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Less invasive transjugular approach with Fallopian bridge technique for facial nerve protection and hearing preservation in surgery of glomus jugulare tumors

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Abstract

For the past three decades, surgery of glomus jugulare tumors (GJTs) has been characterized by extensive combined head and neck, neuro-otologic, and neurosurgical approaches. In recent years, the authors have modified the operative technique to a less invasive approach for preservation of cranial nerves while achieving satisfactory tumor resection. We evaluated and compared the clinical outcomes of our current less invasive approach with our previous more extensive procedures. The clinical records of 39 cases of GJT surgically treated between 1992 and 2011 were retrospectively reviewed. The less invasive transjugular approach with Fallopian bridge technique (LI-TJ) was used for the most recent five cases. The combined transmastoid–transjugular and high cervical (TM-HC) approach was performed in 30 cases, while four cases were treated with a transmastoid–transsigmoid approach with facial nerve translocation. Operative technique, extent of tumor resection, operating time, hospital stay, and morbidity were examined through the operative records, and a comparison was made between the LI-TJ cases and the more invasive cases. No facial nerve palsy was seen in the LI-TJ group while the TM-HC group demonstrated six cases (17.6 %) of facial palsy (House–Brackmann facial nerve function grading scale grade II and III). The complication rate was 0 % in the LI-TJ group and 16.7 % in the more invasive group. The mean operative time and hospital stay were shorter in the LI-TJ group (6.4 h and 4.3 days, respectively) compared with the more invasive group (10.7 h and 8.0 days, respectively). The LI-TJ approach with Fallopian bridge technique provided adequate tumor resection with cranial preservation and definitive advantage over the more extensive approach.

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Acknowledgments

The authors wish to thank to Elizabeth Howe, Kimberly Peterkin, and Lori Radcliffe for providing the follow-up studies and examinations.

Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author information

Authors and Affiliations

  1. Division of Neurosurgery, Duke University Medical Center, Box 3807, 1000 Trent Drive 4520 Hosp South, Durham, NC, 27710, USA

    Yoichi Nonaka, Takanori Fukushima, Kentaro Watanabe, Allan H. Friedman & Ali R. Zomorodi

  2. Carolina Neuroscience Institute, 4030 Wake Forest Rd suite 115, Raleigh, NC, 27612, USA

    Takanori Fukushima

  3. Carolina Ear & Hearing Clinic, PC, 3100 Duraleigh Road suite 300, Raleigh, NC, 27612, USA

    John T. McElveen Jr. & Calhoun D. Cunningham III

  4. Department of Neurosurgery, Fukushima Takanori Skull Base Center, Shin-yurigaoka General Hospital, 255 Furusawa Asao-ku, Kawasaki, Kanagawa, 215-0026, Japan

    Yoichi Nonaka

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  1. Yoichi Nonaka
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  2. Takanori Fukushima
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  3. Kentaro Watanabe
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  4. Allan H. Friedman
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Correspondence to Yoichi Nonaka.

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Comments

Luis A. B. Borba, Curitiba, Brazil

Jean G. de Oliveira, São Paulo, Brazil

We read with great interest the article entitled “Less invasive transjugular approach with fallopian-bridge for facial nerve protection and hearing preservation in surgery of glomus jugulare tumors” by Nonaka et al.

First of all, we congratulate the authors for the results.

In January 2010, we published our series of glomus jugulare tumors which divides these tumors into four types (see reference 1 at the end of this comment). The technique described by Nonaka et al. is extremely similar to our type B tumors.

Those classified as type A are tumors located in the jugular with or without intradural or neck extension but receive blood supply only from branches of the external carotid artery. For this type of tumors, we recommend the infralabyrinthine retrofacial approach without opening the external auditory meatus and exposure of facial nerve. Hearing and facial nerve function is preserved.

Type B tumors have a similar extension of the type A, but with blood supply also from the ICA, which requires a different approach. For type B, a facial nerve is kept in its canal, and the tumor is removed anteriorly and posteriorly to the facial canal. The control of carotid tympanic branches from the ICA is crucial to remove the tumor. The external auditory meatus and structures of the middle ear are not removed. In this type, facial nerve function and hearing are preserved as well.

Some glomus jugulare tumors can grow anteriorly, encasing the ICA from the carotid canal to the cavernous sinus. For this situation, a more anterior and superior approach is required. In the type C approach, the external auditory meatus and middle ear structures are removed to expose the whole extension of the ICA in the petrous bone. In this approach, the facial nerve is kept in place preserving its function. However, the hearing is lost.

Glomus jugulare tumors can reach a very large size, sometimes debuting with facial nerve palsy, or the nerve can be totally encased and infiltrated by the tumor. In this situation, we perform a type D approach. In this approach, the facial nerve is transposed for a new position in the parotid gland or decompressed, or even a nerve graft harvest using the great auricular nerve. A total petrosectomy is performed in these cases.

Some aspects are decisive in jugular foramen tumor (see references 1 and 2 at the end of this comment):

(a) The preoperative evaluation must assess the hearing, facial, and lower cranial nerve functions.

(b) During the opening, begin to prepare the closure. That means that regional flaps with posterior temporal and sternocleidomastoid muscles must be prepared to be used for closure.

(c) The blood supply of the tumor is paramount for the surgical decision-making process.

(d) In order to preserve the lower cranial nerve function, the anterior wall of the jugular bulb must be preserved. Excessive coagulation in this location must be avoided. The use of fibrin glue helps to stop venous bleeding that originated from the inferior petrosal sinus, condylar vein, and anterior jugular branches.

(e) The extension of the surgical approach must be tailored case by case. In several situations when we had planned a less aggressive bone removal, we had to change during the surgery.

Finally, the authors should be congratulated by presenting their experience in dealing with glomus jugulars tumors.

References

1. Borba LA, Araujo JC, de Oliveira JG, Filho MG, Moro MS, Tirapelli LF, et al (2010) Surgical management of glomus jugulare tumors: a proposal for approach selection based on tumor relationships with the facial nerve. J Neurosurg 112(1):88–98. PubMed PMID: 19425885.

2. Borba LA, Ale-Bark S, London C (2004) Surgical treatment of glomus jugulare tumors without rerouting of the facial nerve: an infralabyrinthine approach. Neurosurg Focus. 2004 17(2):E8. PubMed PMID: 15329023.

Giannantonio Spena, Brescia, Italy

The paper by Nonaka et al. is well written and widely analyzes a very specific and particular aspect of the surgical approach to the tumors of the glomus jugulare. This skull base team has an extended experience in treating these very complex tumors, and their attitude is for sure to be shared since the goal to remove the tumor while limiting morbidity is nowadays a must. As they stated, this approach has already been adopted by Jackler (Atlas of Skull Base and Neurotology, 2008), but the use they do of it is clearly commendable.

Still, one point that must be emphasized is that such a dedicated team reached these results in a very long time span, demonstrating the dedication and knowledge it needs to face these tumors.

The paper merits to be read by a large audience, and we hope that the readers not only will learn more about surgical techniques but also will be aware about the necessity to gradually approach this complex surgery and pathology.

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Nonaka, Y., Fukushima, T., Watanabe, K. et al. Less invasive transjugular approach with Fallopian bridge technique for facial nerve protection and hearing preservation in surgery of glomus jugulare tumors. Neurosurg Rev 36, 579–586 (2013). https://doi.org/10.1007/s10143-013-0482-x

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