Microsurgical resection of a samii type D jugular foramen schwannoma via the carotid triangle without removal of bony structure: how I do it

BACKGROUND

Samii Type-D jugular foramen schwannomas (JFSs) are the most challenging for neurosurgeons because of anatomical complexity. Various neurosurgical approaches have been described to gain access to JF.

METHODS

We present a female with incidental diagnosis of the Type-D JFS. Complete radical resection was achieved via the carotid triangle approach without any bony structure removal. And the patient was discharged asymptomatic and without new-developed neurological deficits.

CONCLUSIONS

The carotid triangle is a secure and appropriate approach for some cases of selected Type-D JFSs. However, the specific indications of this approach should be further explored and investigated.

Lower Cranial Nerve Schwannomas: Cohort Study and Systematic Review

BACKGROUND AND OBJECTIVES

Schwannomas originating from the lower cranial nerves (LCNS) are rare and pose a significant surgical challenge. Resection is the mainstay treatment; however, risk of treatment morbidity is considerable, and the available literature regarding differential treatment outcomes in this vulnerable population is sparse.

METHODS

A single-institution cohort study and systematic literature review of LCNS were performed.

RESULTS

Fifty-eight patients were included: 34 underwent surgical resection and 24 underwent stereotactic radiosurgery (SRS). The median age at diagnosis was 48 years (range 17-74). Presenting symptoms were dysphagia (63%), dysarthria/hypophonia (47%), imbalance (33%), and hearing loss/tinnitus (30%). Tumor size was associated with surgical resection, as compared with initial SRS (4.1 cm vs 1.5 cm, P = .0001). Gross total resection was obtained in 52%, with tumor remnants predominantly localized to the jugular foramen (62%). Post-treatment worsening of symptoms occurred in 68% of surgical and 29% of SRS patients ( P = .003). Postoperative symptoms were mostly commonly hypophonia/hoarseness (63%) and dysphagia (59%). Seven patients (29%) had new neurological issues after SRS treatment, but symptoms were overall milder. The median follow-up was 60 months (range 12-252); 98% demonstrated meaningful clinical improvement. Eighteen surgical patients (53%) underwent adjuvant radiation at a median of 5 months after resection (range 2-32). At follow-up, tumor control was 97% in the surgical cohort and 96% among SRS patients.

CONCLUSION

Although LCNS resection is potentially morbid, most postoperative deficits are transient, and patients achieve excellent tumor control-particularly when paired with adjuvant SRS. For minimally symptomatic patients undergoing surgical intervention, we advise maximally safe resection with intracapsular dissection to preserve nerve integrity where possible. For residual or as a primary treatment modality, SRS is associated with low morbidity and high rates of long-term tumor control.

[Accessory nerve meningioma. A case report and literature review]

Meningiomas arising from accessory nerve sheath without dural attachment are rare. To date, only 5 cases are described in the literature. A 53-year-old male presented with long history of occipital pain and headaches. Magnetic resonance imaging revealed a small intradural extramedullary contrast enhanced tumor at the level of foramen magnum. The patient underwent microsurgical resection through minimally invasive midline suboccipital approach. According to intraoperative findings, cystic tumor arose from the left accessory nerve without dural attachment. Gross total resection was achieved without damage to the nerve. Histological analysis revealed angiomatous meningioma. Postoperative period was uneventful without new neurological symptoms. Meningiomas can rarely arise from accessory nerve sheath and mimic schwannoma. These tumors may be totally resected without damage to accessory nerve using minimally invasive surgical approaches.

Managing Multiple Schwannomatosis of Vagus and Hypoglossal Nerves: The Unanticipated Complications

Schwannomas are rare benign tumours of the nerve sheath. Extracranial schwannomas are usually found solitary, in the absence of other features of neurofibromatosis. The non NF1/2 multiple schwannomas are collectively described as the clinical scenario called schwannomatosis. We present a rare case of two extracranial schwannomas involving vagus and hypoglossal nerves in a 22-year-old female along with an unusual surgical complication of CSF leak presenting as post-op neck mass and a review of previously reported similar cases. A thorough literature search using the MeSH terms-'schwannomatosis' or 'Multiple Schwannoma' and 'Vagal Schwannoma' and 'Hypoglossal Schwannoma', was conducted using online databases and augmentated by hand search. A total of 13 reported cases were found and reviewed. Of the 14 cases described from review of literature and our case, 50% had involvement of vagus nerve as one of the components. 12.5% had hypoglossal and cervical sympathetic plexus involvement each. All patients underwent surgical excision. Half of the patients suffered intraoperative nerve sacrifice with resultant severe functional deficits like vocal cord paralysis, Horners syndrome, hypoglossal palsy, facial palsy and eleventh nerve palsy. In our case, there was un-unusual complication of CSF leak presenting as a cervical neck mass. Multiple extracranial head and neck schwannomas are rare and their management is fraught with several complications. Decision to operate is often perplexing. However, early planned surgical excision and preservation of nerve of origin minimizes the impact on quality of life postoperatively.

Microsurgical resection of a right dumbbell-shaped jugular foramen schwannoma through a modified retrosigmoid infra-jugular approach: how I do it

BACKGROUND

Surgical treatment of dumbbell jugular foramen schwannomas can be challenging. The main goals of surgery are maximal resection with preservation of function and overall patient quality of life.

METHODS

In this paper, we present a step-by-step technical description of a microsurgical resection of dumbbell-shaped JF schwannoma using a modified retrosigmoid infra-jugular approach.

CONCLUSION

The modified retrosigmoid infra-jugular is a safe and suitable approach in selected cases. This technique, however, must be limited only to those tumors with minimal extension into the jugular foramen.

Retrosigmoid Infralabyrinthine (Suprajugular) Approach to the Jugular Foramen: Indications, Limitations, and Surgical Nuances

BACKGROUND

Among the several approaches described to the jugular foramen (JF), the retrosigmoid infralabyrinthine (suprajugular) approach was one of the most recently described.

OBJECTIVE

To describe the indications, limitations, and operative nuances of the suprajugular approach.

METHODS

We provided a pertinent review of the anatomy, indications, preoperative evaluation, surgical steps and nuances, and postoperative management.

RESULTS

The suprajugular approach is suitable for tumors occupying the intracranial compartment with limited extension into the JF. Volume, width, and configuration of the foramen dictate the feasibility of the approach. Tumors invading the venous system are not suitable for this approach. Preoperative 3-dimensional MRI and computed tomography are used to evaluate intrajugular extension, relationship between the tumor and the jugular bulb (JB), venous system invasion, and shape of the JF. During surgery, exposition of the entire posterior border of the sigmoid sinus is needed and removing the bone over the JB. After identification of the JF, the jugular notch and intrajugular process of the roof of the foramen are removed and intrajugular resection is completed. In cases of high-riding JB, it may be gently pushed down to allow visualization of the anterior foramen. In cases of JB laceration, it may be repaired using a muscle patch and usually does preclude further resection.

CONCLUSION

The suprajugular approach is variation of the retrosigmoid approach that, when properly indicated, provides excellent exposure of the medial JF, with most anatomical variations and intraoperative complications predicted by a comprehensive preoperative evaluation.

Surgical treatment of selected tumors via the navigated minimally invasive presigmoidal suprabulbar infralabyrinthine approach without rerouting of the facial nerve

The feasibility of a novel skull base approach - the navigated minimally invasive presigmoidal suprabulbar infralabyrinthine approach (NaMIPSI-A) without rerouting of the fallopian canal for selected jugular foramen tumors (JFTs) - has been demonstrated in a neuroanatomical laboratory study. Here, we present our clinical experience with the NaMIPSI-A for selected JFTs, with a particular focus on its efficacy and safety. All patients with JFTs who were treated via the NaMIPSI-A were included in this study. The JFTs were classified according to a modified Fisch classification. The neurological and neuroradiological outcome, the extent of tumor resection, and the approach-related morbidity were examined. Five patients (two women, three men; mean age 57 years, range 48-65) were available. According to the modified Fisch classification, two JFTs were graded as C1, one as De1, and two as De2. Gross total resection (GTR) was achieved in three patients and near-total resection (NTR) in two. Postsurgically, no new neurological deficits and no approach-related morbidity and mortality occurred. One case with a postoperative cerebrospinal fluid leak was managed successfully with lumbar drainage. During the follow-up period (mean 67.6 months, range 12-119 months), tumor recurrence was noted in the NTR group but not in the GTR group. The NaMIPSI-A to the jugular foramen without rerouting of the fallopian canal is highly valuable for selected tumors of the jugular foramen. It is less invasive than other skull base approaches, and it allows safe and complete tumor removal in appropriate patients.

Early-onset adverse events after stereotactic radiosurgery for jugular foramen schwannoma: a mid-term follow-up single-center review of 46 cases

Background

Recently, stereotacitc radiosurgery (SRS) has been in the spotlight as an alternative therapeutic option for jugular foramen schwannomas (JFS). While most reported studies focus on the long-term efficacy and safety issues of SRS, none describe the early-onset adverse events (eAEs). We aimed to investigate the incidence, clinical characteristics, and mid-term outcomes of eAEs occurring within six months after SRS for JFS.

Methods

In this retrospective review, patients who underwent at least six months of follow-up were included among all patients with JFS who have performed SRS at our institution between July 2008 and November 2019. And eAEs were defined as a newly developed neurological deficit or aggravation of pre-existing symptoms during the first six months after SRS.

Results

Forty-six patients were included in the analysis. The median follow-up period was 50 months (range 9–136). The overall tumor control rate was 91.3%, and the actuarial 3-, 5-, and 10-year progression-free survival rates were 97.8%, 93.8%, and 76.9%, respectively. Of the 46 patients, 16 had eAEs, and the median time to onset of eAEs was one month (range 1–6 months), and the predominant symptoms were lower cranial nerve dysfunctions. Thirteen of 16 patients showed improved eAE symptoms during the follow-up period, and the median resolution time was six months (range 1–52). In 11 (68.8%) of 16 patients with eAEs, transient expansions were observed with a mean of 3.6 months after the onset of eAEs, and the mean difference between the initial tumor volume and the transient expansion volume was more prominent in the patients with eAEs (3.2 cm³ vs. 1.0 cm³; p = 0.057). In univariate analysis, dumbbell-shaped tumors (OR 10.56; p = 0.004) and initial tumor volume (OR 1.32; p = 0.033) were significantly associated with the occurrence of eAEs.

Conclusions

Although acute adverse events after SRS for JFS are not rare, these acute effects were not permanent and mostly improved with the steroid treatment. Dumbell-shaped and large-volume tumors are significant predictive factors for the occurrence of eAEs. And the transient expansion also seems to be closely related to eAEs. Therefore, clinicians need to be more cautious when treating these patients and closely monitor the occurrence of eAEs.

Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section Part III: Lower cranial nerve schwannomas, jugular foramen (CN IX, X, XI) and hypoglossal schwannoma (XII)

BACKGROUND

Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations.

METHODS

A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the third of a three-part series describing non-vestibular schwannomas (IX, X, XI, XII).

RESULTS

A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to preoperative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management paradigm is shifting towards the compromise between function preservation and progression free survival.

Simplifying the Surgical Classification and Approach to the Posterolateral Skull Base and Jugular Foramen Using Anatomical Triangles

Introduction Lesions of the jugular foramen (JF) and postero-lateral skull base are difficult to expose and exhibit complex neurovascular relationships. Given their rarity and the increasing use of radiosurgery, neurosurgeons are becoming less experienced with their surgical management. Anatomical factors are crucial in designing the approach to achieve a maximal safe resection. Methods and methods Six cadaveric heads (12 sides) were dissected via combined post-auricular infralabyrinthine and distal transcervical approach with additional anterior transstyloid and posterior far lateral exposures. Contiguous surgical triangles were measured, and contents were analyzed. Thirty-one patients (32 lesions) were treated surgically between 2000 and 2016 through different variations of the retro-auricular distal cervical transtemporal approaches. Results We anatomically reviewed the carotid, stylodigastric, jugular, condylar, suboccipital, deep condylar, mastoid, suprajugular, suprahypoglossal (infrajugular), and infrahypoglossal triangles. Tumors included glomus jugulare, lower cranial nerve schwannomas or neurofibromas, meningiomas, chondrosarcoma, adenocystic carcinoma, plasmacytoma of the occipitocervical joint, and a sarcoid lesion. We classified tumors into extracranial, intradural, intraosseous, and dumbbell-shaped, and analyzed the approach selection for each. Conclusion Jugular foramen and posterolateral skull base lesions can be safely resected through a retro-auricular distal cervical lateral skull base approach, which is customizable to anatomical location and tumor extension by tailoring the involved osteo-muscular triangles.

Surgical treatment of dumbbell-shaped jugular foramen schwannomas via two-piece lateral suboccipital approach: Report of 26 patients

BACKGROUND

Dumbbell-shaped jugular foramen schwannomas (JFS) are rare but challenging for the treatment. Surgical resection is believed to be the optimal therapy; however, postoperative dysfunction of the lower cranial nerves (CNs), tumor residual, cerebrospinal fluid (CSF) leakage, and subcutaneous hydrops are common. The current study's objectives were to describe the optimal surgical strategies for the total removal of dumbbell-shaped JFS, the functional preservation of lower CNs, and the prevention of postoperative CSF leakage.

METHODS

26 consecutive patients with dumbbell-shaped JFS were surgically treated between January 2014 and June 2019. All patients were operated on via two-piece lateral suboccipital approach, vascularized muscle flap was used for the repair of the dural defect after an operation. The clinical information and radiological data of these patients were retrospectively reviewed, and the optimal surgical strategies were further evaluated and discussed.

RESULTS

The tumor was completely removed in all 26 patients, one patient developed new CN Ⅶ paralysis, and 2 developed new CN IX and Ⅹ paralysis after an operation, all patients were significantly relieved during follow up. None of them developed subcutaneous hydrops and postoperative CSF leakage. No tumor recurrence was observed during a mean follow up of 38.8 (16-69) months.

CONCLUSIONS

Dumbbell-shaped JFS could be safely and completely removed via the two-piece lateral suboccipital approach. Postoperative CSF leakage could be effectively prevented by careful repair of the dural defect in the jugular foramen (JF) and filling the mastoid cavity with a vascularized muscular flap.

Efficacy of the Suboccipital Paracondylar-Lateral Cervical Approach: The Series of 64 Jugular Foramen Tumors Along With Follow-Up Data

Objective

Complete resection of jugular foramen tumors with minimal cranial nerve complications remains challenging even for skilled neurosurgeons. Here, we introduce a modified paracondylar approach, named the suboccipital paracondylar-lateral cervical (SPCLC) approach for this purpose. We also share the follow-up data of our series and discuss the advantages and limitations of this modified paracondylar approach.

Methods

We included 64 patients with jugular foramen tumors who underwent surgery by the same senior neurosurgeon between November 2011 and August 2020. All patients were treated with the SPCLC approach, which aimed for gross total tumor removal in a single-stage operation. The clinical characteristics, including preoperative and postoperative neurological status, the extent of surgical resection, and follow-up data were retrospectively acquired and evaluated.

Results

There were 48 schwannomas, nine meningiomas, three paragangliomas, one hemangiopericytoma, one chordoma, one endolymphatic sac tumor, and one Langerhans’ cell histiocytosis. The median age of our patients was 43 years (range: 21–77 years). Dysphagia, hoarseness, and tongue deviation were observed in 36, 26, and 28 patients, respectively. Thirty-two patients had hearing function impairments, including hearing loss or tinnitus. Gross total resection was achieved in 59 patients (59/64, 92.2%). Gamma Knife treatment was used to manage residual tumors in five patients. Postoperatively, new-onset or aggravative dysphagia and hoarseness occurred in 26 and 18 cases, respectively. Nine patients developed new-onset facial palsy, and one patient developed new-onset hearing loss. There were no cases of intracranial hematoma, re-operation, tracheostomy, or death. At the latest follow-up, hearing loss and tinnitus had improved in 20 cases (20/32, 62.5%), dysphagia alleviated in 20 cases (20/36, 55.6%), and hoarseness improved in 14 cases (14/26, 53.8%). Over a mean follow-up period of 27.8 ± 19.5 months (range: 3–68 months), tumor recurrence was observed in one patient.

Conclusion

The SPCLC approach, modified from the paracondylar approach, and was less invasive, safe, and efficient for certain jugular foramen tumors. Taking advantage of the anatomic understanding, clear operational vision, and appropriate surgical skills, it is possible to achieve gross total tumor removal and the preservation of neurological function.

Surgical Management of Jugular Foramen Schwannomas

Simple Summary

Treatments of jugular foramen schwannomas may be challenging due to critical anatomical relations and the involvement of different aspects of the skull base. Advances in microsurgery have led to improved outcomes over recent decades, whereas in contrast, some advocate stereotactic radiotherapy as an effective therapy, controlling the tumor volume with few complications. In this manuscript, we present the outcomes and adverse events in a contemporary cohort and discuss surgical advantages and disadvantages of different performed classic skull base approaches.

Abstract

Background: Resection of jugular foramen schwannomas (JFSs) with minimal cranial nerve (CN) injury remains difficult. Reoperations in this vital region are associated with severe CN deficits. Methods: We performed a retrospective analysis at a tertiary neurosurgical center of patients who underwent surgery for JFSs between June 2007 and May 2020. We included nine patients (median age 60 years, 77.8% female, 22.2% male). Preoperative symptoms included hearing loss (66.6%), headache (44.4%), hoarseness (33.3%), dysphagia (44.4%), hypoglossal nerve palsy (22.2%), facial nerve palsy (33.3%), extinguished gag reflex (22.2%), and cerebellar dysfunction (44.4%). We observed Type A, B, C, and D tumors in 3, 1, 1, and 4 patients, respectively. A total of 77.8% (7/9) underwent a retrosigmoid approach, and 33.3% (3/9) underwent an extreme lateral infrajugular transcondylar (ELITE) approach. Gross total resection (GTR) was achieved in all cases. The rate of shunt-dependent hydrocephalus was 22.2% (2/9). No further complications requiring surgical intervention occurred during follow-up. The median follow-up time was 16.5 months (range 3–84 months). Conclusions: Considering the satisfying outcome, the GTR of JFSs is feasible in performing well-known skull base approaches. Additional invasive and complicated approaches were not needed. Radiosurgery may be an effective alternative for selected patients.

Anatomical study of a surgical approach through the neck to the jugular foramen under endoscopy

OBJECTIVES

To investigate the feasibility of an endoscopic surgical approach through the neck to the jugular foramen, to determine the relevant techniques and extent of exposure, and to provide a new surgical approach with minimal trauma.

METHODS

Nine cadaveric head specimens with attached necks were fixed with 10% formalin solution. Two of the heads were fixed and injected with colored silicone rubber. Through the dissection of these cadaver head and neck specimens, we designed a surgical approach from the neck to the jugular foramen area with the use of a neuroendoscope and performed simulated surgery to determine which anatomical structures were encountered in the approach.

RESULTS

The posterior aspect of the internal jugular vein is adjacent to the rectus capitis lateralis. The internal carotid artery is anteromedial to the internal jugular vein, with the glossopharyngeal nerve, accessory nerve, vagus nerve and hypoglossal nerve in between. Removal of the rectus capitis lateralis can reveal the jugular process, and exposing the space between the superior oblique muscle and the jugular process can reveal the atlanto-occipital joint. Drilling through the occipital condyle can facilitate entrance into the skull, expose the flank of the medulla oblongata, and reveal the medullary olive and accessory nerve, vagus nerve, hypoglossal nerve, vertebral artery and posterior inferior cerebellar artery. Removing the jugular vein and completely opening the posterior wall of the jugular foramen can expose the inferior wall of the jugular bulb and the inferior wall of the sigmoid sinus. Drilling through the styloid process, which is lateral to the internal jugular vein, can expose the lateral area and upper wall of the jugular bulb and cranial nerves (CN) IX-XII; and near the top of the jugular bulb, the tympanic cavity and the external auditory canal can be easily opened.

CONCLUSION

Endoscopic surgical access from the neck to the jugular foramen is feasible. This surgical approach can simultaneously remove intracranial and extracranial tumors and can also be used to remove tumors in the ventral region of the occipital foramen and the hypoglossal canal. Furthermore, this approach is advantageous in that minimal trauma is inflicted. With judicious patient selection, this approach may have significant advantages and may be used as a primary or secondary surgical approach in the future. Nonetheless, this approach is still in development in a laboratory setting, and further research and improvements are needed before facing more complicated situations in clinical practice.

"Interdural" Surgical Strategy for Lower Cranial Nerve Neurinomas-A Report of 14 Cases

OBJECTIVE

We describe the dural relationships and its surgical implications for large lower cranial nerve (CN) neurinomas. The study is based on surgical experience with 14 cases.

METHODS

During the period January 2014 to December 2019, 14 consecutive cases with large lower CN neurinomas were surgically treated with the aim of radical tumor resection.

RESULTS

There were 9 males and 5 females, ranging in age from 17 to 65 years. All patients were operated in a single stage. The principal surgical observation was that the entire extent of tumor, which included intracranial, jugular fossa, and extracranial components, was within the "dural" confines and the tumor adjoining critical neural and vascular structures was displaced around the dome of the tumor. Radical surgical resection was achieved in all cases. During the follow-up period that ranged from 3 to 71 months (average 32 months), no symptomatic recurrence was observed and no patient needed reoperation. At the time of last clinical follow-up, the lower CN function in all patients was better than at the time of presentation.

CONCLUSIONS

The "dural" cover of the lower CN neurinomas forms a strong and reliable plane of compartmentalization and allows safe tumor resection.

Oculomotor Neurofibroma: A Different Histology Implying an Unsatisfying Clinical Outcome

BACKGROUND

Tumors arising from oculomotor nerve are rare, with few cases reported in the literature. Generally, whereas schwannomas are well encapsulated tumors, neurofibromas tend to invade the entire nerve fibers. These differences influence surgical resection and neurological clinical outcome, with neurofibroma often requiring the sacrifice of the nerve. Accordingly, an incorrect preoperative diagnosis can lead to incomplete patient counseling before surgery.

CASE DESCRIPTION

We report 2 cases: a patient with oculomotor schwannoma and a patient with oculomotor neurofibroma. After tumor resection, the patient with a diagnosis of schwannoma recovered with 3rd nerve palsy, while patient with the neurofibroma developed a complete oculomotor nerve deficit. For each patient, surgical strategy and neurological outcome are elucidated in relation with differences in preoperative magnetic resonance imaging and histology.

CONCLUSIONS

To the best of our knowledge, this is the first report of an oculomotor neurofibroma. When an oculomotor nerve tumor is suspected, a careful preoperative evaluation of magnetic resonance imaging guides in distinguishing the different histology, in selecting the treatment strategy, and in correctly informing the patient on expected postoperative neurologic outcome.

The Jugular Process: A Key Anatomical Landmark for Approaches to the Jugular Foramen

OBJECTIVE

To describe the morphology and anatomical relationship of the jugular process (JP) and to elucidate its utility as a surgical landmark in the lateraland posterior lateral approaches to the jugular foramen.

MATERIALS AND METHODS

Eight dry adult skulls and 10 silicon-injected cadaver heads were used for this study. The distances to selected structures and the thickness of the JP at 3 selected sites were measured. We also included the data of 20 thin-sliced 3-dimensional computed tomography scans. The radiology data of these patients were transferred to a workstation for 3-dimensional reconstruction.

RESULTS

The JP, an irregular trapezoid structure, is an important surgical landmark when approaching the jugular foramen. Laterally the JP is rough with 1 or 2 prominences to which the rectus capitis lateralis is attached. The JP is relatively flat medially. The condylar part of the occipital bone could be conceived as a "3-story building." The JP, hypoglossal canal, and lateral and posterior condylar emissary veins are located on the middle floor. The stylomastoid foramen is found constantly in the triangle formed by the styloid process, JP, and the base of the mastoid process.

CONCLUSIONS

The JP is an important surgical landmark in the identification of jugular foramen, especially in the lateral and posterior approaches. A better understanding of its morphology and its relationship with the surrounding structures is a prerequisite for accurate surgical planning and intraoperative orientation.

How I do it: retrosigmoid suprajugular approach to the jugular foramen

BACKGROUND

The retrosigmoid suprajugular approach provides a less-aggressive approach for a subset of tumors of the jugular foramen.

METHOD

We described the retrosigmoid suprajugular approach with its advantages, caveats, and indications. A Samii-B2 glossopharyngeal nerve schwannoma is shown to exemplify the procedure.

CONCLUSION

The retrosigmoid suprajugular approach provides an excellent option for tumors with a variable extension into the cerebellopontine cistern and limited extension into the jugular foramen. It is less destructive than the other approaches and allows a good exposure to the posterior part of the jugular foramen.

Optimal surgical approaches and treatment outcomes in patients with jugular foramen schwannomas: a single institution series of 31 cases and a literature review

Complete resection of jugular foramen schwannomas (JFSs) with minimal cranial nerve complications remains difficult even for skilled neurosurgeons. Between November 2011 and November 2017, 31 consecutive patients diagnosed with JFSs underwent a single-stage operation performed by the same neurosurgeon. We retrospectively analyzed clinical characteristics, surgical approaches, treatment outcomes, and follow-up data for these patients. JFSs were classified according to the Samii classification system. A retrosigmoid approach was used to resect type A tumors, while a suboccipital transjugular process (STJP) approach was used to resect type B tumors. Notably, the present study is the first to report the use of a paracondylar-lateral cervical (PCLC) approach for the treatment of type C and D tumors. Type A-D tumors were observed in seven, four, four, and 16 patients, respectively. Gross-total resection was achieved in 29 patients (93.5%). There were no cases of intracranial hematoma, re-operation, tracheotomy, or death. Adjunctive gamma knife treatment was used to manage residual tumors in two patients. Neurological deficits relieved in half of patients at the last follow-up. By reviewing the studies published on PubMed, the approaches gradually be more conservative, rather than widely expose the skull base. Nonetheless, endoscope and stereotactic radiosurgery plays an important role in the management of JFSs. Both tumor removal and neurological function retention can be obtained by choosing individual treatment.

Strategy for facial nerve management during surgical removal of benign jugular foramen tumors: Outcomes and indications

OBJECTIVE

Classical surgical management of jugular foramen (JF) tumors usually requires facial nerve rerouting which results in permanent facial palsy in most patients. The purpose of the article is to study the outcomes of different rerouting techniques, and to discuss their indications.

MATERIAL AND METHODS

We retrospectively reviewed 98 patients with JF tumors operated at our center between January 2008 and December 2016 using different surgical approaches with the following procedures for facial nerve management: total anterior rerouting (TR), partial anterior rerouting (PR), and fallopian bridge (FB) technique. The data for facial nerve management, surgical outcome and postoperative facial nerve function were collected from the medical records.

RESULTS

In the study, there were 48 males and 50 females. Of them, 61 (62.2%) were jugular paragangliomas, 22 (22.4%) schwannomas, and 15 (15.3%) meningiomas. Total tumor removal was achieved in 95 (96.9%) patients, while near-total removal was achieved in 3 (3.1%) paragangliomas. TR was applied in 31 (31.6%) patients with PR in 26 (26.5%) patients, and FB in 41 (41.8%) patients. The mean follow-up duration was 39.4±22.6 months, and 2 recurrences of paragangliomas were observed. Seventy-five patients (76.5%) had good facial function (HB I-II) at 1 year after surgery, the patients who received a TR approach presented significantly less HB I-II FN function (48.4%) than those with PR (82.6%, P<0.05) or those with FB technique (95.1%, P<0.001). 21 patients (21.4%) presented new-onset lower cranial nerve dysfunction of which 13 recovered at 1 year after surgery.

CONCLUSION

Facial nerve management in JF tumors should be tailored individually. No-rerouting methods, such as the fallopian bridge technique, bring significantly better results in terms of facial nerve function, which might be performed first during surgery; its indication is based mainly on the tumor type and extent.

Quantification of Surgical Route Parameters for Exposure of the Jugular Foramen Via a Trans-Mastoidal Approach Exposing Jugular Foramen in Three-Dimensional Visualization Model

OBJECTIVE

Surgical operation within the region of the jugular foramen presents a great challenge. The authors characterized the quantitative impact of surgical window parameters on the exposure of the jugular foramen via a trans-mastoidal approach.

METHODS

Computed tomography and magnetic resonance imaging data were used to establish a 3-dimensional model of the jugular foramen region. The mastoidale, posterior edge of the mastoid, and the superior edge of the bony external acoustic meatus were selected as points a, b, and c. The anterior edge of the tuberculum jugulare was selected as point d. The midpoints of line segments ab, ac, and bc were selected as points e, f, and g. Triangle abc was divided into triangles aef, beg, cfg, and efg. Surgical corridors of the triangular pyramid were outlined by connecting the above triangles to point d. Anatomic exposure was evaluated by measuring the area and volume of various structures within each route. Statistical comparisons were performed via analysis of variance.

RESULTS

The model allowed for adequate visualization of all structures. The areas of triangles beg and efg were greater than those of triangles aef and cfg (P < 0.05). The volumes of triangular pyramids d-beg and d-cfg were greater than those of triangular pyramids d-aef and d-efg (P = 0.000). Statistically significant differences were also observed for volumes of osseous, venous, and cranial nerve structures in all divided routes (P = 0.000).

CONCLUSION

Our results indicate that 3-dimensional modeling may aid in the quantification of surgical exposure and that division of the craniotomy window may allow for more precise operation.

Optimal treatment of jugular foramen schwannomas: long-term outcome of a multidisciplinary approach for a series of 29 cases in a single institute

BACKGROUND

The goal of treatment for jugular foramen schwannomas (JFSs) is to achieve complete tumor removal with cranial nerve preservation. However, achieving this goal remains a challenge despite the advances in microsurgical techniques. The aim of this study was to determine optimal treatment strategies for JFSs based on a review of a series of 29 surgical cases in our institute.

MATERIALS AND METHODS

Between 1997 and 2013, 29 patients with JFSs underwent surgical treatment by multidisciplinary otoneurosurgical approaches. We retrospectively evaluated various clinical outcomes including the extent of tumor resection, postoperative cranial nerve deficits, and the recurrence rate. Tumor extension was classified using the Kaye and Pellet classification (KPC) system, and the extent of tumor resection was graded as gross total resection (GTR), near total resection (NTR), and subtotal resection (STR). We utilized the House-Brackmann facial nerve grading system (HBFNGS), the average pure-tone audiometry and speech audiometry (PTA/SA) tests, and the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale (ASHA level) for assessment of functional outcomes.

RESULTS

The extent of tumor resection was not related to the degree of immediate postoperative cranial nerve deficits. However, the surgical approach was significantly related to postoperative hearing status and immediate postoperative facial function. Also, among the ten patients who were below the level of acceptable facial function immediately postoperatively, nine patients (90%) recovered to acceptable facial function by the last follow-up. Concerning postoperative swallowing status, all 21 patients recovered swallowing function by the last follow-up. Postoperative Gamma Knife stereotactic radiosurgery (GKRS) was performed for three recurrent and seven residual tumors, and recurrence was not observed in the mean 36-month follow-up period.

CONCLUSIONS

A surgical strategy should be tailored to the individual case, and clinicians should consider the possibility of recurrence and further adjuvant treatment.

Combined Endoscopic Transoral and Endonasal Approach to the Jugular Foramen: A Multiportal Expanded Access to the Clivus

BACKGROUND

The expanded endoscopic endonasal ("far medial") approach to the inferior clivus provides a unique surgical corridor to the ventral surface of the pontomedullary and cervicomedullary junctions. However, exposing neoplasms involving the jugular foramen (JF) through this approach requires extensive nasopharyngeal resection and lateral dissection beyond the boundaries of the endonasal corridor, limiting the extent of resection and restricting to use of this approach to expert surgeons. Here we describe a multiportal endoscopic transoral and endonasal approach to maximize surgical access to the JF and clivus.

METHODS

A multiportal endoscopic transoral and endoscopic approach to the JF and lower clivus was simulated in 8 specimens. A transoral corridor was created through a soft palate incision. The JF and parapharyngeal space were dissected through the transoral trajectory under endoscopic endonasal view. The length of the corridor of the transnasal and transoral trajectories was measured.

RESULTS

The JF was exposed intracranially and extracranially. The exposure extended superiorly to the sphenoid floor, inferiorly to the anterior atlanto-occipital space, and laterally to the internal acoustic meatus and parapharyngeal space. The cisternal parts of the cranial nerves VII-XII and C1 nerve bundles were accessible. Exposure of the JF contents and parapharyngeal space was possible using straight scopes, without Eustachian tube resection. The working corridor to the JF was significantly shorter through the mouth than through the nose (P < 0.0001).

CONCLUSIONS

This approach provides access to the JF from a ventromedial trajectory, enabling panoramic views, and outlines an expanded surgical exposure (superolateral intradural and inferolateral extracranial). It may provide optimal access for resection of dumbbell-shaped lesions of the JF.