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Tympanic and Jugular Paragangliomas
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
6 sections · 115 slides
Overview
- Scope of this presentation
Origin, pathology and genetics
- Origin of paragangliomas
- Historical and current terminology
- Neurovascular anatomy and routes of spread
- Histopathology
- Basis of tumour hypervascularity
- Catecholamine secretion in head and neck paragangliomas
- Clinical features of excess catecholamine secretion
- Biochemical workup
- Perioperative management of secreting lesions
- Genetics of head and neck paragangliomas
- Succinate dehydrogenase subunit mutations
- Paraganglioma syndromes
- Clinical features of the paraganglioma syndromes and their associated succinyl dehydrogenase subunit mutations
- Malignancy in jugulotympanic paraganglioma
Clinical presentation and staging
- Epidemiology and growth behaviour
- Routes of spread
- Routes of spread
- Presenting symptoms
- Lower cranial neuropathies
- Tip of the tumour in the hypotympanum
- Otoscopic findings
- Transcanal exposure of a promontory tumour
- Differential diagnosis of a retrotympanic mass
- Biopsy is contraindicated
- Staging systems in current use
- Modified Fisch-Mattox classification
- Modified Fisch-Mattox classification (continued)
- Modified Fisch-Mattox classification (continued)
- Glasscock–Jackson staging system for temporal bone glomus/paraganglioma tumors
Imaging
- Computed tomography of the temporal bone
- Small promontory tumour on axial CT
- Expanded jugular foramen compared with the normal side
- Canal tumour with carotid canal erosion
- Magnetic resonance imaging features
- Jugular tumour extending to canal and cerebellopontine angle
- Coronal view of hypoglossal canal erosion
- Carotid encasement by a jugular foramen tumour
- Cervical extension and hypoglossal canal involvement
- Salt-and-pepper appearance from intratumoral flow voids
- Pathognomonic MRI signs
- Nuclear medicine imaging
- PET tracers and their selection
- Metastatic uptake on Gallium-68 DOTATATE PET-CT
- Preoperative angiography and embolisation
- Angiographic devascularisation before resection
- Risks of embolisation
- Balloon occlusion testing
Surgical management
- Tympanic and jugular disease are different operations
- Goals of surgery for tympanic paragangliomas
- Transcanal and endoscopic resection technique
- Haemostasis and ossicular considerations
- Approaches for larger tympanic tumours
- Structures never sacrificed and hearing rehabilitation
- Restraint in jugular paraganglioma surgery
- Cranial neuropathy rates: observation versus resection
- Selecting patients for surgery
- Multifocal head and neck disease
- Intraoperative neuromonitoring
- Blood loss and team communication
- Infratemporal fossa approaches
- Positioning and incision
- Ear canal transection and cervical exposure
- Vascular control in the neck
- Cervical exposure in the infratemporal fossa approach
- Temporal bone dissection
- Facial nerve handling and the bridge technique
- Exposing the jugular foramen and carotid
- Sequence of venous control
- Tumour resection and the inferior petrosal sinus
- Facial bridge technique with the jugular bulb opened
- Closure of the surgical defect
- Extended approaches: Fisch types B and C
- Management of the intracranial component
- Surgical outcomes in a large series
- Planned subtotal resection
- Combining limited resection with radiosurgery
- Rehabilitation of facial nerve deficits
- Rehabilitation of voice, swallow and hearing
Radiation, systemic therapy and observation
- Rationale for radiotherapy
- Stereotactic radiosurgery
- Cranial nerve outcomes after radiosurgery
- Comparing treatment modalities
- Demographics (a) and pooled estimates of the rates of tumor control (b) after different treatment modalities for jugular paragangliomas
- Pooled tumour control rates by treatment modality
- Systemic therapy
- Wait-and-scan strategy
- Observation series: growth rates
- Observation series: Prasad and colleagues
- Observation series: Carlson and colleagues
- Limitations of the observation evidence
- Treatment decision pathway
- Key points
- Conclusion
- References
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- References (continued)
- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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