Anatomy involved in the jugular foramen approach for jugulotympanic paraganglioma resection

[Simultaneous occurrence of facial neurinoma in internal auditory canal and middle ear paraganglioma in patient. Unusual combination and difficult surgical task]

CLINICAL CASE

The 59-year-old patient complained of hearing loss on the left, ear murmur for a long time, periodic pain and discomfort in the left ear, dizziness for 6 months. She was found to have concurrent vestibular schwannoma in the internal auditory canal and temporal bone paraganglioma. Both tumors were removed in one operation. The schwannoma was removed by translabirinth access due to preoperative deafness, while the glomus tumor was removed during this access. Postoperative biopsy showed the presence of two unrelated diseases: paraganglioma (ICD-0 code 8690/3) and schwannoma (ICD-0 code 9560/0).

Jugulotympanic paragangliomas in southern Finland: a 40-year experience suggests individualized surgical management

Treatment of jugulotympanic paragangliomas (JTPGLs) remains challenging with no clear guidelines for management or follow-up. The aim of this retrospective case-note study was to assess long-term results of operatively and conservatively managed JTPGLs between years 1974-2013. A total of 36 patients with JTPGLs were identified. Clinical characteristics and management outcomes of patients were reviewed. Data were extracted on demographics, symptoms, timing of diagnosis, tumor location and size, embolization, and management, including pre- and post-operative imaging, analysis of operative techniques, and follow-up. Pulsatile tinnitus and hearing loss were the most common presenting symptoms. Thirty-four (94 %) patients were treated with primary surgical therapy and two (6 %) with radiotherapy. The surgical approaches included endaural approach for Fisch Class A tumors and a variety of approaches for Fisch Class B-D tumors with an increasing predilection for function-preserving surgery. Eight (24 %) patients received subtotal resection. Five (15 %) patients had a local recurrence within 10 years after primary surgery. Two (6 %) patients suffered a permanent cranial nerve (CN) deficit after primary surgery. We advocate radical surgery when tumor resection is possible without compromising CNs. Function-preserving surgery with at least a 10-year follow-up for Fisch Class B-D tumors should be considered if CNs are in danger.

Surgical Approaches to the Jugular Foramen: A Comprehensive Review

Introduction Multiple surgical approaches and combinations thereof have been described to gain access to the jugular foramen. In an area laden with important neurovascular structures, care must be taken in choosing the best surgical approach for treatment of rare pathologies involving this region. Methods This manuscript provides a comprehensive review of the relevant anatomy along with an overview of the various approaches to the jugular foramen. In an attempt to simplify the various concepts, we propose a basic distinction into anterolateral and posterolateral approaches based on the main trajectory targeting the jugular foramen. Conclusion The anatomy surrounding the jugular foramen is exceedingly complex and requires in-depth understanding of skull base and head and neck relationships.

Fibrin Sealant Injection: An Aid to Reduce Venous Bleeding during Jugular Bulb and Sigmoid Sinus Dissection in Glomus Jugulare (Jugulotympanic Paraganglioma) Surgery

Glomus jugulare (jugulotympanic paraganglioma) surgery requires tumor dissection in the region of the jugular bulb, upper internal jugular vein, and sigmoid sinus. Despite ligation or external compression of the sigmoid sinus proximally and ligation of the internal jugular vein distally, troublesome venous bleeding can arise from the inferior petrosal sinus or condylar veins at the medial wall of the jugular bulb. Excessive packing in this area can place the integrity of the lower cranial nerves at risk. We report a technique in which Tisseel(®) fibrin sealant is injected into the ligated sigmoid sinus and internal jugular vein. This forms an internal cast around the tumor in the sigmoid-jugular complex and helps seal the inferior petrosal sinus and condylar veins. This allows for safer dissection with reduced venous bleeding. Our experience in five cases has shown this technique to be effective.

The Juxtacondylar Approach to the Jugular Foramen

Objective:

We sought to describe the juxtacondylar approach to jugular foramen tumors.

Methods:

Through an anterolateral approach, the third segment of the vertebral artery (between C2 and the dura mater) is controlled. The C1 transverse process of the atlas, which is located just inferiorly to the jugular foramen, is then removed. The dissection of the internal jugular vein is performed as high as possible, with control of the IXth, Xth, XIth, and XIIth cranial nerves. If required by a tumor extending into the neck, the internal and external carotid arteries can be exposed and controlled. Through a partial mastoidectomy and after removal of the bone covering the jugular tubercle, the end of the sigmoid sinus and then the posteroinferior part of the jugular foramen are reached.

RESULTS:

This technique is efficient to expose tumors extending into the jugular foramen. Contrary to the infratemporal approach, it has the main advantage of avoiding petrous bone drilling and associated potential complications. Lower cranial nerves are well exposed in the neck. In patients with schwannomas, complete resection with selective dividing of only the few involved rootlets can be achieved.

Conclusion:

The juxtacondylar approach is an efficient approach to tumors located in the jugular foramen. It necessitates control of the third segment of the vertebral artery but has the advantage of avoiding complications associated with petrous bone drilling. Extension beyond the jugular foramen requires combination with an infratemporal or a retrosigmoid approach.

Benign mass lesions deep inside the temporal bone: imaging diagnosis for proper management

CONCLUSION

Among mass lesions inside the temporal bone, benign tumors and cholesteatomas can be differentiated by contrast enhancement in T1-weighted images (T1WI) and by diffusion-weighted images (DWI). Moreover, DWI will also facilitate discrimination between cholesteatomas accompanied by granulation and other non-neoplastic lesions such as mucoceles and cholesterol granulomas.

OBJECTIVES

To review the imaging characteristics of mass lesions inside the temporal bone and to investigate pertinent imaging modalities for differential diagnosis, which is crucial for appropriate treatment planning.

PATIENTS AND METHODS

This was a retrospective case series study of six patients seen between 2002 and 2005 with mass lesions deep inside the temporal bone.

RESULTS

One patient had facial schwannoma, two had glomus jugulare tumor, and three had cholesteatoma. Plain high resolution CT gave few clues to the nature of the mass lesions. MRI study provided us with better clues: contrast enhancement on T1WI was observed only in benign tumors and only cholesteatomas showed high intensity on DWI. With the assistance of neurosurgeons, surgery was successfully performed in all cases.