stopped up from 
time to time, but that by pressing two or three times upon the 
tragus, the hearing seemed to return and to remain as good as 
ever. For the last few months, however, the impairment in 
hearing had been steadily increasing, and he had been able to 
obtain no relief by manipulation of the auricle as on previous 
occasions. 
The meatus was found to be almost completely occluded. 
Upon examining the occluding mass with a probe it was found 
to be hard and apparently attached to the anterior and supe- 
rior walls of the canal. Even a very fine probe could not be 
passed between the growth and the posterior wall of the meatus, 
but still there was evidently a narrow channel between the 
obstruction and this aspect of the canal. 
The patient was at once admitted to the hospital and pre- 
pared for operation in the usual way. There was no hesitation NEOPLASMS OF THE EAR. 
89 
in pronouncing the growth to be osseous in character. Under 
ether anaesthesia it was found that even the finest probe could 
not be passed between the obstruction and the posterior wall 
of the canal. A very narrow space, however, did exist in this 
region, and the growth was found to be attached to the anterior 
and superior walls of the canal. I first attempted to remove 
the mass by means of a chisel introduced through the external 
auditory meatus, the integument having been previously incised 
and the periosteum stripped from the surface of the neo- 
' plasm. A small portion was detached in this way but could 
not be extracted. I immediately, therefore, made an incision 
behind the ear, from the tip of the masioid to a point just 
above the meatus, following closely the line of attachment of 
the auricle to the skull. By means of the periosteum elevator, 
the soft parts were separated from the bone, and the auricle 
turned forward and downward. The posterior wall of the 
fibro-cartilaginous meatus was then separated from the under- 
lying bone and incised so as to expose the margin of the bony 
meatus. It was then possible to introduce the flat end of an 
ordinary surgical probe between the posterior wall of the canal 
and the exostosis. A gouge was then applied and the neoplasm 
easily detached from the antero-superior wall of the meatus by 
a few blows of the mallet, after which it was removed from the 
canal by strong forceps The fragment separated when the 
chisel was used through the external auditory meatus, was 
found lying just within the fibrous canal. Inspection by 
means of the speculum showed that the obstruction had been 
completely removed, the drum membrane being visible through 
its entire extent. The margins of the incision were then brought 
together by means of interrupted catgut sutures and an anti- 
septic dressing was applied so as to cover the ear, the canal 
being loosely plugged with iodoform gauze. 
The dressing was removed four days after the operation, and 
the wound was found to be entirely healed with the exception 
of a small sinus at about the middle of the line of incision. 
This sinus did not communicate with the external auditory 
canal. 
The patient was discharged on the fifth day after operation, 
and since that time has been able to attend to his work in the 
usual manner, the post-auricular wound being dressed with 
iodoform gauze and collodion. 
The patient was directed to irrigate the canal twice daily 
with a syringe, and after each irrigation to instil a few drops 
of an alcoholic solution of boric acid to keep the canal 
thoroughly aseptic. 
Case III.-A male, aged 60, presented at my clinic at the 
Infirmary with the following history : About two years before 90 
DENCH 
he had noticed a small indurated spot upon the left helix, 
which he considered an ordinary " wart." It seemed to cause 
considerable irritation which he had attempted to relieve by 
scratching the surface. The growth had gradually increased in 
size, and attempts had been made by his family physician both 
to destroy it by means of caustics, or to relieve the discomfort 
by means of local applications. The patient also stated that 
internal medication had been employed for a considerable 
period on the supposition that the growth was of specific 
origin, although a specific history was positively denied. 
When I first saw him there was an ulcerated area occupying 
the middle third of the helix and extending anteriorly to the 
antihelix. The superficial ulceration scarcely involved the 
posterior surface of the auricle. The ulcerated area was about 
one inch in length, and three-eighths of an inch in width. The 
margins were indurated, and the denuded surface slightly ele- 
vated above the surrounding borders. Over no portion had 
there been any attempt at cicatrization. Owing to the absence 
of specific history, the character of the ulceration, and the age 
of the patient, I had no hesitation in pronouncing the growth 
to be an epithelioma, and advised immediate operation. 
This was performed a few days later under the ordinary 
aseptic precautions. The neoplasm was included between two 
convergent incisions which met just at the posterior margin 
of the concha. In this way a V-shaped piece was removed 
from the auricle, including the cartilaginous framework, and 
the integument covering it anteriorly and posteriorly. The 
incisions were made so as to lie entirely within healthy tissue 
and the excised portion included every vestige of the neo- 
plasm. The integument was then loosened from the under- 
lying cartilage along the line of these two incisions, and the 
cartilage itself was removed until the margins of the w'ound 
could be approximated without undue tension and in such a 
manner that the auricle was simply reduced in size, but not ma- 
terially changed in contour as compared with the organ on the 
opposite side. The parts were then held in position by fine silk 
sutures, and an antiseptic dressing was applied. This was re- 
moved about seven days after the operation, and firm union was 
found to have taken place throughout. Unfortunately no mi- 
croscopical examination was made of the growth owing to an 
accident to the specimen, but there is little doubt that it was 
carcinomatous in character. It is also interesting to note that 
there was a small indurated area upon the opposite helix which 
had appeared a few months before the patient came under 
observation. This was removed under cocaine anaesthesia and 
was submitted to microscopical examination. It was found to 
be papillomatous in structure and non-malignant. NEOPLASMS OF THE EAR. 
91 
The patient was seen about four months after the operation ; 
at that time there was no evidence of recurrence upon either 
side. Since this time the patient has not been seen. 
Case IV.-A man, 60 years of age, presented with the 
history of marked impairment of hearing in the right ear, 
amounting almost to total deafness, for about eighteen months. 
He stated that some four years previously the hearing had 
become impaired, and that upon application at a charitable 
institution the ear had been syringed, and that a mass of 
wax had been removed. He had been informed at that time 
that this constituted the sole cause of the impairment of func- 
tion. He was also told at this time that the obstruction had 
not been entirely removed from the canal, and was asked to 
return at a subsequent date for further treatment. This he 
failed to do. About a year before he came to my clinic he 
noticed that the right side of the face had become paralyzed, 
the paralysis coming on slowly. There had been but little pain 
in the ear until a few weeks before he came under my observa- 
tion, and at no time had this been severe. 
An examination revealed facial paralysis upon the right side. 
The right external auditory meatus was occluded by a growth 
which tilled the canal and protruded from the meatus. This 
mass was firm in consistency, bright red in color, and bled 
easily when touched with the probe. The external canal was 
so completely filled with the growth as to render any definite 
opinion as to the point of attachment impossible. There 
seemed, however, to be a small space between the posterior 
wall and the occluding mass. When a cotton-tipped probe 
was introduced as far as possible into the meatus and firm 
pressure was made so as to temporarily augment the size of 
the canal, there was a free discharge of pus-apparently from 
the deeper parts. According to the history given by the 
patient, this discharge appeared for the first time, after the 
removal of the obstruction four years previously. A small 
portion of the growth was removed bv means of the snare and 
submitted to microscopical examination. According to the 
report of the pathologist it was fibro-myxomatous in character. 
The patient was admitted to the hospital and after thoroughly 
disinfecting the field of operation, an attempt was made to 
remove the neoplasm under ether anaesthesia. On account of 
the size of the growth I decided to make no attempt at extir- 
pation through the canal, but proceeded at once to detach the 
auricle posteriorly and to dissect out the membranous canal so 
as to expose the bony meatus. When this was done I found 
that the tumor' filling the entrance of the meatus constituted 
but a small part of the neoplasm. After turning the auricle 
forward and downward and incising the posterior wall of 92 
DENCH 
the fibrous canal so as to expose the margin of the bony 
meatus, the external portion was immediately shelled out. 
It was then found'that the neoplasm was attached to the pos- 
terior wall of the bony canal and extended inward to the mid- 
dle ear, the deeper attachment apparently being in the 
tympanic vault. The new growth lying in the canal was thor- 
oughly scraped away by means of the curette, after which the 
superior and posterior walls of the bony meatus were removed 
with the chisel in order to obtain free access to the vault of the 
tympanum and to the channel leading from this to the mastoid 
antrum. By the free use of the sharp spoon a large amount of 
soft tissue resembling granulation tissue was removed from the 
tympanic vault. During this procedure considerable carious 
bone was removed. The softened bone removed evidently 
included the remains of the malleus and incus. As the opera- 
tion proceeded the curette finally entered a cavity whose upper 
wall seemed soft and membranous to the touch. At the same 
time rather free hemorrhage occurred from the deeper portion 
of the wound, the blood being bright in color. The curette 
still continued to bring away portions of the neoplasm. Close 
examination revealed the fact that the growth had perforated 
the roof of the tympanum, and had already involved the over-' 
lying dura. After every vestige of the new growth had been 
scraped away the parts were thoroughly irrigated wilh a solu- 
tion of bichloride of mercury i to 3000, and both the external 
auditory meatus and the wound behind the ear were plugged 
loosely with iodoform gauze. 
An examination of the neoplasm showed that the growth 
was not a fibro-myxoma as previously reported, but that it 
was a fibro-sarcoma. The patient made a good recovery, 
although the convalescence was somewhat prolonged. At 
the present time, eight months after the operation, there is a 
slight discharge from the canal, and the mucous membrane 
lining the atrium and tympanic vault is of a deep red color, 
presenting the appearance of granulation tissue. At the same 
time there is no recurrence of the growth. . The facial paraly- 
'sis has not entirely disappeared, but is certainly not as pro- 
nounced as before the operation. The hearing has been 
materially improved according to the patient's statement, 
although naturally this is of comparatively little importance 
considering the nature of the disease. 
Case V.-A boy about ten years of age, was brought to my 
clinic by my colleague Dr. Weeks, under .whose observation he 
had been for nearly a month. The patient was an Italian and 
as neither he nor his friends could speak English, I was 
obliged to depend upon the services of another patient to act 
as interpreter, and the history obtained was far from satisfac- NEOPLASMS OF THE EAR. 
93 
tory. As nearly as could be learned the patient had received 
a severe scratch at the hands of one of his playmates about 
three months before he came under my observation. The 
original wound was .still visible and presented as a long vertical 
furrow about two inches in length just in front of the right 
tragus. From this time, according to the history, the right ear 
began to increase in size, and ulceration soon occurred upon 
the anterior surface of the auricle. At the time of the exami- 
nation this entire region was occupied by amass of granulation 
tissue which bled freely upon the impact of the probe, and 
over certain areas the tissue.had undergone superficial necrosis. 
The external canal was completely blocked by this mass and 
the auricle was deformed to an extent that rendered it scarcely 
recognizable. Curiously enough the posterior surface of the 
auricle was not involved. Dr. Weeks had at first believed the 
condition to be due to hereditary specific disease, and had put 
the patient upon iodide of potassium in moderate doses. The 
effect of this medication had been, in the Doctor's opinion,- to 
somewhat diminish the size of the growth. Locally nothing 
had been done with the exception of keeping the parts thor- 
oughly cleansed. There was no history of specific disease 
obtainable on questioning, and the appearance of the parts did 
not at the time of my first examination seem to indicate hered- 
itary specific disease. The possibility of a primary lesion 
appearing at this point was borne in mind, but as there were 
no secondary symptoms this view was hardly tenable. The 
age of the patient was decidedly against the growth being car- 
cinomatous in nature although I was inclined to think that it 
was of this character. The diagnosis seemed to lie between 
sarcoma and carcinoma. 
The general condition of the patient was decidedly poor ; he 
was emaciated, and intensely anaemic ; the cervical glands upon 
the right side were much enlarged, and glandular enlargement 
was also found to exist in both axillae and in both inguinal 
regions. Owing to the patient's general condition there seemed 
to be but one course of treatment justifiable, and that was 
immediate removal of the neoplasm, whatever the nature of 
the growth might be. This was done two days after he first 
came under observation. As the posterior surface of the auri- 
cle was not involved, the integument covering this region was 
dissected up from the cartdage, and it was found that the 
cartilage had not been completely destroyed by the growth. 
This flap from the posterior surface was subsequently drawn 
forward, and used to close the large gap which was necessarily 
left anteriorly by the removal of the neoplasm. Two incisions 
were then made, one from the superior border of the auricle, 
the other from the attachment of the lobule below, these in- 94 
DENCH. 
cisions meeting upon the cheek, so as to include the entire 
neoplasm between them. By careful dissection, the new 
growth, which included the cartilaginous framework of the 
auricle and a portion of the fibrous meatus, was removed. The 
hemorrhage was exceedingly free, many large vessels requiring 
ligation. As the deep dissection was continued, it was found 
necessary to take away a considerable portion of the parotid 
gland. After the tumor bad been extirpated, the lower inci- 
sion was continued down along the anterior border of the 
sterno-mastoid muscle, and the enlarged cervical glands, to- 
gether with the posterior lobe of the parotid, were taken away. 
The incision in the neck was closed by means of interrupted 
sutures, and the denuded surface which was left by the re- 
moval of the growth was covered as much as possible by the 
flap of integument taken from the posterior surface of the 
auricle, and by dissecting up the edges of the cutaneous flaps 
along the lines of the incisions which circumscribed the growth. 
An attempt was made to secure a patent external auditory 
meatus by approximating the edges of the periosteum lining 
the bony canal with the edges of the adjacent integument. It 
was found impossible to completely close the wound, a denuded 
area fully one and a half inches in length and an inch in width 
being left in front of the external auditory meatus. The ordi- 
nary antiseptic dressings were applied. For the first two days 
the temperature was very high, reaching at one time 104° F., 
and there was great oedema of both upper and lower lids of the 
right eye. This was undoubtedly due to the tension exerted 
by the sutures in approximating the margins of the incisions. 
'I he first dressings were removed about forty-eight hours 
after operation, and the wound was found to be suppurating 
profusely. All the stitches were removed, the wound was irri- 
gated, and a moist bichloride dressing applied. From this 
time on the patient did exceedingly well. About two weeks 
after the operation my assistant, Dr. McKernon, suggested the 
advisability of attempting to hasten the process of cicatrization 
by the application of skin grafts according to the method of 
Thiersch, and at my request he carried out this procedure. 
The operation was not successful, as none of the grafts became 
attached, but the healing process was undoubtedly more rapid 
than it had been before. The wound gradually healed by 
granulation, the meatus becoming completely occluded during 
this process. 
The improvement in the general condition of the patient 
was very marked, after the immediate effect of the operation 
had passed away. 
At the present time there is no evidence of recurrence, and 
the wound is entirely healed. All glandular enlargement has NEOPLASMS OF THE EAR. 
95 
disappeared, and the patient is in excellent general condition. 
I should state here that no specific treatment, or in fact any 
internal medication of any kind, has been employed since the 
operation. 
A microscopical examination of the tissue removed at first 
seemed to indicate that it was of specific origin ; subsequently, 
however, repeated sections have been prepared, and all who 
have examined the specimens have agreed that the growth was 
undoubtedly a round-celled sarcoma. 
When we turn to the literature of malignant neoplasms of 
the external ear, we are rather impressed by the fact that ma- 
lignant disease in this region is scarcely as serious as when it 
occurs in other portions of the body. This subject has already 
been discussed in the articles alluded to in the beginning of 
this paper. •Cbe Iknicfcerbocher press, Iftew IRocbelle, K 12.