Management of the cervico-petrous internal carotid artery in class C tympanojugular paragangliomas.

BACKGROUND: Management of the cervical and petrous internal carotid artery (ICA) is frequently required in Fisch class C tympanojugular paragangliomas (TJPs). The purpose of this study was to discuss the perioperative intervention of the ICA in patients who underwent surgical resection of a TJP. METHODS: A retrospective study of 237 patients surgically treated for Fisch class C TJPs was done to identify cases that required ICA management. RESULTS: Management of the ICA was required in 176 patients (74.2%). Forty-two patients required just an ICA decompression, 88 underwent a subperiosteal dissection, 19 underwent subadventitial dissection without intraluminal stenting, 17 underwent subadventitial dissection with intraluminal stenting, and 12 underwent arterial resection after permanent balloon occlusion. There were no complications associated with the endovascular procedures. Gross total tumor resection was achieved in 91.5% of the cases. CONCLUSION: Preoperative endovascular intervention, in selected cases, facilitates gross total tumor removal and significantly reduces the risk of an intraoperative ICA injury. © 2015 Wiley Periodicals, Inc. Head Neck 38: 899-905, 2016.

Contemporary management of jugular paragangliomas.

Jugular paragangliomas are generally benign slow-growing tumors that can cause pulsatile tinnitus, hearing loss, and cranial nerves neuropathy. Progressive growth can also lead to intracranial extension. Historically, the treatment of choice for these lesions has been gross total resection. However, over the last 15 years, many groups have adopted less invasive management strategies including stereotactic radiation therapy, subtotal resection, and primary observation in order to reduce treatment-associated morbidity. The focus of this article is to review the modern management of jugular paraganglioma, highlighting the evolving treatment paradigm at the Otology Group of Vanderbilt.

Surgical management of tympanojugular paragangliomas with intradural extension, with a proposed revision of the Fisch classification.

BACKGROUND: Tympanojugular paragangliomas (TJPs) with intradural extension can be successfully treated by a single or staged procedure with low surgical morbidity. OBJECTIVES: To present the clinical findings and treatment methods used for surgically treating TJP with intradural extension, as well as to discuss the complications of treatment and the relative merits of single versus staged surgery by using a comprehensive literature review comparing objective outcome measures. STUDY DESIGN: A retrospective case review of 45 cases of TJP with intradural extension. SETTING: A quaternary skull base and neurotologic center. MATERIALS AND METHODS: The charts of 45 patients with Fisch classification class C or D TJP with intradural extension, who were operated on from April 1988 to April 2010, were analyzed. Clinical findings and preoperative lower cranial nerve (LCN) palsy as well as postoperative totality of resection, postoperative LCN palsy and complications were studied. The types, indications, and distribution of staged procedures were also analyzed. RESULTS: Out of 45 cases, 22 were C3di2. The IX and X cranial nerves were the commonest nerves affected preoperatively. Preoperative internal carotid artery management was performed in 16 cases. Twenty-nine cases had a single procedure and 16 had a staged procedure. The main indication for staged procedures was intradural extension of 2 cm or more. The infratemporal fossa approach (ITFA) type A was the main procedure in all cases. Overall, total resection was achieved in 68.8% of cases with postoperative cerebrospinal fluid leak in 4.4% cases. Postoperative House-Beckmann grade I-III facial nerve status was maintained in 80% of cases, and overall LCN preservation rate was 56.9%. There were no cases requiring tracheostomy, and 3 cases required delayed phonosurgical procedures to improve their voice. CONCLUSIONS: TJP with intradural extension can be successfully managed with the judicious use of staged procedures to reduce the incidence of postoperative cerebrospinal fluid leak. The ITFA did not cause an excessively high rate of facial nerve palsy, and the overall total resection and LCN preservation rate compares very favorably with previously published data.

Paragangliomas de cabeza y cuello / Parangangliomas of the head and neck

Los parangangliomas son tumores altamente vascularizados que se originan de células provenientes de la cresta neural. El tratamiento de elección es la resección quirúrgica completa, lo cual se ve dificultado por su abundante irrigación y por su estrecha relación anatómica con importantes estructuras vásculo-nerviosas. En el presente estudio se revisa retrospectivamenete la experiencia del Departamento de Otorrinolaringología de Clínica Las Condes en el manejo quirúrgico de estas neoplasias. Entre los años 1998 y 2003 se trataron 5 pacientes portadores de paragangliomas de cabeza y cuello: un glomus yugular (GY), 2 glomus carotídeo (GC) y 2 glomus timpánicos (GT). El estudio imagenológico consistió en tomografía computarizada (TC) para todos los casos, complementada con resonancia nuclear magnética (RNM) y/o angiografía en algunos pacientes. El abordaje quirúrgico fue el indicado para cada lesión: timpanotomía retroauricular (GT), cervicotomía (GC) y abordaje infratemporal tipo A de Fisch (GY). En todos se logró una resección tumoral completa, sin presentarse complicaciones perioperatorias de consideración ni recurrencias hasta la fecha. Contando con un adecuado estudio imagenológico y una cuidadosa planificación quirúrgica, la resección de los paragangliomas de cabeza y cuello puede realizarse con un bajo índice de complicaciones, reservando la radioterapia como alternativa terapéutica únicamente en aquellos casos inoperables.

Comparison of radiosurgery and conventional surgery for the treatment of glomus jugulare tumors.

OBJECT: The optimal management of glomus jugulare tumors remains controversial. Available treatments were once associated with poor outcomes and significant complication rates. Advances in skull base surgery and the delivery of radiation therapy by stereotactic radiosurgery have improved the results obtained using these treatment options. The authors summarize and compare the contemporary outcomes and complications for these therapies. METHODS: Papers published between 1994 and 2004 that detailed the use of radiosurgery or surgery to treat glomus jugulare tumors were reviewed. Eight radiosurgery series including 142 patients and seven surgical studies including 374 patients were evaluated for neurological outcome, change in tumor size (radiosurgery) or percent of total resection (surgery), recurrences, tumor control, need for further treatment, and complications. The mean age at treatment for patients who underwent surgery and radiosurgery was 47.3 and 56.7 years, respectively. The mean follow-up duration was 49.2 and 39.4 months, respectively. The surgical control rate was 92.1%, with 88.2% of tumors totally resected in the initial surgery. A cerebrospinal fluid leak occurred in 8.3% of patients who underwent surgery and recurrences were found in 3.1%; the mortality rate was 1.3%. Among patients who underwent radiosurgery, tumors diminished in 36.5%, whereas 61.3% had no change in tumor size, and subjective or objective improvements occurred in 39%. Despite the presence of residual tumor in 100% of radiosurgically treated patients, recurrences were found in only 2.1%, the morbidity rate was 8.5%, and there were no deaths. CONCLUSIONS: Death and recurrences after these treatments are infrequent, and therefore both treatments are considered to be safe and efficacious. Although surgery is associated with higher morbidity rates, it immediately and totally eliminates the tumor. The radiosurgery results are very promising, although the incidence of late recurrence (after 10-20 years) is unknown.

Glomus jugulare tumour presenting with isolated accessory nerve palsy.

Glomus tumours of the skull base are rare, and most frequently present with symptoms of hearing loss and tinnitus. Diagnosis is often delayed due to the slow growth of the tumour. We describe the previously unreported occurrence of a glomus tumour presenting with a unilateral accessory nerve palsy.

[Diagnosis and treatment of glomus jugulare tumor].

OBJECTIVE: To investigate the clinical features, diagnosis, and treatment of glomus jugulare tumor. METHODS: The data of 37 patients of glomus jugulare tumor diagnosed by digital subtraction angiography (DSA) and/or operation and pathology, 14 males (37.8%) and 23 females (62.2%), with an average age of 37.2 (3.5 approximately 66 years) and an average course of 4.3 years (1 month - 19 years), were analyzed. RESULTS: The tumor was located in the left ear in 19 cases, in the right ear in 17 cases, and in both ears in 1 case, totally 38 ears. The tumor was chromaffin in one case with hypertension. One case was complicated by ipsilateral carotid body tumor, and 2 cases were complicated by ipsilateral cholesteatoma. Thirty cases (81.1%) presented pulsatile tinnitus and hearing loss as the main symptoms. Thirteen cases (35.1%) were diagnosed as glomus jugulare tumor at the first visit, and 24 cases (64.9%) were diagnosed as other diseases with an average misdiagnosis period of 4.4 years. Eighteen tumors originated from typanum and 28 tumors from glomus jugulare. According the Fisch classification 1981, the tumors in 11 ears were type A, in 7 ears were type B, in 7 ears type C, in 5 ears type D1, and in 8 ears type D2. All cases, except the one with bilateral lesions, underwent operation. The tumor was completely resected in 30 cases. Postoperatively, facial paralysis was seen in 6 cases, dizziness, hoarseness, and subauricular necrosis was seen in one case respectively. Of the 25 patients followed up with a mean follow-up time of 5.2 years (1.1 - 16.1 years), 3 died of lung cancer, neuroblastoma, or extensive involvement of glomus jugulare tumor respectively, 19 survived without tumor, and 3 survived with the tumor. CONCLUSION: Glomus jugulare tumor is likely to involve surrounding important tissues, and to be misdiagnosed. Early surgical removal of the lesion is important.

Surgical management of large glomus jugulare tumours: infra- and trans-temporal approach.

Surgery may have to be considered in the management of large glomus tumours since other modalities of treatment are not curative. The judicious use of surgical intervention is imperative since a neurological deficit involving the last four cranial nerves may ensue and consideration of the quality of life of the patient in the post-operative period is of paramount importance. A brief description of the historical aspects and pathology of these tumours is followed by an analysis of the clinical presentation, investigation and assessment of a series of 10 patients. Six patients underwent surgery and their tumours were removed by the infra- and trans-temporal approach. This is described and illustrated in detail and the surgical results presented.

Radiotherapy for jugulo-tympanic paragangliomas (glomus jugulare tumours).

Sixty patients with glomus jugulare tumour, seen at St. Bartholomew's Hospital, London, over forty years, have been reviewed. The term 'jugulo-tympanic paraganglioma' is suggested as a more accurate name for these tumours. The following simple classification is recommended: Group I tumours (tympanic paragangliomas) are those with or without VIIth nerve palsy, but with no other cranial nerve involvement. Group II tumours (jugular paragangliomas) are those with involvement of any cranial nerve other than the VIIth. The method and results of treatment by radiotherapy are discussed. It is concluded that surgery and radiotherapy give comparable results in Group I tumours, but radiotherapy gives superior results in Group II tumours.

High-resolution CT in the evaluation of glomus tumors of the temporal bone.

High-resolution computed tomography (HRCT) was performed in 33 cases of glomus tumors of the temporal bone and 10 cases of other tumors in and around the jugular foramen. HRCT helped to differentiate glomus tumors from vascular anomalies and from other benign or malignant lesions, and to determine the extent of deep involvement. It provided essential information for planning the surgical approach. When a lesion is large or appears atypical, complementary angiography is helpful. Otherwise, angiography may not be necessary.

Panel discussion: glomus jugulare tumors of the temporal bone. The surgical management of glomus tumors.

The authors describe the diagnosis and surgical management of 70 glomus tumors seen at the Otology Group in an 8 yr. period. The need for bilateral arteriograms to detect associated tumors (carotid body and intervagale) is stressed. A new surgical technique, the modified intratemporal fossa approach, is described for the removal of large glomus jugulare tumors involving the carotid artery. Complications and results are discussed in detail.