Glomus Jugulare Tumors With Intracranial Extension

C. Gary Jackson, MD; David M. Kaylie, MD; George Coppit, MD; Edward K. Gardner, MD

Disclosures

Neurosurg Focus. 2004;17(2) 

In This Article

Discussion

Defect reconstruction after removal of glomus jugulare lesions will often present challenges that are not seen in other neurootological procedures such as acoustic neuroma surgeries. The temporal bone dissection in acoustic neuroma surgeries is often less extensive than in glomus jugulare resections. Local tissues are often compromised in glomus tumor resection by prior radiation, embolization, or prior surgery, but are readily available in acoustic neuroma surgery. Glomus tumor surgeries also result in increased CSF pressure because of occlusion of the dural venous sinuses, which requires innovative CSF leak prevention strategies. The CA is exposed in all surgeries of glomus tumor with intracranial extension, which is not the case in acoustic neuroma surgery. For these reasons, a comprehensive, multidisciplinary strategy for managing these tumors has been developed.

Glomus tumors with intracranial extension are best resected in a single stage. This can only be achieved when the entire tumor and vital structures are adequately exposed. The surgical team consists of a head and neck/reconstructive surgeon, a neurootological/skull base surgeon, and a neurosurgeon. If this team cannot be assembled, a staged procedure should then be executed.[10] These surgeries take approximately 8 to 12 hours with an experienced surgical team. If the surgery cannot be completed in a reasonable amount of time, a staged procedure should be considered. Subtotal resection is also necessary in some patients. In 11% of surgeries in this series, complete resections were not possible. This is usually because of tumor adherence to brainstem, involvement with the cavernous sinus, or patients' wishes to preserve cranial nerves if they are involved with tumor. Proper imaging includes CT and MR studies, which are used to determine the size, extent, and intracranial extension of the tumor.[5]

The methods described here are based on the concept of defect reconstruction with vascularized tissue at minimized CSF pressure. The evolution of these strategies resulted in reduced CSF leakage rates. The current protocol has been in place since 1987. Before that, 19% of patients with intracranial extension experienced CSF leaks,[10] whereas in this series only three patients had a CSF leak. The CSF dynamics are altered in the perioperative period, and lumbar drains, although not without risks, are a manageable solution for single-stage glomus tumor resection and defect reconstruction.[7]

Conclusions

Skull base surgery has evolved in complexity and elegance. A wide range of surgical and reconstructive options exists for a wide range of tumors. Preoperative planning with a multidisciplinary team allows for an operation that is exactly tailored to the individual patient's needs. When these principles are applied, functional outcome and the chance of tumor cure improve while complications decrease.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....