Surgical Treatment of Glomus Jugulare Tumors Without Rerouting
Surgical Treatment of Glomus Jugulare Tumors Without Rerouting
Object: Glomus jugulare tumors are benign lesions located in the jugular foramen that may or may not extend into the middle ear, petrous apex, and upper neck; these growths sometimes invade intradurally. The surgical management of these tumors is a challenge to neurosurgeons and skull base surgeons. Because of their abundant vascularity, deep location, complex anatomy, and difficult surgical approach, their treatment, has been a controversial issue for many years. Despite advancements in nonsurgical techniques, the only treatment with proven efficacy is radical surgical removal. The authors present a series of patients treated with radical removal, in which the feasibility of removing glomus jugulare tumors with low morbidity and a surgical approach limited to tumor removal are discussed. The extent of surgical exposure is tailored with emphasis placed on the routine anterior transposition of the facial nerve.
Methods: Between May 1997 and March 2004, 24 patients with glomus jugulare tumors were treated; 17 patients were women and seven were men. Their mean age at the time of diagnosis was 50 years (range 18–71 years). The most common symptom was hearing loss in 77%, followed by dysphagia and dysphonia in 55% of patients. In seven patients the clinical presentation was a facial palsy. Radical tumor removal was achieved in 23 patients. An anterior facial nerve transposition was not needed in any case. No surgery-related death was recorded in this series, although one patient died of a pulmonary embolism 70 days after the procedure. A one-stage procedure was performed in 23 patients and a two-stage procedure was used in the other patient. Cerebrospinal fluid leakage occurred in two patients. The lower cranial nerve function was worse in eight patients; however, only one had a new deficit. The facial nerve was preserved in all patients except one, in whom a large intradural tumor caused a temporary facial palsy. In the patients with preoperative facial palsy, the tumor only compressed the nerve in three and it invaded the nerve in four. The nerve was decompressed in the cases with no invasion and a graft was placed in the others. The greater auricular nerve was used as a graft in three and the sural nerve was used in one. On follow-up review, the facial nerve function was House–Brackmann Grade 3 in three patients and Grade 2 in three. After 6 months of follow up with no improvement, one patient was referred for a facial muscle transfer.
Conclusions: The surgical technique must be tailored to each case. The authors believe that the standard surgical approach to jugular foramen tumors with anterior transposition of the facial nerve should be avoided, and that the extent of surgical exposure must be tailored to each case based on the extent of the tumor and the clinical symptoms. Lower morbidity rates and radical removal can be achieved with a good surgical plan.
Benign paragangliomas that originate in or near the jugular foramen are called glomus jugulare tumors. Their complex anatomy, abundant vascularity, and the critical relationship with the lower cranial nerves, ICA, jugular bulb, and facial nerve makes surgical removal of Fisch Class C and D glomus jugulare tumors a challenge for skull base surgeons.
Rosenwasser was the first to attempt radical removal of a glomus jugulare tumor. In 1952 Capps reviewed the current literature and added five new cases of glomus jugulare tumor. This author was the first surgeon to perform an anterior mobilization of the facial nerve, occlusion of the sigmoid sinus and the ligature of the IJV in the neck. In 1964, however, Shapiro and Neues were the first to describe the combination of mastoidectomy, anterior facial nerve transposition, and neck exposure with ligature of the IJV and arterial branches to the tumor. These authors pioneered the use of severe hypotension and hypothermia as crucial factors to avoid death caused by severe bleeding.
In 1978 Fisch restored this approach to its former position as state of the art in the management of glomus jugulare Class C tumors. The key element of the infratemporal approach described by Fisch is an anterior transposition of the facial nerve. This approach gives a straight, direct view of the jugular foramen, allowing a safe and wide exposure of the tumor. Despite very meticulous dissection of the facial nerve, a transitory weakness is often found in the postoperative period. During the last decade several articles have been published concerning radical surgery for removal of glomus jugulare tumors; however, few of them have addressed the need for facial nerve re routing to attain radical removal of the mass.
In this report we present a series of 24 cases of glomus jugulare Class C and D tumors treated without standard rerouting of the facial nerve.
Object: Glomus jugulare tumors are benign lesions located in the jugular foramen that may or may not extend into the middle ear, petrous apex, and upper neck; these growths sometimes invade intradurally. The surgical management of these tumors is a challenge to neurosurgeons and skull base surgeons. Because of their abundant vascularity, deep location, complex anatomy, and difficult surgical approach, their treatment, has been a controversial issue for many years. Despite advancements in nonsurgical techniques, the only treatment with proven efficacy is radical surgical removal. The authors present a series of patients treated with radical removal, in which the feasibility of removing glomus jugulare tumors with low morbidity and a surgical approach limited to tumor removal are discussed. The extent of surgical exposure is tailored with emphasis placed on the routine anterior transposition of the facial nerve.
Methods: Between May 1997 and March 2004, 24 patients with glomus jugulare tumors were treated; 17 patients were women and seven were men. Their mean age at the time of diagnosis was 50 years (range 18–71 years). The most common symptom was hearing loss in 77%, followed by dysphagia and dysphonia in 55% of patients. In seven patients the clinical presentation was a facial palsy. Radical tumor removal was achieved in 23 patients. An anterior facial nerve transposition was not needed in any case. No surgery-related death was recorded in this series, although one patient died of a pulmonary embolism 70 days after the procedure. A one-stage procedure was performed in 23 patients and a two-stage procedure was used in the other patient. Cerebrospinal fluid leakage occurred in two patients. The lower cranial nerve function was worse in eight patients; however, only one had a new deficit. The facial nerve was preserved in all patients except one, in whom a large intradural tumor caused a temporary facial palsy. In the patients with preoperative facial palsy, the tumor only compressed the nerve in three and it invaded the nerve in four. The nerve was decompressed in the cases with no invasion and a graft was placed in the others. The greater auricular nerve was used as a graft in three and the sural nerve was used in one. On follow-up review, the facial nerve function was House–Brackmann Grade 3 in three patients and Grade 2 in three. After 6 months of follow up with no improvement, one patient was referred for a facial muscle transfer.
Conclusions: The surgical technique must be tailored to each case. The authors believe that the standard surgical approach to jugular foramen tumors with anterior transposition of the facial nerve should be avoided, and that the extent of surgical exposure must be tailored to each case based on the extent of the tumor and the clinical symptoms. Lower morbidity rates and radical removal can be achieved with a good surgical plan.
Benign paragangliomas that originate in or near the jugular foramen are called glomus jugulare tumors. Their complex anatomy, abundant vascularity, and the critical relationship with the lower cranial nerves, ICA, jugular bulb, and facial nerve makes surgical removal of Fisch Class C and D glomus jugulare tumors a challenge for skull base surgeons.
Rosenwasser was the first to attempt radical removal of a glomus jugulare tumor. In 1952 Capps reviewed the current literature and added five new cases of glomus jugulare tumor. This author was the first surgeon to perform an anterior mobilization of the facial nerve, occlusion of the sigmoid sinus and the ligature of the IJV in the neck. In 1964, however, Shapiro and Neues were the first to describe the combination of mastoidectomy, anterior facial nerve transposition, and neck exposure with ligature of the IJV and arterial branches to the tumor. These authors pioneered the use of severe hypotension and hypothermia as crucial factors to avoid death caused by severe bleeding.
In 1978 Fisch restored this approach to its former position as state of the art in the management of glomus jugulare Class C tumors. The key element of the infratemporal approach described by Fisch is an anterior transposition of the facial nerve. This approach gives a straight, direct view of the jugular foramen, allowing a safe and wide exposure of the tumor. Despite very meticulous dissection of the facial nerve, a transitory weakness is often found in the postoperative period. During the last decade several articles have been published concerning radical surgery for removal of glomus jugulare tumors; however, few of them have addressed the need for facial nerve re routing to attain radical removal of the mass.
In this report we present a series of 24 cases of glomus jugulare Class C and D tumors treated without standard rerouting of the facial nerve.
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