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P266: ADVANCED AURICULAR BASAL CELL CARCINOMA WITH TEMPORAL BONE AND DURAL INVASION: CASE REPORT OF DELAYED ENCEPHALOCELE AND CSF LEAK
Michael Evans, MS¹; Ricardo J Ramirez, MD²; ¹Kansas City University; ²Department of Otolaryngology, Mercy Clinic Springfield, Springfield, Missouri, USA

Background: Basal cell carcinoma (BCC) is the most common cutaneous malignancy, with auricular involvement often resulting from chronic sun exposure. While typically indolent, neglected lesions can cause extensive local destruction. Extension into the temporal bone and dura is rare but associated with significant morbidity. Advanced auricular BCC often necessitates wide oncologic resection with free flap reconstruction, though postoperative complications can delay adjuvant therapy and predispose to late sequelae such as osteoradionecrosis, encephalocele, and cerebrospinal fluid (CSF) leak.

Case Presentation: We report a 66-year-old male with a 10-year history of progressively enlarging left auricular BCC. Initial imaging demonstrated involvement of the auricle and adjacent temporal scalp with mastoid effusion but no apparent osseous invasion. He underwent total auriculectomy, radical excision of a 7.3 cm tumor, lateral temporal bone resection, superficial parotidectomy with facial nerve preservation, modified radical neck dissection, dural resection with grafting, and anterolateral thigh free flap reconstruction. Pathology confirmed BCC with temporal bone and dural invasion, perineural spread, and negative margins; all lymph nodes were negative.

The postoperative course was complicated by partial flap necrosis and chronic wound infection, delaying adjuvant radiotherapy for five months. The patient ultimately completed 60 Gy in 30 fractions. Two years later, he developed a progressively enlarging, pulsatile left temporal mass. MRI revealed herniation of temporal lobe parenchyma through a calvarial defect at the prior craniectomy site, consistent with temporal encephalocele. Multidisciplinary management included wide local excision, temporal craniotomy, resection of gliotic brain tissue, dural repair with AlloDerm, titanium mesh cranioplasty, and latissimus dorsi free flap reconstruction. Pathology showed necrotic skin and gliotic brain without residual carcinoma.

Subsequently, the patient developed clear rhinorrhea, with β2-transferrin testing confirming CSF leak. Nasal endoscopy demonstrated egress from the left eustachian tube orifice with Valsalva. Definitive management consisted of endoscopic eustachian tube obliteration (EETO) using autologous fat and fascia lata with V-Loc suture closure, combined with lumbar drainage. At 6-month follow-up, he remained free of recurrence and CSF leak.

Conclusions: This case highlights the challenges of managing advanced auricular BCC with skull base extension, the importance of aggressive multidisciplinary resection, and the potential for delayed, non-malignant postoperative complications such as temporal encephalocele and CSF leak. Auricular BCC with temporal bone and dural invasion is rare but carries significant morbidity when neglected. Early recognition, aggressive resection, and multidisciplinary reconstruction are crucial, with a focus on the potential for delayed complications. Innovative approaches, including endoscopic eustachian tube obliteration, may provide effective management of these rare sequelae.

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