Selective embolization of glomus jugulare tumors

Four patients with grade C or D(1) glomus jugulare tumors who underwent preoperative highly selective embolization followed by infratemporal fossa removal of their tumors were compared to three patients undergoing surgery alone with respect to intraoperative blood loss, operative time, cranial nerve palsy, length of hospitalization, and perioperative complications. Embolized patients demonstrated a marked reduction in blood loss (650 vs 1375 cc) compared with the nonembolized group. Operative time was shortened (by 51 minutes). Facial nerve function did not appear related to embolization but was directly related to intraoperative nerve manipulation. Hospital stay, perioperative complications, and lower cranial nerve palsies were not related to embolization.     

Tumours of the glomus jugulare

Two cases are reported using a two stage procedure for the excision of glomus jugulare tumours. The anaesthetic problems which this may produce are discussed, and recommendations are made regarding the anaesthetic conduct for this procedure. A two stage, combined procedure is suggested to reduce anaesthetic morbidity.     

Management of a glomus jugulare tumour with internal carotid artery involvement

A previously healthy 40-year-old female presented for surgical resection of a large glomus jugulare tumour with extensive involvement of the carotid siphon and intracranial extension. Conduct of anaesthesia with specific reference to cerebral protection is discussed. A combination of induced hypothermia, barbiturate therapy, normotension, normocarbia and prior clamping of the distal internal carotid artery was chosen. The role of barbiturates as a therapeutic intervention is debated.     

Efficiency of gamma knife radiosurgery in the treatment of glomus jugulare tumors.

This study was performed to assess the impact of gamma knife radiosurgery (RS) in the treatment of glomus jugulare tumors. Between February 1993 and February 1999, thirteen patients (9 women, 4 men; mean age 63.5 years, range 29 to 79 years) underwent stereotactic radiosurgery for glomus jugulare tumors with the Leksell Gamma Knife at the Neurosurgical Department of the University of Vienna. Four patients, mean age 74.5 years, range 67 to 79 years, underwent radiosurgery as the only treatment. Nine patients received radiosurgery as adjuvant therapy after previous treatment had failed: surgical resection in 9 patients and additional fractionated external beam radiation in two of these patients. Pretreatment evaluation included the staging of all tumors according to the Fisch Classification: De1 (7), De2 (1), Di1 (4) and Di2 (1). The mean follow-up period was 4.2 years, range 0.7 to 6.7 years. Ten patients, 77 %, were treated prior to 1997, the mean follow-up period being 5 years. Six patients showed no clinical changes, while six experienced an improvement of their clinical symptoms and neurological deficits. One patient was lost to follow-up. Radiation-induced transient cranial nerve neuropathies were observed in two patients. Serial MRI scans revealed tumor control in all patients, with unaltered tumor size in 10 and shrinkage in three patients. The results indicate that RS is an attractive treatment option for glomus jugulare tumors and will occupy an increasingly important role in the management of these tumors in selected patients.     

Complex tumors of the glomus jugulare: criteria,treatment, and outcome

OBJECT: Tumors of the glomus jugulare are benign, slow-growing paragangliomas. Their natural history, surgical treatment, and outcome have been well addressed in the recent literature; however, there remains a subgroup of complex tumors--multiple, giant, malignant, neuropeptide-secreting lesions, and those treated previously by an intervention with an adverse outcome--that is high risk, presents surgical challenges, and is associated with treatment controversy. In this article the authors report on a series of patients with complex glomus jugulare tumors and focus on treatment decisions, avoidance of complications, surgical refinements, and patient outcomes. METHODS: In this retrospective study, the patient population was composed of 11 male and 32 female patients (mean age 47 years) with complex tumors of the glomus jugulare who were treated by the senior author within the past 20 years. These include 38 patients with giant tumors, 11 with multiple paragangliomas (seven bilateral and four ipsilateral), two with tumors that hypersecreted catecholamine, and one with a malignant tumor. Six patients had associated lesions: one dural arteriovenous malformation, one carotid artery (CA) aneurysm, two adrenal tumors, and two other cranial tumors. All but one patient presented with neurological deficits. Cranial nerve deficits, particularly those associated with the lower cranial nerves, were the prominent feature. Twenty-eight patients underwent resection in an attempt at total removal, and gross-total resection was achieved in 24 patients. Particularly challenging were cases in which the patient had undergone prior embolization or CA occlusion, after which new feeding vessels from the internal CA and vertebrobasilar artery circulation developed. The surgical technique was tailored to each patient and each tumor. It was modified to preserve facial nerve function, particularly in patients with bilateral tumors. Intrabulbar dissection was performed to increase the likelihood that the lower cranial nerves would be preserved. Each tumor was isolated to improve its resectability and prevent blood loss. No operative mortality occurred. In one patient hemiplegia developed postoperatively due to CA thrombosis, but the patient recovered after an endovascular injection of urokinase. In four patients a cerebrospinal fluid leak was treated through spinal drainage, and in five patients infection developed in the external ear canal. Two of these infections progressed to osteomyelitis of the temporal bone. There were two recurrences, one in a patient with a malignant tumor who eventually died of the disease. CONCLUSIONS: Despite the challenges encountered in treating complex glomus jugulare tumors, resection is indicated and successful. Multiple tumors mandate a treatment plan that addresses the risk of bilateral cranial nerve deficits. The intrabulbar dissection technique can be used with any tumor, as long as the tumor itself has not penetrated the wall of the jugular bulb or infiltrated the cranial nerves. Tumors that hypersecrete catecholamine require perioperative management and malignant tumors carry a poor prognosis.     

Surgical management of intravascular glomus jugulare tumor

Extensions of glomus jugulare tumors into the internal jugular vein are unique in that they do not involve the wall of the vein but grow as fingerlike projections in the lumen of the vessel. These intravascular tumor extensions are potentially lethal by direct extension into the heart or as fatal emboli at the time of excision of the primary lesion or during the course of radiotherapy.     

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.     

Excision of a glomus jugulare tumor after embolization

The authors report the case of a patient with a glomus jugulare tumor. After embolization of the external carotid artery branches feeding the tumor, a complete removal had been performed by a combined otoneurological approach. Although clearly defined and cleavable at the jugulare foramen, the chemodectoma had invasive characteristics in its intrapetrous extension, indicative post operative radiotherapy. In addition a review of publications support preoperative embolization and otoneurosurgical cooperation.     

Otogenic pasteurella multocida brain abscess and glomus jugulare tumour

We report the occurrence of a Pasteurella multocida temporal lobe abscess in an elderly woman who had a history of neglected chronic purulent otitis and in whom an extensive ipsilateral glomus tumour invading the petrous bone was found. We believe this is the first report in the literature of an otogenic cerebral abscess associated with a glomus jugulare tumour and the fifth report of a Pasteurella multocida brain abscess. The synergistic pathogenesis of the otitis and the glomus tumour in the evolution of the abscess is hypothesized.     

Diagnostic and therapeutic angiography in the evaluation and treatment of glomus jugulare tumors. Apropos of 32 cases

This report is based on 32 cases of jugular paraganglioma treated by embolization, of which 7 had cervical and/or intrajugular extensions, five a giant extension involving mainly the carotid canal and one excretory activity. Aims and methods of diagnostic and therapeutic angiography are envisaged as well as results in the three angiographic types encountered: tumors vascularized by the external carotid artery only, those supplied by the internal (and external) carotid arteries and those fed by the vertebral artery or even the three arterial axes.