Glomus tympanicum tumour: an alternative surgical technique

Endoscopic transcanal coblation excision of glomus tympanicum: a novel technique

OBJECTIVE

To evaluate the feasibility of coblation in excision of glomus tympanicum tumors.

PATIENTS AND METHODS

A retrospective study carried out over 28 patients with types I and II glomus tympanicum tumors according to GLASSCOCK-JACKSON classification. Preoperative radiological and endocrinal evaluation were performed. All patients underwent endoscopic transcanal excision of their glomus tympanicum tumors using coblation.

RESULTS

None of the patients developed recurrence during the 1-year follow up period proved radiologically. None of the patients developed facial palsy postoperatively. Differences between preoperative and postoperative dizziness and taste disturbance were statistically non-significant. Tinnitus disappeared completely in 22 patients postoperatively. A statistically significant reduction in Tinnitus Handicap Inventory (THI) after surgery was found. Statistically significant reductions in postoperative air conduction (AC) threshold and air bone gap (ABG) were recorded while bone conduction (BC) threshold showed statistically non-significant change.

CONCLUSION

Coblation is an effective and safe tool in excision of glomus tympanicum tumors. Further studies comparing coblation with laser and piezosurgery are strongly recommended.

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.

Microscopic Versus Endoscopic Ear Surgery for Early-Stage Glomus Tympanicum Tumors

Purpose: Glomus tympanicum tumors are benign primary tumors of the middle ear that can be completely removed using modern surgery. We compared endoscopic ear surgery (EES) to traditional microscopic ear surgery (MES) in terms of the removal of early-stage glomus tympanicum tumors. Methods: We retrospectively reviewed 25 cases treated from 2003 to 2021 that were of Grade I or II based on the Glasscock-Jackson classification system. Overall, 18 cases underwent MES: 8 via trans-tympanic bone and 10 via canal-wall-down or canal-wall-up tympanomastoidectomy (CWDT or CWUT) and 7 underwent EES. We compared surgery durations, the lengths and costs of hospitalization, postoperative complications, and relapse rates between the two groups and among the three specific operation ways. Results: The postoperative follow-up period ranged from 1 to 19 years. There was no between-group difference in operative time or the length or cost of hospitalization. Operative time and cost of hospitalization did not show a statistically significant correlation to the three surgical procedures, whereas it was found that the group of MES via the trans-tympanic bone had shorter length of hospitalization when compared with CWUT or CWDT group. All tumors were completely resected; pulsatile tinnitus improved in all patients, and there was no major complication. Two patients who underwent CWUT or CWDT (one each) relapsed; no patient relapsed in the EES group. Conclusion: MES via the trans-tympanic bone and EES via the ear canal safely and reliably remove early-stage tumors without excessive patient discomfort.

Glomus tympanicum removal using transcanal endoscopic assisted surgery: An experience with six cases

Objective

To evaluate an endoscopic approach in the management of glomus tumor, and also to investigate and evaluate its appropriateness and feasibility.

Methods

Glomus tumors, also known as paragangliomas, are benign primary tumors of the middle ear. The advent of endoscopic ear surgery has provided new dimensions to the management of this highly vascular tumor. Retrospective analysis of six patients of glomus tympanicum, operated between July 2014 and June 2019, with modified Fisch classification Type A and B1, who were managed by a retroauricular transcanal endoscopic approach. Preoperative and postoperative analysis was done for these patients.

Results

The chief complaint was pulsatile tinnitus, which disappeared in five cases and reduced in severity in one of them. Hearing was improved with reduction in air-bone gap in all the cases. No major complications or recurrence were observed in any of the patients after 12 months of follow-up.

Conclusion

This endoscopic approach serves as a safe and reliable technique for tumor removal. It thus provides postoperative comfort for most of the patients.

Neurosurgical Causes of Pulsatile Tinnitus: Contemporary Update

Traditionally in the domain of the otolaryngologist, pulsatile tinnitus (PT) has become increasingly relevant to neurosurgeons. PT may prove to be a harbinger of life-threatening pathology; however, often, it is a marker of a more benign process. Irrespectively, the neurosurgeon should be familiar with the many potential etiologies of this unique and challenging patient population. In this review, we discuss the myriad causes of PT, categorized by pulse-phase rhythmicity.

Hemostatic Control with Gelatin Sponge and Quantum Molecular Resonance Coagulation in a Case of Glomus Tympanicum

Surgical removal of tumor is the primary treatment of choice for glomus tympanicum (GT). However, because the tumor has abundant blood flow, bleeding control is crucial, and preoperative embolization may be performed. Here, we report the case of a 46-year-old female who visited our hospital with a complaint of right pulsatile tinnitus. A red pulsatile mass was found in the right tympanic cavity, and she was diagnosed with class B1 GT and subsequently underwent surgical treatment. We judged that bleeding could be controlled by intratympanic cavity manipulation alone and decided to perform transmeatal tumor resection without preoperative arterial embolization. After creating a tympanomeatal flap and performing an atticotomy, some pieces of Spongel^® were inserted between the tumor and the tympanic wall. The Spongel^® absorbed the blood and created a space between the tumor and tympanic wall, which allowed for the insertion of the tip of the Vesalius^® handpiece to coagulate the tumor. The coagulation caused the tumor to shrink, thereby widening the space and allowing for further resection. Although the surgical manipulation caused bleeding, complete resection was achieved by the application of Spongel^® and coagulation with Vesalius^®. Since the tip of the Vesalius^® was not burned, hemostasis was successfully achieved, and the operation proceeded while maintaining a clear field of view. There was little bleeding and no postoperative complications. The patient was discharged on the sixth postoperative day. One year after surgery, pure tone audiometry showed no change in the level of bone conduction. Spongel^® and Vesalius^® are useful tools that allow to safely perform surgeries even in narrow spaces such as the tympanic cavity.

Endoscopic Management of Early Stage Middle Ear Paragangliomas - An Australian Case Series

OBJECTIVE

To analyze the outcomes of the endoscopic transcanal approach for removal of early stage middle ear paraganglioma tumors (MEPT).

STUDY DESIGN

Cases series with chart review.

SETTING

Two tertiary Australian Otology centers.

PATIENTS

Adult patients with middle ear paraganglioma tumors treated with transcanal endoscopic approach from 2/2016 to 12/2019. Tumor staging was described using the Modified Fisch-Mattox (MFM). Inclusion criteria included patients with an MFM Class A or B. Exclusion criteria included higher staged or syndromic disease.

INTERVENTION

All tumors were managed with transcanal endoscopic approach.

MAIN OUTCOME MEASURES

Primary outcome measures included disease clearance and hearing measured according to the AAO-HNS guidelines. Secondary outcomes included complications, duration of surgery, and length of stay.

RESULTS

Ten patients underwent totally endoscopic transcanal resection of MEPT (9 female, mean age of 45.5 years, 70% were left sided). Mean tumor size was 6.1 mm (SD 3.4 mm). Five cases (50%) were classified using the MFM system as class A1, two cases were class A2, and three cases were class B1. Three cases required canalplasty for access but were completed entirely endoscopically. Nine of the 10 cases had complete audiometric data. Pre- and postoperative mean air conduction remained stable with a decrease in mean air-bone gap of 2.84 dB. Postoperative complications include one pinhole perforation. There were no facial nerve complications. Mean follow-up period was 10 months (range 4-25 mo) with all cases having resolution of pulsatile tinnitus and no tumor recurrence.

CONCLUSION

The transcanal endoscopic approach for early stage MEPT offers excellent visualization and permits safe and effective removal of disease with the advantages of a minimally invasive technique for patient recovery.

Pulsatile tinnitus: contemporary assessment and management

PURPOSE OF REVIEW

Pulsatile tinnitus is an uncommon otologic symptom, which often presents a diagnostic and management dilemma to the otolaryngologist. The majority of patients with pulsatile tinnitus have a treatable cause. Failure to establish correct diagnosis may have disastrous consequences, because a potentially life-threatening, underlying disorder may be present. The purpose of this review is to familiarize the otolaryngologist with the most common causes, evaluation, and management of pulsatile tinnitus.

RECENT FINDINGS

The pathophysiology, classification, various causes, evaluation, and management of the most common causes of pulsatile tinnitus are presented in this review.

SUMMARY

Pulsatile tinnitus deserves a thorough evaluation and, in the majority of cases, there is a treatable underlying cause. The possibility of a life-threatening cause needs to be ruled out in every patient with pulsatile tinnitus. The otolaryngologist should be familiar with the evaluation and management of this symptom.

Usefulness of ultrafast dynamic 3D-T1w data acquisition in detection of hypervascular lesions of the middle ear: first experience

OBJECTIVE

To evaluate ultrafast dynamic 3D-T1w acquisition for improved detection of tympanic hypervascularized lesions.

METHODS

Retrospective evaluation of a total of 50 patients referred from ENT-Department for suspected tympanic lesion. All underwent magnetic resonance imaging including ultrafast dynamic 3D-T1w acquisition imaging. Quantitative and qualitative evaluation was performed as well as statistical analysis. Comparison with intra-operative results.

RESULTS

12/50 patients showed a hypervascularized lesion proved intraoperative as 8 paragangliomas, 2 adenoms, 1 hemangioma and 1 neurinoma. 8/50 do not show hypervascularization though an enhancement was detected. Intra-operative granulation tissue was found. 30 patients did not show any lesions or enhancement. Sensitivity and specificity was 100%/100% for ultrafast dynamic imaging.

CONCLUSION

Additional ultrafast dynamic 3D-T1w imaging is superior to conventional imaging in detection of hypervascularized lesions.

Middle ear and mastoid glomus tumors (glomus tympanicum): an algorithm for the surgical management

OBJECTIVE

Glomus tumors are slow-growing benign lesions and represent the most common primary neoplasms of the middle ear. The objective of the present study is to report our surgical strategy in the management of glomus tympanicum tumors.

METHODS

Between December 1988 and July 2008, 68 patients with histologically confirmed glomus tympanicum tumor underwent surgical treatment. The follow-up of the series ranged from 6 to 194 months (mean, 33.4 months).

RESULTS

Distribution of tumors according to Fisch and Mattox classification was as follows: type A, 44 cases (64.7%); type B, 24 cases (35.3%). All of the 44 Class A tumors were safely removed via either a stapedectomy-type transcanal approach or a retroauricolar-transcanal approach. Five patients with Class B tumors were operated on through a transmastoid approach. Nineteen patients with larger Class B tumors underwent a subtotal petrosectomy with blind sac closure of the external auditory canal and middle ear obliteration. Gross total tumor removal was achieved in all 68 cases. In one case (1.4%) there was recurrence after 9 years, for which the patient was re-operated. No residual/recurrence has been detected on computed tomography in the rest of the patients.

CONCLUSION

Surgical excision of glomus tympanicum tumors is a safe procedure, allowing total tumor removal with minimal morbidity, a low recurrence rate, and a low complication rate.

Posterior circulation stroke following embolization of glomus tympanicum?relevance of anatomy and anastomoses of ascending pharyngeal artery. A case report

SUMMARY

Embolization in the territory of the ascending pharyngeal artery (APA) can be unsafe even after detailed pretherapeutic angiographic evaluation due to changes in haemodynamics and opening of anastomotic channels. A 60-year-old woman underwent angiogram and embolization for glomus tympanicum tumour. The glomus tympanicum tumour was embolized using contour PVA particles of 150-250 um. At the end of the particulate injection the patient had posterior circulation stroke. The check angiogram showed near total devascularisation of the tumour and in addition filling of the left vertebral artery through an anastomotic channel. MRI confirmed the infarct in the posterior circulation. The ascending pharyngeal artery has potential anastomoses to all neighbouring major arteries, and the anastomoses to the vertebral artery in our case were through the musculospinal artery. This case highlights the importance of potential vascular anastomotic channels as a cause of ischaemic complication during the embolization procedure. It also highlights the fact that dangerous anastomoses may only be visualised in the later phase of embolization probably due to changes in the haemodynamic pressure. The angiographic anatomy of APA is reviewed with potential communications with the internal and external carotid and vertebrobasilar systems.

Skull base surgery for removal of temporal bone tumors

CONCLUSION

When selecting the appropriate surgical approach the pathological type of tumor, the physiological status as well as the functional aspects should be considered. Understanding the strengths and weaknesses of each surgical technique and knowledge of the particular tumor biology facilitates selection of the most appropriate surgical approach and a successful outcome.

OBJECTIVES

The purpose of this study was to review cases that underwent skull base surgery for a variety of tumors that involved the temporal bone. We reviewed a single center's 25-year experience for epidemiologic characteristics, symptoms, treatment type and outcomes.

PATIENTS AND METHODS

The medical records and radiological images of 91 patients, who underwent skull base surgery, were retrospectively reviewed.

RESULTS

Among the 91 patients, 61 cases had benign disease and 30 had malignancies. A facial nerve schwannoma was the most common benign intratemporal tumor and a squamous cell carcinoma was the most common malignant tumor. With the facial nerve schwannoma, facial nerve paralysis and hearing loss were the most common presenting complaints; otalgia was the most common presenting symptom for temporal bone cancer. For patients with a glomus tumor, there was a characteristic pulsating tinnitus. A majority of the facial nerve schwannomas were resectable through the transmastoid approach. The infratemporal fossa approach type A was usually required for lower cranial nerve schwannomas and glomus jugulare tumors. However, the fallopian bridge technique with hypotympanectomy was another surgical option. Partial temporal bone resection and subtotal temporal bone resections were performed in cases with temporal bone cancer. The disease free 5-year survival of the temporal bone cancers was 42% and for the squamous cell carcinomas, it was 44%.

[Immunohistochemical and clinical features of patients with benign middle ear tumors]

The middle ear is a rare site for benign tumors. We report six patients with benign middle ear tumors surgicaly removed: three with carcinoid, one with adenoma, and two with paraganglioma. These tumors showed similar histological features in trabecular and glandular architecture, so further immunohistochemical study was needed to make a definitive histopathological diagnosis. When we analyzed clinical features of patients diagnosed immunohistochemically, the differentiation of two patients with paraganglioma from the remaining four with adenomatous tumors such as adenoma and carcinoid was relatively easy from otomicroscopic findings and enhancement in temporal bone MRI. It was however difficult to differentiate patients with adenomatous tumors from each other because they induced similar clinical symptoms and showed similar findings in images. For a definitive diagnosis, it is necessary to conduct exploratory tympanotomy or removal of the tumors to obtain enough specimen for histological and immunohistochemical studies. Tumors induced no bone destruction or complications. We recommend staged operations for total removal of tumors and for good postoperative hearing.

Surgical management of glomus tympanicum tumor

Glomus tympanicum tumor (also known as paraganglioma or chemodectoma) is the most benign tumor of temporal bone. Treatment may be palliative or curative. Palliative therapy includes watchful observation or radiotherapy and curative treatment is surgical. During 1995 to 2005, 18 cases of glomus tympanicum were managed at Basavanagudi ENT Care Centre Bangalore. We review retrospectively the diagnosis and surgical management of these cases. Advances in the imaging and refinements in traditional surgery have made correct diagnosis and complete excision of these tumors possible in most of the cases.

Current trends in the diagnosis and management of head and neck paragangliomas

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the diagnosis and management of head and neck paragangliomas.

RECENT FINDINGS

The review will focus on three main areas of interest: genetics, newer imaging modalities, and management with radiation therapy.

SUMMARY

The succinate dehydrogenase enzyme complex is important in the pathogenesis of paragangliomas. Magnetic resonance angiography and functional imaging have become very helpful in diagnosing these tumors. Surgery is still the mainstay of therapy, but conventional or stereotactic radiotherapy seems to be a very safe option in very large or inoperable tumors.