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Cinibulak Z, Martinez Santos JL, Poggenborg J, Schliwa S, Ostovar N, Keles A, Baskaya MK, Nakamura M. Comparative Anatomic Analysis of Neuronavigated Transmastoid-Infralabyrinthine Approaches for Jugular Fossa Pathologies: Short Anterior Rerouting Versus Nonrerouting and Tailored Nonrerouting Techniques. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01128. [PMID: 38634695 DOI: 10.1227/ons.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/21/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Access to the jugular fossa pathologies (JFPs) via the transmastoid infralabyrinthine approach (TI-A) using the nonrerouting technique (removing the bone anterior and posterior to the facial nerve while leaving the nerve protected within the fallopian canal) or with the short-rerouting technique (rerouting the mastoid segment of the facial nerve anteriorly) has been described in previous studies. The objective of this study is to compare the access to Fisch class C lesions (JFPs extending or destroying the infralabyrinthine and apical compartment of the temporal bone with or without involving the carotid canal) between the nonrerouting and the short-rerouting techniques. Also, some tailored steps to the nonrerouting technique (NR-T) were outlined to enhance access to the jugular fossa (JF) as an alternative to the short-rerouting technique. METHODS Neuronavigated TI-A was performed using the nonrerouting, tailored nonrerouting, and short-rerouting techniques on both sides of 10 human head specimens. Exposed area, horizontal distance, surgical freedom, and horizontal angle were calculated using vector coordinates for nonrerouting and short-rerouting techniques. RESULTS The short-rerouting technique had significantly higher values than the NR-T ( P < .01) for the exposed area (169.1 ± SD 11.5 mm 2 vs 151.0 ± SD 12.4 mm 2 ), horizontal distance (15.9 ± SD 0.6 mm vs 10.6 ± SD 0.5 mm 2 ), surgical freedom (19 650.2 ± SD 722.5 mm 2 vs 17 233.8 ± SD 631.7 mm 2 ), and horizontal angle (75.2 ± SD 5.1° vs 61.7 ± SD 4.6°). However, adding some tailored steps to the NR-T permitted comparable access to the JF. CONCLUSION Neuronavigated TI-A with the short-rerouting technique permits wider access to the JF compared with the NR-T. However, the tailored NR-T provides comparable access to the JF and may be a better option for class C1 and selected class C2 and C3 JFPs.
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Affiliation(s)
- Zafer Cinibulak
- Department of Neurosurgery, Merheim Hospital, Cologne , Germany
- Faculty of Health, Witten/Herdecke University, Witten , Germany
| | - Jaime L Martinez Santos
- Department of Neurosurgery, Medical University of South Carolina, Charleston , South Carolina,USA
| | - Jörg Poggenborg
- Faculty of Health, Witten/Herdecke University, Witten , Germany
- Department of Radiology, Merheim Hospital, Cologne , Germany
| | - Stefanie Schliwa
- Institute of Anatomy, Anatomy and Cell Biology, University of Bonn, Bonn , Germany
| | - Nima Ostovar
- Department of Neurosurgery, Merheim Hospital, Cologne , Germany
- Faculty of Health, Witten/Herdecke University, Witten , Germany
| | - Abdullah Keles
- Department of Neurological Surgery, University of Wisconsin School of Medicine & Public Health, Madison , Wisconsin,USA
| | - Mustafa K Baskaya
- Department of Neurological Surgery, University of Wisconsin School of Medicine & Public Health, Madison , Wisconsin,USA
| | - Makoto Nakamura
- Department of Neurosurgery, Merheim Hospital, Cologne , Germany
- Faculty of Health, Witten/Herdecke University, Witten , Germany
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Marini K, Florou V, Skliris JP, Marangos N, Kamargiannis N. Jugulotympanic Paraganglioma With Preoperative Embolization That Led to Facial Nerve Paralysis and Surgical Rerouting of the Nerve. Cureus 2023; 15:e41997. [PMID: 37593266 PMCID: PMC10428081 DOI: 10.7759/cureus.41997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Paragangliomas are mostly benign, slow-growing, hypervascular tumors originating from neural crest derivatives. Head and neck (H&N) paragangliomas represent <1% of all H&N tumors and <5% are malignant. They are mostly non-secreting tumors that originate from autonomous parasympathetic paraganglia. We present a case of right middle ear jugulotympanic paraganglioma, a subtype of H&N paragangliomas, which had been misdiagnosed as otosclerosis for about 10 years. The patient was suffering from worsening tinnitus along with hearing impairment. High clinical suspicion of jugular paraganglioma prevented us from taking a biopsy. Complete surgical excision after preoperative embolization was decided. Embolization resulted in facial nerve paralysis, however, facial nerve rerouting was performed during the complete surgical excision of the tumor. The patient remains disease-free three years postoperatively, with House-Brackmann III facial nerve paralysis.
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Affiliation(s)
- Katerina Marini
- Department of Otorhinolaryngology-Head and Neck Surgery, 'G. Gennimatas' General Hospital, Thessaloniki, GRC
| | - Vasiliki Florou
- Department of Otorhinolaryngology-Head and Neck Surgery, 'G. Gennimatas' General Hospital, Thessaloniki, GRC
| | | | - Nikolaos Marangos
- Department of Otolaryngology-Head and Neck Surgery, Center of ENT and Head and Neck Surgery, Rottweil, DEU
| | - Nikolaos Kamargiannis
- Department of Otorhinolaryngology-Head and Neck Surgery, 'G. Gennimatas' General Hospital, Thessaloniki, GRC
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Hara T, Mahmoud MS, Martinez-Perez R, McGahan BG, Hardesty DA, Albonette-Felicio T, Carrau RL, Prevedello DM. Morphometric comparison of Fisch type A and endoscopic endonasal far-medial supracondylar approaches to the jugular foramen. J Neurosurg 2022; 137:1124-1134. [PMID: 35061978 DOI: 10.3171/2021.11.jns212065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The jugular foramen (JF) is one of the most complex and challenging skull base regions to approach surgically. The extreme medial approach to access the JF provides the approach angle from an anterior direction and does not require dissection and sacrifice of the jugular bulb (JB) to reach the pars nervosa. The authors compared the Fisch type A approach to the extreme medial approach to access the JF and evaluated the usefulness of the extreme medial approach. METHODS This study was performed at the Anatomical Laboratory for Visuospatial Innovations in Otolaryngology and Neurosurgery of The Ohio State University. For the comparison of surgical maneuverability and visualization, two angles were measured: 1) the angle of attack (AoA), defined as the widest angle of movement achieved with a straight dissector; and 2) the angle of endoscopic exposure (AoEE), defined as the widest angle of movement in the nasal cavity. The differences in eustachian tube (ET) management, approach angle, surgical maneuverability, and surgical application of the Fisch type A approach to the extreme medial approach were compared. RESULTS There was no difference between ET mobilization and transection regarding cranial-caudal (CC) or medial-lateral (ML) AoA (p = 0.646). The CC-AoA of the Fisch type A approach was significantly wider than the CC-AoA of the extreme medial approach (p = 0.001), and the CC-AoEE was significantly wider than the CC-AoA of the extreme medial approach (p < 0.001). There was no significant difference between the CC-AoA of the Fisch type A approach and the CC-AoEE. The ML-AoA of the Fisch type A approach was significantly wider than the ML-AoA of the extreme medial approach (p = 0.033), and the ML-AoEE was significantly wider than ML-AoA in the extreme medial approach (p < 0.001). The ML-AoEE was significantly wider than the ML-AoA in the Fisch type A approach (p = 0.033). CONCLUSIONS The surgical maneuverability of the extreme medial approach was not inferior to that of the Fisch type A approach. The extreme medial approach can provide excellent surgical field visualization, while preserving the JB. Select cases of chordomas, chondrosarcomas, and JF schwannomas should be considered for an extreme medial approach. These two approaches are complementary, and a case-by-case detailed analysis should be conducted to decide the best approach.
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Affiliation(s)
- Takuma Hara
- 1Department of Neurological Surgery, and
- 3Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Mohammad Salah Mahmoud
- 2Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | | | | | | | | | - Ricardo L Carrau
- 1Department of Neurological Surgery, and
- 2Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Daniel M Prevedello
- 1Department of Neurological Surgery, and
- 2Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Youssef AS, Arnone GD, Farell NF, Thompson JA, Ramakrishnan VR, Gubbels S, Cohen-Gadol AA, Cass S, Labib MA. The Combined Endoscopic Endonasal Far Medial and Open Postauricular Transtemporal Approaches As a Lesser Invasive Approach to the Jugular Foramen: Anatomic Morphometric Study With Case Illustration. Oper Neurosurg (Hagerstown) 2021; 19:471-479. [PMID: 32510567 DOI: 10.1093/ons/opaa080] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/02/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Access to the jugular foramen (JF) requires extensive approaches. An endoscopic endonasal far medial (EEFM) approach combined with a postauricular transtemporal (PTT) approach may provide adequate exposure with limited morbidities. OBJECTIVE To provide a quantitative anatomic comparison of the EEFM, the PTT, and the combined EEFM/PTT approaches. A clinical case of the combined approach is presented. METHODS Five cadaveric heads were dissected. Each specimen received PTT and EEFM approaches on opposite sides followed by an EEFM approach on the side of the PTT approach. Morphometric and quadrant analyses were conducted. Three groups were obtained and compared: PTT (group A), EEFM (group B), and combined (group C). RESULTS Group B had a significantly higher area of exposure of the JF as compared to group A (112.3 and 225 mm2, respectively, P = .004). The average degree of freedom (DOF) in the cranio-caudal plane for groups A and B was 63.6 and 12.6 degrees, respectively (P < .00001). Group A had a higher DOF in the medial-lateral plane than group B (49 vs 13.4 degrees, respectively, P < .00001. The average volume of exposure in groups A and B was 1469.2 and 1897.4 mm3, respectively (P = .02). By adding an EEFM approach to the PTT approach, an additional 56.1% of the anterior quadrant was exposed, representing a 584.4% increase in the anterior exposure. CONCLUSION The PTT and EEFM approaches provide optimal exposures to different aspects of the JF and in combination may constitute a less invasive alternative to the more extensive approaches.
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Affiliation(s)
- A Samy Youssef
- Department of Neurosurgery, University of Colorado, Aurora, Colorado.,Department of Otolaryngology, University of Colorado, Aurora, Colorado
| | - Gregory D Arnone
- Department of Neurosurgery, University of Colorado, Aurora, Colorado
| | - Nyssa Fox Farell
- Department of Otolaryngology, University of Colorado, Aurora, Colorado
| | - John A Thompson
- Department of Neurosurgery, University of Colorado, Aurora, Colorado.,Department of Neurology, University of Colorado, Aurora, Colorado
| | | | - Samuel Gubbels
- Department of Otolaryngology, University of Colorado, Aurora, Colorado
| | | | - Stephen Cass
- Department of Otolaryngology, University of Colorado, Aurora, Colorado
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Grinblat G, Dandinarasaiah M, Braverman I, Taibah A, Lisma DG, Sanna M. "Large and giant vestibular schwannomas: overall outcomes and the factors influencing facial nerve function". Neurosurg Rev 2020; 44:2119-2131. [PMID: 32860105 DOI: 10.1007/s10143-020-01380-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 11/24/2022]
Abstract
(1) To study the overall outcomes of patients surgically treated for large/giant vestibular schwannomas (VSs) and (2) to identify and analyze preoperative and intraoperative prognostic factors influencing facial nerve (FN) outcome. A retrospective clinical study was conducted at a quaternary referral otology and skull-base center. A total of 389 cases were enrolled. The inclusion criteria were patients with tumor > 30 mm undergoing surgery with a minimum follow-up of 12 months. Neurofibromatosis-II, previous radiotherapy, revision surgeries, preoperative FN House-Brackmann (HB) grade > I, partial resections, incomplete records, or those lost to follow-up for a minimum period of 1 year were excluded. In addition, partial resections and cases where FN was sacrificed intraoperatively were also excluded and were analyzed separately. The mean duration of symptoms was 35.4 months, pronounced more in elderly (58.3 months) than in younger individuals (28.4 months). Mean tumor diameter was 36 mm and 52.7% was cystic. Total resection (TR), near total resection (NTR), and subtotal resections (STR) were achieved in 77.4%, 9.5%, and 13.2% of cases, respectively. Regrowth was observed only after STR (19.6%). Good (HB I-II), moderate (HB III), and poor (HB IV-VI) FN functions were observed in 36.8%, 51.7%, and 11.6% cases, respectively. Younger individuals underwent TR in 259 (86.9%) cases against 42 (46.2%) in elderly individuals. Non-total resections (NTR/STR) were performed in 49 (53.8%) cases in elderly as against 39(13.1%) in younger individuals. Good FN outcome was observed in 28 (57.1%) cases of non-total resections in elderly as against 13 (33.3%) cases in younger individuals. On multiple logistic regression analysis, size of the tumor, preoperatively prolonged duration of symptoms, profound deafness, and antero-superiorly located FN with respect to the tumor played a detrimental role in the final facial nerve outcome postoperatively. On the contrary, in large tumors (3-3.9 cm), presence of vertigo/disequilibrium had a relatively better impact on final FN outcome. Partial resections accounted for 41(7.8%) cases and FN was interrupted in 71(13.6%) cases in total. Factors detrimental to better FN outcome were giant VSs (> 4 cm), antero-superiorly located FN intratumorally, preoperatively prolonged duration of symptoms, and profound deafness. In large tumors (3-3.9 cm), presence of vertigo/disequilibrium had a better impact on FN outcome. Understandably, cases with TR in comparison with NTR/STR had worse FN outcomes. In comparison with younger patients, elderly patients underwent higher NTR/STR resulting in better FN outcomes. The above factors can be used as prognosticators for patient counseling and surgical decision making.
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Affiliation(s)
- Golda Grinblat
- Department of Otology & Skull Base Surgery, Gruppo Otologico, Via Emmanueli, 42, 29121, Piacenza, Italy.,Department of ENT, Head and Neck Surgery, Hillel Yaffe Medical Center, Technion University, 169, 38100, Hadera, Israel
| | - Manjunath Dandinarasaiah
- Department of Otology & Skull Base Surgery, Gruppo Otologico, Via Emmanueli, 42, 29121, Piacenza, Italy. .,Department of ENT, Head and Neck surgery, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, 580021, India.
| | - Itzak Braverman
- Department of ENT, Head and Neck Surgery, Hillel Yaffe Medical Center, Technion University, 169, 38100, Hadera, Israel
| | - Abdelkader Taibah
- Department of Otology & Skull Base Surgery, Gruppo Otologico, Via Emmanueli, 42, 29121, Piacenza, Italy
| | - Dario Giuseppe Lisma
- Department of Otology & Skull Base Surgery, Gruppo Otologico, Via Emmanueli, 42, 29121, Piacenza, Italy
| | - Mario Sanna
- Department of Otology & Skull Base Surgery, Gruppo Otologico, Via Emmanueli, 42, 29121, Piacenza, Italy
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Facial nerve management in jugular paraganglioma surgery: a literature review. The Journal of Laryngology & Otology 2015; 130:219-24. [DOI: 10.1017/s0022215115003394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:This literature review analysed facial nerve management strategies in jugular paraganglioma surgery and discusses the tumour resection rate and the facial nerve outcome associated with each technique.Methods:A retrospective review of PubMed and Medline articles on the surgical treatments for jugular paraganglioma was performed. Tumour resection rates and post-operative facial nerve function after non-rerouting, short anterior rerouting and long anterior rerouting approaches were evaluated for each article.Results:A total of 15 studies involving a total of 688 patients were included. Post-operative facial nerve function was similar after non-rerouting and short anterior rerouting approaches (p= 0.169); however, both of these techniques had significantly better post-operative facial nerve outcomes compared with long anterior rerouting (p< 0.001 andp= 0.001, respectively). The total tumour removal rate was significantly higher for long anterior rerouting than with the non-rerouting approach (p= 0.016). There was no difference in total tumour removal rate between the long and short anterior rerouting approaches (p= 0.067) and between the short anterior rerouting and non-rerouting approaches (p= 0.867).Conclusion:No strict guidelines for facial nerve management in jugular paraganglioma resection are available. Although long anterior rerouting provides the best tumour exposure along with a low morbidity rate, case-by-case selection of the surgical approach is recommended.
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Yi JS, Lim HW, Chang YS, Choi SH, Cho YS, Chung JW. Results of anterior facial nerve rerouting procedures for removing skull base tumors. Ann Otol Rhinol Laryngol 2014; 123:141-7. [PMID: 24574470 DOI: 10.1177/0003489414523711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The purpose of this study was to estimate the rates of functional recovery of the facial nerve and of total tumor resection in patients who undergo short anterior rerouting and long anterior rerouting of the facial nerve in removal of skull base tumors. METHODS We retrospectively collected data on 37 patients with skull base tumors who underwent facial nerve rerouting during the procedure for tumor removal. Information on the rerouting technique, the completeness of tumor resection, and changes in facial nerve function were obtained from the medical records. Rerouting techniques were classified as short anterior rerouting or long anterior rerouting. RESULTS Ten of 16 patients (62.5%) in the group with short anterior rerouting showed postoperative facial palsy, and all completely recovered within 1 year. In the group with long anterior rerouting, 18 of 21 patients (85.7%) showed postoperative facial palsy, and recovery to a preoperative level of facial function was found in 10 patients at 1 year of follow-up. Total tumor resection was possible in 94% and 81% of patients with short rerouting and long rerouting, respectively. The mean operation time was not significantly related to the postoperative recovery of facial function. CONCLUSIONS Short rerouting techniques, when appropriately chosen on the basis of tumor and patient characteristics, offer excellent preservation of facial function and tumor resection, comparable to those of long rerouting techniques.
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Affiliation(s)
- Jong Sook Yi
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine (Yi, Chung), Seoul
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Schick B, Dlugaiczyk J. Surgery of the ear and the lateral skull base: pitfalls and complications. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2013; 12:Doc05. [PMID: 24403973 PMCID: PMC3884540 DOI: 10.3205/cto000097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgery of the ear and the lateral skull base is a fascinating, yet challenging field in otorhinolaryngology. A thorough knowledge of the associated complications and pitfalls is indispensable for the surgeon, not only to provide the best possible care to his patients, but also to further improve his surgical skills. Following a summary about general aspects in pre-, intra-and postoperative care of patients with disorders of the ear/lateral skull base, this article covers the most common pitfalls and complications in stapes surgery, cochlear implantation and surgery of vestibular schwannomas and jugulotympanal paragangliomas. Based on these exemplary procedures, basic "dos and don'ts" of skull base surgery are explained, which the reader can easily transfer to other disorders. Special emphasis is laid on functional aspects, such as hearing, balance and facial nerve function. Furthermore, the topics of infection, bleeding, skull base defects, quality of life and indication for revision surgery are discussed. An open communication about complications and pitfalls in ear/lateral skull base surgery among surgeons is a prerequisite for the further advancement of this fascinating field in ENT surgery. This article is meant to be a contribution to this process.
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Affiliation(s)
- Bernhard Schick
- Dept. of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Julia Dlugaiczyk
- Dept. of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
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Sanna M, Shin SH, Piazza P, Pasanisi E, Vitullo F, Di Lella F, Bacciu A. Infratemporal fossa approach type a with transcondylar-transtubercular extension for Fisch type C2 to C4 tympanojugular paragangliomas. Head Neck 2013; 36:1581-8. [DOI: 10.1002/hed.23480] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 07/20/2013] [Accepted: 08/23/2013] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mario Sanna
- Gruppo Otologico Piacenza-Rome and University of Chieti; Italy
| | - Seung-Ho Shin
- Department of Otolaryngology-Head and Neck Surgery; CHA University; Seongnam Republic of Korea
| | - Paolo Piazza
- Department of Neuroradiology; University-Hospital of Parma; Parma Italy
| | - Enrico Pasanisi
- Department of Clinical and Experimental Medicine; Otolaryngology Unit, University-Hospital of Parma; Parma Italy
| | | | | | - Andrea Bacciu
- Department of Clinical and Experimental Medicine; Otolaryngology Unit, University-Hospital of Parma; Parma Italy
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Bacciu A, Ait Mimoune H, D'Orazio F, Vitullo F, Russo A, Sanna M. Management of facial nerve in surgical treatment of previously untreated fisch class C tympanojugular paragangliomas: long-term results. J Neurol Surg B Skull Base 2013; 75:1-7. [PMID: 24498582 DOI: 10.1055/s-0033-1349061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022] Open
Abstract
The aim of this study was to evaluate the long-term facial nerve outcome according to management of the facial nerve in patients undergoing surgery for Fisch class C tympanojugular paragangliomas. The study population consisted of 122 patients. The infratemporal type A approach was the most common surgical procedure. The facial nerve was left in place in 2 (1.6%) of the 122 patients, anteriorly rerouted in 97 (79.5%), anteriorly rerouted with segmental resection of the epineurium in 7 (5.7%), and sacrificed and reconstructed in 15 (12.3%). One patient underwent cross-face nerve grafting. At last follow-up, House-Brackmann grade I to II was achieved in 51.5% of patients who underwent anterior rerouting and in 28.5% of those who underwent anterior rerouting with resection of the epineurium. A House-Brackmann grade III was achieved in 73.3% of patients who underwent cable nerve graft interposition. The two patients in whom the facial nerve was left in place experienced grade I and grade III, respectively. The patient who underwent cross-face nerve grafting had grade III. Gross total resection was achieved in 105 cases (86%). Management of the facial nerve in tympanojugular paraganglioma surgery can be expected to ensure satisfactory facial function long-term outcome.
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Affiliation(s)
- Andrea Bacciu
- Department of Clinical and Experimental Medicine, Otolaryngology Unit, University-Hospital of Parma, Parma, Italy
| | | | - Flavia D'Orazio
- Department of Oral and Nano-Biotechnological Sciences, Gruppo Otologico Piacenza-Rome and University of Chieti, Chieti, Italy
| | - Francesca Vitullo
- Department of Oral and Nano-Biotechnological Sciences, Gruppo Otologico Piacenza-Rome and University of Chieti, Chieti, Italy
| | - Alessandra Russo
- Department of Oral and Nano-Biotechnological Sciences, Gruppo Otologico Piacenza-Rome and University of Chieti, Chieti, Italy
| | - Mario Sanna
- Department of Oral and Nano-Biotechnological Sciences, Gruppo Otologico Piacenza-Rome and University of Chieti, Chieti, Italy
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Borba LAB, Araújo JC, de Oliveira JG, Filho MG, Moro MS, Tirapelli LF, Colli BO. Surgical management of glomus jugulare tumors: a proposal for approach selection based on tumor relationships with the facial nerve. J Neurosurg 2010; 112:88-98. [DOI: 10.3171/2008.10.jns08612] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed.MethodsBetween December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41%; and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients.ResultsRadical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%.ConclusionsRadical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches, with or without closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients.
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Affiliation(s)
- Luis A. B. Borba
- 1Department of Neurosurgery, Evangelic Medical School
- 2Department of Neurosurgery, Federal University of Parana, Curitiba, Parana
- 3Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo; and
- 4Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Jean G. de Oliveira
- 3Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo; and
| | | | - Marlus S. Moro
- 2Department of Neurosurgery, Federal University of Parana, Curitiba, Parana
| | - Luis Fernando Tirapelli
- 4Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Benedicto O. Colli
- 4Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Abstract
OBJECTIVE Surgical approaches to the jugular foramen, most often used for the resection of glomus jugulare tumors, may include removal of the external auditory canal wall and overclosure of the meatus, resulting in maximal conductive hearing loss. Modifications have been described that maintain hearing by preserving the canal wall at the price of decreased exposure and are, therefore, suitable only for small and favorably located tumors. Our technique for removal and then reconstruction of the canal wall with hydroxyapatite cement allows for complete anterior translocation of the facial nerve as far proximal as the geniculate ganglion, giving uncompromising exposure of even the most extensive tumors, with the potential for preservation of normal hearing. The purpose of this study was to describe and report our experience with this technique. STUDY DESIGN : Retrospective review. SETTING Private otology practice. PATIENTS Between 2000 and 2005, seven patients between the ages of 34 and 77 years were identified who underwent procedures using this technique. INTERVENTION Surgical management of jugular foramen tumors. MAIN OUTCOME MEASURES Successful anatomical reconstruction of the external auditory canal and middle ear. Preoperative and postoperative audiograms are compared, and facial nerve function is reported. Complications are discussed. RESULTS All seven patients had successful reconstruction of the external auditory canal. Complications were minor and did not require additional surgical intervention. Postoperative pure-tone average differed from the preoperative average by a mean of 7.5 dB. Facial nerve function ranged from House-Brackmann Grades I to III when checked at least 7 months after surgery. CONCLUSION This study reveals that this technique of external auditory canal reconstruction using hydroxyapatite cement allows complete anterior translocation of the facial nerve, while safely and reliably preserving the potential for normal hearing, without any compromise in exposure of the jugular foramen in the setting of an infratemporal fossa approach.
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Affiliation(s)
- Steven R Gold
- Charlotte Eye, Ear, Nose, and Throat Associates, Charlotte, North Carolina 28226, USA.
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13
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Abstract
PURPOSE OF REVIEW Craniotomy created through the base of the skull has improved exposure of many types of extraaxial tumors and thus enhanced both tumor control and preservation of neural function. The purpose of this article is to review recent advances in this emerging field. RECENT FINDINGS Use of microscopes and endoscopes has allowed these procedures to become progressively less invasive. Electrophysiological monitoring has enhanced neural identification and preservation. The increasingly documented efficacy of stereotactic radiation for certain tumor types (e.g. meningioma, schwannoma) has permitted nonoperative therapy for some individuals. In large tumors, selective use of less-than-complete microsurgical resection is establishing an increasing role, at times combined with focused radiotherapy of the surgical remnant. The role for transbasal craniotomy is well established in both benign tumors and vascular lesions, but has only limited applicability for high-grade malignant lesions. Today, the vast majority of procedures can be conducted in a single stage by a multidisciplinary team. SUMMARY Operative trajectories created through the cranial base, although technically demanding, have led to substantially improved outcomes for a wide variety of inaccessible intracranial lesions.
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Sanna M, Flanagan S. The Combined Transmastoid Retro- and Infralabyrinthine Transjugular Transcondylar Transtubercular High Cervical Approach for Resection of Glomus Jugulare Tumors. Neurosurgery 2007; 61:E1340; author reply E1340. [DOI: 10.1227/01.neu.0000306136.66849.5c] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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15
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Abstract
The infratemporal fossa approach type A is the best way to deal with recurrent tympano-jugular paragangliomas because facial nerve rerouting is fundamental to reaching the area of the internal carotid artery, where recurrence is likely to occur. Preservation of lower cranial nerve function is not feasible when there is tumor infiltration of the medial wall of the jugular bulb; any attempt at nerve dissection increases the risk of leaving some tumor remnants. Correct management of the internal carotid artery, including preoperative stent insertion or permanent preoperative balloon occlusion, is usually a fundamental step when dealing with these highly vascularized lesions. Because of the tumor tendency to infiltrate the bony structures, aggressive drilling of the temporal bone is also advised, especially at the level of the petrous apex. Patients affected by uncontrolled recurrences still die of this disease.
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Affiliation(s)
- Mario Sanna
- Gruppo Otologico, via Emmanueli 42, 29100, Piacenza, Italy.
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Parhizkar N, Hiltzik DH, Selesnick SH. Facial Nerve Rerouting in Skull Base Surgery. Otolaryngol Clin North Am 2005; 38:685-710, ix. [PMID: 16005726 DOI: 10.1016/j.otc.2005.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Facial nerve rerouting techniques were developed to facilitate re-section of extensive tumors occupying the skull base. Facial nerve rerouting has its own limitations and risks, requiring microsurgical expertise, additional surgical time, and often some degree of facial nerve paresis. This article presents different degrees of anterior and posterior facial nerve rerouting, techniques of facial nerve rerouting, and a comprehensive review of outcomes. It then reviews anatomic and functional preservation of the facial nerve in acoustic neuroma resection, technical aspects of facial nerve dissection, intracranial facial nerve repair options, and outcomes for successful acoustic neuroma surgery.
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Affiliation(s)
- Nooshin Parhizkar
- Department of Otolaryngology, Weill Medical College of Cornell University, New York, 530 East 70th Street, New York, NY 10021, USA
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