Metastatic Malignant Glomus Jugulare Tumor: A Rare Case Report with Clinical Manifestations and Treatment Approach

BACKGROUND Paragangliomas are neuroendocrine neoplasms derived from paraganglia of the sympathetic and parasympathetic nervous systems. Parasympathetic ganglia-derived tumors, also called non-chromaffin, are located almost exclusively in the neck and skull base and are usually non-secretory and inactive. A case of malignant glomus jugulare with a metastatic cervical lymph node is described here. CASE REPORT A 24-year-old woman was referred to an otolaryngology clinic for concern of voice change for 1 month, which was associated with right progressive hearing loss, pulsating tinnitus, and right facial weakness. A clinical examination revealed a reddish mass in the right ear behind an intact tympanic membrane with right facial weakness of House-Brackmann grade VI. A bedside flexible nasopharyngoscopy revealed an immobile right vocal fold. A computed tomography scan of the brain revealed a destructive lesion within the right jugular foramen. The patient underwent embolization followed by glomus tumor resection via infra-temporal fossa with Fisch type A approach. Pathology revealed that the tumor was an infiltrative epithelioid tumor with a spindle and nesting pattern separated by fibrovascular stroma. The submitted lateral neck lymph node revealed a metastatic tumor. CONCLUSIONS Glomus jugulare tumors are uncommon paragangliomas, and malignant behavior with metastasis is extremely rare. Metastatic tumors are often associated with facial and vagal nerves palsy. There are no histological features that distinguish malignant glomus jugulare tumors. Malignant neoplasms are characterized by the presence of metastases. Tumors of the glomus jugulare that are malignant are treated with surgery, radiotherapy, or both. However, our search of the literature revealed no clear guidelines, given the scarcity of cases. Moreover, the presence of metastasis increases the risk of death.

Evaluation of linear accelerator-based stereotactic radiosurgery in the management of glomus jugulare tumors

AIMS AND BACKGROUND

Although mostly benign and slow-growing, glomus jugulare tumors have a high propensity for local invasion of adjacent vascular structures, lower cranial nerves and the inner ear, which may result in substantial morbidity and even mortality. Treatment strategies for glomus jugulare tumors include surgery, preoperative embolization followed by surgical resection, conventionally fractionated external beam radiotherapy, radiosurgery in the form of stereotactic radiosurgery or fractionated stereotactic radiation therapy, and combinations of these modalities. In the present study, we evaluate the use of linear accelerator (LINAC)-based stereotactic radiosurgery in the management of glomus jugulare tumors and report our 15-year single center experience.

METHODS AND STUDY DESIGN

Between May 1998 and May 2013, 21 patients (15 females, 6 males) with glomus jugulare tumors were treated using LINAC-based stereotactic radiosurgery at the Department of Radiation Oncology, Gulhane Military Medical Academy. The indication for stereotactic radiosurgery was the presence of residual or recurrent tumor after surgery for 5 patients, whereas 16 patients having growing tumors with symptoms received stereotactic radiosurgery as the primary treatment.

RESULTS

Median follow-up was 49 months (range, 3-98). Median age was 55 years (range, 24-77). Of the 21 lesions treated, 13 (61.9%) were left-sided and 8 (38.1%) were right-sided. Median dose was 15 Gy (range, 10-20) prescribed to the 85%-100% isodose line encompassing the target volume. Local control defined as either tumor shrinkage or the absence of tumor growth on periodical follow-up neuroimaging was 100%.

CONCLUSIONS

LINAC-based stereotactic radiosurgery offers a safe and efficacious management strategy for glomus jugulare tumors by providing excellent tumor growth control with few complications.

[Diagnosis and management of jugulare glomus tumor and carotid body tumor]

OBJECTIVE

To investigate diagnosis method and treatment experience of jugulare glomus tumor (JGT) and carotid body tumor (CBT).

METHOD

Retrospective analysis. Clinical materials from 4 patients at one genealogy with JGT and CBT were collected. The clinical features, radiological characteristics, surgical methods and prognosis were assessed. The proband suffered from left JGT and left CBT, her younger sister had right CBT as well as her younger female cousin had bilateral CBT and right JGT, her older male cousin had bilateral CBT and left JGT. These JGT and CBT in four patients were resected under general anesthesia after preoperative ultrasound, CT or CT angiography (CTA), MRI, and digital subtraction angiography (DSA) examination as well as preoperative vascular embolization.

RESULT

The surgery was uneventful in four cases, and there was no hemiplegia or deaths. All patients were followed up for 2 years to 29 months without recurrence. Six months after operation, the hoarseness also disappeared in the older male cousins but did not improve significantly in younger female cousin. The younger female cousin get right peripheral facial paralysis 1 year after surgery and her temporal bone CT indicated a right JGT.

CONCLUSION

It is very important to assess JGT and CBT by Ultrasound, CT, CTA, MRI and DSA. Surgical resection is the first optional treatment for JGT and CBT. Blood loss can be reduced by preop erative vascular embolization. Serious complications could be avoid by operating under microscope, which can supply a clear surgical field and make the surgeon to protect the large blood vessels and nerve.

Paraganglioma presenting as cholesterol granuloma of the petrous apex

We report the unique finding of a petrous apex cholesterol granuloma associated with a paraganglioma, also known as a glomus jugulare tumor, in a 52-year-old woman who presented to our department with pulsatile tinnitus, hearing loss, aural fullness, and disequilibrium. She had been treated for a petrous apex cholesterol granuloma 20 years earlier, at which time she had undergone drainage of the granuloma via subtotal petrous apicectomy. When she came to our facility approximately 20 years later, she had signs and symptoms consistent with a jugular paraganglioma, which was likely to have been present at the time of her initial presentation for the cholesterol granuloma. In fact, microscopic bleeding from the paraganglioma might have led to the formation of the cholesterol granuloma. The metachronous presentation of these two entities, which to our knowledge has not been reported previously in the literature, indicates the potential association of paragangliomas with the formation of cholesterol granulomas of the petrous apex.

Collet-Sicard syndrome secondary to a large glomus jugulotympanicum

Collet-Sicard syndrome is caused by various neoplastic and non-neoplastic lesions affecting the base of the skull with involvement of IX, X, XI and XII cranial nerves. Paraganglioma accounts for < 1% of all the neoplasms in the head and neck region. They are traditionally considered as benign, slow growing, locally invasive, encapsulated and highly vascular tumors. We report a case of Collet-Sicard syndrome secondary to a large glomus jugulotympanicum in a 45-year-old woman who presented to the emergency department with complaints of recurrent episodes of a fresh bleeding from the left ear for the previous 5 days. She had pain and decreased hearing for the last 3 years and features of multiple cranial nerve palsies. A radiological diagnosis of glomus jugulotympanicum (paraganglioma) was made, which was confirmed by the biopsy tissue. At 6-month follow up, episodes of recurrent bleeding had stopped, but cranial nerve palsies persisted.

Glomus jugulare: a rare cause of facial nerve palsy

PURPOSE

To report a case of an unusual presentation of a glomus jugulare tumour.

DESIGN

Case report.

RESULTS

Glomus jugulare is a very rare brain tumour that usually presents with tinnitus, hearing loss, dysphagia and hoarseness. We report a case where this extremely rare diagnosis presented quite differently, with ipsilateral proptosis and subsequent facial nerve palsy. Furthermore, the sibling of the presented case had also been diagnosed with the same tumour.

CONCLUSIONS

There have only been a few case reports in the literature describing facial nerve palsy in the context of a glomus jugulare tumour. This case highlights that although paragangliomas are exceedingly rare causes of facial palsy, they should be included in the differential diagnosis.

The presentation and management of multiple paraganglioma in head and neck

OBJECTIVE

We report the presentation and management of an 18-year-old male, who presented with bilateral carotid body paragangliomas and a unilateral jugular body paraganglioma.

METHOD

A comprehensive review of the medical literature concerning paragangliomas in the pediatric and adult population is discussed.

RESULTS

Presentations of multiple paragangliomas in an 18-year-old have never been described.

CONCLUSION

This is the first case of multiple paragangliomas in a 18-year-old male, who was treated with embolisation and surgical resection and remains disease free 2 years from surgery.

Glomus jugulare tumours: certain clinical and radiological aspects observed following Gamma Knife radiosurgery

INTRODUCTION

Glomus jugulare tumours represent a great therapeutic challenge. Previous papers have documented good results from Gamma Knife surgery (GKS) with these tumours. However, the relationship between clinical improvement and tumour shrinkage has never been assessed.

MATERIALS AND METHODS

There were 14 patients, 9 women and 5 men. The mean follow-up period was 28 months (range 6 to 60 months). All the tumours except one were Fisch type D and the mean volume was 14.2 cm(3) (range 3.7-28.4 cm(3)). The mean prescription dose was 13.6 Gy (range 12-16 Gy).

RESULTS

None of the tumours have continued to grow. Eight are smaller and 6 unchanged in volume. Two patients with bruit have had no improvement in their symptoms. Among the other 12 patients, 5 have had symptomatic improvement of dysphagia, 4 in dysphonia, 3 in facial numbness, 3 in ataxia and 2 in tinnitus. Individual patients have experienced improvement in vomiting, vertigo, tongue fasciculation, hearing, headache, facial palsy and accessory paresis. One patient developed a transient facial palsy. Symptomatic improvement commonly began before any reduction in tumour volume could be detected. The mean time to clinical improvement was 6.5 months whereas the mean time to shrinkage was 13.5 months.

CONCLUSIONS

Gamma Knife treatment of glomus jugulare tumours is associated with a high incidence of clinical improvement with few complications, using the dosimetry recorded here. Clinical improvement would seem to be a more sensitive early indicator of therapeutic success than radiological volume reduction. Further follow-up will be needed.

Jugular foramen schwannoma--a very rare entity

Jugular foramen schwannoma is a very rare tumour and very few cases have been reported in the literature. Usually it is misdiagnosed as acoustic neuroma and the diagnosis is made peroperatively. It has significant neurological morbidity and mortality. In addition to the experience and expertise of the surgeon, introduction of better anaesthesia and microsurgical techniques have significantly reduced the morbidity and mortality. We present a case of jugular foramen schwannoma who was operated by the senior author. The outcome was very good and the patient recovered without any permanent deficits. The epidemiology, pathophysiology, clinical features, radiographic findings and treatment of this rare entity are reviewed.

[Glomus tumor with diplopia]

This paper highlights the case of a 46-year-old female patient who seeks ophthalmic medical advice for her complaint about double vision on right gaze. Patient's medical history reveals several symptoms like headaches, progressive hearing loss on right side and dysphonia for which all investigations proved irrelevant. Thourough clinical examination, lab exams and imaging techniques revealed the cause for this symptoms i.e. glomic tumour with middle ear extention. We find this case to be exceptional as ocular symptoms led to the diagnose of a non-ocular serious, possible life threatening condition, bearing in mind that previously occured non-ocular symptoms couldn't elucidate the cause.

[Digital subtraction angiography on glomus jugularis tumors]

OBJECTIVE

To analysis the effectiveness of preoperative digital subtraction angiography (DSA) on glomus jugularis tumors.

METHODS

A retrospective study of 14 cases of glomus jugularis tumors which received preoperative DSA was carried out. Among them, 10 cases were accepted balloon occlusion test and selective embolization of supplied vessels.

RESULTS

Hypervascular changes was found in all 14 cases and compression of internal carotid artery was found in 5 cases. Ascending pharyngeal artery was the main supplied vessel. Balloon occlusion test was applied in 10 cases, 2 were intolerable and 8 were passed occlusion test. Ten cases were accepted embolizations and tumor blood supply was conspicuous decreased. Neurovascular complications did not occurred after DSA but postoperatively in 2 cases. Intraoperative bleeding was less in embolization patients than that of without embolization.

CONCLUSIONS

Preoperative DSA association with balloon occlusion test and embolizations might be a safe option on surgery of glomus jugularis tumors.

Fractionated stereotactic radiotherapy of glomus jugulare tumors. Local control, toxicity, symptomatology, and quality of life

BACKGROUND AND PURPOSE

For glomus jugulare tumors, the goal of treatment is microsurgical excision. To minimize postoperative neurologic deficits, stereotactic radiosurgery (SRS) was performed as an alternative treatment option. Stereotactic fractionated radiotherapy (SRT) could be a further alternative. This study aims at the assessment of local control, side effects, and quality of life (QoL).

PATIENTS AND METHODS

Between 1999-2005, 17 patients were treated with SRT. 11/17 underwent previous operations. 6/17 received primary SRT. Treatment was delivered by a linear accelerator with 6-MV photons. Median cumulative dose was 57.0 Gy. Local control, radiologic regression, toxicity, and symptomatology were evaluated half-yearly by clinical examination and MRI scans. QoL was assessed by Short Form-36 (SF-36).

RESULTS

Median follow-up was 40 months. Freedom from progression and overall survival for 5 years were 100% and 93.8%. Radiologic regression was seen in 5/16 cases, 11/16 patients were stable. Median tumor shrinkage was 17.9% (p=0.14). Severe acute toxicity (grade 3-4) or any late toxicity was never seen. Main symptoms improved in 9/16 patients, 7/16 were stable. QoL was not affected in patients receiving primary SRT.

CONCLUSION

SRT offers an additional treatment option of high efficacy with less side effects, especially in cases of large tumors, morbidity, or recurrences after incomplete resections.

Lipomatous hemangiopericytoma of the skull base and parapharyngeal space

OBJECTIVE

To discuss the diagnosis and clinical management of lipomatous hemangiopericytoma.

STUDY DESIGN

Case report.

SETTING

Tertiary referral center.

PATIENT

A 36-year-old woman was encountered with symptoms of facial numbness, blurred vision, headache, and lightheadedness of 6 weeks' duration. Magnetic resonance imaging revealed a 5.0-cm mass in the right parapharyngeal space and skull base extending inferiorly to the level of the carotid bifurcation. The mass was consistent radiographically with a glomus jugulare tumor, and surgical extirpation was performed.

INTERVENTION

The patient underwent a transtemporal approach to the right posterior fossa and jugular foramen including mastoidectomy and isolation and preservation of Cranial Nerves VII, X, XI, and XII. Microscopic analysis of the mass revealed a highly cellular spindled mesenchymal tumor with a pericytoma pattern. Almost half of the mass displayed a mature lipomatous component. These findings were consistent with a lipomatous hemangiopericytoma.

RESULTS

The authors describe the first case of lipomatous hemangiopericytoma involving the skull base. This rare variant of the more common hemangiopericytoma has been described previously in the retroperitoneal and lower extremities. Although one case of lipomatous hemangiopericytoma has been described in the occipital region, this is the first report of this entity involving the parapharyngeal space, skull base, and jugular foramen.

CONCLUSION

The authors demonstrate that lipomatous hemangiopericytoma can occur in the parapharyngeal space and skull base. Once thought to be an aggressive variant, this tumor has an extremely low propensity for distant or local recurrence. Adjuvant therapies such as radiation and chemotherapeutic agents are reserved for recurrent or metastatic lesions.

[Multiple paragangliomas: about two cases]

The multiple paragangliomas are rare tumours, with slow evolution, posing diagnostic and therapeutic problems. The carotid and jugulo-tympanic localization are the most frequent, and the aortic localization is very infrequent. The association of two, three and four localization is possible in the multiple forms. These multiple localizations are more frequent in familial forms. Surgical removal is the first intention treatment of these tumours. In the multiple forms, the therapeutic strategy must be adapted to each case: usually, the intervention begins by the carotid localization. We report two cases of chemodectoma with multiple localizations. The first case is a 44 years-old woman, who presented a double localization: carotid (bilateral) and aortic (arch). The second case is a patient with a double aortic localization, carotid and aortic, associated to a tympano-jugular localization. Surgical treatment was performed for all these localization, except for the tympano-jugular localization, treated by embolization. The post-operative periods were uneventful. The first case had adjunctive radiotherapy.

Angiomatous type of jugular foramen meningioma with neck extension: differential diagnosis from paraganglioma and schwannoma

BACKGROUND

Meningiomas involving the jugular foramen and parapharyngeal space are extremely rare. They most commonly occur intracranially and then extend to the extracranial region through the foramen of the skull base, such as jugular foramen. Clinically, these tumors mimic the more common glomus jugulare tumor. Preoperative diagnosis can be correct on the basis of the characteristic imaging findings.

METHODS

A 52-year-old woman was seen with a left neck mass and mixed-type hearing loss. She underwent physical examination, MRI, high-resolution CT, and angiography.

RESULTS

Physical examination revealed a retro-tympanic, pulsatile red mass in the left ear, and mild bulging of the left oropharyngeal wall. The patient was found to have the spreading, carpet-like, meningioma with extracranial extensions via jugular foramen to parapharyngeal space. Preoperative imaging strategy allowing accurate preoperative diagnosis is discussed.

CONCLUSIONS

Accurate distinction between meningioma and glomus tumor or schwannoma is possible in most cases, with attention to fine radiologic detail.

Brain Tumour Foundation Award 2007. Glomus jugulare tumours: are they really so benign?

Glomus jugulare tumours are rare, hypervascular and usually benign tumours involving the skull base. Diagnosis can be significantly delayed due to the slow and insidious clinical presentation. The primary manifestations involve auditory and lower cranial nerve deficits. Treatment options may include surgery, radiation and embolization. Surgery is the optimal treatment modality, but is not without serious potential complications. These complications are linked to the location and vascular nature of the tumour. Glomus jugulare tumours present a significant diagnostic and management challenge to all members of the health care team.

GAMMA KNIFE RADIOSURGERY FORGLOMUS JUGULARE TUMORS

OBJECTIVE

Stereotactic radiosurgery has been used increasingly for the treatment of glomus jugulare tumors. The authors report their experience treating these tumors using gamma knife radiosurgery (GKRS), documenting the clinical and radiological outcome.

METHODS

A retrospective analysis identified 17 patients with glomus jugulare tumors who underwent GKRS. Besides analysis of clinical outcome, a radiological volumetric analysis was also performed after treatment.

RESULTS

There were 15 women and two men (average age, 63.1 yr) with a median follow-up period of 48 months. The median radiosurgical dose to the tumor margin was 15 Gy (range, 13–18 Gy). Eight patients (47.1%) improved clinically, two (11.8%) worsened, and seven (41.2%) were unchanged. No relationship between internal auditory canal dose and hearing loss was recorded. Tinnitus and otalgia were the symptoms that responded most favorably to GKRS. No patients experienced new lower cranial nerve palsies after GKRS. Tumor volume showed a transient increase in seven patients. Analysis of tumor volume at the time of the last magnetic resonance imaging scan recorded a decrease in eight patients, an increase in four patients, and no change in five patients.

CONCLUSION

GKRS is a safe, effective treatment for glomus jugulare tumors, particularly in patients with preserved glossopharyngeal and vagus nerve function, after surgical recurrence, in the elderly, and in patients with serious preexisting medical conditions. Longer follow-up periods are required to assess long-term effects.

Tumors of the jugular foramen: diagnosis and management

OBJECTIVE

Jugular foramen tumors are rare cranial base lesions that present diagnostic and management difficulties. With the availability of new diagnostic procedures these tumors have been more precisely studied and questions of whether, when, and how these lesions should be treated often arise. Data from 106 consecutive patients surgically treated in the past 17 years were retrospectively analyzed to identify surgical outcomes.

METHODS

The tumors were approached by a multidisciplinary team composed of neurosurgeons, ear, nose, and throat surgeons, and neuroradiologists. Hypervascular lesions were embolized 3 to 5 days before surgery. The same surgical technique was used to resect all tumors. The surgical defect was covered with vascularized myofascial flaps. The internal carotid artery was infiltrated in two patients, and a saphenous graft bypass was carried out before removal of the lesions. The facial nerve was reconstructed with nerve grafts (great auricular nerve) or XII/VII anastomosis in five cases. Postoperative radiotherapy was carried out for malignant and invasive tumors.

RESULTS

Paragangliomas were the most frequent lesions, followed by schwannomas and meningiomas. Complete excision was possible in 89% of benign tumors and 80% of paragangliomas. Lower cranial nerve deficit was the most frequent complication (10 patients, 9.4%), transient in 4 patients. Facial and cochlear nerve paralysis occurred in 8 patients (7.5%). The function of the facial nerve recovered spontaneously in 3 patients. Four patients (3.7%) developed postoperative cerebrospinal fluid leakage. Four patients (3.7%) died after surgery.

CONCLUSION

Radical removal of benign jugular foramen tumors is the treatment of choice and may be curative. Large lesions can be radically excised in one surgical procedure with preservation of lower cranial nerves. Cranial base reconstruction with vascularized myofascial flaps reduces the incidence of postoperative cerebrospinal fluid leakage. Damage of the lower cranial nerves is the most serious surgical complication.

Management of cervical paragangliomas: review of a 15-year experience

BACKGROUND AND AIMS

Cervical paragangliomas are highly vascular neoplasms and should be considered in the evaluation of all lateral neck masses. The aim of this study is to review an institutional experience in the management of these tumors.

MATERIALS AND METHODS

Thirteen patients with 14 paragangliomas were treated in our institution during a period of 15 years. There were eight women (61.5%) and five men (38.5%) with a mean age of 41.3+/-15 years. A painless lateral neck mass was the main finding in 69.2% of patients. There was no evidence of a functional tumor. Carotid angiography was performed in all patients to define the vascular anatomy of the lesion. The 78.6% of paragangliomas underwent selective embolization of the major feeding arteries. Surgical resection followed within the next 48 h.

RESULTS

The majority of the lesions were paragangliomas of the carotid bifurcation (85.7%), while one patient was diagnosed with a jugular and one with a vagal paraganglioma. In one patient, bilateral paragangliomas in the carotid bifurcation were detected. There was no evidence of malignancy in any case. Preoperative embolization has proven successful in reducing tumor vascularity. Vascular reconstruction was necessary in one patient. The main postoperative complication was transient cranial nerve deficit in seven (53.8%) patients, and a permanent Horner's syndrome was documented in one patient. No stroke occurred. The jugular paraganglioma was treated with irradiation due to skull base extension with significant symptomatic relief.

CONCLUSION

Combined therapeutic approach with preoperative selective embolization followed by surgical resection by an experienced team offers a safe and effective method for complete excision of the tumors with a reduced morbidity rate.

Surgical Removal of Jugular Paragangliomas After Stenting of the Intratemporal Internal Carotid Artery: A Preliminary Report

OBJECTIVE

Jugular paragangliomas with extensive involvement of the internal carotid artery (ICA) represent a true challenge for surgeons, especially in the presence of inadequate collateral circulation through the circle of Willis. The aim of our study is to present a preliminary report of our experience with the surgical removal of three such cases using the stenting of the ICA as the method of choice for protecting and preserving the integrity of the artery.

METHODS

This retrospective study was conducted at Gruppo Otologico, a private referral center for neurotology and skull base surgery. The subjects of our study are three cases of jugular paragangliomas with extensive involvement of the ICA and inadequate collateral circulation. These cases are the first three cases operated at our center after stenting of the intratemporal portion of the ICA.

RESULTS

Complete surgical removal of the tumor, including the part involving the ICA, was achieved in all cases. Over a follow-up period of 22 to 30 months, no complications occurred and the patency of the stented arteries was preserved.

CONCLUSION

Although more follow-up is still needed before establishing the exact long-term outcome of stenting the intratemporal ICA, our preliminary report shows that the stent has facilitated the complete surgical removal of the tumor, preserving the integrity of the ICA.

Short-term tumor control and acute toxicity after stereotactic radiosurgery for glomus jugulare tumors

OBJECTIVE

Glomus jugulare tumors (GJT) have traditionally been treated by surgery or fractionated external beam radiation therapy (XRT). This study evaluates acute toxicity and short-term efficacy of single-fraction stereotactic radiosurgery (SRS) for the treatment of GJT.

STUDY DESIGN AND SETTING

Eight patients (age range 28-74) with GJT underwent SRS (Brainlab linear accelerator) as primary treatment. A nominal dose of 15-16 Gy was prescribed.

RESULTS

After undergoing SRS, 7 of 8 patients (87.5%) reported complete resolution of presenting symptoms. Follow-up MRIs showed tumor stabilization in 100% of patients. Transient vertigo occurred in one patient. One patient suffered acute GI upset and transient lower cranial neuropathy.

CONCLUSION

Stereotactic radiosurgery is an effective alternative for patients with GJT in achieving tumor control and resolution of symptoms.

EBM RATING

C-4.

[Paralysis of vocal fold as the first symptom of Vernet's syndrome in the course of jugular chemodectoma]

INTRODUCTION

Chemodectomas are relatively frequent tumors of the head and neck but their diagnosis in consideration of the slow growth is difficult. The aim of this study is pointing out of the attention on: (1) non-typical beginning of ill and diagnostic difficulties leading to delaying of putting the proper diagnosis, (2) symptoms which are cause of notifying the patient to the doctors of different specializations e.g. the laryngologist and the neurologist.

MATERIAL AND METHODS

The case of 72-year-old man with the paraganglioma situated near to the foramen of the jugular vein is discribed. Clinical symptoms, giving at last typical picture of Vernet's syndrome, the diagnostic procedure as well as treatment of the entity are discussed in the report.

CONCLUSIONS

(1) In cases of paralysis of any cranial nerve is necessary close cooperation among a laryngologist and a neurologist. (2) In idiopathical paralysis of the vocal fold, changes runing near by the internal jugular vein's foramen should be taken into account. (3) The computer scanning of skull's bases and angiograpy are the most useful in the differential diagnostics. (4) The radiotherapy allow to obtain good therapeutic's results especially in persons stricken in years.

[Glomus caroticum, jugulare and vagale--problems in diagnosis and treatment]

INTRODUCTION

The paraganglia tissue in 80% is located in suprarenal glands. The rest (20%) are with close association with autonomic nerves and some cranial nerves. Paraganglioma, being tumors arising from the paraganglion cells of the parasympathetic system, were first reported in man in 1935. Although histologically these tumors have been shown to contain neurosecretory granules, they are rarely functional. There are four kinds of paragangliomas: deriving from carotid artery baroreceptors (glomus caroticum), internal jugular vein (glomus jugulare); placed along vagal nerve (glomus vagale) and paragangliomas of tympanic cavity (glomus tympanicum). The first three of them are clinically recognized as tumor of the neck.

MATERIAL AND METHODS

Authors present group of 7 patients with paragangliomas treated in ENT Department in Poznań in the years 1994-2004. There were treated 4 patients with glomus caroticum, two with glomus vagale and one patient with glomus jugulare.

RESULTS

All patients were treated surgically. In one case in group with glomus caroticum in histological examination tendency to infiltration of internal carotid artery was stated (chemodectoma malignum). The tumor was removed totally with partial excision of communis, external and internal carotid artery. The internal carotid artery was closed by the tumor.

CONCLUSION

Authors underline three aspects of process of treatment in whole group of patients: diagnostic problems, way of treatment and long term results.

Familial paraganglioma

Paragangliomas are unusual tumors that are sometimes familial. We treated a family who exhibited multiple head and neck paragangliomas (HNPGs) and pheochromocytomas. The purpose was to determine the clinical characteristics of paragangliomas with familial history and to define a better standardized proceeding in the management of these tumors. Patients diagnosed with head and neck paragangliomas and identified retrospectively through clinical otolaryngology practices were given a medical and family history questionnaire. We studied a family who exhibited familial paragangliomas. This relationship was examined by reviewing the medical records of family members with verified tumors, carrying out neck computed tomography or magnetic resonance imaging on their relatives to look for tumors that had been unrecognized in the past. All patients underwent a complete head and neck examination. The initial evaluation usually included CT and/or MRI. Computed tomography and magnetic resonance imaging contributed additional information about tumor extension. Angiography was performed in every patient with carotid body tumor, with one undergoing therapeutic embolization to reduce the tumor size. Eleven tumors were identified in four patients with a familial history. Familial disease was initially determined by pedigree analysis. Four patients with a median age of 31 years (range: 25-42) underwent surgery. Median follow-up was 5 years (range 2-14); carotid angiography provided essential mainstays for the definite diagnosis. All patients underwent successful surgical resection of the tumor after the appropriate preoperative preparation. There were no perioperative deaths or hemiplegia. Three patients had bilaterality carotid body paragangliomas. One patient had three paragangliomas, and two patients had bilateral carotid body paragangliomas associated with pheochromocytoma. Clinically functioning tumors and malignant tumors were not identified, and none of the patients died after surgery. During follow-up, none of the patients developed recurrence or metastatic disease. The carotid body paraganglioma (CBPG) and glomus vagale manifested as asymptomatic neck masses. The clinical pheochromocytomas typically present with uncontrolled hypertension. In conclusion, paragangliomas are rare, with multicentricity being more common in patients with a familial history. In patients with familial paragangliomas, high-resolution computed tomography and magnetic resonance imaging are recommended for early screening and contributed additional information about the tumor extension and definitive treatment. Early surgery is recommended to minimize major risks.

Differentiating imaging findings in primary and secondary tumors of the jugular foramen

The preoperative diagnosis of a jugular foramen tumor may be challenging, since a large variety of unusual lesions may be located in this region. These tumors may be classified as primary lesions (which are located in the jugular foramen or extend from the jugular foramen into the surrounding structures) and as secondary lesions (that extend from the surrounding structures into the jugular foramen). Primary tumors include glomus jugulare tumors, schwannomas, meningiomas and peripheral primitive neuroectodermal tumors, while secondary tumors comprise chordomas, chondrosarcomas, chondroblastomas, giant-cell tumors, cholesterol granulomas, giant cholesterol cyst, endolymphatic sac tumors, reactive myofibroblastic tumors, temporal bone carcinomas and metastases. Accurate preoperative radiological suspicion is of great value for preoperative patient counseling and has a direct impact on the surgical planning in these cases. The present study describes and discusses the main differentiating imaging features of lesions involving the jugular foramen, whose accurate preoperative radiological evaluation is essential for proper surgical planning.

Treatment of Glomus Jugulare Tumors in Patients with Advanced Age: Planned Limited Surgical Resection Followed by Staged Gamma Knife Radiosurgery: A Preliminary Report

OBJECTIVE

To minimize treatment comorbidities in glomus jugulare tumor patients with advanced age while reducing pulsatile tinnitus and preserving or improving residual hearing using a limited middle ear/mastoid tumor resection and postoperative gamma knife radiosurgery to tumor remnants in the jugular foramen region.

STUDY DESIGN

Retrospective consecutive case review of five patients.

SETTING

Tertiary referral, academic medical center.

PATIENTS

Patients with advanced age (mean, 69.6 yr; range, 61-78 yr) harboring symptomatic glomus jugulare tumors.

INTERVENTION

All patients were treated with resection of middle ear and mastoid portions of tumor and subsequent gamma knife radiosurgery to jugular foramen portion of tumor.

MAIN OUTCOME MEASURES

Length of hospitalization; hearing, pulsatile tinnitus, cranial nerve, and tumor control status.

RESULTS

All patients were treated on an outpatient surgical basis without the need for blood transfusion. There were no incidents of a change in cranial nerve status (Cranial Nerves VII, IX, X, XI, and XII) in the immediate postoperative period. All patients had improvement or resolution of pulsatile tinnitus with preservation or improvement of preoperative hearing levels. Tumor volume was stable or reduced in all patients at mean follow-up of 19 months (range, 11-24 mo). Gamma knife radiosurgery (mean peripheral dose of 15 Gy) was not associated with any significant immediate or delayed complications.

CONCLUSION

Short-term data reveals that staged microsurgical and radiosurgical therapy for glomus jugulare tumors in the symptomatic patient with advanced age is safe and yields favorable results regarding tinnitus, hearing, and cranial nerve status. Long-term data are needed to further evaluate the effectiveness of this treatment algorithm before extrapolating this treatment option to younger patients.

[The diagnosis and treatment of glomus jugulare tumors]

OBJECTIVE

To discuss the diagnosis and management of glomus jugulare tumors.

METHOD

Eighteen cases of jugulare tumors were reviewed. Eighteen different kinds of surgical approaches were selected and used in the eighteen cases,eight cases adjuvant therapies were investigated.

RESULT

After the operation, complete resection was achieved in of the fourteen cases; two had a recurrence after three years; four patients with residual tumor had no changes after taking radiotherapy for three years.

CONCLUSION

Surgical approaches allow complete resection of the tumor. And preoperative embolization is able to reduce the operation time and blood loss. Radiotherapy is able to control the residual tumor.

Imaging and management of head and neck paragangliomas

Paragangliomas of the head and neck are highly vascular lesions originating from paraganglionic tissue located at the carotid bifurcation (carotid body tumors), along the vagus nerve (vagal paragangliomas), and in the jugular fossa and tympanic cavity (jugulotympanic paragangliomas). Diagnostic imaging can be considered in two clinical situations: (1) patients who present with clinical symptoms suggestive of a paraganglioma, and (2) individuals from families with hereditary paragangliomas. It is not only necessary to detect and characterize the lesion, but also to study the presence of multiplicity. For these purposes, MR imaging, and especially 3D TOF MRA, is the modality of choice. CT scanning is especially useful to show destruction of the temporal bone. Angiography in combination with embolization will mainly be used prior to surgical resection, but can also be used for diagnostic purposes when the diagnosis is not yet clear. Many parameters play a role in the decision to treat of which multifocality and impairment of cranial nerves are the most important. The primary therapeutic option for paragangliomas is complete excision of tumor with preservation of vital neurovascular structures. Resection however, should be balanced against a more conservative "wait and scan" policy or palliative treatments such as radiotherapy.

The value of MR angiography techniques in the detection of head and neck paragangliomas

OBJECTIVE

The objective of this study was to compare three-dimensional phase-contrast angiography (3D PCA), 2D time-of-flight (2D TOF), and 3D TOF magnetic resonance (MR) angiography and a proton density weighted technique in terms of their ability to detect head and neck paragangliomas.

MATERIALS AND METHODS

14 patients with 29 paragangliomas were examined at 1.5 T. Three MR angiography sequences (3D PCA, 2D TOF, and multi-slab 3D TOF) and a proton density (PD) weighted sequence were reviewed by four neuroradiologists. The gold standard was digital subtraction angiography. Presence of tumor was assessed in five grades of confidence. Sensitivity and specificity were calculated after dichotomizing the results. Data was analyzed using the logistic regression method.

RESULTS

Mean sensitivity and specificity for the four observers were for PD: 72%/97%, for 3D PCA: 75%/90%, for 2D TOF: 66%/93%, and for 3D TOF: 90%/92%. Sensitivity was significantly better for 3D TOF MRA (P < 0.001). No substantial between-observer variation for tumor detection was present.

CONCLUSION

Our results demonstrate that, using 3D TOF MRA, paragangliomas in the head and neck region can be detected with high sensitivity and specificity. Further investigation is necessary to judge the value of 3D TOF MR angiography against fat suppressed contrast enhanced T1 weighted and fat suppressed T2 weighted MR sequences to find the optimal imaging sequence for paragangliomas.

[Three kinds of chemodectoma in one patient--a rare case]

Tumors arising from paraganglioma tissue are properly called paragangliomas. Preferentially these tumors are named for their site of origin. In the head and neck they are most commonly found arising from the carotid body (glomus caroticum), the jugular bulb (glomus jugulare), the tympanic cavity (glomus tympanicum) and the vagal ganglia (glomus vagale). Mutiple paragangliomas may occur in 2-10%. The purpose of this study was to present the rare case of patient with three kinds of chemodectoma: glomus tympanicum, jugulare i vagale.

[Diagnosis and management of cervical paragangliomas: the Freiburg experience]

BACKGROUND

Paragangliomas of the head and neck represent rare tumors of neural crest origin that arise from chemoreceptors. They are highly vascular neoplasms that are benign in the majority of cases. There are controversial discussions concerning the different treatment options for cervical paragangliomas.

PATIENTS

Between January 1992 and November 2003 a total of 13 patients with 15 cervical paragangliomas were treated at the Department of Otorhinolaryngology - Head and Neck Surgery, University of Freiburg. Our study includes eight female and five male patients with a mean age of 39.9 years (range: 20 - 79 years). There were 14 carotid body tumors and one vagal paraganglioma.

RESULTS

14 tumors were resected and one underwent primary radiation. In four patients we noted a total of 8 permanent, postoperative nerve deficits. During follow-up no recurrent tumors were seen.

CONCLUSION

Complete surgical removal represents the therapy of choice for the majority of cervical paragangliomas. In cases of multiple head and neck paragangliomas or in patients with underlying diseases, primary radiation should be discussed as a treatment option.

Glomus jugulare tumor presentation and management: a case study

Glomus jugulare tumors are rare, normally benign, paragangliomas located in and around the jugular foramen at the base of the skull. They may cause significant lower cranial nerve deficits due to mass effect, and as part of the chromaffin cell system (including pheochromocytomas), they may also actively secrete catecholamines. Resection, while frequently difficult, is the treatment of choice. Nurses caring for patients with glomus jugulare tumors need to be skilled in recognizing lower cranial nerve deficits and complications that may arise related to inappropriate catecholamine release or due to disruption of cerebral venous return by tumor or surgery.

[Diagnosis and therapy of glomus tympanicum and glomus jugulare tumors]

OBJECTIVE

To report on a series of patients with glomus tympanicum or glomus jugulare tumors, and to focus on its diagnosis, treatment, and outcomes.

METHODS

Ten patients with glomus tympanicum or glomus jugulare tumors at Peking Union College Hospital during a 17-year period were reviewed retrospectively.

RESULTS

There were 7 patients with glomus tympanicum, 3 with glomus jugulare tumors, 1 patient with familial paraganglioma and 1 with functioning glomus jugulare tumors. The most common presenting symptoms were pulsatile tinnitus and hearing loss. Other symptoms included facial nerve paralysis, vertigo, otalgia, dysphagia, hoarseness, throat sore, episodic hypertension with headaches and tachycardia. The most common physical sign was a vascular middle ear mass. The other physical signs included Brown sign, upper neck mass, pharyngeal plump, Collet-Sicard syndrome, Homer's syndrome as well as deficit of cranial nerve V. The radiographic evaluation included computed tomograph (9 cases), angiography (4 cases) and magnetic resonance imaging (1 case). Eight patients initially refered to ENT department, and 2 patients initially consulted neurology or endocrinology specialists. The treatment included preoperative embolization in 2 cases, simple surgery in 4 cases and surgery followed by radiation therapy in 6 cases. No significant complications occurred. Nine of the 10 patients were followed up, but 1 was lost. The mean follow-up time was 12 years (ranged, 2-19 years). No tumor recurrence occured in the 6 cases with total tumor removal. Three cases with subtotal tumor resection had no tumor progression.

CONCLUSIONS

The diagnosis and treatment of glomus tympanicum and glomus jugulare tumors is particularly challenging. Typical clinical manifestations and radiographic evaluation should be considered together to establish the diagnosis. The primary treatment for glomus tympanicum is surgery, if necessary, followed by radiotherapy. Subtotal tumor resection followed by radiation yields satisfying outcome for glomus jugulare tumors.

Surgical treatment of glomus jugulare tumors without rerouting of the facial nerve: an infralabyrinthine approach

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.

Jugular foramen tumors: diagnosis and treatment

Object

Jugular foramen tumors are rare skull base lesions that present diagnostic and complex management problems. The purpose of this study was to evaluate a series of patients with jugular foramen tumors who were surgically treated in the past 16 years, and to analyze the surgical technique, complications, and outcomes.

Methods

The authors retrospectively studied 102 patients with jugular foramen tumors treated between January 1987 and May 2004. All patients underwent surgery with a multidisciplinary method combining neurosurgical and ear, nose, and throat techniques. Preoperative embolization was performed for paragangliomas and other highly vascularized lesions. To avoid postoperative cerebrospinal fluid (CSF) leakage and to improve cosmetic results, the surgical defect was reconstructed with specially developed vascularized flaps (temporalis fascia, cervical fascia, sternocleidomastoid muscle, and temporalis muscle). A saphenous graft bypass was used in two patients with tumor infiltrating the internal carotid artery (ICA). Facial nerve reconstruction was performed with grafts of the great auricular nerve or with 12th/seventh cranial nerve anastomosis. Residual malignant and invasive tumors were irradiated after partial removal.

The most common tumor was paraganglioma (58 cases), followed by schwannomas (17 cases) and meningiomas (10 cases). Complete excision was possible in 45 patients (77.5%) with paragangliomas and in all patients with schwannomas. The most frequent and also the most dangerous surgical complication was lower cranial nerve deficit. This deficit occurred in 10 patients (10%), but it was transient in four cases. Postoperative facial and cochlear nerve paralysis occurred in eight patients (8%); spontaneous recovery occurred in three of them. In the remaining five patients the facial nerve was reconstructed using great auricular nerve grafts (three cases), sural nerve graft (one case), and hypoglossal/facial nerve anastomosis (one case). Four patients (4%) experienced postoperative CSF leakage, and four (4.2%) died after surgery. Two of them died of aspiration pneumonia complicated with septicemia. Of the remaining two, one died of pulmonary embolism and the other of cerebral hypoxia caused by a large cervical hematoma that led to tracheal deviation.

Conclusions

Paragangliomas are the most common tumors of the jugular foramen region. Surgical management of jugular foramen tumors is complex and difficult. Radical removal of benign jugular foramen tumors is the treatment of choice, may be curative, and is achieved with low mortality and morbidity rates. Larger lesions can be radically excised in one surgical procedure by using a multidisciplinary approach. Reconstruction of the skull base with vascularized myofascial flaps reduces postoperative CSF leaks. Postoperative lower cranial nerves deficits are the most dangerous complication.

Glomus jugulare tumors with intracranial extension

Glomus tumors provide unique surgical challenges for both tumor resection and defect reconstruction. Tumors with intracranial extension compound these challenges. Surgical techniques have evolved, and now, with a multidisciplinary team, single-stage surgeries are the standard. In this paper the authors will report the results of the Otology Group protocol for surgical management of glomus tumors with intracranial extension. Particular attention will be paid to prevention of cerebrospinal fluid leaks with the use of vascularized tissue for defect reconstruction.

Octreotide scintigraphy in the detection of recurrent paragangliomas

OBJECTIVE

Conventional follow-up of surgically and radiotherapy-treated paragangliomas is usually carried out with physical examinations and either magnetic resonance imaging and/or computed tomography. Up to now, octreotide has been reserved for primary diagnosis, for which it has been shown to be a reliable imaging modality. However, the postsurgical and postradiation changes seen on conventional imaging make the diagnosis of small recurrent lesions difficult. We sought to evaluate the role of octreotide scintigraphy in the detection of recurrent paragangliomas.

STUDY DESIGN

We based this case series on 3 patients who were found to have recurrent paragangliomas after primary surgical resection. All patients underwent octreotide scintigraphy during routine follow-up.

RESULTS

Three patients were found to have recurrent paragangliomas using octreotide scintigraphy. In one of the patients, conventional imaging (magnetic resonance imaging, computed tomography) failed to detect the recurrence.

CONCLUSION

The octreotide study was able to detect the small recurrences because octreotide binds directly to receptors on the tumor and is not affected by postsurgical or postradiotherapy changes. The intrinsic resolution of most commercially available gamma cameras is about 1 cm, making it quite sensitive to detect small tumors. Although this patient did not have synchronous lesions, octreotide scintigraphy can also aide in the detection of such lesions.

[Malignant jugular paraganglioma: a case report]

Paragangliomas are usually benign tumors. Overall, less than 10% of all paragangliomas become malignant. Although the indicator of malignancy is regarded as detection of histopathological findings of tumor by some authors, most authors accept extension to regional lymph nodes or distant metastasis as the only reliable indicators of malignancy. A 66-year old woman was admitted to our hospital with hearing loss, vertigo, and hoarseness. CT examination revealed a mass in the left jugular foramen. The tumor was confirmed as malignant paraganglioma. Indicators of malignant paragangliomas are discussed in this article.

Meningioma of the Jugular Foramen: Glomus Jugulare Mimic and Surgical Challenge

OBJECTIVES

Meningiomas involving the jugular foramen are rare lesions, with approximately 34 cases reported in the English literature. Clinically, these tumors mimic the more common glomus jugulare tumor. After surgical resection, meningiomas have worse cranial nerve outcomes and higher recurrence rates than glomus tumors. There is controversy regarding the selection of surgical approach, particularly with regard to management of the facial nerve. A reliable means of accurate preoperative diagnosis would help surgical planning and patient counseling.

STUDY DESIGN

We present a series of six consecutive large jugular foramen meningiomas resected by a single surgeon from 1996 to 2002.

METHODS

Retrospective case series (chart review).

RESULTS

The preoperative diagnosis was correct in nearly all (6/7) cases on the basis of the characteristic imaging findings seen with a combination of temporal bone dedicated computed tomography and high-resolution enhanced magnetic resonance imaging. Five of six patients had lateral facial nerve rerouting (infratemporal fossa Fisch type A), and three patients also had posterior rerouting (transcochlear approach with division of greater superficial petrosal nerve). Total tumor removal was accomplished in 83%. One patient suffered recurrence over a mean follow-up period of 2.5 years. New postoperative vocal cord palsies occurred in 50% of patients, and all required vocal cord medialization. At 1 year, 50% of patients had normal or near normal (House-Brackmann I or II) facial function. Postoperative cerebrospinal fluid leaks occurred in two patients, and both eventually required ventriculoperitoneal shunts.

CONCLUSIONS

Meningiomas involving the jugular foramen are surgically challenging tumors that pose unique diagnostic issues. The majority of these lesions can be completely resected. A relatively high postoperative complication rate, which can be controlled with appropriate intervention, is seen with these surgeries.

Dynamic contrast enhancement of paragangliomas of the head and neck: evaluation with time-resolved 2D MR projection angiography

Our objective was to evaluate tumor hemodynamics of paragangliomas of the head and neck. A 2D magnetic resonance projection angiography (MRPA) protocol was developed. Six patients with histologically proven paragangliomas were included in the study. The sequence protocol and data post-processing procedure were optimized in view of a high temporal resolution and maximum contrast-to-noise ratio. Image-time series of two freely orientated slabs could be obtained. Correlation analysis was performed to generate selective arterial and venous weighted angiographic images. Glomus tumors showed a rapid and intense homogeneous enhancement following the intravenous administration of contrast material. The smallest tumors investigated measured 10 mm and could be visualized clearly. Time-resolved analysis of the tumor enhancement revealed an early bolus arrival within the vascular bed of the tumor and prolonged incomplete washout indicating blood pooling. The dynamic contrast enhancement of glomus tumors can be evaluated non-invasively with MRPA providing a high temporal resolution and high image quality. The characteristic contrast enhancement of glomus tumors can be helpful in the diagnostic workup of lesions that may mimic glomus tumors.