Long term surgical and hearing outcomes in the management of tympanomastoid paragangliomas

Tumor progression in tympanojugular paragangliomas: the role of radiotherapy and wait and scan

INTRODUCTION

Tympanojugular paragangliomas (TJ PGLs) are rare tumors characterized by bone infiltration and erosion and a close relationship with critical structures, such as cranial nerves and internal carotid artery. For these reasons, their management represents a tough challenge. Since the fifties, radio-therapy (RT) has been proposed as an alternative treatment aimed at avoiding tumor progression. However, the indolent nature of the tumor, characterized by slow growth, is a crucial factor that needs to be considered before offering radiation.

METHODS

This study aims to examine tumor progression in RT patients through a systematic review of the literature and in TJ PGL patients who underwent solely wait and scan at our department.

RESULTS

The rate of tumor progression in the RT group was 8.9%, while in the wait and scan cohort was 12.9%. This data suggests the innate slow growth of PGLs. However, it is not possible to draw certain conclusions because of the wide heterogeneity of the studies.

CONCLUSION

When complete surgical excision of TJ PGLs is not feasible, appropriate counseling and patient selection, including comprehensive tumor classification, should be performed before proposing RT to control tumor progression, since wait and scan may represent a reasonable option in selected cases.

Critical Steps and Common Mistakes during Temporal Bone Dissection: A Survey among Residents and a Step-by-Step Guide Analysis

BACKGROUND

Given that the temporal bone is one of the most complex regions of the human body, cadaveric dissection of this anatomical area represents the first necessary step for the learning and training of the young oto-surgeon in order to perform middle ear surgery, which includes the management of inflammatory pathology, hearing rehabilitation, and also cognitive decline prevention surgery. The primary objective of this study was to identify common mistakes and critical passages during the initial steps of temporal bone dissection, specifically cortical mastoidectomy and posterior tympanotomy.

METHODS

A survey among 100 ENT residents was conducted, gathering insights into the most prevalent errors encountered during their training to uncover the most challenging aspects faced by novice surgeons during these procedures.

RESULTS

The most common mistakes included opening the dura of the middle cranial fossa (MCF), injury of the sigmoid sinus (SS), chorda tympani (CT), and facial nerve (FN) injury while performing the posterior tympanotomy. The most important critical steps to prevent mistakes are related to the absence of wide exposure during cortical mastoidectomy and the consequent impossibility of identifying the landmarks of the facial recess before performing posterior tympanotomy. Injury of these structures was more common in younger surgeons and in the ones who performed less than five temporal bone dissection courses.

CONCLUSIONS

Numerous temporal bone dissections on cadavers are mandatory for ENT residents looking forward to performing middle ear surgery.

Subtotal Petrosectomy: Pictorial Review of Clinical Indications and Surgical Approach

Subtotal petrosectomy (STP) is characterized by obliteration of the middle ear and occlusion of the external auditory canal. The advent of the endoscope has allowed a reduction in morbidity for some conditions such as cholesteatoma and other middle ear disorders, but STP still plays an important role. A retrospective review of medical records and videos of patients who had undergone STP was performed. Perioperative data and images were collected from various clinical cases who had undergone subtotal petrosectomy at our tertiary referral university hospital in Verona. We confronted our experience with a review of the literature to present the main indications for this type of procedure. STP allows a variety of diseases to be managed effectively as it offers the possibility of a definitive healing with radical clearance of temporal bone. Moreover, it can be safely combined with other procedures with a very low complication rate. Although the endoscope represents a revolution in ear surgery, STP, when indicated, is nowadays a surgical option that should be included in the otosurgeon's portfolio.

Transcanal Endoscopic Management of Middle Ear Paragangliomas

OBJECTIVE

To evaluate the clinical and audiological outcomes of transcanal endoscopic resection of middle ear paragangliomas.

STUDY DESIGN

Retrospective multicenter study.

SETTING

Tertiary referral center and private otology clinic.

PATIENTS

Patients who underwent transcanal endoscopic surgery between January 2015 and September 2020.

INTERVENTIONS

Transcanal endocope-assisted resection of middle ear paragangliomas.

MAIN OUTCOME MEASURES

Demographic data.

RESULTS

Twenty-three patients (2 men, 21 women) with a mean (standard deviation [SD]) age of 50.5 (11.8) years and stage 1 or 2 disease were included in the study. The mean follow-up time was 2.7 years (range, 1-5 yr). Preoperatively, the mean (SD) air-conduction threshold was 33.8 (17.9) dB, and the mean (SD) air-bone gap was 13.1 (13.9) dB. Postoperatively, the mean (SD) air-conduction threshold was 25.7 (10.2) dB, the mean (SD) air-bone gap was 6.3 (6.1) dB. The mean (SD) hospital stay was 27.7 (9.9) hours. No tumor regrowth was detected on magnetic resonance imaging during postoperative follow-up.

CONCLUSIONS

Endoscopic transcanal tumor resection is effective and feasible in the treatment of stage 1 and 2 tumors and is associated with short operative time, low risk of perioperative and postoperative complications, and rapid discharge.

Comparison of surgical outcomes between early and advanced class of jugular paragangliomas following application of our modified surgical techniques

To compare the safety and effectiveness of surgical treatment of jugular paragangliomas (JPs) following the application of our modified surgical techniques. Fifty-six patients with JPs were analyzed for tumor classification, surgical outcomes, and intratumor blood vessels. The gross total resection in C1-2 (100%) was significantly greater than that in C3 and D (66.7%). Good postoperative facial nerve (FN) function (House-Brackmann I-II) was achieved in 89.5% C1-2 cases, which was not significantly different from C3 and D (93.3%) (P = 0.694). Preoperative and postoperative lower cranial nerve (LCN) deficits correlated with the Fisch's classification of tumors (P < 0.05), and intraoperative blood loss was greater in advanced tumors (P = 0.050). Further study showed that the cross-sectional area of intratumor blood vessels was positively associated with intraoperative blood loss (P < 0.001). Surgical excision of JPs is a safe and effective strategy, and early surgical treatment is a good option for patients with C1-2 tumors without surgical contraindications.

Comparison of Lower Cranial Nerve Function Between Tympanojugular Paraganglioma Class C1/C2 With and Without Intracranial Extension: A Four-Decade Experience

OBJECTIVE

To compare preoperative and postoperative lower cranial nerve (LCN) function between Class C1 and C2 tympanojugular paraganglioma (TJP) with/without intracranial intradural (Di)/extradural (De) extensions, according to the experience of a single surgeon over four decades.

STUDY DESIGN

Retrospective review.

SETTING

Quaternary referral center for otology and skull base surgery.

MATERIAL AND METHODS

A chart review was conducted of all the patients operated for C1/C2 TJPs from September 1983 to December 2018. The tumors were classified as: Limited-Group (C1/C2 without Di/De extensions) and Extended-Group (C1/C2 with Di/De extensions).

RESULTS

Of 159 patients, 107 (67.3%) were women; the mean age at surgery was 46.5 years. The Limited-Group (56.6%) comprised C1 (41.1%) and C2 (58.9%) tumors; the Extended-Group (43.4%) comprised C1+Di/De (14.5%) and C2+Di/De (85.5%) tumors. The prevalence of preoperative LCN palsy was 11.9 times higher in Extended than Limited tumors: 61.9% versus 4.9% (p < 0.05). The risk for postoperative LCN palsy was 4.7 times greater in Extended than Limited tumors: 29.2% versus 12.9%, p = 0.01.

CONCLUSION

Especially in younger patients, complete removal of Limited C1/C2 tumors, before they extend intracranially, reduces the risk of dysfunctionality of LCNs and the burden of residual tumor. The incidence of new tumors increased over four decades. However, new-postoperative LCN palsy did not occur in any Limited C1/C2 tumors operated after the year 2000, and declined to less than 10% of Extended C1/C2 tumors.

Vertigo as the sole complaint of tympanomastoid paraganglioma

Background

Tympanomastoid paragangliomas are usually benign, slowly growing, painless tumors. The common presenting symptoms of this tumor are pulsatile tinnitus and conductive hearing loss. Vertigo as the cardinal or initial symptom is extremely are, especially in the early stages of the disease.

Case presentation

A 53-year-old female patient presented only with intermittent recurrent vertigo and was later found to have a tympanomastoid paraganglioma. Her symptoms disappeared completely after resection of the tumor. This is the first report in literature of a case of tympanomastoid paraganglioma with vertigo as the single symptom.

Conclusion

The tympanomastoid paraganglioma is rare and its clinical symptoms are nonspecific, so it is easy to be misdiagnosed or missed. It is worth noting that although clinically uncommon, vertigo can also be the first or sole symptom of tympanomastoid paraganglioma. Detailed physical examination and imaging examination of the ear are necessary and should be carried out meticulously.

Temporal Bone Paraganglioma: Hearing Outcomes and Rehabilitation

Despite numerous advancements in the treatment of skull base tumors, the management of jugular paragangliomas remains controversial and nuanced. Contemporary treatment objectives focus not only on achieving durable tumor control but also on maximizing post-treatment quality of life. While this philosophy places appropriate attention on limiting cranial neuropathies, less discussed morbidities such as hearing loss can have a profound impact on quality of life outcomes. The objective of this retrospective review is to provide a comprehensive review of hearing outcomes following the treatment of tympanojugular paragangliomas. A particular focus is placed on the variable audiologic outcomes as it relates to disease pathology, extent of disease, as well as chosen treatment modality. This review underscores the importance of considering treatment-related effects on hearing.