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Designing Information-Preserving Mapping Schemes For OPERATIVE NUANCES T h e C o m b in e d T ransmastoid R e t r o - a n d James K. Liu, M .D . I nfralabyrinthine T ransjugular T ranscondylar Department of Neurosurgery, University of Utah T ranstubercular H ig h C er v ic a l A p p r o a c h fo r School of Medicine, Salt Lake City, Utah R es e c t io n o f G l o m u s J u g u l a r e T u m o r s Tetsuro Sameshima, M*DV Ph.D. COMPLEX TUMORS OF the glomus jugulare present a surgical challenge because of Carolina Neuroscience Institute, their difficult location, extreme vascularity, and involvement with multiple cranial Raleigh, North Carolina nerves. Modern microneurosurgical and cranial base techniques have enabled safe total removal of these complicated tumors. W e describe a one-stage transjugular Oren N. Gottfried, M.D. posterior infratemporal fossa approach for radical resection of glomus jugulare tumors Department of Neurosurgery, University of Utah located around the jugular foramen, the lower clivus, and the high cervical region from School of Medicine, an anterolateral direction. This approach is a combination of transmastoid, suprajugu- Salt Lake City, Utah lar, transjugular, extreme lateral infrajugular transcondylar transtubercular, and high cervical approaches. Total exposure of the jugular foramen can be achieved, and William T. Couldwell, M.D., multidirectional approaches can be performed, including infralabyrinthine/ Ph.D. suprajugular, retrosigmoid/transcondylar/infrajugular, and transjugular exposures. Ex­ Department of Neurosurgery, University of Utah posure of the vertical C 7 segment of the infratemporal internal carotid artery and the School of Medicine, lower clivus can be performed without permanent rerouting of the facial nerve. The Salt Lake City, Utah details of this approach are described and illustrated in a stepwise fashion, and the microsurgical anatomy is reviewed. Takanori Fukushima, M.D., D.M .Sc. KEY W O R D S: Cranial base approach, Glomus jugulare tumor, Jugular foramen exposure, Microsurgical Carolina Neuroscience Institute, anatomy Raleigh, North Carolina Neurosurgery 59IONS Suppl 1 l:ONS-115-ONS-125. 2006 DOI: 10.1227/01.N Fb .0000220025.31500.3D Reprint requests: William T. Couldwell, M.D., Ph.D., Department of Neurosurgery, University of Utah f ' ^ lomus jugulare tumors are formidable (23, 33, 35). The majority of glomus jugulare School of Medicine, ■ _ lesions of the cranial base. Guild (14) tumors are benign; in rare occasions, they ex­ 30 North 1900 East, Suite 3B409, was the first to coin the term, "glomus hibit malignant pathology (2). Salt Lake City, UT 84132. jugularis," or jugular body, to describe para- The surgical removal of these tumors re­ Email: william.couldwell@ hsc.utah.edu ganglionic tissue composed largely of capil­ mains a challenge. They may involve adjacent lary or precapillary vessels interspersed with structures, such as the jugular bulb, carotid Received, July 5, 2005. numerous epithelioid cells found along the artery, middle ear, petrous apex, clivus, infra­ Accepted, January 26, 2006. jugular bulb in human temporal bone speci­ temporal fossa, and posterior fossa. Two grad­ mens. He also noted that approximately half ing systems have been developed to classify of these "glomus tumors" were situated in the glomus tumors on the basis of their location, adventitia of the jugular bulb dome, and half size, and extent of disease: the Fisch classifi­ were situated along the course of the tym­ cation (8, 21) and the Glasscock-Jackson clas­ panic branch of the glossopharyngeal nerve sification (17,18). These classification systems (Jacobson's nerve) or the auricular branch of can facilitate operative planning and provide the vagus nerve (Arnold's nerve). This divi­ a system for reporting and analysis of surgical sion eventually led to the distinction of glo­ results. mus tympanicum tumors (glomus tumors Advances in neuroimaging, microneurosur­ arising from the middle ear) and glomus jugu­ gery, and modern cranial base surgery have lare tumors (glomus tumors arising from the allowed safe resection of these tumors with region of the jugular bulb) (3, 28). Larger tu­ lower rates of morbidity and mortality (1, 2, 4, mors involving both regions have been 6, 9,11-13,15-18, 20, 27, 35). Total removal of termed "glomus jugulotympanicum" tumors these tumors increases the likelihood of NEUROSURGERY VO I UM E 59 | OPERATIVE NEUROSURGERY 1 | JUI Y 2006 | 01X15-115 Liu et a l . achieving surgical cure. Fisch (7, 8) has described several computed tomographic scan of the cranial base is useful to lateral infratemporal fossa approaches for resection of large evaluate the bony anatomy of the temporal bone. glomus jugulare tumors (Fisch Type C and D) that emphasize Magnetic resonance angiography and venography are par­ transection and blind sac closure of the external ear canal, ticularly useful for assessing cerebrovascular anatomy and the permanent rerouting of the facial nerve, and anterior displace­ blood supply of the tumor and for confirming patency and ment of the mandible for exposure of the vertical infratempo­ dominance of the venous sinuses. Conventional angiography ral C7 segment of the internal carotid artery. These maneuvers is useful for visualizing the feeding arteries and the venous may result in conductive hearing loss, facial nerve palsy, and drainage of the tumor. In patients who have tumor encasing problems with jaw opening or mastication, respectively. A the internal carotid artery, a balloon occlusion test is per­ combined two-stage resection has also been advocated for formed to assess the risk involved with performing a carotid Fisch Type D2 tumors (tumors with intracranial extension artery sacrifice and subsequent reconstruction of the carotid greater than 2 cm in diameter) (8, 10). artery with a high-flow bypass. Tumor involvement may be We describe a one-stage transjugular posterior infratempo­ limited to the periosteal sheath, and a subperiosteal plane of ral fossa approach that allows radical resection of tumors that dissection can be achieved to free the tumor from the carotid are located around the jugular foramen, the lower clivus, and artery. If tumor has invaded the adventitial wall, however, the high cervical region from an anterolateral direction. This saphenous vein reconstruction and high-flow bypass of the approach is a combination of the transmastoid, retro- and carotid artery may be necessary (24, 31). Preoperative embo­ infralabyrinthine, transjugular, extreme lateral infrajugular lization of feeding arteries is an excellent adjunctive modality transcondylar transtubercular, and high cervical approaches. for reducing intraoperative blood loss, thereby facilitating the Total exposure of the jugular foramen can be achieved, and complete removal of glomus jugulare tumors (25, 36). Arterial multidirectional approaches can be performed, including su- feeders most commonly arise from the ascending pharyngeal prajugular (infralabyrinthine), transjugular, and infrajugular artery and feeders from the external carotid artery. (retrosigmoid/transcondylar) exposures. Both intracranial Preoperative assessment for catecholamine secretion by the and extracranial tumor can be removed in a one-stage proce­ tumor should be performed in all patients (26, 29). Although dure. Glomus tumors, schwannomas of the lower cranial the incidence of catecholamine secretion is approximately 4% nerves, meningiomas, chordomas, and chondrosarcomas at (5, 19), complications of wide fluctuations in blood pressure the foramen magnum and high cervical region are accessible and pulse can occur during surgical manipulation of the tu­ through this approach. Transection of the external ear canal mor. The release of norepinephrine can result in a hyperten­ and permanent rerouting of the facial nerve is not necessary; sive crisis, whereas the release of histamine and bradykinin instead, slight anterior transposition of the facial nerve, in can result in severe hypotension (22). In patients with hyper- select cases, can provide adequate exposure of the infratem­ secreting tumors, pretreatment with alpha or beta blockers is poral vertical C7 segment of the internal carotid artery, with­ warranted. An abdominal computed tomographic scan should out anterior displacement of the mandible. Furthermore, ac­ also be obtained to rule out an adrenal source of catechol­ cess to the lower clivus is facilitated by anterior translocation amine secretion (2). of the vertical portion of the internal carotid artery and infe­ rior translocation of the lower cranial nerves. SURGICAL APPROACH This complex approach for total jugular foramen exposure (see video at web site) can be simplified in a stepwise fashion: 1) postauricular infra­ temporal incision; 2) retrolabyrinthine mastoidectomy; 3) high cervical exposure; 4) skeletonization and anterior transloca­ Patient Positioning and Skin Incision tion of the facial nerve; 5) lateral suboccipital craniotomy and The patient is placed in the supine position with the head transcondylar-transtubercular exposure; 6) removal of the in­ turned laterally away from the side of the lesion. A shoulder ternal jugular vein, jugular bulb, and sigmoid sinus; and 7) roll is used to elevate the shoulder ipsilateral to the lesion. All intradural exposure. pressure points are carefully padded with foam or gel pads. The patient is secured to the operating table with adhesive tape to allow safe rotation of the table during the operation to PREOPERATIVE CONSIDERATIONS improve the surgeon's line of sight. In obese patients with
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