[Diagnosis and treatment of glomus tumors of the skull base and neck]

Preoperative percutaneous Onyx embolization of carotid body paragangliomas with balloon test occlusion

Objectives

The study aims to analyze our first experience with direct percutaneous embolization of carotid body tumors (CBTs) using ethylene-vinyl alcohol copolymer (Onyx) along with balloon test occlusion (BTO).

Methods

A retrospective preliminary single-center study was conducted at the Otorhinolaryngology and Head and Neck Surgery Department and the Medical Imaging Department of the University Teaching Hospital. A consecutive series of three patients with CBTs was treated at the local institution between October 2018 and June 2019. All three patients underwent preoperative percutaneous embolization using ethylene-vinyl alcohol copolymer (Onyx 18) with the addition of BTO. Outcome measures were the percentage of tumor devascularization, intraoperative blood losses, and operation times. BTO was evaluated by clinical neurological examination and neurosonological transcranial Doppler examination of the middle cerebral artery (MCA).

Results

Devascularization of all three tumors was complete or near complete. All three tumors were surgically extirpated with excellent surgical outcomes. The blood losses were minimal, and the average operation time was 2 h and 8 min. BTO was positive in one patient, which was valuable additional information on carotid branches ligation limitations. The other two patients showed negative BTOs with the result of safety of eventual carotid arteries ligations.

Conclusion

Preoperative direct percutaneous embolization of CBT with Onyx is a highly effective procedure that significantly facilitates surgery. BTO provides valuable additional information on the most appropriate and safe surgical approach.

Surgical management of tympanojugular paragangliomas using the flexible CO2 laser

PURPOSE

Surgery is a standard therapy for tympanojugular paragangliomas (TJP). Maintaining the quality of life (QoL) requires functional preservation. The flexible CO₂ laser allows contact-free tumor removal. This retrospective study compares the postoperative functional outcomes of TJP surgery with and without the flexible CO₂ laser.

METHODS

Between 2005 and 2019, 51 patients with TJP were surgically treated at a tertiary hospital. Until 2012, 17 patients received conventional surgery. Thereafter, the flexible laser was used in 34 patients. Tumor extend, pre- and postoperative cranial nerve function, and complications were compared between the groups.

RESULTS

The cohort consisted of 33 class A and B tumors and 18 class C and D tumors. Preoperative embolization was performed in 17 cases. Class C/D TJP were usually removed via an infratemporal fossa type A approach. Gross total tumor removal was achieved in 14/18 class C/D tumors. 3/51 patients suffered from long-term partial or complete facial palsy. No differences in post-therapeutic cranial nerve function or complications were noted between the conventional and laser group. One recurrence was observed after complete tumor resection.

CONCLUSION

The flexible CO₂ laser was shown to be a safe and effective alternative to conventional bipolar cauterization, which is appreciated by the surgeon in these highly vascularized tumors. Both techniques allowed a high tumor control rate and good long-term results also from a functional point of view.

The Long-Term Outcome of CyberKnife-Based Stereotactic Radiotherapy for Head and Neck Paragangliomas: A Single-Center Experience

OBJECTIVE

To assess long-term outcomes of hypofractionated stereotactic radiotherapy (hSRT) for head and neck paragangliomas (HNPGs).

METHODS

Patients who underwent hSRT with CyberKnife for HNPGs from 2010 to 2019 were retrospectively reviewed.

RESULTS

A total of 34 HNPGs in 29 patients were identified. Mean patient age was 50 ± 16 years, and 15 patients (52%) were female. Fifteen patients (55%) had undergone previous procedures. Four cases (14%) were functional in hormone production. According to the Fisch classification, 1 (3%) case was B, 12 (42%) cases were C, 14 (48%) cases were D, and 2 (7%) cases were unclassified.¹ The median prescribed dose covering 95% of the planning target volume was 2500 cGy (interquartile range 2100-2600 cGy), and the median target volume was 10 cm³ (interquartile range 6.0-18.3 cm³). The local control rate was 97%. The median progression-free survival was 66 months (interquartile range 28-95 months), and 96% of patients were free of tumor progression at 8 years. During follow-up, 1 case (3%) resulted in permanent facial nerve palsy (House-Brackmann grade II), and another case (3%) resulted in asymptomatic cerebellar radiation necrosis. Univariate and multivariate analysis showed that no previous surgical history (odds ratio 8.58, 95% confidence interval 1.2-59.7, P = 0.03) was a positive predictor of symptomatic improvement.

CONCLUSIONS

hSRT for HNPGs was an effective treatment with minimal side effects over the long term and may have a role as first-line therapy, especially for symptomatic nonfunctional HNPGs, for better symptom control.

Rare Diseases of the Middle Ear and Lateral Skull Base

Otalgia, otorrhea and hearing loss are the most common ear-related symptoms that lead to the consultation of an otolaryngologist. Furthermore, balance disorders and affections of the cranial nerve function may play a role in the consultation. In large academic centres, but also in primary care, the identification of rare diseases of the middle ear and the lateral skull base is essential, as these diseases often require interdisciplinary approaches to establish the correct diagnosis and to initiate safe and adequate treatments. This review provides an overview of rare bone, neoplastic, haematological, autoimmunological and infectious disorders as well as malformations that may manifest in the middle ear and the lateral skull base. Knowledge of rare disorders is an essential factor ensuring the quality of patient care, in particular surgical procedures. Notably, in untypical, complicated, and prolonged disease courses, rare differential diagnoses need to be considered.