Long-term results of surgery for temporal bone paraganglioma

Long-Term Surgical Outcome of Class A and B Tympanomastoid Paragangliomas

OBJECTIVE

To analyze the long-term facial function as well as overall postoperative condition in surgically treated tympanomastoid PGL patients.

STUDY DESIGN

Retrospective study.

METHOD

The medical records of patients with surgically managed class A and B tympanomastoid PGLs between 1983 and 2023 were thoroughly evaluated.

RESULT

Our center has treated a total of 213 cases of tympanomastoid PGL surgically. The mean age of patients was 54, and the male-to-female ratio was 1:6. The most common symptoms at presentation were hearing loss (80%), pulsatile tinnitus (77%), and vertigo (15%). According to the modified Fisch classification, 45% of the cases were classified as class A (A1 and A2), while 55% were classified as class B (B1, B2, and B3). All class A and most class B1 and B2 tumors were removed either with transcanal or retroauricular-transcanal approaches. However, more advanced class B3 lesions were removed with subtotal petrosectomy (SP) along with middle ear obliteration. Facial nerve outcome was excellent in all class A and B cases, while chances of postoperative paresis slightly increased with the size and extent of the tumor (p < 0.05). The hearing outcome is excellent for class A1, A2, B1, and B2 tumors, whereas more advanced class B3 cases have a loss of air conduction (AC) and increased bone conduction (BC) threshold (p < 0.05). Complete surgical removal was achieved in 97% of our cases. The most common late complication was permanent TM perforation (7%), and the recurrence rate was 3%.

CONCLUSIONS

Tympanomastoid PGL represents the most common neoplasm of the middle ear space. The most frequent presenting symptoms include pulsatile tinnitus and hearing loss, whereas the presence of retrotympanic mass was evident in all cases at the time of initial otoscopic evaluation. Proper documentation of facial function and audiometric evaluation are crucial elements of preoperative workup. The most preferred preoperative radiologic examination is high-resolution computer tomography (HRCT), whereas magnetic resonance imaging (MRI) with or without gadolinium enhancement is reserved for cases with a dilemma of carotid artery or jugular bulb involvement. The main goal of tympanomastoid PGL treatment is complete disease removal with preservation of hearing and facial functions. Surgical treatment remains the preferred treatment modality with the benefits of complete disease removal, lower rate of recurrence and complication, and acceptable postoperative hearing level. Here, we present our 40 years of experience, which, to the very best of our knowledge, is the largest series of tympanomastoid PGL in the English literature.

Clinical characteristics and surgical strategy of glomus tympanicum tumors

OBJECTIVES

To summarize the clinical characteristics of glomus tympanicum tumors, and to explore the surgical methods and the strategy for auditory protection.

METHODS

Ten cases (ears) of glomus tympanicum tumors were collected from the Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University from August 2014 to February 2022. All patients underwent endoscopic or microscopic surgery to achieve total removal of the tumor, followed up for 3 months to 8 years. We summarized and analyzed its clinical characteristics, compared the preoperative and postoperative hearing levels of patients, and made a retrospective summary of the surgical methods and the strategy for auditory protection.

RESULTS

Ten patients were all female at (49.50±8.00) years old. Their medical history ranged from 15 days to 6 years. Seven patients complained of pulsatile tinnitus, and 80% (8/10) of the affected ears suffered different degrees of hearing loss. According to the modified Fisch & Mattox classification of glomus tympanicum tumors, 3 ears (30%) of 10 ears were A1, 2 ears (20%) were A2 and 5 ears (50%) were B1. In all 10 cases (ears), hearing was improved in 3 cases, bone gas conductance was maintained in 6 cases, and hearing was slightly decreased in 1 case. The difference of bone gas conductance was 0-10 dB in 7 cases (ears) after operation, and 10-20 dB in 3 cases (ears). There was no significant difference in the average air conduction hearing threshold, bone conduction hearing threshold and air-bone conduction difference between before and after operation (all P>0.05). All cases had no postoperative complications, and the external auditory canal and the incision behind the ear healed well. There was no recurrence after follow-up.

CONCLUSIONS

Glomus tympanicum tumor is easy to bleed, so it is a challenge for total tumor resection and hearing function protection during operation. For type A and type B1 tumors, they can be completely removed under the condition of keeping the tympanic membrane and the ossicular chain. At the same time, the postoperative hearing function can be preserved, and even the hearing can be improved.

Radiosurgery for Paragangliomas of the Head and Neck: Another Step for the Validation of a Treatment Paradigm

BACKGROUND

Paragangliomas are highly vascular and predominantly benign neoplasms that traditionally have been treated by surgery, embolization, and/or external beam radiotherapy. The aim of this study was to evaluate long-term local tumor control and the safety of radiosurgery for head and neck paragangliomas.

METHODS

Data were obtained from prospectively maintained databases of patients affected by brain tumors treated with radiosurgery at our institution. The inclusion criteria were histologically proven or radiologic-suspected diagnosis of paragangliomas; a follow-up period of at least 12 months, an magnetic resonance imaging-based tumor growth control analysis and a signed written consent. Twenty patients (21 paragangliomas) met the eligibility criteria and were included in the present study. All patients were clinically and radiologically evaluated before and after treatment.

RESULTS

The mean follow-up at the time of the present analysis was 46 months. Seven patients had a follow-up longer than 60 months. Seven lesions underwent a single-session radiosurgery with a mean dose of 12.2 Gy (range 11-13 Gy). Fourteen lesions underwent multisession radiosurgery with a mean dose of 25.7 Gy (range 20-30 Gy) delivered in 3-5 fractions. The mean tumor volume for single-session radiosurgery was 4 cc (range 1.4-9.2). The mean volume for multisession radiosurgery was 18.9 cc (range 1.3-50.9). None of the lesions showed progression on radiology during the follow-up period. Neurologic conditions generally are maintained or improved.

CONCLUSIONS

Both single and multisession radiosurgery were confirmed as a safe and effective treatment modality for paragangliomas. Multisession radiosurgery appears effective to treat large lesions.

Treatment of glomus tympanicum tumors by preoperative embolization and total surgical resection

PURPOSE

The purpose of this study was to evaluate the effectiveness on function preservation and tumor control of the treatment of glomus tympanicum tumors with pre-operative embolization followed by total surgical resection.

MATERIAL AND METHODS

We describe a series of 6 patients with a glomus tympanicum tumor who were treated in our hospital using the same technique: the day before surgery selective tumor embolization due to denaturation with 96% ethanol. Following parameters were considered: tumor classification, tumor control, clinical and audiological outcome, effectiveness of embolization, percentage of tumor necrosis and treatment complications.

RESULTS

There were no severe complications due to embolization or surgery. Tumor blush disappeared completely in 5 patients on DSA post embolization and histologic evaluation of the resected tissue showed a median of 69.2% of tumor necrosis. Pulsatile tinnitus disappeared in all patients and 3 patients had no symptoms at all. Hearing ameliorated in 4 patients, 1 patient without hearing loss pre- treatment still had normal hearing after treatment and 1 patient's hearing was worse after treatment. Average follow-up was 21.3months.

CONCLUSIONS

Treatment of glomus tympanicum tumors by pre-operative embolization with ethanol and surgical resection has not been described before. Our results show that it is a safe procedure with a good long term tumor control, good clinical and audiological outcome.

Long term surgical and hearing outcomes in the management of tympanomastoid paragangliomas

OBJECTIVE

To analyze the long term outcomes after surgery in tympanomastoid paragangliomas.

STUDY DESIGN

Retrospective study.

METHODS

The charts of 145 patients with tympanomastoid paragangliomas managed between 1988 and 2013 were reviewed. The clinical features, audiological data, pre- and postoperative notes were noted. The tumors were staged according to the modified Fish and Mattox classification. The surgical approaches for all patients were formulated according to the surgical algorithm developed at our center.

RESULTS

34 (23.5%), 46 (31.7%), 22 (15.2%), 18 (12.4%) and 25 (17.2%) patients were diagnosed to have TMP class A1, A2, B1, B2 and B3 tumors respectively. Gross tumor resection was achieved in 141 (97.2%) patients. The facial nerve was uncovered in four patients and infiltrated in three. The cochlea was found eroded in seven cases. The mean follow-up was 48.4 months. Recurrence was seen in one patient (0.7%). In the cases where the facial nerve was preserved (n=143), the nerve function was graded as HB grade 1 in 138 patients (97%). Postoperatively, the mean AC showed an improvement in all categories except in class B2 and B3, which corresponds to the classes that include patients who underwent subtotal petrosectomy.

CONCLUSION

We report the long term surgical outcomes in tympanomastoid paragangliomas in the largest series published till date. It is possible to completely eradicate all types of tympanomastoid paragangliomas with minimum sequelae by choosing the correct surgical approach to achieve adequate exposure for individual tumor classes as described in our classification and algorithm.

LEVEL OF EVIDENCE

IIb.

Radiotherapy for benign head and neck paragangliomas: a 45-year experience

BACKGROUND

Paragangliomas of the head and neck are rare, slow-growing, generally benign tumors of neuroendocrine cells associated with the peripheral nervous system that commonly involve the carotid body, jugular bulb, vagal ganglia, and temporal bone. Treatment options include surgery, radiotherapy (RT), stereotactic radiosurgery (SRS), and observation. This article briefly reviews our 45-year institutional experience treating this neoplasm with RT.

METHODS

From January 1968 through March 2011, 131 patients with 156 benign paragangliomas of the temporal bone, carotid body, jugular bulb, or glomus vagale were treated with RT at a median dose of 45 Gy in 25 fractions. The mean and median follow-up times were 11.5 years and 8.7 years, respectively.

RESULTS

Five tumors (3.2%) recurred locally after RT, all within 10 years of treatment. The overall local control rates at 5 and 10 years were 99% and 96%, respectively. The cause-specific survival rates at 5 and 10 years were 98% and 97%, respectively. The distant-metastasis free survival rates at 5 and 10 years were 99% and 99%, respectively. The overall survival rates at 5 and 10 years were 91% and 72%, respectively. There were no severe complications.

CONCLUSION

RT for benign head and neck paragangliomas is a safe and efficacious treatment associated with minimal morbidity. Surgery is reserved for patients in good health whose risk of associated morbidity is low. SRS may be suitable for patients with skull base tumors <3 cm where RT is logistically unsuitable. Observation is a reasonable option for asymptomatic patients with a limited life expectancy.

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.

Robotic Stereotactic Radiosurgery in Patients with Unresectable Glomus Jugulare Tumors

We evaluated the treatment results of robotic stereotactic radiosurgery (SRS) in our patients with unresectable glomus jugulare tumors (GJTs). The medical charts of fourteen patients with GJT, who were treated with robotic SRS, were retrospectively evaluated. The gross tumor volume was described as the clinical target volume. The median dose to the tumor was 25 Gy in median 5 fractions. The dose was normalized to 80% isodose line. All patients were evaluated for tumor growth and clinical outcome every 6 months in the first 2 years and then annually. Median follow-up was 39 months (range, 7–60 months). Lesions were stable in 8 patients, and tumor regression was observed in 6 patients. We did not observe any treatment related toxicity in our patients. In conclusion, according to our early experience, robotic SRS seems to be successful treatment option in the management of unresectable GJTs.

Stereotactic radiosurgery as the primary treatment for new and recurrent paragangliomas: is open surgical resection still the treatment of choice?

OBJECTIVE

Paragangliomas (PGs) or glomus tumors are rare, and publications comparing treatment alternatives are few. We sought to analyze our experience with stereotactic radiosurgery (SRS), review the literature, and develop treatment guidelines.

METHODS

We retrospectively examined the outcomes of 41 PGs in 36 patients treated with SRS at Stanford. Our data from medical records, telephone interviews, and imaging studies were combined with previously reported SRS data and compared to results following other treatments.

RESULTS

With a median clinical follow-up of 4.8 years (3.9 years radiographic), local control was 100%. Complications included increase in preexistent vertigo in one patient and transient cranial neuropathies in two patients. Published surgical series describe a lower local control rate as well as more frequent and severe complications. Published radiation therapy (RT) series document a slightly lower local control rate than SRS, but SRS can be delivered more quickly and conveniently. Open surgery and other combinations of treatments appear to be required for several subpopulations of PG patients.

CONCLUSIONS

We feel that SRS should be the primary treatment for most new and recurrent PGs. Even some very large PGs are appropriate for SRS. RT remains an appropriate option in some centers, especially those where SRS is not available. PGs occurring in the youngest patients, catecholamine secreting PGs, and PGs causing rapidly progressing neurologic deficits may be more appropriate for open resection. Metastatic PGs may benefit from combinations of chemotherapy and SRS or RT. Treatment guidelines are proposed.

Paragangliomas and paraganglioma syndromes

Paragangliomas are rare tumors of neural crest origin. They are benign in the majority of cases and are characterized by a strong vascularisation.

In the head and neck region they most commonly occur as carotid body tumors. Jugulotympanic and especially vagal paragangliomas are seen less frequently. Complete surgical resection represents the only curative treatment option even though resection of locally advanced tumors regularly results in lesions of the lower cranial nerves and major vessels.

Appoximately 30% of all head and neck paragangliomas (HNPs) are hereditary and associated with different tumor syndromes. The paraganglioma syndromes 1, 3 and 4 (PGL 1, 3 and 4) make up the majority of those familial cases. PGL 1 is associated with mutations of the succinate dehydrogenase subunit D (SDHD) gene, PGL 3 is caused by SDHC and PGL 4 by SDHB gene mutations. Multiple HNPs and the occurance of HNPs together with pheochromocytomas are seen in SDHD as well as SDHB mutation carriers. In patients with SDHB mutations the risk for the development of malignant paraganglial tumors is significantly higher compared to SDHC and SDHD patients as well as patients with sporadic tumors. SDHC mutation carriers almost exclusively present with benign HNP that are unifocal in the majority of cases. The role of transmission is autosomal dominant for all three symptoms. Interestingly, there is a “parent-of-origin-dependent-inheritance” in subjects with SDHD gene mutations. This means that the disease phenotype may only become present if the mutation is inherited through the paternal line. We recommend screening for mutations of the genes SDHB, SDHC and SDHD in patients with HNPs. Certain clinical parameters can help to set up the order in which the three genes should be tested.

Jugular and vagal paragangliomas: Systematic study of management with surgery and radiotherapy

BACKGROUND

The definitive treatment for head and neck paraganglioma (PG) is surgical excision. Unfortunately, surgery, particularly of vagal paraganglioma (VPG; "glomus vagale") and foramen jugulare ("glomus jugulare") tumors, may be complicated by injuries to the lower cranial nerves, a high price to pay for treatment for a benign tumor. Alternatively these tumors may be followed without treatment, or irradiated. The purpose of this review was to compare the existing evidence concerning the efficacy and safety of surgery, external beam radiotherapy (EBRT), and stereotactic radiosurgery (SRS), for jugular paragangliomas (JPGs) and VPGs.

METHODS

Relevant articles were reviewed using strict criteria for systematic searches. Forty-one surgical studies met the criteria which included 1310 patients. Twenty articles including 461 patients treated with EBRT, and 14 radiosurgery studies comprising 261 patients were also evaluated. Results were compared between treatment modalities using analysis of variance (ANOVA) tests.

RESULTS

A total of 1084 patients with JPGs and 226 VPGs were treated with different surgical procedures. Long-term control of the disease was achieved in 78.2% and 93.3% of patients, respectively. A total of 715 patients with JPG were treated with radiotherapy: 461 with EBRT and 254 with SRS. Control of the disease with both methods was obtained in 89.1% and 93.7% of the patients, respectively. The treatment outcomes of a JPG treated with surgery or radiotherapy were compared. Tumor control failure, major complication rates, and the number of cranial nerve palsies after treatment were significantly higher in surgical than in radiotherapy series. The results of SRS and EBRT in JPGs were compared and no significant differences were observed in tumor control. Because only 1 article reported on the treatment of 10 VPGs with radiotherapy, no comparisons with surgery could be made. Nevertheless, the vagus nerve was functionally preserved in only 11 of 254 surgically treated patients (4.3%).

CONCLUSION

There is evidence that EBRT and SRS offer a similar chance of tumor control with lower risks of morbidity compared with surgery in patients with JPGs. Although the evidence is based on retrospective studies, these results suggest that surgery should be considered only for selected cases, but the decision should be individual for every patient.

Transmastoid-infralabyrinthine tailored surgery of jugular paragangliomas

This article presents our experience with the management and outcomes of patients with sporadic glomus jugular tumors using a tailored surgical approach. We conducted a retrospective study of 49 patients with sporadic jugular paragangliomas. Thirty-eight patients (78%) were treated using the transmastoid-infralabyrinthine (TM-IL) approach, and 11 (22%) were treated with the infratemporal fossa type A (IFT-A) approach. Mean follow-up period was 8.2 years. Surgical cure was achieved in all but 6 patients using the TM-IL approach (84%) and in 8 of 11 patients with the IFT-A approach (73%). A House-Brackmann grade of I or II facial nerve function was obtained postoperatively in 84% of TM-IL cases and in 56% of the IFT-A cases. The incidence of other complications-meningitis and transient cerebrospinal fluid leak-was higher in the TM-IL group (8% and 13%, respectively) compared with the IFT-A group (0% and 9%, respectively). We concluded that the TM-IL approach with individually tailored management of the facial nerve fulfills the long-term requirements of both keeping good postoperative facial function and obtaining adequate tumor resection.

Consensus statement and guidelines on the management of paragangliomas of the head and neck

Paragangliomas (PGLs) of the head and neck (H&N) are uncommon tumors that either arise spontaneously or as part of an inherited syndrome. Hereditary PGL is an autosomal-dominant tumor predisposition syndrome in which an affected individual has greatly increased risk of developing PGL at any or several sites in the autonomic nervous system. The mode of inheritance for some is affected by maternal imprinting. These tumors are generally very slow growing, often taking a decade to double in size. A few are or can become malignant and can metastasize widely. Because of their site of origin, patients with these tumors may develop cranial nerve deficits that have a significant impact on their quality of life. Patients may present to specialists from widely differing disciplines, and some of these may not appreciate the full implications of their patient's disease. As a result, management can become fragmented or inappropriate, and some aspects of care may even be overlooked. This article is the distillation of consensus opinion derived from current published and unpublished data in this field, with particular reference to the management of temporal bone PGLs. We propose guidelines for the management of both sporadic and hereditary PGLs. A multidisciplinary team approach to the management of this complex disorder is advocated. Progress could be made by adopting these guidelines and by widespread dissemination of standardized information. Collaborative research should be promoted with the aim of harnessing advances in molecular genetics to develop targeted therapies for patients, particularly those with hereditary PGL.

Prognostic Factors Including Proliferation Markers Ki-67, bax, and bcl-2 in Temporal Bone Paraganglioma

Valuable criteria with which to predict the clinical behavior of the temporal bone paraganglioma or the response to treatment are lacking. The analysis of markers of cell proliferation is a possibility to estimate the prognosis. Extensive patient data on 40 temporal bone paragangliomas were gathered over the years and correlated with the data obtained by staining histologic sections with bcl-2, bax, and MIB I markers of cellular proliferation. The immunohistochemistry was in all cases negative for bcl-2, positive for bax, and for Ki-67 positive in 20% of tumors. The scores for Ki-67 did not correlate with the majority of clinical parameters, except for treatment modality, preoperative hearing loss, and cranial nerve involvement. The tendency toward poorer hearing and a higher incidence of preoperative lower cranial nerve palsies was demonstrated in patients with higher Ki-67 scores. Furthermore, the higher rate of subtotal tumor removals in these patients reveals technical difficulties in accomplishing a radical removal, although the incidence of residual tumors was thus not affected. In view of the present information obtained with proliferation markers, the site of tumor origin still remains the most predictive variable for the course of the disease.

Hearing results after hypotympanotomy for glomus tympanicum tumors

OBJECTIVE

We postulate, that glomus tympanicum tumors (GTTs) may be safely removed without interference with the ossicular chain via a hypotympanotomy approach.

STUDY DESIGN

Prospective, nonrandomized anatomic and clinical study.

SETTING

Tertiary referral center.

PATIENTS

All 17 patients between 1989 and 2009 with GTTs without involvement of the lumen of the jugular bulb.

INTERVENTIONS

We used a modified hypotympanotomy approach. Our technique is a modification of the one first published by Shambaugh (1955). Pure-tone audiograms were performed in all patients. Preoperative and postoperative audiograms were modeled in a linear mixed model evaluating hearing threshold for air and bone conduction and air-bone gap at 500, 1,000, 2,000, and 3,000 Hz. In an effort to preserve the normal sound conducting apparatus and hearing, we used a retroauricular approach, exposing widely the jugular bulb, the carotid artery, the protympanum, and even the bony part of the Eustachian tube via a hypotympanotomy. Three formalin-fixed and one macerated temporal bones were dissected step by step under the operating microscope to demonstrate the approach in cadaver dissections.

MAIN OUTCOME MEASURE

To evaluate if GTTs can be completely resected without interference with the ossicular chain to improve conductive hearing loss.

RESULTS

We found a substantial improvement of hearing threshold after surgery at all frequencies in air conduction. For bone conduction, there was only a slight gain within random variation. The air-bone gap decreased significantly after surgery.

CONCLUSION

Our approach demonstrated a safe avenue for complete tumor removal without interference with the continuity of the ossicular chain.

A meta-analysis of tumor control rates and treatment-related morbidity for patients with glomus jugulare tumors

Object

Because of the rarity of glomus jugulare tumors, a variety of treatment paradigms are currently used. There is no consensus regarding the optimal management to control tumor burden while minimizing treatment-related morbidity. In this study, the authors assessed data collected from 869 patients with glomus jugulare tumors from the published literature to identify treatment variables that impacted clinical outcomes and tumor control rates.

Methods

A comprehensive search of the English-language literature identified 109 studies that collectively described outcomes for patients with glomus jugulare tumors. Univariate comparisons of demographic information between treatment cohorts were performed to detect differences in the sex distribution, age, and Fisch class of tumors among various treatment modalities. Meta-analyses were performed on calculated rates of recurrence and cranial neuropathy after subtotal resection (STR), gross-total resection (GTR), STR with adjuvant postoperative radiosurgery (STR+SRS), and stereotactic radiosurgery alone (SRS).

Results

The authors identified 869 patients who met their inclusion criteria. In these studies, the length of follow-up ranged from 6 to 256 months. Patients treated with STR were observed for 72 ± 7.9 months and had a tumor control rate of 69% (95% CI 57%–82%). Those who underwent GTR had a follow-up of 88 ± 5.0 months and a tumor control rate of 86% (95% CI 81%–91%). Those treated with STR+SRS were observed for 96 ± 4.4 months and had a tumor control rate of 71% (95% CI 53%–83%). Patients undergoing SRS alone had a follow-up of 71 ± 4.9 months and a tumor control rate of 95% (95% CI 92%–99%). The authors' analysis found that patients undergoing SRS had the lowest rates of recurrence of these 4 cohorts, and therefore, these patients experienced the most favorable rates of tumor control (p < 0.01). Patients who underwent GTR sustained worse rates of cranial nerve (CN) deficits with regard to CNs IX–XI than those who underwent SRS alone; however, the rates of CN XII deficits were comparable.

Conclusions

The authors' analysis is limited by the quality and accuracy of these studies and may reflect source study biases, as it is impossible to control for the quality of the data reported in the literature. Finally, due to the diverse range of data presentation, the authors found that they were limited in their ability to study and control for certain variables. Some of these limitations should be minimized with their use of meta-analysis methods, which statistically evaluate and adjust for between-study heterogeneity. These results provide the impetus to initiate a prospective study, appropriately controlling for variables that can confound the retrospective analyses that largely comprise the existing literature.

Management of the facial nerve in lateral skull base surgery analytic retrospective study

BACKGROUND

Surgical approaches to the jugular foramen are often complex and lengthy procedures associated with significant morbidity based on the anatomic and tumor characteristics. In addition to the risk of intra-operative hemorrhage from vascular tumors, lower cranial nerves deficits are frequently increased after intra-operative manipulation. Accordingly, modifications in the surgical techniques have been developed to minimize these risks. Preoperative embolization and intra-operative ligation of the external carotid artery have decreased the intraoperative blood loss. Accurate identification and exposure of the cranial nerves extracranially allows for their preservation during tumor resection. The modification of facial nerve mobilization provides widened infratemporal exposure with less postoperative facial weakness. The ideal approach should enable complete, one stage tumor resection with excellent infratemporal and posterior fossa exposure and would not aggravate or cause neurologic deficit. The aim of this study is to present our experience in handling jugular foramen lesions (mainly glomus jugulare) without the need for anterior facial nerve transposition.

METHODS

In this series we present our experience in Kasr ElEini University hospital (Cairo-Egypt) in handling 36 patients with jugular foramen lesions over a period of 20 years where the previously mentioned preoperative and operative rules were followed. The clinical status, operative technique and postoperative care and outcome are detailed and analyzed in relation to the outcome.

RESULTS

Complete cure without complications was achieved in four cases of congenital cholesteatoma and four cases with class B glomus. In advanced cases of glomus jugulare (28 patients) (C and D stages) complete cure was achieved in 21 of them (75%). The operative complications were also related to this group of 28 patients, in the form of facial paralysis in 20 of them (55.6%) and symptomatic vagal paralysis in 18 of them (50%).

CONCLUSIONS

Total anterior rerouting of the facial nerve carries a high risk of facial paralysis. So it should be reserved for cases where the lesion extends beyond the vertical ICA. Otherwise, for less extensive lesions and less aggressive pathologies, less aggressive approaches could be adopted with less hazards.

Paragangliomas of head and neck: a treatment option with CyberKnife radiosurgery

Paragangliomas are highly vascular and predominantly benign neoplasms that have traditionally been treated by surgery, embolization and/or external beam radiotherapy (EBRT). The aim of this study is to evaluate the short-term local tumor control and safety of CyberKnife radiosurgery for these lesions. Nine patients, eight with jugular glomus paragangliomas and one with a carotid body paraganglioma, were treated. The target contouring was performed on merged CT and MR images. Eight patients were treated with doses ranging from 11 to 13 Gy (mean 12.5 Gy) in a single fraction and one with 24 Gy in three fractions prescribed to 72-83% isodose line. The mean follow-up was 20 months. One patient died from unrelated causes. There were no local recurrences. All eight patients also demonstrated neurological stability or improvement. Neither cranial nerve palsies have arisen, nor has deterioration beyond baseline been observed. In conclusion, CyberKnife radiosurgery appears to be both safe and effective in the treatment of skull base paragangliomas. Determining whether long-term complications will arise will require further investigation.

Glomus jugulare tumours: certain clinical and radiological aspects observed following Gamma Knife radiosurgery

INTRODUCTION

Glomus jugulare tumours represent a great therapeutic challenge. Previous papers have documented good results from Gamma Knife surgery (GKS) with these tumours. However, the relationship between clinical improvement and tumour shrinkage has never been assessed.

MATERIALS AND METHODS

There were 14 patients, 9 women and 5 men. The mean follow-up period was 28 months (range 6 to 60 months). All the tumours except one were Fisch type D and the mean volume was 14.2 cm(3) (range 3.7-28.4 cm(3)). The mean prescription dose was 13.6 Gy (range 12-16 Gy).

RESULTS

None of the tumours have continued to grow. Eight are smaller and 6 unchanged in volume. Two patients with bruit have had no improvement in their symptoms. Among the other 12 patients, 5 have had symptomatic improvement of dysphagia, 4 in dysphonia, 3 in facial numbness, 3 in ataxia and 2 in tinnitus. Individual patients have experienced improvement in vomiting, vertigo, tongue fasciculation, hearing, headache, facial palsy and accessory paresis. One patient developed a transient facial palsy. Symptomatic improvement commonly began before any reduction in tumour volume could be detected. The mean time to clinical improvement was 6.5 months whereas the mean time to shrinkage was 13.5 months.

CONCLUSIONS

Gamma Knife treatment of glomus jugulare tumours is associated with a high incidence of clinical improvement with few complications, using the dosimetry recorded here. Clinical improvement would seem to be a more sensitive early indicator of therapeutic success than radiological volume reduction. Further follow-up will be needed.

Definitive radiotherapy in the management of paragangliomas arising in the head and neck: a 35-year experience

BACKGROUND

An evaluation of the treatment results for 104 patients with 121 paragangliomas of the temporal bone, carotid body, and/or glomus vagale who were treated with radiation therapy (RT) at the University of Florida between 1968 and 2004.

METHODS

Eighty-nine paragangliomas (86%) were treated with conventional megavoltage techniques, 15 (14%) patients with stereotactic fractionated radiation therapy, 6 (6%) patients with stereotactic radiosurgery (SRS), and 11 (11%) patients with intensity-modulated radiation therapy (IMRT).

RESULTS

There were 6 local recurrences. One recurrence was salvaged with additional RT. The actuarial local control and cause-specific survival rates at 10 years were 94% and 95%. The overall local control rate for all 121 lesions was 95%; the ultimate local control rate was 96%. The incidence of treatment-related complications was low.

CONCLUSION

Fractionated RT offers a high probability of tumor control with minimal risks for patients with paragangliomas of the temporal bone and neck.

Radiosurgery for glomus jugulare tumors: experience treating 16 patients in Iran

Object

Glomus jugulare tumors (GJT) have traditionally been treated by surgery or fractionated external-beam radiotherapy. The aim of this retrospective study was to determine the tumor control rate, clinical outcome, and short-term complications of stereotactic radiosurgery in subsets of patients who are poor candidates for these procedures, based on age, medical problems, tumor size, or prior treatment failure.

Methods

The Leksell Gamma Knife was used to treat 16 patients harboring symptomatic, residual, recurrent, or unresectable GJTs. The age of the patients ranged from 12 to 77 years (median 46.5 years). Gamma Knife surgery (GKS) was performed as primary treatment in five patients (31.3%). Microsurgery preceded radiosurgery in 10 patients (62.5%) and fractionated radiotherapy in three patients (18.8%). The median tumor volume was 9.8 cm3 (range 1.7–20.6 cm3). The median marginal dose applied to a mean isodose volume of 50% (range 37–70%) was 18 Gy (range 14–20 Gy).

Neurological follow-up examinations revealed improved clinical status in 10 patients (62.5%), a stable neurological status in six (37.5%), and no complications. After radiosurgery, follow-up imaging was conducted in 14 patients; the median interval from GKS to the last follow up was 18.5 months (range 4–28 months). Tumor size had decreased in six patients (42.9%), and the volume remained unchanged in the remaining eight (57.1%). None of the tumors increased in volume during the observation period.

Conclusions

According to the authors' experience, GKS represents a useful therapeutic option to control symptoms and may be safely conducted in patients with primary or recurrent GJTs with no death and no acute morbidity. Because of the tumor's naturally slow growth rate, however, long-term follow-up data are needed to establish a cure rate after radiosurgery.

Glomus Jugulare Tumors

OBJECTIVE:

Glomus jugulare tumors are generally considered slow-growing, benign lesions. However, their pronounced local aggressiveness frequently results in severe neurological deficits. Surgical removal is rarely radical and is usually associated with morbidity. There is increasing evidence that stereotactic radiosurgery, particularly gamma knife radiosurgery (GKR), may play a relevant role as a therapeutic option in these tumors.

METHODS:

Between 1996 and 2005, we used GKR to treat 20 patients bearing growing glomus jugulare tumors, mostly classified as Glasscock-Jackson Grade IV or Fisch Stage D1. Follow-up (mean, 50.85 mo) data was available for 20 patients (four men, 16 women; mean age, 56 yr): eight out of 20 tumors were surgical recurrences, three out of 20 patients had GKR as the primary treatment, and 11 out of 20 patients previously underwent endovascular embolization. Regarding the radiosurgical dose planning, the average tumor volume was 7.03 cm3 (range, 1.5–13.4 cm3) and the mean marginal dose was 17.3 Gy (range, 13–24 Gy).

RESULTS:

Neurological signs and symptoms were unchanged in 13 out of 20 patients. An improvement of cranial nerve function was observed in five patients and hearing deterioration was observed in two patients. Tumor volume was unchanged in 11 out of 20 patients and was slightly (≤ 20%) decreased in eight out of 20 patients. In one unusual case of a bulky cavernous sinus recurrence, neoplastic regression was particularly pronounced.

CONCLUSION:

Despite the constraints of the limited case material, considering the estimated doubling time of these rare tumors (4.2 yr), our preliminary results with GKR at a mid-term follow-up examination suggest an effective tumor growth control with negligible incidence of untoward sequelae.

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.

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.

Radiosurgery for paraganglioma of the temporal bone

PURPOSE

To report the outcome of patients with paraganglioma of the temporal bone treated with stereotactic radiosurgery at the University of Florida.

METHODS AND MATERIALS

Between January 1997 and June 1999, five patients with paraganglioma of the temporal bone were treated with Linac-based stereotactic radiosurgery at the University of Florida. The ages of the three female and two male patients were between 40 and 88 years (median, 49 years). Four patients were treated at initial presentation, and one had recurrent disease. Treatment volumes ranged from 4.9 cm3 to 18.4 cm3, with a mean of 10.84 cm3. The dose applied to the margin of the tumor varied from 12.5 to 15 Gy (median, 15 Gy). The treatment dose was specified to the 80% isodose shell in two cases and to the 70% isodose shell in three cases. The median follow-up time was 27 months, ranging from 14 to 50 months.

RESULTS

One of four previously untreated patients had a relapse at the primary tumor site. Treatment failure occurred at the field margin 6 months after radiosurgery; the patient was subsequently treated with fractionated stereotactic radiotherapy and at the time of analysis had no evidence of disease, 21 months after initiation of salvage therapy. The patient treated at the time of recurrence after conventional radiotherapy had a local recurrence 40 months after radiosurgery. At the time of this recurrence, the patient had biopsy-proven metastatic disease in two cervical lymph nodes, and no salvage therapy was performed. All patients were alive at the time of the analysis, one with disease present. Presenting symptoms improved in two patients and stabilized in one. The two patients who had local recurrence develop had worsening of their symptoms. One patient had a cranial nerve V palsy develop 6 months after treatment, which resolved after a few months.

CONCLUSIONS

In this series, the results with stereotactic radiosurgery are discouraging compared with our results with conventional fractionated radiotherapy in patients with paraganglioma of the temporal bone.

Definitive radiotherapy in the management of chemodectomas arising in the temporal bone, carotid body, and glomus vagale

PURPOSE

To evaluate the results of treatment for 71 patients with 80 chemodectomas of the temporal bone, carotid body, or glomus vagale who were treated with radiation therapy (RT) alone (72 tumors in 71 patients) or subtotal resection and RT (8 tumors) at the University of Florida between 1968 and 1998.

METHODS AND MATERIALS

Sixty-six lesions were previously untreated, whereas 14 had undergone prior treatment (surgery, 11 lesions; RT, 1 lesion; or both, 2 lesions) and were treated for locally recurrent disease. All three patients who received prior RT had been treated at other institutions. Patients had minimum follow-up times as follows: 2 years, 66 patients (93%); 5 years, 53 patients (75%); 10 years, 37 patients (52%); 15 years, 29 patients (41%); 20 years, 18 patients (25%); 25 years, 12 patients (17%); and 30 years, 4 patients (6%).

RESULTS

There were five local recurrences at 2.6 years, 4.6 years, 5.3 years, 8.3 years, and 18.8 years, respectively. Four were in glomus jugulare tumors and one was a carotid body tumor. Two of the four patients with glomus jugulare failures were salvaged, one with stereotactic radiosurgery and one with surgery and postoperative RT at another institution. Two of the five recurrences had been treated previously at other institutions with RT and/or surgery. Treatment for a third recurrence was discontinued, against medical advice, before receiving the prescribed dose. There were, therefore, only 2 failures in 65 previously untreated lesions receiving the prescribed course of RT. The overall crude local control rate for all 80 lesions was 94%, with an ultimate local control rate of 96% after salvage treatment. The incidence of treatment-related complications was low.

CONCLUSIONS

Irradiation offers a high probability of tumor control with relatively minimal risks for patients with chemodectomas of the temporal bone and neck. There were no severe treatment complications.

Lateral Skull Base Surgery for Glomus Tumors: Long-Term Control

OBJECTIVE

The age of modern microsurgery has made resection of glomus tumors with extensive skull base involvement possible. Resection of extensive lesions is not without risk of major complication or new cranial nerve deficit. Because glomus tumors are rare and slow growing, data reflecting recurrence risk after resection using modern skull base techniques are lacking. These factors complicate the accurate definition of efficacy of surgical resection and its functional cost. The object of this review is to determine the current incidence of major complications, the surgical cranial nerve deficit, the long-term control rate, and the recurrence risk in patients undergoing surgical resection of glomus jugulare tumors.

STUDY DESIGN

Retrospective case review.

SETTING

Private practice tertiary referral center.

PATIENTS AND INTERVENTIONS

One hundred seventy-six patients with glomus tumors underwent 182 lateral skull base resections between 1972 and 1998.

MAIN OUTCOME MEASURES

Major complications, tumor recurrence, postoperative functional capacity, and factors affecting the incidence of each were assessed.

RESULTS

Complete surgical control was achieved in 85% of cases. There were nine cases of recurrence, for a recurrent rate of 5.5% (9/164). Cerebrospinal fluid leakage occurred in 4.5% of cases with intracranial extension. New deficits for cranial nerves IX, X, XI, and XII occurred in 39%, 25%, 26%, and 21% of cases, respectively. Satisfactory functional recovery was achieved in an overwhelming majority of cases. The mortality rate was 2.7% (5/182).

CONCLUSIONS

Surgical resection of glomus tumors is established as an effective technique with good functional outcomes and long-term control.

Long-term control of surgically treated glomus tympanicum tumors

OBJECTIVE

The glomus tumor is an enigmatic middle ear neoplasm commonly delayed in diagnosis. Frequently grouped with its skull base counterpart, surgery and radiation are often recommended as therapy. The objective of this report is to highlight the diagnosis and surgical treatment of this neoplasm in a large series. Tumor control in the long term is defined.

STUDY DESIGN

Retrospective case review.

SETTING

Private practice-tertiary referral center.

PATIENTS

All patients surgically treated for glomus tympanicum tumors from May 25, 1972 to July 3, 1998 (N = 80).

INTERVENTIONS

Surgical excision of glomus tympanicum tumors.

MAIN OUTCOME MEASURE

Total tumor control in the long term.

RESULTS

Surgical treatment resulted in long-term tumor control for the vast majority of the patients studied.

CONCLUSIONS

Surgery provides excellent control of glomus tympanicum tumors. It is safe and well tolerated, with minimal morbidity.

Long-term results of surgery for temporal bone paragangliomas

OBJECTIVES

Assessment of the long-term results of surgery for temporal bone paragangliomas with special consideration of the patient's ability to cope with the functional deficits.

STUDY DESIGN

Retrospective review of 36 patients who had undergone resection of a temporal bone paraganglioma 10 to 15 years previously. Assessment of the patients' subjective view of the functional outcome and quality of life by a questionnaire.

METHODS

Clinical records were reviewed regarding size of tumor, technique of surgery, supportive therapy, and tumor recurrence. Patients were sent a 50-item questionnaire evaluating their quality of life and the preoperative and postoperative function of cranial nerves VII through XII.

RESULTS

A complete tumor removal was achieved in 30 patients (83%). There was only one tumor recurrence. The major negative effects of surgery involved hearing and dysphagia, which deterioriated in 14 and 12 patients, respectively. Thirty-five of the 36 patients (97%) reported that, despite deterioration, the cranial nerve deficits were still acceptable. Seventy-five percent of the patients regained their preoperative quality of life and 97% returned to their previous occupation in 1 to 2 years.

CONCLUSIONS

The otologic extradural approach allowed complete tumor removal in 83%, with minimal perioperative morbidity. No surgically induced central nervous system lesions occured. Tracheostomy was avoided and all patients resumed oral feeding. Full rehabilitation after removal of class C and CD paragangliomas may take 1 to 2 years. However, the fact that 97% of the patients finally resumed normal social life showed the ability of most patients to cope with the sequelae of surgery even in class C and CD paragangliomas.