Glomus Jugulare Tumor Presentation and Management: A Case Study

Mark C. Coles

Disclosures

J Neurosci Nurs. 2004;36(4) 

In This Article

Management

Treatment options were discussed. Radiation therapy 4-6 months preoperatively has been utilized to decrease vascularity or as primary treatment for large tumors, although benefit is controversial (Al-Mefty, 2002). Embolization may be employed as sole treatment for inoperable lesions or preoperatively for certain tumors to reduce size or limit intraoperative hemorrhage in tumors with appropriate feeders (Greenberg, 2001). The treatment of choice, however, particularly for young patients exhibiting partial lower cranial nerve deficits, is complete resection to halt the progression of lower cranial nerve dysfunction.

Successful resection of glomus jugulare tumors requires an extensive battery of preoperative testing because of the complicated anatomy of the skull base. Information regarding extent of bony involvement, endocrine dysfunction, tumor arterial supply, and cerebral venous outflow is required, along with baseline assessment of lower cranial nerve function.

Computed tomography (CT) is superior to MRI for the evaluation of bony involvement. A CT scan of the head, without and with contrast, with special attention to the skull base was obtained. Extensive bony destruction in the region of the jugular foramen extending intracranially and into the hypotympanum of the left middle ear was noted (Fig. 3). The appearance was consistent with a glomus jugulare tumor with the differential diagnosis including other paragangliomas such as carotid body or intravagal tumor, schwannoma, meningioma, metastasis, and much less likely entities such as parotid tumor or epidermoid cyst.

Axial CT image demonstrating extensive bony destruction and proximity to mastoid and IAC

As glomus tumors may actively secrete catecholamines (Borba, De Castro, & Al-Mefty 2000), a 24-hour urine collection was ordered for vanillylmandelic acid, metanephrines, and total catecholamines. These results, however, were within normal limits. If catecholamine levels are elevated, preoperative treatment may include alpha and/or beta blockade to counter catecholamine oversecretion and hypertensive crisis.

Preoperative workup may also include magnetic resonance angiography/magnetic resonance venography (MRA/MRV) or pancerebral angiography to determine ipsilateral and contralateral arterial and venous circulation. It is important to verify contralateral venous patency as the ipsilateral jugular vein may need to be sacrificed, if not already occluded by tumor. In addition, feeder vessels for potential arterial embolization, either preoperative or intraoperative, may be identified.

Consultation with an ear, nose, and throat surgeon may be appropriate if the tumor is primarily intracervical or for assistance with portions of the surgery, such as mastoidectomy, or if a team approach is otherwise anticipated. Preoperative speech and swallowing evaluation is recommended as vagal nerve involvement increases aspiration risk. Nursing staff members involved in postoperative care need to be aware of the degree of preoperative deficit to evaluate any deterioration.

Baseline hearing function should be established. Four months before, the patient had tested normally, although review of systems revealed tinnitus and vertigo. Repeat audiometry testing revealed severe high-frequency sensory hearing loss.

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