Rehabilitation of cranial nerve deficits after neurotologic skull base surgery

Multi-Disciplinary Approach to Skull Base Paragangliomas

The treatment of skull base paragangliomas has moved towards the use of cranial nerve preservation strategies, using radiation therapy and subtotal resection in instances when aiming for gross total resection would be expected to cause increased morbidity compared to the natural history of the tumor itself. The goal of this study was to analyze the role of surgery in patients with skull base paragangliomas treated with CyberKnife stereotactic radiosurgery (SRS) for definitive tumor control. A retrospective review identified 22 patients (median age 65.5 years, 50% female) treated with SRS from 2010-2022. Fourteen patients (63.6%) underwent microsurgical resection. Gross total resection was performed in four patients for tympanic paraganglioma (n = 2), contralateral paraganglioma (n = 1), and intracranial tumor with multiple cranial neuropathies (n = 1). Partial/subtotal resection was performed for the treatment of pulsatile tinnitus and conductive hearing loss (n = 6), chronic otitis and otorrhea (n = 2), intracranial extension (n = 1), or episodic vertigo due to perilymphatic fistula (n = 1). Eighteen patients had clinical and imaging follow-up for a mean (SD) of 4.5 (3.4) years after SRS, with all patients having clinical and radiological tumor control and no mortalities. Surgery remains an important component in the multidisciplinary treatment of skull base paraganglioma when considering other outcomes besides local tumor control.

Gracin's Syndrome, a Rare Clinical Challenge in the Setting of Invasive Mucormycosis: A Systematic Review

Garcin's Syndrome is a rare pathology involving multiple cranial nerves in the setting of invasive mucormycosis, usually in immunocompromised patients. Owing to its extremely high mortality rate, clinician should have a high suspicion for diagnosis. This article presents a rare case of Rhino-Orbito-Cerebral Mucormycosis with Garcin's syndrome in a 33-years old male along with a discussion of previously reported cases. The case is discussed in light of scant contemporary literature on the cited subject. A thorough search using the keywords Garcin's Syndrome, Invasive Mucormycosis, Rhino-orbital, Rhino-cerebral mucormycosis, was conducted on Pubmed/MEDLINE, Google scholar, LILACS, medRxiv and Google. A total of six reported cases found in international literature published between 2000 and 2020 were reviewed and analyzed. Garcin's Syndrome is associated with a high mortality rate. In our review, of the total seven patients, only three survived, bringing the collective mortality to 42.85%. Patients had multiple cranial nerve involvement leading to long term sequelae. Our case showed the unique finding of VIII nerve involvement. Early intervention helped in patient survival and better functional outcome. This literature review highlights the distinct clinical nature of the presentation of disease and the importance of prompt diagnosis and early management in the reversal of complications in an otherwise potentially fatal disease.

Comparison of Lower Cranial Nerve Function Between Tympanojugular Paraganglioma Class C1/C2 With and Without Intracranial Extension: A Four-Decade Experience

OBJECTIVE

To compare preoperative and postoperative lower cranial nerve (LCN) function between Class C1 and C2 tympanojugular paraganglioma (TJP) with/without intracranial intradural (Di)/extradural (De) extensions, according to the experience of a single surgeon over four decades.

STUDY DESIGN

Retrospective review.

SETTING

Quaternary referral center for otology and skull base surgery.

MATERIAL AND METHODS

A chart review was conducted of all the patients operated for C1/C2 TJPs from September 1983 to December 2018. The tumors were classified as: Limited-Group (C1/C2 without Di/De extensions) and Extended-Group (C1/C2 with Di/De extensions).

RESULTS

Of 159 patients, 107 (67.3%) were women; the mean age at surgery was 46.5 years. The Limited-Group (56.6%) comprised C1 (41.1%) and C2 (58.9%) tumors; the Extended-Group (43.4%) comprised C1+Di/De (14.5%) and C2+Di/De (85.5%) tumors. The prevalence of preoperative LCN palsy was 11.9 times higher in Extended than Limited tumors: 61.9% versus 4.9% (p < 0.05). The risk for postoperative LCN palsy was 4.7 times greater in Extended than Limited tumors: 29.2% versus 12.9%, p = 0.01.

CONCLUSION

Especially in younger patients, complete removal of Limited C1/C2 tumors, before they extend intracranially, reduces the risk of dysfunctionality of LCNs and the burden of residual tumor. The incidence of new tumors increased over four decades. However, new-postoperative LCN palsy did not occur in any Limited C1/C2 tumors operated after the year 2000, and declined to less than 10% of Extended C1/C2 tumors.

Head and Neck Paragangliomas in the Czech Republic: Management at the Otorhinolaryngology Department

Head and neck paragangliomas (HNPGLs) are rare neuroendocrine tumors, comprising only 3% of all head and neck tumors. Early diagnosis forms an integral part of the management of these tumors. The two main aims of any treatment approach are long-term tumor control and minimal cranial nerve morbidity. The scope of this article is to present our case series of HNPGLs to stress most important clinical aspects of their presentation as well as critical issues of their complex management. Thirty patients with suspected HNPGLs were referred to our otorhinolaryngology clinic for surgical consultation between 2016–2020. We assessed the demographical pattern, clinicoradiological correlation, as well as type and outcome of treatment. A total of 42 non-secretory tumors were diagnosed—16.7% were incidental findings and 97% patients had benign tumors. Six patients had multiple tumors. Jugular paragangliomas were the most commonly treated tumors. Tumor control was achieved in nearly 96% of operated patients with minimal cranial nerve morbidity. Surgery is curative in most cases and should be considered as frontline treatment modality in experienced hands for younger patients, hereditary and secretory tumors. Cranial nerve dysfunction associated with tumor encasement is a negative prognostic factor for both surgery and radiotherapy. Multifocal tumors and metastasis are difficult to treat, even with early detection using genetic analysis. Detecting malignancy in HNPGLs is challenging due to the lack of histomorphological criteria; therefore, limited lymph node dissection should be considered, even in the absence of clinical and radiological signs of metastasis in carotid body, vagal, and jugular paragangliomas.

Long-term Dysphagia following Acoustic Neuroma Surgery: Prevalence, Severity, and Predictive Factors

Background Acoustic neuroma (AN) may compress the cerebellum and brainstem and may cause dysfunction of bulbar cranial nerves.

Objective To describe swallowing function outcomes in the late postoperative period after AN surgery.

Methods This cohort study included patients operated on between 1999–2014, with a mean follow up of 6.4 ± 4.5 years. The swallowing function was assessed through the functional oral intake scale (FOIS). The primary outcome was defined by scores 5 to 1, which implied oral feeding restriction or adaptation. Risks factors were identified through multivariate logistic regression.

Results 101 patients were evaluated. As many as 46 (45.5%) presented dysphagia on the late postoperative period. Women comprised 77.2%, and the mean age was 47.1 ± 16.0 years (range 19–80). Dysphagic patients presented more type II neurofibromatosis (NF II) (32.6% vs. 10.9%, p = 0.007), larger tumors (3.8 ± 1.1 vs. 3.1 ± 1.0 cm, p < 0.001), partial resection (50.0% vs. 85.5%, p < 0.001) and needed more surgeries (≥2, 39.1% vs. 18.2%, p = 0.019). Important peripheral facial palsy (PFP) (House–Brackmann [HB] grade ≥3) was present before the surgery on 47.5% and worsened on 55.4%. Postoperative PFP (p < 0.001), but not preoperative PFP, was predictive of postoperative dysphagia. On multivariate analysis, the following factors were risk factors for dysphagia: NF II (OR 5.54, p = 0.034), tumor size (each 1 cm, OR 2.13, p = 0.009), partial resection (OR 5.23, p = 0.022) and postoperative HB grade ≥3 (OR 12.99, p = 0.002).

Conclusions Dysphagia after AN surgery is highly correlated to postoperative facial motor function. NF II, tumor size, and extent of resection were also predictive of this morbidity in the late postoperative period.

Genetic Variants in Patients with Multiple Head and Neck Paragangliomas: Dilemma in Management

Multiple head and neck paragangliomas (HNPGLs) are neuroendocrine tumors of a mostly benign nature that can be associated with a syndrome, precipitated by the presence of a germline mutation. Familial forms of the disease are usually seen with mutations of SDHx genes, especially the SDHD gene. SDHB mutations are predisposed to malignant tumors. We found 6 patients with multiple tumors amongst 30 patients with HNPGLs during the period of 2016 to 2021. We discuss the phenotypic and genetic patterns in our patients with multiple HNPGLs and explore the management possibilities related to the disease. Fifty percent of our patients had incidental findings of HNPGLs. Twenty-one biochemically silent tumors were found. Four patients had germline mutations, and only one had a positive family history. Three out of five underwent surgery without permanent complications. Preventative measures (genetic counselling and tumor surveillance) represent the gold standard in effectively controlling the disease in index patients and their relatives. In terms of treatment, apart from surgical and radiotherapeutic interventions, new therapeutic measures such as gene targeted therapy have contributed very sparsely. With the lack of standardized protocols, management of patients with multiple HNPGLs still remains very challenging, especially in those with sporadic or malignant forms of the disease.

Surgical Rehabilitation of Voice and Swallowing after Jugular Foramen Surgery

Objectives

We sought to determine the patient population that will benefit from surgical rehabilitation of voice and swallowing after jugular foramen tumor (JFT) resection.

Methods

We performed a retrospective case study of patients with a history of JFT resection. The patients' files were reviewed for data on preoperative and postoperative function of cranial nerves VII and IX through XII, voice and swallowing function, and surgical procedures for voice and swallowing rehabilitation and their timing.

Results

Twenty-one patients underwent JFT resection. Thirty-eight percent presented with deficits of cranial nerves VII and IX through XII, and 61% developed new postoperative deficits. Three patients recovered glossopharyngeal nerve function, 2 recovered vagus nerve function, and 1 recovered facial nerve function. Surgical rehabilitation procedures were undertaken in 8 patients. Patients who eventually underwent surgical rehabilitation procedures for voice and swallowing tended to have larger tumors, tumors within the nerve bundle in the jugular foramen, and multiple nerve deficits.

Conclusions

Most patients with multiple deficits of cranial nerves VII and IX through XII after JFT resection are unlikely to regain spontaneous nerve function, will experience long-term dysphonia and dysphagia, and will elect to undergo corrective surgery to improve voice and swallowing. Preoperative evaluation and close postoperative follow-up can identify patients who would benefit from early surgical rehabilitation.

Gamma Knife radiosurgery for glomus jugulare tumors: a single-center series of 75 cases

OBJECTIVE Glomus jugulare tumors are rare indolent tumors that frequently involve the lower cranial nerves (CNs). Complete resection can be difficult and associated with lower CN injury. Gamma Knife radiosurgery (GKRS) has established its role as a noninvasive alternative treatment option for these often formidable lesions. The authors aimed to review their experience at the National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom, specifically the long-term tumor control rate and complications of GKRS for these lesions. METHODS Clinical and radiological data were retrospectively reviewed for patients treated between March 1994 and December 2010. Data were available for 75 patients harboring 76 tumors. The tumors in 3 patients were treated in 2 stages. Familial and/or hereditary history was noted in 12 patients, 2 of whom had catecholamine-secreting and/or active tumors. Gamma Knife radiosurgery was the primary treatment modality in 47 patients (63%). The median age at the time of treatment was 55 years. The median tumor volume was 7 cm³, and the median radiosurgical dose to the tumor margin was 18 Gy (range 12-25 Gy). The median duration of radiological follow-up was 51.5 months (range 12-230 months), and the median clinical follow-up was 38.5 months (range 6-223 months). RESULTS The overall tumor control rate was 93.4% with low CN morbidity. Improvement of preexisting deficits was noted in 15 patients (20%). A stationary clinical course and no progression of symptoms were noted in 48 patients (64%). Twelve patients (16%) had new symptoms or progression of their preexisting symptoms. The Kaplan-Meier actuarial tumor control rate was 92.2% at 5 years and 86.3% at 10 years. CONCLUSIONS Gamma Knife radiosurgery offers a risk-versus-benefit treatment option with very low CN morbidity and stable long-term results.

Hypopharyngeal Pharyngoplasty in the Management of Pharyngeal Paralysis: A New Procedure

Dysphagia after a high vagal nerve injury may be associated with a patulous hypopharynx that serves as a reservoir for pharyngeal secretions, contributing to primary or secondary aspiration. We describe a new hypopharyngeal pharyngoplasty procedure for the paralyzed pharynx to improve swallow. The paralyzed pyriform sinus is resected to remove insensate and redundant mucosa. The inferior constrictor muscle is then advanced anterior to the oblique line of the thyroid cartilage to improve pharyngeal tone and prevent pharyngeal dilatation. The surgery is performed in conjunction with medialization laryngoplasty and arytenoid adduction. The utility of this procedure is reviewed retrospectively in 8 patients. They were evaluated by clinical evaluation, fiberoptic endoscopic evaluation of swallow, and modified barium swallow study. All had significant preoperative dysphagia. Three patients were gastrostomy tube-dependent. After operation, all patients had subjective and objective improvements in swallow and progressed to peroral feeding. There were no operative complications. We conclude that hypopharyngeal pharyngoplasty diminishes pyriform sinus pooling and improves pharyngeal transit. Dysphagia patients with unilateral pharyngeal paralysis secondary to cranial nerve palsies may benefit from this new procedure.

Initial radiographic tumor control is similar following single or multi-fractionated stereotactic radiosurgery for jugular paragangliomas

OBJECTIVE

To evaluate radiographic tumor control and treatment-related toxicity in glomus jugulare tumors treated with stereotactic radiosurgery (SRS).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic referral center.

PATIENTS

Glomus jugulare tumors treated with SRS between 1998 and 2014 were identified. The data analysis only included patients with at least 18months of post-treatment follow up (FU).

INTERVENTION

Patients were treated with either single fraction or fractionated SRS.

MAIN OUTCOME MEASURE

Patient demographics and tumor characteristics were assessed. Radiographic control was determined by comparing pre and post treatment MRI, and was categorized as no change, regression, or progression.

RESULTS

Eighteen patients were treated with SRS, and 14 met inclusion criteria. Median age at treatment was 55years (range 35-79), and 71.4% of patients were female. 5 patients (35.7%) received single fraction SRS (dose range 15-18Gy), and 9 (64.3%) fractionated therapy (dose 3-7Gy×3-15 fractions). Median tumor volume was 3.78cm(3) (range 1.15-30.6). Median FU was 28.8months (range 18.6-56.1), with a mean of 31.7months. At their last recorded MRI, 7 patients (50%) had tumor stability, 6 (42.9%) had improvement, and 1 (7.1%) had progression. Disease improvement and progression rates in the single fraction group were 40% and 0%, and in the multiple-fraction group, 44.4% and 11.1%, respectively. There was no statistically significant difference in disease improvement (p=0.88) or progression (p=0.48) rates between groups (unpaired t-test).

CONCLUSIONS

At a median follow up of 28months, both single fraction and fractionated SRS appear to have comparable radiographic tumor control outcomes and toxicity profiles.

Natural History of Glomus Jugulare

Objective

To characterize clinical disease progression and radiologic growth in a series of observed, previously untreated, glomus jugulare tumors (GJT).

Study Design

Retrospective review.

Setting

Tertiary neurotologic referral center.

Subjects and Methods

All patients with primary GJTs that were observed without intervention for a minimum of 2 years. Primary outcome measures included progression of cranial neuropathy and/or radiologic growth.

Results

A total of 15 patients (80% female; median age, 69.6 years) with 16 GJTs met inclusion criteria. The most common indications for observation included advanced age (11; 73%) and patient preference (11; 73%). Cranial nerve function remained stable in most subjects over a median clinical follow-up period of 86.4 months. Among the 12 with serial imaging, 5 (42%) GJTs demonstrated radiologic growth, while 7 (58%) remained stable. The median growth rate of the 5 enlarging tumors using the maximum linear dimension was 0.8 mm/y (range, 0.6-1.6 mm/y) or 0.4 cm3/y (0.1-0.9 cm3/y) using volumetric analysis. There were no deaths attributable to tumor progression or treatment.

Conclusion

In an older subset of patients, we found that a significant number of GJTs do not grow after time of diagnosis and symptoms frequently remain stable for many years. Even with disease progression, most GJTs exhibit indolent growth with slowly progressive cranial neuropathy, affording satisfactory physiologic compensation in most patients. In the absence of brainstem compression or concern for malignancy, observation of GJTs is a viable initial management option for elderly patients.

Subtotal Resection for Management of Large Jugular Paragangliomas with Functional Lower Cranial Nerves

Objectives

To evaluate tumor control following subtotal resection of advanced jugular paragangliomas in patients with functional lower cranial nerves and to investigate the utility of salvage radiotherapy for residual progressive disease.

Study Design

Case series with planned chart review.

Setting

Tertiary academic referral center.

Subjects and Methods

Patients who presented with advanced jugular paragangliomas and functional lower cranial nerves were analyzed. Primary outcome measures included extent of resection, long-term tumor control, need for additional treatment, and postoperative lower cranial nerve function.

Results

Twelve patients (mean age, 46.2 years; 7 women, 58.3%) who met inclusion criteria were evaluated between 1999 and 2013. The mean postoperative residual tumor volume was 27.7% (range, 3.5%-75.0%) of the preoperative volume. When the residual tumor volume was less than 20% of the preoperative volume, no tumor growth occurred over an average of 44.6 months of follow-up ( P < .01). Four tumors (33.3%) demonstrated serial growth at a mean of 23.5 months following resection, 2 of which were treated with salvage stereotactic radiotherapy providing control through the last recorded follow-up. No patient experienced permanent postoperative lower cranial neuropathy as a result of surgery.

Conclusion

Subtotal resection of jugular paragangliomas with preservation of the lower cranial nerves is a viable management strategy. If more than 80% of the preoperative tumor volume is resected, the residual tumor seems less likely to grow.

The management of head-and-neck paragangliomas

Paragangliomas (PGLs) are tumours originating from neural crest-derived cells situated in the region of the autonomic nervous system ganglia. Head-and-neck PGLs (HNPGLs) originate from the sympathetic and parasympathetic paraganglia, most frequently from the carotid bodies and jugular, tympanic and vagal paraganglia, and are usually non-catecholamine secreting. Familial PGLs are considered to be rare, but recently genetic syndromes including multiple PGLs and/or phaeochromocytomas have been more thoroughly characterised. Nowadays, genetic screening for the genes frequently implicated in both familial and sporadic cases is routinely being recommended. HNPGLs are mostly benign, generally slow-growing tumours. Continuous growth leads to the involvement of adjacent neurovascular structures with increased morbidity rates and treatment-related complications. Optimal management mostly depends on tumour location, local involvement of neurovascular structures, estimated malignancy risk, patient age and general health. Surgery is the only treatment option offering the chance of cure but with significant morbidity rates, so a more conservative approach is usually considered, especially in the more difficult cases. Radiotherapy (fractionated or stereotactic radiosurgery) leads to tumour growth arrest and symptomatic improvement in the short term in many cases, but the long-term consequences are unclear. Early detection is essential in order to increase the chance of cure with a lower morbidity rate. The constant improvement in diagnostic imaging, surgical and radiation techniques has led to a safer management of these tumours, but there are still many therapeutic challenges, and no treatment algorithm has been agreed upon until now. The management of HNPGLs requires a multidisciplinary effort addressing the genetic, surgical, radiotherapeutic, oncological, neurological and endocrinological implications. Further progress in the understanding of their pathogenesis will lead to more effective screening and earlier diagnosis, both critical to successful treatment.

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.

Normal life expectancy for paraganglioma patients: a 50-year-old cohort revisited

The objective of this study was to assess the long-term survival of patients with a paraganglioma of the head and neck compared with the survival of the general Dutch population. This historic cohort study was conducted using nationwide historical data of paraganglioma patients. We retrieved a cohort of 86 patients diagnosed with a paraganglioma of the head and neck between 1945 and 1960 in the Netherlands. Dates of death were retrieved from the national bureau of genealogy. Survival after diagnosis was compared with age and sex adjusted survival in the general population, by means of Wilcoxon signed rank test and Kaplan-Meier actuarial survival curves. Although surgery had more complications in the studied era than today and the death of five patients with carotid body tumors caused immediate excess mortality, the survival of the followed cohort was not significantly reduced if compared with the general population. Paragangliomas of the head and neck do not reduce life expectancy.

Rehabilitation after treatment for jugular foramen lesions

Swallowing problems following jugular foramen surgery are more common than is often acknowledged and affect up to a third of our patients. They have a significant effect on quality of life. We have become more proactive in this respect and anticipate these problems before they become established. In this article we present our management protocol that has evolved over the past 30 years as a result of our experience treating 134 glomus jugulare tumors. Our current protocol involves a thorough preoperative assessment of swallowing. After jugular foramen surgery, patients undergo further evaluation using fiberoptic endoscopic evaluation of swallowing (FEES), videofluoroscopy, and manometry. Those with prolonged or poorly compensated dysphagia are offered rehabilitation surgery. We describe this technique, which has proved beneficial to our patients. Guidelines for management are proposed.

First-Bite Syndrome Complicating Carotid Endarterectomy: A Case Report and Literature Review

First-bite syndrome (FBS) is an infrequently encountered complication of parapharyngeal space surgery. Patients experience excruciating pain in the ipsiltateral parotid gland region at the first bite of each meal, which improves with subsequent mastication. This is thought to be due to parotid gland sympathetic denervation from surgery with resultant hypersensitivity to parasympathetic impulses. There is no consensus on best treatment for FBS although symptoms tend to improve with time. There are only 2 case reports linking carotid endarterectomy and FBS so far. We report the third case of FBS after carotid endarterectomy to raise awareness among vascular surgeons of the possibility of this complication.

Retropharyngeal lymphadenectomy with transoral robotic surgery for papillary thyroid cancer

Retropharyngeal metastasis of papillary thyroid carcinoma is a rare but well recognized phenomenon. Traditional open surgical approaches to nodal metastasis located in the retropharyngeal space are particularly morbid considering the relatively indolent nature of some thyroid cancers. Minimally invasive surgical approaches offer a useful alternative that is both low in morbidity and high in levels of patient acceptance. To assess feasibility and safety, we report a case series of robotic lymphadenectomy in two patients with thyroid cancer metastatic to the retropharyngeal space. Two patients, ages 66 and 73, with unilateral recurrent papillary carcinoma of the retropharyngeal lymph nodes had previously undergone thyroidectomy, neck dissection, and radioactive iodine ablation prior to retropharyngeal resection. Retropharyngeal lymphadenectomy via transoral robotic surgery was performed for both patients: for the first, the oropharyngeal wound was left to heal by secondary intention, while for the other patient, simple pharyngeal flap closure was performed. Retropharyngeal lymph node dissections were successfully carried out using a transoral robotic retropharyngotomy with the da Vinci surgical robotic system. Both patients tolerated the procedure well. One patient did developed temporary dysphagia which resolved with conservative measures, not requiring a feeding tube. We report the first two cases of transoral robot-assisted resection of thyroid cancer metastatic to the retropharyngeal lymph nodes. The technique is feasible, minimally invasive, and appears to be as safe as conventional surgical methods in achieving the goals of management of regionally metastatic disease.

Linac-based stereotactic body radiation therapy for treatment of glomus jugulare tumors

BACKGROUND

Glomus jugulare tumors are rare, typically benign, tumors that arise from the neural crest cells that are associated with the autonomic ganglia in and around the jugular bulb. Treatment options for glomus jugulare tumors include embolization followed by resection, fractionated external beam radiation therapy (EBRT), stereotactic radiosurgery (SRS), and/or stereotactic body radiation therapy (SBRT).

MATERIALS AND METHODS

18 patients were treated with linear-accelerator based stereotactic body radiation therapy (SBRT) between May 2002 and November 2008. Fifteen patients (83%) had single glomus jugulare tumors and 3 patients had bilateral glomus jugulare tumors (although each of these patients had a single tumor targeted). The median tumor volume was 5.83 cm(3) (range, 0.32-35.47 cm(3)). Ten tumors (56%) were previously untreated, and 8 (44%) tumors were persistent after previous surgical resection. One patient had undergone previous EBRT and 2 patients were previously treated with Gamma Knife radiosurgery to the intracranial portion of their tumor, with planned SBRT to the extracranial portion 2-4 months later at our institution. The median prescribed dose was 20 Gy in 3 fractions (range: 16-25 Gy in 1-5 fx) to the 80% isodose line. The median prescription coverage of the tumor was 93.6% (range: 83-98.72%).

RESULTS

Median follow-up for the entire cohort was 22 months. All the patients were alive at the time of the last follow-up with imaging available for review. The tumor was stable in 17 patients and decreased in size in one patient--yielding a local control rate of 100%. No patients experienced any new or worsening treatment-related neurologic deficits.

CONCLUSIONS

SBRT is a safe and efficacious treatment modality for glomus jugulare tumors.

Glomus tumors in patients of advanced age: a conservative approach

OBJECTIVES

Identify and discuss controversies in the management of paragangliomas in elderly patients. Assess and evaluate a conservative treatment strategy involving limited surgical resection and vigilant monitoring of the outcome measures of tumor control, peritreatment morbidity, symptom resolution, and hearing preservation.

STUDY DESIGN

Retrospective case review.

METHODS

All of the patients in this study were over age 60 with temporal bone glomus tumors. Primary outcome assessment included length of hospitalization, perioperative morbidity, symptom resolution, hearing preservation, and long-term tumor control.

RESULTS

Twelve female patients with mean age of 74.5 years (range 61-85 years) with follow-up from 24 months to 33 years (mean/median: 5/7.8 years) were identified. Nine (75%) of the patients presented with pulsatile tinnitus. Seven patients (58%) underwent surgical excision of the middle ear component of the paraganglioma. Tumors extending to the jugular foramen were purposely not resected. Five patients (45%) had relative or absolute contraindications to surgical resection and were treated with observation or primary radiation therapy. Post-treatment audiometric evaluation confirmed stable or improved hearing. Pulsatile tinnitus resolved in all patients. No patient experienced cranial nerve deficits, extended hospitalization, or blood transfusions. All patients were followed closely with radiological imaging. The majority of patients demonstrated no disease or stable disease, while two patients demonstrated tumor growth 6 years after diagnosis.

CONCLUSION

A prolonged natural history and the morbidity associated with surgical intervention have led to controversies in the treatment of glomus tumors in an elderly population. Our experience supports recent limited reports advocating conservative surgical excision and vigilant long-term monitoring in this population.

Treatment of Glomus Jugulare Tumors in Patients with Advanced Age: Planned Limited Surgical Resection Followed by Staged Gamma Knife Radiosurgery: A Preliminary Report

OBJECTIVE

To minimize treatment comorbidities in glomus jugulare tumor patients with advanced age while reducing pulsatile tinnitus and preserving or improving residual hearing using a limited middle ear/mastoid tumor resection and postoperative gamma knife radiosurgery to tumor remnants in the jugular foramen region.

STUDY DESIGN

Retrospective consecutive case review of five patients.

SETTING

Tertiary referral, academic medical center.

PATIENTS

Patients with advanced age (mean, 69.6 yr; range, 61-78 yr) harboring symptomatic glomus jugulare tumors.

INTERVENTION

All patients were treated with resection of middle ear and mastoid portions of tumor and subsequent gamma knife radiosurgery to jugular foramen portion of tumor.

MAIN OUTCOME MEASURES

Length of hospitalization; hearing, pulsatile tinnitus, cranial nerve, and tumor control status.

RESULTS

All patients were treated on an outpatient surgical basis without the need for blood transfusion. There were no incidents of a change in cranial nerve status (Cranial Nerves VII, IX, X, XI, and XII) in the immediate postoperative period. All patients had improvement or resolution of pulsatile tinnitus with preservation or improvement of preoperative hearing levels. Tumor volume was stable or reduced in all patients at mean follow-up of 19 months (range, 11-24 mo). Gamma knife radiosurgery (mean peripheral dose of 15 Gy) was not associated with any significant immediate or delayed complications.

CONCLUSION

Short-term data reveals that staged microsurgical and radiosurgical therapy for glomus jugulare tumors in the symptomatic patient with advanced age is safe and yields favorable results regarding tinnitus, hearing, and cranial nerve status. Long-term data are needed to further evaluate the effectiveness of this treatment algorithm before extrapolating this treatment option to younger patients.

Gamma knife surgery for glomus jugulare tumors: an intermediate report on efficacy and safety

OBJECT

Glomus jugulare tumors are rare tumors that commonly involve the middle ear, temporal bone, and lower cranial nerves. Resection, embolization, and radiation therapy have been the mainstays of treatment. Despite these therapies, tumor control can be difficult to achieve particularly without undo risk of patient morbidity or mortality. The authors examine the safety and efficacy of gamma knife surgery (GKS) for glomus jugulare tumors.

METHODS

A retrospective review was undertaken of the results obtained in eight patients who underwent GKS for recurrent, residual, or unresectable glomus jugulare tumors. The median radiosurgical dose to the tumor margin was 15 Gy (range 12-18 Gy). The median clinical follow-up period was 28 months, and the median period for radiological follow up was 32 months. All eight patients demonstrated neurological stability or improvement. No cranial nerve palsies arose or deteriorated after GKS. In the seven patients in whom radiographic follow up was obtained, the tumor size decreased in four and remained stable in three.

CONCLUSIONS

Gamma knife surgery would seem to afford effective local tumor control and preserves neurological function in patients with glomus jugulare tumors. If long-term results with GKS are equally efficacious, the role of stereotactic radiosurgery will expand.

Surgical management of parapharyngeal space masses

BACKGROUND

We sought to examine surgical techniques used to remove parapharyngeal space (PPS) masses.

METHODS

This retrospective search was conducted from 1980 to 2003. Age, sex, diagnosis, surgical approach, complications, and outcome were collected.

RESULTS

One hundred sixty-six PPS masses were identified: 21 (12.7%) were malignant, 145 (87.3%) were benign, 76 (45.8%) were vascular, and 69 (41.6 %) involved the skull base. Transcervical techniques were used in all cases. Removing the styloid and its musculature and level II lymphadenectomies enhanced exposure for vascular and skull base tumors. Thirty transcervical-transmastoid dissections (20.4%) facilitated removal of vascular skull base tumors. To identify the facial nerve, 20 transparotid-transcervical approaches (13.6%) were performed. Three mandibulotomies (2.0%) were required for internal carotid artery involvement. Expected neurologic sequelae resulted from cranial nerve involvement by tumor. Three patients (2.0%), all presenting with recurrent cancer, had local recurrences.

CONCLUSION

Careful patient assessment and surgical techniques allow the oncologically safe removal of benign, vascular, and skull base PPS tumors.

Gamma knife surgery for glomus jugulare tumors: an intermediate report on efficacy and safety

Object. Glomus jugulare tumors are rare tumors that commonly involve the middle ear, temporal bone, and lower cranial nerves. Resection, embolization, and radiation therapy have been the mainstays of treatment. Despite these therapies, tumor control can be difficult to achieve particularly without undo risk of patient morbidity or mortality. The authors examine the safety and efficacy of gamma knife surgery (GKS) for glomus jugulare tumors.

Methods. A retrospective review was undertaken of the results obtained in eight patients who underwent GKS for recurrent, residual, or unresectable glomus jugulare tumors. The median radiosurgical dose to the tumor margin was 15 Gy (range 12–18 Gy). The median clinical follow-up period was 28 months, and the median period for radiological follow up was 32 months.

All eight patients demonstrated neurological stability or improvement. No cranial nerve palsies arose or deteriorated after GKS. In the seven patients in whom radiographic follow up was obtained, the tumor size decreased in four and remained stable in three.

Conclusions. Gamma knife surgery would seem to afford effective local tumor control and preserves neurological function in patients with glomus jugulare tumors. If long-term results with GKS are equally efficacious, the role of stereotactic radiosurgery will expand.

Stereotactic radiosurgery in patients with glomus jugulare tumors

Object

Microsurgical removal of glomus jugulare tumors is frequently associated with injury of the lower cranial nerves. To decrease the morbidity associated with tumor management in these patients, gamma knife surgery (GKS) was performed as an alternative to resection.

Methods

Between 1990 and 2003, 42 patients underwent GKS as the primary management (19 patients) or for recurrent glomus jugulare tumors (23 patients). Facial weakness and deafness were more common in patients with recurrent tumors than in those in whom primary GKS was performed (48% compared with 11%, p = 0.02). The mean tumor volume was 13.2 cm3; the mean tumor margin dose was 14.9 Gy. The mean follow-up period for the 39 patients in whom evaluation was possible was 44 months (range 6–149 months). After GKS, 12 tumors (31%) decreased in size, 26 (67%) were unchanged, and one (2%) grew. The patient whose tumor grew underwent repeated GKS. Progression-free survival after GKS was 100% at 3 and 7 years, and 75% at 10 years. Six patients (15%) experienced new deficits (hearing loss alone in three, facial numbness and hearing loss in one, vocal cord paralysis and hearing loss in one, and temporary imbalance and/or vertigo in one). In 26 patients in whom hearing could be tested before GKS, hearing preservation was achieved in 86 and 81% at 1 and 4 years posttreatment, respectively. No patient suffered a new lower cranial nerve deficit after one GKS session; the patient in whom repeated GKS was performed experienced a new vocal cord paralysis 1 year after his second procedure.

Conclusions

Gamma knife surgery provided tumor control with a low risk of new cranial nerve injury in early follow-up review. This procedure can be safely used as a primary management tool in patients with glomus jugulare tumors that do not have significant cervical extension, or in patients with recurrent tumors in this location.

The role of Gamma Knife radiosurgery in the management of glomus jugular tumours

BACKGROUND

Glomus jugular tumours are usually managed by microsurgical resection and/or radiotherapy with considerable risk for treatment-related morbidity. The role of Gamma Knife Radiosurgery (GKRS) in the management of these lesions remains to be defined.

METHOD

Between May 1992 and November 2000, 19 patients with glomus tumours underwent GKRS at our department. Nine patients received radiosurgery for residual or recurrent paragangliomas following microsurgical resection and in 10 cases GKRS was performed as primary treatment. The median tumour volume was 5.22 ccm (range: 0.38-33.5 ccm). Marginal doses of 12-20 Gy (median 14 Gy) were applied to enveloping isodose volume curves (Range: 30-55%, median 50%).

FINDINGS

Except for an 81-year-old patient who died 9 months after radiosurgery the observation time ranged from 1.5 to 10 years (median 7.2 yrs). The total tumour control rate was 94.7% (7 cases with decreased and 11 with stable tumour size). The only patient with tumour progression (5.3%) underwent repeated radiosurgical treatment 85 months after initial GKRS. A newly diagnosed second lesion in the cavernous sinus was treated radiosurgically as well 53 months after the first Gamma Knife procedure. On clinical examination 10 patients (52.6%) presented with improved and 8 patients (42.1%) with unchanged neurological status. Deterioration in one patient (5.3%) was not related to tumour or radiosurgery.

INTERPRETATION

As GKRS demonstrated to be a minimally invasive treatment alternative to microsurgery and radiotherapy with no acute or chronic toxicity it should be considered more frequently in the primary or adjuvant strategy for glomus jugular tumours.

Improved outcomes with early vocal fold medialization for vocal fold paralysis after thoracic surgery

OBJECTIVE

To determine the clinical impact of early versus late surgical therapy for new onset unilateral vocal cord paralysis (UVCP) after thoracic surgery.

STUDY DESIGN

Patients diagnosed with new onset UVCP after esophagectomy, pneumonectomy or pulmonary lobectomy were reviewed to determine the incidence of pneumonia, need for postoperative bronchoscopy and length of stay (LOS). Comparisons were made between patients undergoing early (< or = 4 days after thoracic procedure) versus late rehabilitation (> or = 5 days after thoracic procedure) of their UVCP with vocal cord medialization.

RESULTS

Some 86 patients (27 esophagectomies, 43 pneumonectomies and 16 lobectomies) with new onset UVCP were examined. A total of 32 patients (37.2%) underwent early vocal cord medialization and 54 (62.8%) underwent late repair. The pneumonia rate for patients undergoing early vocal cord medialization (6.3%) was significantly lower than the rate for vocal cord medialization (37.0%, P=0.001, chi(2)). Early medialization patients required fewer postoperative bronchoscopies (mean number of bronchoscopies, 0.26) than late medialization patients (mean bronchoscopies, 0.94, P=0.013). The median LOS was significantly decreased for early versus late medialization patients in both pneumonectomy (reduction in LOS of 8 days) and lobectomy groups (reduction in LOS of 7 days).

CONCLUSIONS

Early vocal cord medialization decreases the pneumonia rate, the requirement for postoperative bronchoscopies and the LOS for patients suffering from new onset UVCP after thoracic surgery.

SIGNIFICANCE

Consideration should be given to early medialization for new onset UVCP when medically sound.

[Consequences of the bilateral vagus nerve section at a cervical level]

We present the consequences corresponding to a bilateral section of the main trunk of vagus nerve at cervical level in a patient with an oropharyngeal carcinoma with bilateral neck nodes. As a consequence of the bilateral resection of both vagus nerves during neck dissections, as well as motor and sensitive damage of the larynx and pharynx, we could observe affection of the normal tone of the oesophagus, stomach and duodenum which forced to enteral nutrition by direct jejunal access, and a disorder of the cardiac rhythm due to loss of the parasympathetic innervation appeared.

Palatal adhesion: the treatment of unilateral palatal paralysis after high vagus nerve injury

BACKGROUND

Resection of skull base tumors commonly necessitates intraoperative sacrifice of lower cranial nerves at the level of the jugular foramen. Sequelae of unilateral vagus nerve loss include ipsilateral laryngeal paralysis, ipsilateral palatal and pharyngeal paralysis, and velopharyngeal incompetence (VPI) marked by hypernasal speech and nasopharyngeal reflux of liquids during swallowing.

METHODS

Palatal adhesion (PA), a procedure whereby the unilaterally paralyzed palate is attached to the posterior pharyngeal wall, decreases the size of the velopharyngeal port and minimizes the symptoms. This study assessed the outcome of PA in 31 patients with VPI secondary to proximal vagus nerve injury.

RESULTS

PA decreased postoperative nasality in 96% of patients. Nasopharyngeal reflux was significantly improved in 83%. Three patients (11%) had minor wound breakdown postoperatively, all of which healed completely with conservative management.

CONCLUSION

PA offers a favorable result with minimal concomitant morbidity and is recommended for patients with VPI secondary to unilateral proximal vagus nerve paralysis.

Glomus jugulare tumor: tumor control and complications after stereotactic radiosurgery

BACKGROUND

We evaluated toxicity and long-term efficacy of stereotactic radiosurgery in patients with symptomatic or progressive glomus jugulare tumors.

METHODS

Twenty-five consecutive patients (age, 30-88 years; 17 women, 8 men) who underwent stereotactic radiosurgery with the Leksell Gamma Knife (dose, 12-18 Gy) were prospectively followed. MRI and clinical examinations were performed at 6 months and 1, 2, and 3 years, and then every 2 years.

RESULTS

None of the tumors increased in size, 17 were stable, and 8 decreased (median imaging follow-up, 35 months; range, 10-113 months). Symptoms subsided in 15 patients (60%); vertigo occurred in 1, but balance improved with vestibular training (median clinical follow-up, 37 months; range, 11-118 months). No other new or progressive neuropathy of cranial nerves V-XII developed.

CONCLUSIONS

Stereotactic radiosurgery can achieve excellent tumor control with low risk of morbidity in the treatment of glomus jugulare tumors. The lower cranial nerves can safely tolerate a radiosurgical dose of 12 to 18 Gy.

Stereotactic radiosurgery: the preferred management for patients with nonvestibular schwannomas?

PURPOSE

To review patient outcomes after radiosurgery of nonvestibular schwannomas.

MATERIALS AND METHODS

From April 1992 to February 2000, 23 patients had radiosurgery at our center for nonvestibular schwannomas. Affected cranial nerves included the trochlear (n = 1), trigeminal (n = 10), jugular foramen region (n = 10), and hypoglossal (n = 2). Nine patients had undergone one or more prior tumor resections. One patient had a malignant schwannoma; 2 patients had neurofibromatosis. The median prescription isodose volume was 8.9 cc (range, 0.2 to 17.6 cc). The median tumor margin dose was 18 Gy (range, 12 to 20 Gy); the median maximum dose was 36 Gy (range, 24 to 40 Gy). The median follow-up after radiosurgery was 43 months (range, 12 to 111 months).

RESULTS

Twenty-two of 23 tumors (96%) were either smaller (n = 12) or unchanged in size (n = 10) after radiosurgery. One patient with a malignant schwannoma had tumor progression outside the irradiated volume despite having both radiosurgery and fractionated radiation therapy (50.4 Gy); he died 4 years later. Morbidity related to radiosurgery occurred in 4 patients (17%). Three of 10 patients with trigeminal schwannomas suffered new or worsened trigeminal dysfunction after radiosurgery. One patient with a hypoglossal schwannoma had eustachian tube dysfunction after radiosurgery. No patient with a lower cranial nerve schwannoma developed any hearing loss, facial weakness, or swallowing difficulty after radiosurgery.

CONCLUSIONS

Although the reported number of patients having radiosurgery for nonvestibular schwannomas is limited, the high tumor control rates demonstrated after vestibular schwannoma radiosurgery should apply to these rare tumors. Compared to historical controls treated with surgical resection, radiosurgery appears to have less treatment-associated morbidity for nonvestibular schwannomas, especially for schwannomas involving the lower cranial nerves.

Vagal paragangliomas

The management of vagal paragangliomas is extremely challenging. Treatment of these lesions must be tailored individually for each patient. The best treatment modality depends on the patient's age and health and the size and extent of the tumor. This article discusses clinical presentation, multicentric and malignant vagal paragangliomas, evaluation, embolization, surgical management, and special considerations in the management of vagal paragangliomas.

Sympathetic paraganglioma as an unusual cause of Horner's syndrome

BACKGROUND

Paragangliomas are rare tumors arising from paraganglionic tissue of neural crest origin. They are present in any location where autonomic ganglia are found. The most common location in the head and neck is the carotid body, followed by the jugular bulb and vagus nerve.

METHODS

A 30-year-old woman with a slowly growing left neck mass, aniscoria, and left eyelid ptosis was found to have a vascular tumor consistent with a paraganglioma arising near the left carotid bifurcation. After preoperative embolization, the patient underwent resection of the tumor.

RESULTS

The tumor was found to be arising from the left sympathetic trunk and did not involve any other surrounding structures. Histopathologic analysis revealed the typical findings of a paraganglioma.

CONCLUSIONS

Sympathetic paragangliomas are exceedingly rare tumors in the head and neck and should be considered in the differential diagnosis when clinical and radiographic evidence suggest a paraganglioma. The presentation is typically a slow-growing neck mass with the presence of an ipsilateral Horner's syndrome.

Tinnitus. Current evaluation and management

Evaluation and management of tinnitus presents a significant challenge to the internist and the otolaryngologist. Tinnitus may be divided into two basic categories: subjective and objective. The importance of a thorough history and physical examination is emphasized in this article. The steps in a complete evaluation and the rationale for referral to an otolaryngologist are outlined. Multidisciplinary care of the tinnitus patient is best coordinated by the otolaryngologist.

Intravagal paragangliomas: report of four cases

The intravagal paraganglioma is a very rare tumor of the head and neck that accounts for only 5% of the paragangliomas in that area. A painless mass in the high neck with extension into the peripharyngeal space is the most common characteristic of this tumor. Malignant paragangliomas with invasion of the cervical lymph nodes and carotid artery have been reported, but the presence of metastasis, rather than the histological findings, is the only parameter for classifying them as malignant tumors. Despite the numerous descriptions of the efficacy of radiation therapy, the histological findings of irradiated specimens have shown little effect of radiation therapy on the chief cells. The only curative therapy for intravagal paragangliomas is the total resection of the tumor. Using the supra-adventitia dissection plane, we were able to achieve total resections in four cases of complex intravagal paraganglioma. The surgical management of these cases was complex because of the following: 1) misdiagnosis as a carotid body tumor, 2) previous radiation therapy and surgical procedure, 3) association with glomus jugulare, and 4) a giant tumor with invasion of the temporal bone and encasement of the internal carotid artery. We report the surgical management of intravagal paragangliomas and the role of radiation therapy, hormonal secretion, and rehabilitation care.

The management of dysphagia in jugular foramen surgery

From 1985-1994, the Skull Base Unit at St. Vincent's Hospital, Sydney, operated on 61 patients with tumours involving the jugular foramen. Pre-operative assessment by a Speech Pathologist and the institution of swallowing techniques prior to surgery have improved post-operative morbidity. Ancillary procedures at the time of surgery were not required in the majority of cases. An individual assessment of each patient early in the postoperative period was found to be more important with regard to the benefits of supplementary surgery. The majority of patients with dysphagia settled with conservative management and only a few underwent ancillary surgery. It is perceived that the cortical and subcortical control of swallowing is a major factor in the rehabilitation of these patients.

Evolution of outcomes in cranial base surgery

Cranial base surgery is a young field of head and neck and neuro-oncology. It deals with solid tumors at the skull base which were not previously treated with surgery. The development of new cranial base approaches incorporating intracranial exposure and new reconstructive techniques now enable an "en bloc" resection of most of these difficult tumors. In order to analyze the evolution of cranial base surgery and its contribution to the treatment of carcinomas and sarcomas, we reviewed the results reported in the literature over the past 40 years. We have designated three periods of time that reflect the advances and impact of skull base surgery and have summarized the outcomes of the major contributors in each era. The pioneers of the first period (1960s-1970s) achieved 3- and 5-year survivals of 52 and 49% while attempting resection of tumors without intracranial or pytergopalatine extension. In the second period (1970s-1980s), improved surgical techniques allowed resection of more extensive tumors, including intracranial invasion, and 3-year survivals rose to 57-59% with limited reports of 5-year survivals in the range of 49%. The third period of cranial base surgery (1980s-1990s) brought further refinement of techniques, introduced the concept of a coordinated multispecialty approach, and resulted in increased 5-year survivals to 56-70%.

Carotid body tumors: a review of 30 patients with 46 tumors

Minimal morbidity occurs with resection of most carotid body tumors (CBT). With larger tumors significant injury to the cranial nerves has been reported. In order to assess the operative sequelae rate, 30 patients with CBT were reviewed. Sixteen patients either presented with bilateral carotid body tumors or had previously undergone a resection of the contralateral carotid body tumors, for a total carotid body tumor count of 46. Sixteen patients demonstrated a familial pattern while 14 were nonfamilial. Within the familial group, 14 of 16 presented with multiple paragangliomas as compared to 6 of 14 in the nonfamilial group. Tumor size ranged from 0.8 to 12 cm. Vascular replacement occurred in 2 of 20 patients with tumors < 5.0 cm, compared with 5 of 9 with tumors > 5.0 cm. Four patients lost cranial nerves with the resection: superior laryngeal nerve (SLN), 4; cranial nerve X, 1; cranial nerve XII, 1. Ten patients developed baroreceptor failure secondary to bilateral loss of carotid sinus function. First-bite pain occurred in 10 of 25 operative patients. Cranial nerve loss can be minimal with resection of carotid body tumors, however, baroreceptor failure and first-bite pain are postoperative sequelae that are often disregarded in the postoperative period.

Glomus jugulare tumours: a review of 61 cases

A retrospective study of 61 patients with glomus jugulare tumours treated at the National Hospital for Neurology and Neurosurgery, and at the Royal National Throat, Nose and Ear Hospital, London. The average age at presentation was 41.7 years. The patients were mainly treated by a posterolateral combined otoneurosurgical approach. 42/61 of the patients had total or subtotal excision of their tumours, 7/61 had partial removal and the remaining 11/61 had no operation. Only one case required a 2-staged procedure. There were two deaths in the postoperative period, one from intracerebral haemorrhage and the other from the left hemisphere infarction. Postoperative radiotherapy was given to 5/7 of the patients who had partial removal. 3/40 of the patients with total removal had postoperative radiotherapy, and a further 3/40 had received radiotherapy pre-operatively. Of the 11 patients who did not undergo surgery, 7/11 were treated with radiotherapy and 4/11 had embolisation only.