Microsurgical treatment of large and giant tympanojugular paragangliomas

Friend or Foe? Preoperative Embolization in Jugular Paraganglioma Surgery-A Systematic Review and Meta-Analysis

BACKGROUND

Jugular paragangliomas are highly vascularized tumors that can grow in challenging neurovascular compartments and are particularly challenging to resect. There is still no consensus whether preoperative embolization should be employed to minimize intraoperative morbidity.

METHODS

A systematic review and meta-analysis was conducted by searching PubMed, Web of Science, and Embase databases for key terms including "embolization," "jugular paragangliomas," and "surgery."

RESULTS

This review included 25 studies with 706 patients and 475 (67%) preoperative embolizations. Polyvinyl alcohol particles were the most common embolic agent (97.8% of all patients who underwent embolization). Complication rate of embolization was 1% (95% confidence interval [CI]: 0%, 2%). Preoperative embolization was significantly associated with less intraoperative estimated blood loss (mean difference of -7.92 dL [95% CI: -9.31 dL, -6.53 dL]), shorter operating room times (mean difference of -55.24 minutes [95% CI: -77.10 minutes, -33.39 minutes]), and less overall tumor recurrence (odds ratio = 0.23 [95% CI: 0.06, 0.91]) compared with resective surgery alone. Preoperative embolization had no impact on the development of postoperative new cranial nerve deficits not associated with embolization (odds ratio = 1.17 [95% CI: 0.47, 2.91]) and achievement of gross total resection (odds ratio = 1.92 [95% CI: 0.67, 5.53]).

CONCLUSIONS

Preoperative embolization may provide surgical efficiency with faster surgical times and less bleeding and safety with diminished overall recurrence via safe embolization with minimal risks. These results must be considered taking into account the nonrandomness of studies.

Efficacy and Safety of Preoperative Embolization in Glomus Jugulare Tumors: A Systematic Review and Meta-analysis of Clinical Outcomes and Complications

PURPOSE

This study aims to provide a comprehensive review of the clinical benefits, complications, and safety profile associated with preoperative embolization in Glomus jugulare tumors (GJTs).

MATERIALS AND METHODS

A comprehensive search in PubMed, Embase, and Web of Science was conducted for English articles published up to March 2023, focusing on GJTs and preoperative embolization. Included studies involved patients over 18 with GJTs. We excluded studies that explored embolization methods other than the standard endovascular approach, as well as studies involving paragangliomas that did not provide specific data related to GJTs. Key variables such as hemorrhage volume and surgical time, as well as clinical outcomes, were analyzed. Data were analyzed using a random-effects model meta-analysis, assessing heterogeneity with the I2 statistic.

RESULTS

This review encompasses 19 studies with a total of 328 patients. The studies incorporated into our meta-analysis display considerable differences and inconsistencies in their data. The findings of the meta-analysis show a mean hemorrhage volume of 636 ml (95% confidence interval (CI) 473-799) following preoperative embolization, and a mean surgical duration of 487 min (95% CI 350-624). The study also notes potential complications: facial nerve deficits occurred in 20% of cases (95% CI 11-32%), and vagal nerve deficits in 22% (95% CI 13-31%).

CONCLUSION

This study suggests that preoperative embolization could decrease surgery duration and blood loss, but emphasizes the importance of evaluating risks like nerve damage. However, the generalizability of these findings is restricted due to the diversity of available data.

Comparison of surgical outcomes between early and advanced class of jugular paragangliomas following application of our modified surgical techniques

To compare the safety and effectiveness of surgical treatment of jugular paragangliomas (JPs) following the application of our modified surgical techniques. Fifty-six patients with JPs were analyzed for tumor classification, surgical outcomes, and intratumor blood vessels. The gross total resection in C1-2 (100%) was significantly greater than that in C3 and D (66.7%). Good postoperative facial nerve (FN) function (House-Brackmann I-II) was achieved in 89.5% C1-2 cases, which was not significantly different from C3 and D (93.3%) (P = 0.694). Preoperative and postoperative lower cranial nerve (LCN) deficits correlated with the Fisch's classification of tumors (P < 0.05), and intraoperative blood loss was greater in advanced tumors (P = 0.050). Further study showed that the cross-sectional area of intratumor blood vessels was positively associated with intraoperative blood loss (P < 0.001). Surgical excision of JPs is a safe and effective strategy, and early surgical treatment is a good option for patients with C1-2 tumors without surgical contraindications.

Surgical management of tympanojugular paragangliomas using the flexible CO2 laser

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Disease and Treatment-Related Sequelae in Patients with Complex Jugulotympanic Paraganglioma

Background: Jugulotympanic paraganglioma (JTP) are benign, high-vascularized lesions that frequently invade the jugular foramen, temporal bone, the upper neck, and the posterior fossa cavity, resulting in a wide variety of clinical symptoms. Methods: In this retrospective study, we assess the clinical symptoms and discuss the individual multidisciplinary treatment and outcome of 22 patients with JTP. Results: In 12 patients, a hearing deficit was the presenting symptom, whereas pulsatile tinnitus and otalgia were present in six and four patients respectively. Facial nerve involvement was seen in six patients (three HB Grade 1–2 and three HB Grade 4–6). Four patients presented with lower cranial nerve impairment. Rare symptoms were ataxia caused by brainstem compression and papilledema due to cerebral sinus obstruction. A new or worsening of the preoperative facial nerve or lower cranial nerve function occurred in two and four patients respectively. Conclusion: The treatment strategy and the surgical approach for JTP should be tailored to the tumor extension and the patient’s clinical symptoms.

Endovascular Approach to Glomus Jugulare Tumors

Background

Paragangliomas are benign neuroendocrine tumors derived from the glomus cells of the vegetative nervous system. Typically, they are located in the region of the jugular bulb and middle ear. The optimal management is controversial and can include surgical excision, stereotactic radiosurgery and embolization.

Case Report

We report the endovascular approach to three patients harboring glomus jugulare paragangliomas. In all cases incomplete occlusion of the lesions was achieved and recanalization in the follow-up period was revealed. Two patients presented no clinical improvement and the remaining one experienced a transient withdrawal of tinnitus.

Conclusions

It is technically difficult to achieve complete obliteration of glomus jugulare tumors with the use of embolization and the subtotal occlusion poses a high risk of revascularization and is not beneficial in terms of alleviating clinical symptoms.

Gamma Knife radiosurgery for glomus jugulare tumors: a single-center series of 75 cases

OBJECTIVE Glomus jugulare tumors are rare indolent tumors that frequently involve the lower cranial nerves (CNs). Complete resection can be difficult and associated with lower CN injury. Gamma Knife radiosurgery (GKRS) has established its role as a noninvasive alternative treatment option for these often formidable lesions. The authors aimed to review their experience at the National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom, specifically the long-term tumor control rate and complications of GKRS for these lesions. METHODS Clinical and radiological data were retrospectively reviewed for patients treated between March 1994 and December 2010. Data were available for 75 patients harboring 76 tumors. The tumors in 3 patients were treated in 2 stages. Familial and/or hereditary history was noted in 12 patients, 2 of whom had catecholamine-secreting and/or active tumors. Gamma Knife radiosurgery was the primary treatment modality in 47 patients (63%). The median age at the time of treatment was 55 years. The median tumor volume was 7 cm³, and the median radiosurgical dose to the tumor margin was 18 Gy (range 12-25 Gy). The median duration of radiological follow-up was 51.5 months (range 12-230 months), and the median clinical follow-up was 38.5 months (range 6-223 months). RESULTS The overall tumor control rate was 93.4% with low CN morbidity. Improvement of preexisting deficits was noted in 15 patients (20%). A stationary clinical course and no progression of symptoms were noted in 48 patients (64%). Twelve patients (16%) had new symptoms or progression of their preexisting symptoms. The Kaplan-Meier actuarial tumor control rate was 92.2% at 5 years and 86.3% at 10 years. CONCLUSIONS Gamma Knife radiosurgery offers a risk-versus-benefit treatment option with very low CN morbidity and stable long-term results.