Glomus Jugulare Tumor Presentation and Management: A Case Study

Mark C. Coles

Disclosures

J Neurosci Nurs. 2004;36(4) 

In This Article

Surgery

Surgical principles include isolation of the lesion to increase the likelihood of complete resection and to lessen blood loss. Technique is modified based on anatomical variation and the extent of intracranial and/or intracervical involvement.

On the day of surgery, the patient underwent an MRI/MRV scan (see Fig 4) with fiducial placement for utilization of the image-guided neuronavigation system. A CT scan of the bases occiput was also obtained. Following routine prepping, positioning, and registration, a classic curvilinear left posterior fossa incision was made. Following extensive stripping and retraction of occipital and cervical paraspinal muscles, a modified radical mastoidectomy was performed with skeletonization of the sigmoid sinus and amputation of the mastoid tip. The bony facial nerve canal was left intact with intraoperative monitoring of the facial and lower cranial nerves. With further extensive meticulous drilling while a 360-degree exposure was being attempted, moderate bleeding occurred following a tear of the transverse sinus, necessitating proximal jugular vein ligation. Using microsurgical technique with 5-mm, 4-mm, and 2-mm diamond burrs with copious irrigation to follow the course of the sigmoid sinus to the jugular foramen, the ninth and tenth nerves were partially visualized posterior and medial to the jugular bulb. The dura overlying the cerebellum was tense, and upon incision, mannitol was given and the craniectomy extended due to significant edema, subsequently controlled. With lifting of the cerebellar hemisphere from its bed, no intradural, intracranial tumor extension was noted and the VII and VIII nerves were identified as well as IX and X. Following satisfactory exposure and with control of bleeding, the tumor was approached from inside the jugular foramen and total removal was thought to be achieved with preservation of the IX and X nerves with the exception of a thin strand of IX. At no time was the facial nerve manipulated. The dural defect was covered and the wound closed in four layers. No spinal fluid leak was appreciated and no lumbar drain was placed.

Preoperative MR venogram demonstrating patient contralateral jugular vein and reduced ipsilateral flow due to compression by tumor

The most common problems following surgery involve worsening of lower cranial nerve dysfunction. Although large tumors may also manifest brain stem involvement, vocal cord paralysis with increased aspiration risk is a more common concern and may necessitate tracheotomy and/or gastrostomy tube. Hemorrhage, cerebrospinal fluid (CSF) leak, infection, meningitis, and catecholamine crisis may all result. Excessive catecholamine release is primarily an intraoperative complication due to manipulation but may also result from postoperative edema. CSF leak is managed by lumbar drainage often placed prophylactically during surgery. Infection may develop in the internal or external auditory canal with risk of progression to osteomyelitis of the temporal bone. Antibiotic prophylaxis is recommended. Stroke may occur secondary to carotid artery thrombus while pulmonary embolism due to clot or air is a potential risk with jugular resection. The facial nerve is particularly sensitive, and every effort must be made to avoid or minimize manipulation. Intraoperative facial nerve monitoring is routinely utilized (Boulos et al., 2000) to verify function should case facial nerve transposition be necessary.

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