Jugular Foramen Paragangliomas.

Paragangliomas are the most common tumors at jugular foramen and pose a great surgical challenge. Careful clinical history and physical examination must be performed to adequately evaluate neurological deficits and its chronologic evolution, also to delineate an overview of the patient performance status. Complete imaging evaluation including MRI and CT scans should be performed, and angiography is a must to depict tumor blood supply and sigmoid sinus/internal jugular vein patency. Screening for multifocal paragangliomas is advisable, with a whole-body imaging. Laboratory investigation of endocrine function of the tumor is necessary, and adrenergic tumors may be associated with synchronous lesions. Preoperative prepare with alpha-blockage is advisable in norepinephrine/epinephrine-secreting tumors; however, it is not advisable in exclusively dopamine-secreting neoplasms. Best surgical candidates are young otherwise healthy patients with smaller lesions; however, treatment should be individualized each case. Variations of infratemporal fossa approach are employed depending on extensions of the mass. Regarding facial nerve management, we avoid to expose or reroute it if there is preoperative function preservation and prefer to work around facial canal in way of a fallopian bridge technique. If there is preoperative facial nerve compromise, the mastoid segment of the nerve is exposed, and it may be grafted if invaded or just decompressed. A key point is to preserve the anteromedial wall of internal jugular vein if there is preoperative preservation of lower cranial nerves. Careful multilayer closure is essential to avoid at most cerebrospinal fluid leakage. Residual tumors may be reoperated if growing and presenting mass effect or be candidate for adjuvant stereotactic radiosurgery.

Jugular foramen stenosis in external hydrocephalus in infants.

OBJECTIVE: To measure the size of jugular foramina in infants affected by external hydrocephalus (EH) and in a control group, to support the hypothesis that a jugular foramen (JF) stenosis may determine dural venous sinus alterations and increased venous outflow resistance as main pathophysiological factor. METHODS: Minimum, maximum, and mean values of JF areas were measured in a series of phase-contrast magnetic resonance venous angiography (angio MRV PCA3D) performed on 81 infants affected by EH. Results were compared with a group of 54 controls. RESULTS: Smaller JF area was significantly smaller in patients versus controls (43.1 ± 14.6 vs. 52.7 ± 17.8; p < 0.001) resulting in a significantly smaller mean JF areas in patients vs. controls (51.6 ± 15.8 vs. 57.0 ± 18.3; p = 0.043). In patients, smaller JF areas were significantly associated with higher venous obstruction grading score (VOGS) both on the right (p = 0.018) and on the left side (p = 0.005). Positional plagiocephaly (cranial vault asymmetry index > 3.5%) was more frequent among EH patients than controls (38/17) but the difference was not significant (p = 0.07). In the 38 plagiocephalic patients, JF area was smaller on the flattened side than the contralateral in a significant number of cases both in right (21/7) and left (9/1) plagiocephaly (p < 0.0005) as well as the mean area (48.2 + 16.4 mm2 vs. 57.5 + 20.7 mm2, p = 0.002) and VOGS was significantly higher on the plagiocephalic side than on the contralateral side (1.6 ± 1.1 vs. 1.1 ± 0.9, p = 0.019). CONCLUSION: In this series of infants affected by EH, the mean size of the ostium of both JF resulted significantly smaller than controls. JF stenosis was significantly associated with higher degrees of venous obstruction on both sides, suggesting a direct extrinsic effect of JF size on dural sinus lumen and possible consequent effect on venous outflow resistance. Positional plagiocephaly, when present, was associated with a decreased JF area and increased VOGS on the flattened side.

Stereotactic radio-neurosurgery for jugular foramen schwannomas.

BACKGROUND: Stereotactic radiosurgery (SRS) represents a minimally invasive and valuable alternative for jugular foramen schwannomas (JFS), both as upfront and/or adjuvant treatment (in hybrid approaches). METHODS: We conducted a retrospective review of our cases treated at the Lausanne University Hospital (CHUV) from June 2010 to October 2023. Eleven patients underwent SRS, among whom three had prior surgery, two in our center in the frame of a planned combined approach and one in another center. Two patients received "volume-staged" SRS. The mean age at SRS was 60 years (median 68; range 29-83). Cranial nerve (CN) symptoms were present in six patients, while five were asymptomatic. The mean tumor volume at SRS was 2.1 cc (median 1.2; range 0.068-7.3 cc), with a 12 Gy marginal dose prescribed in all cases. RESULTS: The mean follow-up period was 3.9 years (median 2, range 1-7). Cranial nerve function improved after SRS in six patients, while five remained stable. At the last follow-up, all tumors showed a decrease in volume, except for one patient, who underwent surgery at 18 months after SRS, for volumetric increase at 6 and 12 months, with further XII-th CN palsy and medulla oblongata compression. Although tumor decreased at 18 months, such patient needed microsurgical resection for symptom persistence and was further controlled. The mean tumor volume at 1 year post-SRS was 1.6 cc (median 0.55; range 0.028-7.77 cc), at 2 years was 1.31 cc (median 0.76; range 0.19-5), and at 3 years was 1.32 cc (median 0.59; range 0.23-4.8). No adverse radiation events were observed. CONCLUSIONS: Stereotactic radiosurgery is considered a safe and effective treatment for jugular foramen schwannomas, ensuring high rates of tumor control in all patients over the long term. The cranial nerve function improved after SRS in the 6 patients who had deficits and the other 5 patients who had no deficits remained asymptomatic. For larger tumors, combined/hybrid approaches can be a valuable alternative, to obtain tumor control and to preserve neurological function.

Microsurgical resection of a samii type D jugular foramen schwannoma via the carotid triangle without removal of bony structure: how I do it.

BACKGROUND: Samii Type-D jugular foramen schwannomas (JFSs) are the most challenging for neurosurgeons because of anatomical complexity. Various neurosurgical approaches have been described to gain access to JF. METHODS: We present a female with incidental diagnosis of the Type-D JFS. Complete radical resection was achieved via the carotid triangle approach without any bony structure removal. And the patient was discharged asymptomatic and without new-developed neurological deficits. CONCLUSIONS: The carotid triangle is a secure and appropriate approach for some cases of selected Type-D JFSs. However, the specific indications of this approach should be further explored and investigated.

The intrabulbar or extrabulbar growth pattern and its surgical outcomes of jugular foramen paragangliomas.

OBJECTIVE: This study is to define a subclassification system of jugular foramen paragangliomas (JFPs) and to demonstrate corresponding microsurgical outcomes of JFPs. STUDY DESIGN: Retrospective study. SETTING: A single-center study. METHODS: We conducted a retrospective review of the clinical data of 44 patients with JFPs who underwent surgical management. Extrabulbar(Be) tumor and intrabulbar(Bi) tumor are defined based on the growth patterns, receiver operating characteristic (ROC) curves of the imaging profile were generated and was confirmed based on intraoperative findings. Area Under Curve (AUC), accuracy, sensitivity, and specificity for diagnostic imaging were revealed. We also compared the correlation between the two growth patterns with Fisch's classification, blood loss, lower cranial nerves (LCNs) deficit. RESULTS: There are 27 (69%) cases of Bi tumor and 17 (39%) cases of Be tumor. Significant radiomics features between the two growth patterns were demonstrated, ROC curves achieved excellent AUCs for MRI sequences (T1W1 MRI, MR contrast-enhanced sequence, MR complex sequences and MR complex + DSA by 0.833, 0.833, 0.875, 0.944) and had statistically significant in diagnosis of two growth patterns (P<0.05). There was no statistical correlation between growth patterns of JFPs and intra-operative blood loss. Preoperative LCNs deficits and Fisch's classification of tumors were correlated with the growth patterns of JFPs (P < 0.05). CONCLUSION: We proposetd two growth patterns of JFPs in term of the inferior petrous sinus involvement. Identification of Bi or Be growth patterns preoperatively is helpful to design optimal surgical strategies and minimize postoperative complications.

Computed tomographic features of canine intracranial and jugular foraminal masses involving the combined glossopharyngeal, vagus, and accessory nerve roots.

A chronic cough, gag, or retch is a common presenting clinical complaint in dogs. Those refractory to conservative management frequently undergo further diagnostic tests to investigate the cause, including CT examination of their head, neck, and thorax for detailed morphological assessment of their respiratory and upper gastrointestinal tract. This case series describes five patients with CT characteristics consistent with an intracranial and jugular foraminal mass of the combined glossopharyngeal (IX), vagus (X), and accessory (XI) cranial nerves and secondary features consistent with their paresis. The consistent primary CT characteristics included an intracranial, extra-axial, cerebellomedullary angle, and jugular foraminal soft tissue attenuating, strongly enhancing mass (5/5). Secondary characteristics included smooth widening of the bony jugular foramen (5/5), mild hyperostosis of the petrous temporal bone (3/5), isolated severe atrophy of the ipsilateral sternocephalic, cleidocephalic, and trapezius muscles (5/5), atrophy of the ipsilateral thyroarytenoideus and cricoarytenoideus muscles of the vocal fold (5/5), and an ipsilateral "dropped" shoulder (4/5). Positional variation of the patient in CT under general anesthesia made the "dropped" shoulder of equivocal significance. The reported clinical signs and secondary CT features reflect a unilateral paresis of the combined cranial nerves (IX, X, and XI) and are consistent with jugular foramen syndrome/Vernet's syndrome reported in humans. The authors believe this condition is likely chronically underdiagnosed without CT examination, and this case series should enable earlier CT diagnosis in future cases.

Jugular bulb anatomical variations and pneumatization patterns: a comprehensive CBCT analysis.

PURPOSE: This study aims to assess the anatomical possibilities of the jugular bulb (JB). METHODS: Fifty archived CBCT scans were analyzed. RESULTS: The average distance between the internal acoustic canal (IAC) and the JB was 7.97 mm on both sides (Right: SD = 2.56 mm, range 3.16-13.3 mm; Left: SD = 2.5 mm, range 2.9-13.6 mm). JB walls' pneumatization was classified into eight patterns. Deep petrosal cells (DPCs) prevailed in the lateral wall of the JB. The absence of pneumatization (NP) was commonly found on the left side. The presence of infralabyrinthine and hypotympanic cells varied. Less common types included accessory occipital cells (AOCs), posteromedial tracts (PMTs), and basi-occipital cells (BOCs), which determined a consistent variation of the lateral wall pneumatization patterns. Pneumatization of the medial wall was not observed in 50 right sides and 49 left sides. The inferior wall analysis revealed symmetry in AOC distribution and a predominant occurrence of NP. Cases with hypotympanum (HT) in the lateral wall showed a statistically significant IAC-JB distance increase by an average of 4.67 mm compared to NPs. Specific pneumatizations, particularly HT on the lateral side, have a significant effect on the IAC-JB distance, showing a clear pattern of increasing distance from DPC to NP and then to HT. A significant distance increase in HT pneumatization was noted. There were also recorded instances of JB hypoplasia and hyperplasia, JB diverticula, dehiscent JBs, and high JBs. CONCLUSION: This study establishes a novel classification of JB pneumatizations to aid in the understanding of the temporal bone anatomy.

V3 segment of the right vertebral artery taking an anomalous posterosuperior course and penetrating occipital bone (wall of the jugular foramen) diagnosed by magnetic resonance angiography.

PURPOSE: To describe a case of an anomalous posterosuperior course of the V3 segment of the right vertebral artery (VA) that penetrated the occipital bone (wall of the jugular foramen). METHODS: A 33-year-old healthy woman underwent cranial magnetic resonance (MR) imaging and MR angiography from the upper cervical to the intracranial region using a 3-Tesla scanner to screen for asymptomatic brain lesions, including cerebrovascular diseases. RESULTS: MR angiography showed no pathological arterial lesions such as aneurysms; however, there was an anomalous posterosuperior course of the V3 segment of the right VA. On MR angiographic source images and coronal reformatted images, the right VA was observed to penetrate the occipital bone lateral to the right hypoglossal canal and is located on the inferoposteromedial wall of the right jugular foramen and enter the posterior fossa at a higher level than the foramen magnum. CONCLUSION: We present a case in which the right VA showed an anomalous posterosuperior course at the craniovertebral junction. It is extremely rare for a VA to take a higher course. To our knowledge, this is the first report of such a VA variation in the relevant English-language literature. We speculated that the right VA of our patient was formed by the persistence of one more cephalad primitive artery than the first intersegmental artery, not by the persistence of the primitive hypoglossal artery. Careful observation of MR angiographic source is useful and important for identifying the VA penetrating the occipital bone.

[Jugular Foramen, Foramen Magnum Meningiomas].

The jugular foramen, also known as the foramen magnum, is a highly intricate region of the skull base through which numerous critical blood vessels and nerves traverse. Meningiomas, the most common tumors in neurosurgical pathology, can arise at any location where the meninges are present, posing significant challenges. Meningiomas involving the jugular foramen and sublingual neural tube are particularly notable for their potential to extend from intracranial to extracranial sites, necessitating familiarity with extracranial anatomy, which is not typically encountered in clinical practice. A comprehensive understanding of anatomical characteristics, along with an ample field of view and working space, is crucial for handling the cerebellum, brainstem, and nerves meticulously. The use of surgical support tools such as neuromonitoring and navigation is essential for enhancing the safety of the procedure. Furthermore, preparedness for treatment options, rehabilitation, and adjunctive therapies is vital in the event of neurological symptoms such as those affecting the glossopharyngeal, vagal, or hypoglossal nerves.

Precise differentiation between jugular foramen paragangliomas and metastases: utility of diffusion-weighted and dynamic contrast-enhanced magnetic resonance imaging.

PURPOSE: This study tested the utility of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCE-MRI) in differentiating paragangliomas and metastases in the jugular foramen in combination with conventional imaging. METHODS: Forty-nine consecutive patients with paragangliomas or metastases between January 2015 and April 2022 were included in this retrospective study. All patients had pretreatment DWI and DCE-MRI. Between paragangliomas and metastases, normalized apparent diffusion coefficient (nADCmean) and DCE-MRI parameters were compared along with conventional imaging features (enhancement pattern, presence of flow voids, cystic/necrotic change, and bone erosion). The diagnostic performance was tested using receiver operating characteristic (ROC) analysis. RESULTS: Thirty-five paragangliomas (5 male; median 49 years) and 14 metastases (9 male; median 61 years) were analyzed. The most common 3 primary cancers included 4 lung cancers, 3 breast cancers, and 3 melanomas. The presence of flow void was significantly different between paragangliomas and metastases (21/35 vs 2/14; P = 0.0047) in conventional imaging features, while fractional plasma volume (Vp) was significantly different between the two tumor types (median 0.46 vs 0.19; P < 0.001) in DWI and DCE-MRI parameters. The areas under the ROC curves (AUCs) of the presence of flow void and Vp were 0.72 and 0.93, respectively. The AUC of the combination of the presence of flow void and Vp was 0.95 and significantly improved compared to that of the presence of flow void (P < 0.001). CONCLUSION: Adding DCE-MRI to the head and neck protocol can aid in the precise differentiation between jugular foramen paragangliomas and metastases.

Microsurgical resection of a right dumbbell-shaped jugular foramen schwannoma through a modified retrosigmoid infra-jugular approach: how I do it.

BACKGROUND: Surgical treatment of dumbbell jugular foramen schwannomas can be challenging. The main goals of surgery are maximal resection with preservation of function and overall patient quality of life. METHODS: In this paper, we present a step-by-step technical description of a microsurgical resection of dumbbell-shaped JF schwannoma using a modified retrosigmoid infra-jugular approach. CONCLUSION: The modified retrosigmoid infra-jugular is a safe and suitable approach in selected cases. This technique, however, must be limited only to those tumors with minimal extension into the jugular foramen.

Endoscope-assisted resection of a Samii type B jugular foramen schwannoma.

BACKGROUND: Tumors involving the jugular foramen region are challenging for surgical resection. With the development of endoscope in the past decade, surgical approaches assisted by endoscope have been widely emerged in the treatment of skull base tumors. METHODS: Herein, we report a case of jugular foramen schwannoma (Samii type B). Surgical resection was applied via a suboccipital retrosigmoidal craniotomy using surgical microscope assisted by endoscope. Gross total resection was achieved. And the patient recovered without obvious neurological deficits. CONCLUSIONS: Samii type B schwannomas involving the jugular foramen is approachable by endoscope-assisted surgery.

Anterolateral (juxtacondylar) approach with limited mastoidectomy to resect a jugular foramen meningioma.

BACKGROUND: The anterolateral (juxtacondylar) approach with limited mastoidectomy is a suitable option to expose the postero-inferior part of the jugular foramen (JF). It is particularly indicated for tumors extending in the neck beyond the jugular foramen, especially in those cases necessitating both neck control as well as control of the mastoid segment of facial nerve. METHOD: We describe here the steps to safely perform an anterolateral approach with mastoidectomy along with a brief description of its indications and limits. CONCLUSION: This approach represents a valid option to reach the JF. Its knowledge can improve the process of optimal approach selection when dealing with complex pathology involving the JF.

Extraskeletal Myxoid Chondrosarcoma of the Jugular Foramen in a Pediatric Patient: A Case Report and Comprehensive Review of the Literature.

INTRODUCTION: Extraskeletal myxoid chondrosarcoma of the jugular foramen is a rare clinical entity, especially in the pediatric population. Thus, it can be confused with other pathologies. CASE PRESENTATION: We report an extremely rare case of a 14-year-old female patient with jugular foramen myxoid chondrosarcoma that was completely removed through microsurgical resection. CONCLUSION: The primary purpose of the treatment is gross total resection of the chondrosarcomas. However, adjuvant methods such as radiotherapy should additionally be applied in patients who have high-grade diseases or cannot undergo gross total resection because of anatomic localization.

Anatomy of small canals around the jugular foramen: Special reference to Jacobson's and Arnold's nerves.

The jugular foramen harbors anatomically complex bony, venous and neural structures. It is closely associated with small canals including the mastoid, tympanic, and cochlear canaliculi, and the stylomastoid foramen. The minute intraosseous branches of Arnold's and Jacobson's nerves (<1 mm in length) remain difficult to study with current imaging techniques, and cadaveric dissection is the most reliable approach. Our aim was to examine the variations of Jacobson's and Arnold's canaliculi and nerves and to provide detailed cadaveric graphics. To reveal the anatomical structures of small canals around the jugular foramen, 25 sides of dry skulls and 14 sides of cadaveric heads were examined. Intraosseous branches varied more in Arnold's nerve than Jacobson's nerve. In our cadaveric dissection, all specimens formed a single canal for Jacobson's nerve connecting the jugular foramen to the tympanic cavity. The intraosseous course of Arnold's nerve varied in its communication with the facial nerve. A descending branch crossing the facial nerve was identified in five of 14 sides, an ascending branch in 13. In two specimens, an ascending branch clearly reached the base of the stapedius muscle. Classical anatomical studies of cadavers remain a supplementary tool for analyzing these tiny structures. The present study confirms Gray's findings of 1913. Variations of these nerves could be even more complex than previously reported. Our study provides additional information regarding the anatomy of Jacobson's and Arnold's nerves.

[Jugular foramen anatomy in lateral skull base paraganglioma surgery]. / Anatomiya yaremnogo otverstiya v khirurgii paragangliom lateral'nogo osnovaniya cherepa.

In this article we present the surgical approaches to the temporal bone paraganglioma based on the anatomical studies. OBJECTIVE: To detalize the anatomy of the jugular foramen according to the comparison of cadaver dissections findings and the CT scans data that were performed before the dissections, for improvement of quality of treatment of patients with temporal bone paraganglioma (Fisch type C). MATERIAL AND METHODS: The data of CT scans and the steps of the approaches to the jugular foramen (retrofacial and infratemporal approaches with opening of jugular bulb and identification of the anatomical structures of jugular foramen) were analyzed on 10 cadaver heads, 20 sides. Clinical implementation was demonstrated in case of temporal bone paraganglioma type C. RESULTS: Based on the detail study of the CTs data we revealed the individual features of the temporal bone structures. Due to the results of 3D rendering the average length of the jugular foramen in anterior-posterior direction was 10.1 mm. The length of vascular part was larger than the nervous part. The posterior part had the bigger height wherein the shortest part we detected between jugular ridges, which in some cases caused the dumbbell shape of jugular foramen. According to 3D multiplanar reconstruction the distances between jugular crests (3.0 mm) had the lowest measures and the largest was between internal auditory canal (IAC) and jugular bulb (JB) (8.01mm). At the same time, one of the largest variations of values was also identified between IAC and JB (from 4.39 to 9.84 mm). The distance between the facial nerve in the mastoid segment and JB was variable (from 3.4 to 10.2 mm) and determined by the volume and position of the JB. The results of the dissection corresponded to the measurements according to the CT scans, taking into account the 2-3 mm error due to the massive removal of temporal bone during performing of surgical approaches. CONCLUSION: The detailed knowledge of the surgical anatomy of the jugular foramen based on a thorough analysis of preoperative CT data is the key to an adequate surgical tactic for the removal of different types of temporal bone paraganglioma while preserving the function of vital structures and the quality of life. A larger study on the big data is needed to determine the statistical relationship between the volume of JB and the size of the jugular crest; the correlation between the dimensions of jugular crests and the tumor invasion in the anterior part of the jugular foramen.

Surgical treatment of selected tumors via the navigated minimally invasive presigmoidal suprabulbar infralabyrinthine approach without rerouting of the facial nerve.

The feasibility of a novel skull base approach - the navigated minimally invasive presigmoidal suprabulbar infralabyrinthine approach (NaMIPSI-A) without rerouting of the fallopian canal for selected jugular foramen tumors (JFTs) - has been demonstrated in a neuroanatomical laboratory study. Here, we present our clinical experience with the NaMIPSI-A for selected JFTs, with a particular focus on its efficacy and safety. All patients with JFTs who were treated via the NaMIPSI-A were included in this study. The JFTs were classified according to a modified Fisch classification. The neurological and neuroradiological outcome, the extent of tumor resection, and the approach-related morbidity were examined. Five patients (two women, three men; mean age 57 years, range 48-65) were available. According to the modified Fisch classification, two JFTs were graded as C1, one as De1, and two as De2. Gross total resection (GTR) was achieved in three patients and near-total resection (NTR) in two. Postsurgically, no new neurological deficits and no approach-related morbidity and mortality occurred. One case with a postoperative cerebrospinal fluid leak was managed successfully with lumbar drainage. During the follow-up period (mean 67.6 months, range 12-119 months), tumor recurrence was noted in the NTR group but not in the GTR group. The NaMIPSI-A to the jugular foramen without rerouting of the fallopian canal is highly valuable for selected tumors of the jugular foramen. It is less invasive than other skull base approaches, and it allows safe and complete tumor removal in appropriate patients.

Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section Part III: Lower cranial nerve schwannomas, jugular foramen (CN IX, X, XI) and hypoglossal schwannoma (XII).

BACKGROUND: Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations. METHODS: A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the third of a three-part series describing non-vestibular schwannomas (IX, X, XI, XII). RESULTS: A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to preoperative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management. CONCLUSION: This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management paradigm is shifting towards the compromise between function preservation and progression free survival.

Jugular foramen capillary hemangioma masquerading as a paraganglioma.

Capillary hemangiomas are benign vascular lesions that are common in head and neck, but hemangiomas of jugular foramen and temporal bone are rare with only a few cases reported in the literature. We present a case report of this rare disease entity highlighting the subtle radiographic nuances that can benefit clinicians when encountered with similar unusual clinical scenario. Although radiographic features of capillary hemangioma can be distinctive, they are not specific. In this case, the lack of significant involvement of the jugular bulb and the absence of the typical pattern of osseous erosion of the jugular carotid spine led to the alternative diagnosis of a rare capillary hemangioma of the jugular foramen.

Intraoperative recording of laryngeal adductor reflex and cortical motor evoked potentials during jugular foramen schwannoma surgery: a case report and literature review.

PURPOSE: Schwannoma, a tumor originating from the peripheral nervous system, may arise from the vagus nerve, although it is not very often. Injury of the vagus nerve by surgical attempts may have consequences that will seriously affect the patient's quality of life. In recent years, continuous monitoring of the laryngeal adductor reflex (LAR) has become a promising methodology for evaluating vagus nerve function intraoperatively. We refer to our experience changing our surgical strategy due to concurrent deterioration in LAR and CoMEPs intraoperatively. We also provide a literature review and summarize the current knowledge of this technique. METHODS: The LAR was elicited and recorded by an electromyographic endotracheal tube in a 36-year-old man diagnosed with vagal nerve schwannoma. Subdermal needle electrodes were placed in both cricothyroid (CTHY) muscles for corticobulbar motor evoked potentials (CoMEPs) recording. RESULTS: Recordings of ipsilateral LAR and CTHY CoMEPs were obtained despite preoperative ipsilateral cord vocalis weakness. The surgical strategy was altered after the simultaneous decrease of CTHY CoMEPs and LAR amplitudes, and the surgery was completed with subtotal resection. No additional neurological deficit was observed in the patient except dysphonia, which resolved within a few weeks after the surgery. CONCLUSIONS: We conclude that LAR with vagal nerve CoMEPs are two complementary methods and provide reliable information about the functional status of the vagus nerve during surgery.