Immediate postembolization excision of glomus jugulare tumors: advantages of new combined techniques

Friend or Foe? Preoperative Embolization in Jugular Paraganglioma Surgery-A Systematic Review and Meta-Analysis

BACKGROUND

Jugular paragangliomas are highly vascularized tumors that can grow in challenging neurovascular compartments and are particularly challenging to resect. There is still no consensus whether preoperative embolization should be employed to minimize intraoperative morbidity.

METHODS

A systematic review and meta-analysis was conducted by searching PubMed, Web of Science, and Embase databases for key terms including "embolization," "jugular paragangliomas," and "surgery."

RESULTS

This review included 25 studies with 706 patients and 475 (67%) preoperative embolizations. Polyvinyl alcohol particles were the most common embolic agent (97.8% of all patients who underwent embolization). Complication rate of embolization was 1% (95% confidence interval [CI]: 0%, 2%). Preoperative embolization was significantly associated with less intraoperative estimated blood loss (mean difference of -7.92 dL [95% CI: -9.31 dL, -6.53 dL]), shorter operating room times (mean difference of -55.24 minutes [95% CI: -77.10 minutes, -33.39 minutes]), and less overall tumor recurrence (odds ratio = 0.23 [95% CI: 0.06, 0.91]) compared with resective surgery alone. Preoperative embolization had no impact on the development of postoperative new cranial nerve deficits not associated with embolization (odds ratio = 1.17 [95% CI: 0.47, 2.91]) and achievement of gross total resection (odds ratio = 1.92 [95% CI: 0.67, 5.53]).

CONCLUSIONS

Preoperative embolization may provide surgical efficiency with faster surgical times and less bleeding and safety with diminished overall recurrence via safe embolization with minimal risks. These results must be considered taking into account the nonrandomness of studies.

A Rare Differential of Epistaxis

Glomus tympanicum is a type of glomus tumor that affects the middle ear, located at the auricular branch of the vagus nerve. Glomus tumors, in general, are rare, slow-growing tumors and may not require surgery in some patients. It can be challenging to manage due to its hypervascularity, location, and advanced stage of diagnosis. Although glomus tympanicum commonly presents with pulsatile tinnitus and conductive hearing loss, it presented in our patient with large-volume hemoptysis and epistaxis, requiring urgent diagnostic and therapeutic interventions. We highlight the unique presentation of a 48-year-old female with sudden onset large-volume hemoptysis and epistaxis, leading to the discovery of a hypervascular glomus tympanicum in the right middle ear, identified via MRI. On arrival, her vitals were within normal limits, and a physical examination was pertinent for the obvious ongoing bleeding from her mouth. The examination revealed increased respiratory effort and bilateral crackles. Laboratory values were pertinent for hemoglobin of 11.8 g/dl. Ear examination revealed a large, vascular-appearing mass filling the right ear. An MRI of the face and neck showed an avidly enhancing 3.7 cm x 1.8 cm x 1.2 cm mass within the right middle ear and mastoid cavity, extending into the external auditory canal and through the eustachian tube into the nasopharynx. The mass was inseparable from the lateral border of the internal auditory canal in the petrous canal. Due to concern for glomus tympanicum, the patient underwent urgent embolization and subsequent tumor resection. Considering our patient initially presented large-volume hemoptysis, there was concern for alveolar hemorrhage. However, as she had no increased oxygen requirement, there was suspicion of massive epistaxis mistaken for hemoptysis. Due to large volume epistaxis, she underwent urgent embolization as resection could have been challenging due to increased vascularity. It is important to remember that massive epistaxis may not present with blood in the anterior nares, thereby delaying diagnosis and management. Furthermore, probing such tumors should be avoided as it may lead to life-threatening bleeding.

Efficacy and Safety of Preoperative Embolization in Glomus Jugulare Tumors: A Systematic Review and Meta-analysis of Clinical Outcomes and Complications

PURPOSE

This study aims to provide a comprehensive review of the clinical benefits, complications, and safety profile associated with preoperative embolization in Glomus jugulare tumors (GJTs).

MATERIALS AND METHODS

A comprehensive search in PubMed, Embase, and Web of Science was conducted for English articles published up to March 2023, focusing on GJTs and preoperative embolization. Included studies involved patients over 18 with GJTs. We excluded studies that explored embolization methods other than the standard endovascular approach, as well as studies involving paragangliomas that did not provide specific data related to GJTs. Key variables such as hemorrhage volume and surgical time, as well as clinical outcomes, were analyzed. Data were analyzed using a random-effects model meta-analysis, assessing heterogeneity with the I2 statistic.

RESULTS

This review encompasses 19 studies with a total of 328 patients. The studies incorporated into our meta-analysis display considerable differences and inconsistencies in their data. The findings of the meta-analysis show a mean hemorrhage volume of 636 ml (95% confidence interval (CI) 473-799) following preoperative embolization, and a mean surgical duration of 487 min (95% CI 350-624). The study also notes potential complications: facial nerve deficits occurred in 20% of cases (95% CI 11-32%), and vagal nerve deficits in 22% (95% CI 13-31%).

CONCLUSION

This study suggests that preoperative embolization could decrease surgery duration and blood loss, but emphasizes the importance of evaluating risks like nerve damage. However, the generalizability of these findings is restricted due to the diversity of available data.

Post-Embolization Excision of Glomus Tympanicum: A Case Report

Glomus tympanicum is a slow-growing benign tumor that can be locally destructive, spreading along the path of least resistance. Conventionally seen as soft tissue mass in the middle ear, it is difficult to distinguish glomus tympanicum from other soft tissue masses of the tympanic cavity, especially as it hides behind an intact tympanic membrane. The primary diagnostic modalities are CT scan and MRI for evaluation of the exact anatomical extent and size of the glomus tumors. Embolization following an angiographic study helps to identify the feeding arteries with subsequent blocking of the same, thus helping in the reduction of intraoperative hemorrhage. The currently available modalities of treatment are mainly surgery and radiotherapy.

Here, we report a case of a 40-year-old female who presented with unilateral deafness and tinnitus, with no co-morbidities. She showed a red bulging mass behind an intact tympanic membrane on otoscopy and otomicroscopy with mild conductive hearing loss. MRI showed an intensely enhancing lesion in the mesotympanum and hypotympanum along the cochlear promontory. A diagnosis of glomus tympanicum was made based on clinical, audiological, and radiological findings. Pre-operative embolization was carried out 48 hours before the surgery. Complete resection of the tumor was achieved by microsurgery.  

Surgical management of giant transdural glomus jugulare tumors with cerebellar and brainstem compression

Objective The objective of this study is to discuss the management of advanced glomus jugulare tumors (GJTs) presenting with intradural disease and concurrent brainstem compression. Study Design This is a retrospective case series. Results Over the last decade, four patients presented to our institution with large (Fisch D2; Glasscock-Jackson 4) primary or recurrent GJTs resulting in brainstem compression of varying severities. All patients underwent surgical resection through a transtemporal, transcervical approach resulting in adequate brainstem decompression; the average operative time was 12.75 hours and the estimated blood loss was 2.7 L. All four patients received postoperative adjuvant radiotherapy in the form of intensity-modulated radiation therapy or stereotactic radiosurgery. Combined modality treatment permitted tumor control in all patients (range of follow-up 5 to 9 years). Conclusion A small subset of GJTs may present with intracranial transdural extension with aggressive brainstem compression mandating surgical intervention. Surgical resection is extremely challenging; the surgical team must be prepared for extensive operating time and the patient for prolonged aggressive rehabilitation. Newly diagnosed and recurrent large GJTs involving the brainstem may be controlled with a combination of aggressive surgical resection and postoperative radiation.

Jugulotympanic paragangliomas: 75 years of evolution in understanding

Jugulotympanic paragangliomas were first described approximately 75 years ago. Since that time, there has been considerable evolution in knowledge of tumor biology, methods of classification, and appropriate management strategies. This paper attempts to summarize these gains in information.

Preoperative embolization of paragangliomas (glomus tumors) of the head and neck: histopathologic and clinical features

Forty-eight surgical specimens were examined histologically and the case histories reviewed to determine the histopathologic features of embolized paragangliomas (glomus tumors) in relation to the time interval between embolization and surgery. Different degrees of thrombus formation and of multinucleated foreign body giant cells occurred during the first 7 days after embolization; thereafter, glant cells with active phagocytosis, fragmentation of embolic material, and partial revascularization were observed. Only one third of the tumor vessels were embolized. Complete obliteration of 40% of embolized vessels occurred more than 2 months postembolization. The histologic changes induced by embolization in paragangliomas of the head and neck may be classified in four stages. Histologically, the best time for surgery is within 8 days from embolization; surgery performed more than 8 days following embolization, however, is not compromised by revascularization.

Basic fibroblastic growth factor as a potential meningeal angiogenic factor

Vascular supply plays a significant role in the management of skull base tumors. The diagnosis is aided by contrast-enhanced imaging and angiographic techniques, and embolization procedures are used to devascularize certain lesions. The degree of surgical technical difficulty is strongly influenced by the degree of tumor vascularity. Although the importance of this blood supply is clearly understood, the mechanism involved in developing a system of tumor-perfusing vessels is yet to be defined. The development of a vascular network, or angiogenesis, is an important event in allowing tumor proliferation to progress beyond small clusters of cells. Basic fibroblastic growth factor (bFGF) is an especially attractive candidate as an angiogenic growth factor because of its ability to stimulate processes that are characteristic of angiogenesis in vitro. Tumors that involve the meninges may have the ability to liberate normally stored bFGF, which may, in turn, induce new vessel formation for continued tumor proliferation. An immunohistochemical analysis of rodent and bovine meninges to study this phenomenon is described. The dura, arachnoid, and their associated vessels are shown clearly to contain this growth factor. Ultimately, an adjuvant therapy based on the inhibition of angiogenesis may provide a reasonable alternative to aggressive surgical approaches in skull base tumors that are incompletely resectable.

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.

Partition of Calibrated Tris-acryl Gelatin Microspheres in the Arterial Vasculature of Embolized Nasopharyngeal Angiofibromas and Paragangliomas

PURPOSE

To determine the location of calibrated tris-acryl gelatin microspheres (TGMs) in the arterial vasculature of nasopharyngeal angiofibromas (NAFs) and paragangliomas (PGs).

MATERIALS AND METHODS

Forty-nine specimens (25 PGs and 24 NAFs) treated operatively after embolization with TGMs of various sizes (100-300 microm to 900-1200 microm) were stained with hematoxylin and eosin saffron and analyzed at an objective magnification of 10 or 20 with a micrometric eyepiece (magnification, x12.5). The diameter of occluded vessels, their localization (intra- or extratumoral), and the number and diameter of TGMs they contained were determined.

RESULTS

Embolized vessels (N = 1125) were measured: 440 in PGs and 685 in NAFs. Vessels were 89% intratumoral and 11% extratumoral. The diameter of the occluded vessels increased significantly with the size range of TGMs used for embolization for each tumor type (P < .0001). Intratumoral occluded vessels were significantly smaller than extratumoral vessels (P < .0001). Distribution of TGMs within the vascular network (intratumoral or extratumoral location) were similar for NAFs and PGs. The intratumoral and extratumoral dissemination of TGMs was different when comparing 100-300-microm TGMs versus 500-700-microm TGMs (P = .0006) as well as 300-500-microm TGMs versus 500-700-microm TGMs (P = .0001).

CONCLUSIONS

The size of the vessels occluded by TGMs and their intra- or extratumoral location directly depend on the size of the injected TGMs. The vessels located inside the tumors were smaller than those located outside the tumors. A threshold for the intratumoral penetration of TGMs in the vasculature can be proposed from these data. There was no evidence of different behavior of TGMs in NAFs versus PGs.

Glomus jugulare tumors: historical overview of the management of this disease

The treatment of glomus jugulare tumors presents the surgeon with a significant management problem. Because the neoplasm originates in the region of the jugular bulb, it frequently involves the lower cranial nerves, with occasional extension into the posterior fossa. Despite extensive work on the development of surgical and radiation treatment strategies, considerable controversy still exists regarding the optimal management of these lesions. A historical review of the development of management options for glomus jugulare tumors is presented in an effort to offer a foundation for understanding their contemporary treatment.

[Glomus tumors of the temporal bone: a report of 6 cases]

The authors review the clinical, radiological and pathological features of 6 cases of glomus tumors of the temporal bone. Out of the 6 patients, 5 were female; age was distributed between 22 and 76 years (mean 48 years). The main clinical features were hypoacusia, tinnitus and otoscopic findings suggestive of the diagnosis. In one case was noted the concomitant presence of a neurinoma of the VIII cranial nerve with a ipsilateral glomus tumor, and in another case there was a concomitancy of carotid body tumor with temporal glomus jugularis tumor. Metastases were not observed in any case. Tumoral lesions were successfully ressected employing microsurgical techniques and a multidisciplinary staff involving neurosurgeons, head and neck surgeons and otolaryngologists. Radioteraphy was not employed, neither pre-operative embolization. Some aspects related to the nosology, embriology, pathophysiology, diagnosis and treatment of this interesting type of neoplasms are discussed.

A combined infratemporal and posterior fossa approach for the removal of giant glomus tumors and chondrosarcomas

Giant glomus jugulare tumors with a large posterior fossa extension are considered either inoperable or at least requiring of a two-stage operation. Likewise, the surgical approach and treatment for chondrosarcomas of the temporal bone are controversial. We describe a combined approach in which, with the aid of microsurgical and laser techniques, such tumors can be removed in one stage. The surgical approach involves a lateral infratemporal approach combined with a posterior fossa craniectomy. This technique was used in seven cases: five glomus jugulare tumors and two chondrosarcomas. There were no deaths, and surgical morbidity consisted of weakness in the facial nerve in four of these patients and gastrointestinal hemorrhage and respiratory distress syndrome in one patient.

Radiotherapy for jugulo-tympanic paragangliomas (glomus jugulare tumours)

Sixty patients with glomus jugulare tumour, seen at St. Bartholomew's Hospital, London, over forty years, have been reviewed. The term 'jugulo-tympanic paraganglioma' is suggested as a more accurate name for these tumours. The following simple classification is recommended: Group I tumours (tympanic paragangliomas) are those with or without VIIth nerve palsy, but with no other cranial nerve involvement. Group II tumours (jugular paragangliomas) are those with involvement of any cranial nerve other than the VIIth. The method and results of treatment by radiotherapy are discussed. It is concluded that surgery and radiotherapy give comparable results in Group I tumours, but radiotherapy gives superior results in Group II tumours.

Management of vascular soft tissue neoplasms using transcatheter embolization and surgical excision

Preoperative embolization of highly vascular soft tissue tumors was performed in four patients. Selective catheterization of branch vessels supplying the tumors successfully avoided inadvertent embolization of adjacent normal tissue. Operative blood loss was significantly less than anticipated, permitting an easier, more precise, and quicker operation. Two of the lesions were benign intramuscular hemangiomas; one was a fibrosarcoma, and one, a malignant schwannoma. Three tumors were resected completely. A small portion of one hemangioma could not be removed. All patients were free of recurrence during follow-up periods of 6 to 14 months.

Paraganglioma of vagal origin

Vagal paragangliomas are anatomically specific tumors of neuroectodermal origin. The history, embryology, and anatomic classification of these tumors will be reviewed and our present experience with six patients with vagal paragangliomas summarized. All patients had vocal cord dysfunction; various other findings depended upon the extent of the tumor. We found that massive tumors extending rostral to the jugular fossa may be difficult or impossible to distinguish from jugulotympanic paragangliomas.