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External auditory canal (EAC) carcinoma is a rare and unusual malignancy. The complex anatomy and relationship between the tumor and surrounding tissues in a limited space render it difficult to attain safe resection margins during surgery. A high jugular bulb (HJB) is one such anatomical variation that has important surgical implications that complicate the surgical procedure for EAC carcinoma. A 73-year-old woman presented with a 3-month history of right ear pain. Pathological findings and computed tomography (CT) revealed EAC carcinoma, which was expanding to the middle ear (ME). Although there was no cavity inside the ME, an HJB was detected. Surgical treatment using a temporal incision for temporal craniotomy achieved complete resection of the tumor and preserved facial nerve function. The patient recovered without complications and was discharged 17 days after the operation. Temporal incision and temporal craniotomy is a useful approach for EAC carcinoma with HJB.

Background: To determine factors that delay surgical recovery and increase intraoperative hemorrhage in skull base surgery. Methods: Factors related to delayed postoperative recovery were retrospectively reviewed in 33 patients who underwent open skull base surgery. Early and late recovery phases were assessed as “days required to walk around the ward (DWW)” and “length of hospital stay (LHS),” respectively. Intraoperative blood loss was cal­culated every hour and analyzed in 4 steps, i.e., craniotomy and intracranial manipulation, cranial fossa osteotomy, extracranial osteotomy, and reconstruction. Results: More than 4,000 mL of blood loss (B = 2.7392, Exp[B] = 15.4744; 95% CI 1.1828–202.4417) and comorbidi­ty (B = 2.3978, Exp[B]) = 10.9987; 95% CI 1.3534–98.3810) significantly prolonged the DWW; the occurrence of postoperative complications significantly delayed the LHS (p = 0.0316). Tumor invasion to the hard palate, the maxillary sinus, the pterygopalatine fossa, the base of the pterygoid process, the sphenoid sinus, the middle cranial fossa, and the cavernous sinus and a long operation time (>13 h) were associated with increased total hemorrhage. The optimal cut-off hemorrhage volume associated with total massive blood loss in craniotomy and intracranial manipulation (AUC = 0.8364), cranial fossa osteotomy (AUC = 0.8000), and extracranial osteotomy (AUC = 0.8545) was 1,111, 750, and 913 mL, respectively. Persistent infection (6%) and neuropsychiatric disorder (6%) are direct causes of delayed LHS. Conclusion: Blood loss, comorbidity, and postoperative complications were risk factors for delayed surgical recovery. Meticulous preoperative planning, intraoperative surefire hemostasis, and perioperative holistic management are prerequisites for safe skull base surgery.

Under extreme conditions and in palliative settings, shared decision making with the patient is vital; narrative decisions beyond evidence could be considered. If there is a chance of symptom palliation, extended surgery should not be avoided merely because of the limited life expectancy.