Summer is approaching which is a good reminder for hearing practitioners to look out for suspicious lesions and spots in, on and around the ears to be referred to doctors. HPA gleans some valuable insight from Darwin audiologist Kerry Bell and leading dermatologist Dr Stephen Schumack.
Northern Territory audiologist Ms Kerry Bell is challenging audiologists to be on the lookout for skin cancers and melanomas on and around the ears. She says Australia has no national skin cancer screening program so the onus is on individuals monitoring their own skin – and ears are often overlooked when it comes to sun protection, hats and sunscreen.
“Audiologists are uniquely placed to fill this gap,” Bell told delegates in an informative session on skin cancers on the ears, other ear lesions and skin conditions at The Sound Exchange’24 Audiology Australia event in Melbourne earlier in 2024.
“We look at ears every day and see the direct population at higher risk for skin cancer and melanoma such as older people so it’s a good opportunity to check when we are doing otoscopy,” she told the event.
Around the pinna, she says squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs) commonly present as small lesions that don’t heal over time and may itch or bleed.
“About 10% of skin cancers occur on the outer ear and can progress into cancers in the ear.
“It’s important to look all around the ear during otoscopy and ask patients how long suspicious spots have been there. We don’t need to be diagnosing but act as a screener. It’s more a matter of highlighting lesions to the patient and asking them to monitor them and see a GP for investigation.”
She says the pinna plays an important part in the auditory pathway and if a patient has the pinna removed in skin cancer surgery, it can affect sound localisation tasks and ability to impartially separate sound and noise. Custom device options such as hearing aids, bone conduction and middle ear implants, and cochlear implants can assist those with skin cancer of the ear, she adds.
Bell advises that if audiologists are unsure or concerned about any skin lesions or conditions they see on, in or near a patient’s ear, they should take clinical notes and always refer them to a GP or dermatologist.
A free dermatology website, dermnetnz.org, is a good resource to assist.
Dr Stephen Shumack from the Australasian College of Dermatologists did not speak at The Sound Exchange but has since given HPA an outline of what audiologists need to know and provided the below tips about skin conditions and cancers on or around the ears.
Skin conditions
Eczema is the most common inflammatory skin condition around the ears and favours other flexions too such as elbows and knees, along with eyelids, face and body. It can also exist in the ear canals and can blister and ooze. People with eczema can also develop red and scaly skin from secondary bacterial infection.
Patients can be advised to use soap-free cleansers such as QV, Cetaphil and Dermeze, topical steroid lotions/creams, and non-steroidal topical therapy on the ears, and to avoid irritants.
Seborrheic dermatitis is another form of eczema which can affect the ears, eyebrows, nasal folds and eyelids but is more pink than eczema and favours creases. Treatment is similar to eczema including 1% hydrocortisone cream twice daily for the face and over-the-counter antifungal shampoo such as Selsun Gold or Nizoral shampoo 3-5ml used twice weekly for a month and then weekly.
Psoriasis may occur in people with other conditions such as arthritis, Crohn’s disease, ulcerative colitis and coeliac disease. Plaques tend to be thick and scaly and removing triggers such as alcohol, smoking and extra weight can help. Topical therapy as used in eczema is helpful along with vitamin D analogues and 15 minutes a day of sun exposure.
People with comedonal acne should be advised to wear oil free cosmetics, use soap-free cleansers, and use OTC benzoyl peroxide topical lotion or cream.
Large brown or pink age spots (seborrhoeic keratoses) or barnacles can appear in older people, have a waxy appearance and are benign.
Chondrodermatitis nodularis helicis (CNH) affects the outer ear rim and involves inflammation and a small hard bump on the ear cartilage. These areas can be quite tender to the touch. They are often caused by pressure such as sleeping on one spot with headphones pressing on that spot. They can also be caused by heat or cold. They have a crust on top and are tender. and if they don’t resolve, referral to a GP or dermatologist is required.
Skin cancers
Basal cell carcinomas (BCC) are the most common type of skin cancer and the least concerning but must still be treated through excision. After years of sun exposure, BCCs can develop on the pinna.
Those at higher risk are older men, people who have had other non-melanoma skin cancers, have fair skin and light hair, are immunosuppressed, have had previous skin injury or have Gorlin syndrome.
BCCs are generally slow growing and the least invasive skin cancer. They are nodular and include pearly nodules with blood vessels crossing the surface. They can be cut out and sent to a pathologist for confirmation of diagnosis.
Features include rolled edges and central ulceration, itchy bleeding sunspots and a BCC on the ear often appears as a crusty spot that will not heal. BCCs should be referred to a GP or a dermatologist for formal diagnosis and treatment.
Squamous cell carcinomas (SCCs) are tender, grow quickly and these patients should be referred to a GP or a dermatologist as soon as possible. SCCs can be painful and itchy, feature scaly red patches, open sores and rough, thickened or wart-like skin. Lymph nodes may be enlarged. People who have had a lot of sun exposure, a history of smoking or immunosuppression are at higher risk. Surgery and radiotherapy may be required.
Actinic keratoses are rough, scaly patches on the skin that develop from years of sun exposure. They are often found on the face, lips, ears, forearms, scalp, neck or back of the hands. Those with fair skin who have had a lot of sun exposure, older people and the immunosuppressed are at higher risk. Actinic keratoses feature a red base with a small white crusty lesion and can be precancerous. They are generally not tender but if tender and thickened, they should be biopsied.
SCC in situ or Bowen’s disease in the superficial epidermis is a pre-invasive, very slow growing and very early form of SCC. It can be confused with psoriasis and appears in sun exposed areas. It is larger and thicker than actinic keratosis and should not be tender but if it becomes tender it requires biopsy. Those at higher risk of Bowen’s disease include people who have had a lot of sun exposure or ionising radiation exposure and the immunosuppressed. There is a 3-5% chance of it becoming invasive SCC. OTC urea or salicylic acid cream can help. Transplant patients may require excision.
Pigmented lesions
Naevus or moles are very common and generally round. People with lots of moles are at increased risk for melanoma and should be referred to a GP if there is a change in size or structure of a mole, if a new mole, different from the others, appears when they are over age 40 or it has ABCD characteristics (asymmetry, border irregularity, colour variation or a diameter over 6mm).
There have been many new therapies for melanomas including systemic treatments in recent years. Patients with a melanoma on their ear are generally older and might have had previous melanoma, BCC or SCC. Risk factors for melanoma include having many moles, fair skin, UV exposure, working outside or being immunosuppressed.
Melanomas are flat and while generally a brown or black raised lump with dark, irregular colours and borders, they can also appear like a pinkish raised lump or mole that grows quickly. Some can lack pigment and have no colour. If changes occur such as sudden bleeding, there is a risk of metastases and death.
New systemic treatments can work wonders but have side-effects. If detected early, melanomas are very treatable with excision. Always refer to a GP or dermatologist for consideration of biopsy and excision.
Remind patients to wear sunscreen and a hat that covers their ears. If they have red, itchy, scaly, painful, bleeding, new, rapidly changing or failing to heal lesions, or a rash that is not improving with topical cream, refer them to a GP or a dermatologist.
About the authors
Audiologist Kerry Bell came to the NT on a university placement in 2009 and has worked in rehabilitation and diagnostics from outreach in Cape York, to private practice and humanitarian audiology in the Pacific. She works for NextSense supporting the Cochlear Implant and Implantable Devices Program for Territorians and works as a lecturer and tutor for Charles Darwin University’s Master of Audiology program.
Dr Stephen Shumack OAM is a general clinical dermatologist, Clinical Associate Professor at the Sydney Medical School (Northern) of the University of Sydney and a senior staff specialist at the Royal North Shore Hospital of Sydney in St Leonards. He is the treasurer of the International League of Dermatological Societies, a past chairman of the board of the Skin and Cancer Foundation Australia, a former president of the Australasian College of Dermatologists and former editor in chief and now on the editorial board of the Australasian Journal of Dermatology. He has published and spoken widely on dermatological care including psoriasis, eczema and skin cancer diagnosis, management and research.
