Blue laser for the exclusive endoscopic transcanal approach to middle ear paraganglioma.

BACKGROUND: The management of glomus tympanicum tumours can be challenging. Blue laser coagulation may improve bleeding control thus facilitating an endoscopic transcanal excision. The objective of this presentation is to illustrate the authors' experience using this novel tool. METHODS: Case report of a patient that underwent exclusive endoscopic transcanal blue laser surgery of a class A2 glomus tympanicum tumour in a tertiary referral center. CONCLUSION: The present study provides evidence of the safety and efficacy of endoscopic blue laser surgery, for the minimally invasive treatment of early-stage glomus tympanicum tumours.

Transcanal endoscopic ear surgery for glomus tympanicum removal: A case series on the necessity of preoperative embolization.

BACKGROUND: Transcanal endoscopic ear surgery (TEES) has become popular in recent years in the treatment of glomus tympanicum tumors (GTT). The most significant risk for TEES is bleeding. In some cases, preoperative vascular embolization is performed to mitigate bleeding during TEES. However, guidelines regarding the necessity and efficacy of preoperative vascular embolization have not been established yet. CASE PRESENTATION: This report aimed to assess the necessity and usefulness of preoperative vascular embolization in TEES for GTT by comparing the surgical findings of TEES without preoperative vascular embolization (Case 1) and TEES with preoperative vascular embolization (Case 2). Compared to Case 1, Case 2 included less bleeding and a more convenient procedure. However, no significant difference was observed. CONCLUSIONS: For GTT confined to the middle ear cavity (Glasscock-Jackson Grade II or less), when performed by a proficient otolaryngologist, TEES alone is sufficient without preoperative vascular embolization.

Clinical characteristics and surgical strategy of glomus tympanicum tumors. / 鼓室体瘤的临床特征及手术策略.

OBJECTIVES: To summarize the clinical characteristics of glomus tympanicum tumors, and to explore the surgical methods and the strategy for auditory protection. METHODS: Ten cases (ears) of glomus tympanicum tumors were collected from the Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University from August 2014 to February 2022. All patients underwent endoscopic or microscopic surgery to achieve total removal of the tumor, followed up for 3 months to 8 years. We summarized and analyzed its clinical characteristics, compared the preoperative and postoperative hearing levels of patients, and made a retrospective summary of the surgical methods and the strategy for auditory protection. RESULTS: Ten patients were all female at (49.50±8.00) years old. Their medical history ranged from 15 days to 6 years. Seven patients complained of pulsatile tinnitus, and 80% (8/10) of the affected ears suffered different degrees of hearing loss. According to the modified Fisch & Mattox classification of glomus tympanicum tumors, 3 ears (30%) of 10 ears were A1, 2 ears (20%) were A2 and 5 ears (50%) were B1. In all 10 cases (ears), hearing was improved in 3 cases, bone gas conductance was maintained in 6 cases, and hearing was slightly decreased in 1 case. The difference of bone gas conductance was 0-10 dB in 7 cases (ears) after operation, and 10-20 dB in 3 cases (ears). There was no significant difference in the average air conduction hearing threshold, bone conduction hearing threshold and air-bone conduction difference between before and after operation (all P>0.05). All cases had no postoperative complications, and the external auditory canal and the incision behind the ear healed well. There was no recurrence after follow-up. CONCLUSIONS: Glomus tympanicum tumor is easy to bleed, so it is a challenge for total tumor resection and hearing function protection during operation. For type A and type B1 tumors, they can be completely removed under the condition of keeping the tympanic membrane and the ossicular chain. At the same time, the postoperative hearing function can be preserved, and even the hearing can be improved.

Nuances in transcanal endoscopic surgical technique for glomus tympanicum tumors.

OBJECTIVE: To describe the utility and nuances of transcanal endoscopic surgery (TCES) on glomus tympanicum tumors from a single surgeon's experience. PATIENTS/INTERVENTION: Twelve patients, eight female and four males, diagnosed pre-operatively with glomus tympanicum tumors. They all underwent endoscopic resection by a single surgeon. MAIN OUTCOME MEASURES: Feasibility of endoscopic resection of glomus tympanicum tumors without conversion to a microscopic approach. Secondary outcomes include tumor stage, pre and post-operative audiometry, vertigo, sensorineural hearing loss (SNHL) and integrity of the facial nerve, ossicles, chorda tympani and tympanic membrane. RESULTS: Twelve patients underwent TCES, eight patient's pathology results were glomus tympanicum, ranging from Glasscock-Jackson grade I-III. Due to loss in follow up, 6/8 patients had complete audiometric data, which were analyzed. Average pre-operative air-bone-gap (ABG) was 5.41 compared to post-operative ABG of 5.08 (p > 0.89). No patients resulted in any, post-operative vertigo, tinnitus, SNHL, facial nerve injury or chorda tympani nerve injury. Two patients had intentional tympanic membrane perforations secondary to tumor adherence to the membrane. They were repaired with tragal perichondrium graft. No patients have had any recurrences. CONCLUSIONS: Endoscopic resection of glomus tympanicum tumors is a feasible and effective, alternative visualization modality for the neurotologist. Surgical pearls are described herein.

KTP-laser-assisted endoscopic management of glomus tympanicum tumors: A case series.

Endoscopic technology is widely used in rhinology and anterior skull base surgery, but it has been less quickly incorporated into otologic practice. The design of the instrumentation forces surgeons to work one-handed and limits depth perception. Nevertheless, endoscopy also offers wide fields of view and access to spaces that are typically difficult to visualize. Its advantages have broadened the type and extent of operations that can be performed via the ear canal. We describe a method of endoscopic resection of glomus tympanicum tumors in 5 adults who had undergone endoscopic or endoscopy- assisted resection. A successful resection was achieved in all patients-exclusively via the ear canal in 4 of them. A KTP laser was used to address the tumor's vascular supply. Attachment of a neonatal feeding tube to the endoscope for use as a suction catheter obviated the need to repeatedly switch instruments while using the laser. At a minimum of 12 months of follow-up, all patients were free of recurrence. Postoperative audiometry detected no significant adverse hearing outcomes in any patient. We conclude that the minimally invasive endoscopic transcanal approach is a feasible technique for addressing middle ear tumors. We have also developed a method that allows surgeons constant use of the KTP laser to resect a glomus tympanicum tumor.

Endoscopic Management of Middle Ear Paragangliomas: A Case Series.

OBJECTIVE: To investigate the efficacy and safety of endoscopic middle ear paraganglioma (glomus tympanicum) resection. STUDY DESIGN: Case series with chart review. SETTING: Multi-institutional tertiary university medical centers. PATIENTS: Adult patients with middle ear paragangliomas treated via a transcanal endoscopic approach from 1/2012 to 11/2015. INTERVENTION: All tumors were initially approached via a transcanal endoscopic technique. An operating microscope was used only if the tumor could not be adequately visualized or resected with endoscopic techniques alone. MAIN OUTCOME MEASURES: The main outcome was completeness of tumor resection via the endoscopic technique. Secondary measures were resolution of pulsatile tinnitus, audiometric outcomes, surgical duration, and surgical complications. RESULTS: Endoscopic resection was attempted on 14 middle ear paragangliomas. Thirteen patients (93%) were women with a mean age of 61.6 years. The mean tumor size was 6.2 mm (SD, 3.3). Eleven cases (79%) had complete resection via an exclusive endoscopic approach. The mean surgical duration was 108.1 minutes (SD, 55.6). One case required use of an operating microscope via a transcanal route and two cases required postauricular incisions with mastoidectomy. There were no significant postoperative complications. Two patients (14%) had tympanic membrane perforations repaired intraoperatively without residual perforation on follow-up. All patients had normal postoperative facial nerve function. Pulsatile tinnitus resolved after surgery in all 13 patients who presented with this symptom preoperatively. The mean pure-tone average improved by 5.9 dB (SD, 4.6) after surgery. CONCLUSIONS: Endoscopic management of middle ear paraganglioma is safe, feasible, and effective.

A blue middle ear mass: Cholesterol granuloma mimicking a glomus tumor and endolymphatic sac tumor.

Cholesterol granuloma (CG) is the most common benign lesion of the petrous apex, however, it can grow significantly large and become destructive causing a diagnostic dilemma. This case presents a 25-year-old female with 2-year history of left-sided progressive and profound hearing loss, a transient left-sided facial paralysis and cranial nerve 10 palsy who presented with a blue middle ear mass. Her diagnosis did not become apparent until direct visualization intraoperatively. The objective of this case study is to highlight the destructive capabilities of CG and the importance to keep it in the differential diagnosis of a large, erosive, expansile skull base lesion in order to avoid overly aggressive resection or other unnecessary treatment.

Treatment of glomus tympanicum tumors by preoperative embolization and total surgical resection.

PURPOSE: The purpose of this study was to evaluate the effectiveness on function preservation and tumor control of the treatment of glomus tympanicum tumors with pre-operative embolization followed by total surgical resection. MATERIAL AND METHODS: We describe a series of 6 patients with a glomus tympanicum tumor who were treated in our hospital using the same technique: the day before surgery selective tumor embolization due to denaturation with 96% ethanol. Following parameters were considered: tumor classification, tumor control, clinical and audiological outcome, effectiveness of embolization, percentage of tumor necrosis and treatment complications. RESULTS: There were no severe complications due to embolization or surgery. Tumor blush disappeared completely in 5 patients on DSA post embolization and histologic evaluation of the resected tissue showed a median of 69.2% of tumor necrosis. Pulsatile tinnitus disappeared in all patients and 3 patients had no symptoms at all. Hearing ameliorated in 4 patients, 1 patient without hearing loss pre- treatment still had normal hearing after treatment and 1 patient's hearing was worse after treatment. Average follow-up was 21.3months. CONCLUSIONS: Treatment of glomus tympanicum tumors by pre-operative embolization with ethanol and surgical resection has not been described before. Our results show that it is a safe procedure with a good long term tumor control, good clinical and audiological outcome.

(111)In-octreotide SPECT-CT in head and neck paragangliomas.

Head and neck paragangliomas are rare neuroendocrine tumors expressing somatostatin receptors on their cell surface, particularly subtype 2. Due to this distinctive feature, images can be obtained in Nuclear Medicine using synthetic analogues of somatostatin, mainly octreotide, which allow selective display by planar scintigraphy, SPECT-CT or PET-CT imaging after radiolabeling with (111)In or (68)Ga. Three cases have been selected and presented from a series of patients that illustrate the utility of SPECT-CT studies with (111)In-octreotide in the diagnosis and monitoring of this type of tumor. These are characterization at initial diagnosis, staging, and detection of local recurrence or metastasis, with added value with respect to anatomical images (nuclear magnetic resonance, computed axial tomography, angiography), for example in the differentiation between functional tissue or scar in patients who had previously undergone surgery.

Glomus tympanicum tumors.

Glomus tympanicum (GT) tumors are benign arising from paraganglion cells of the tympanic plexus in the middle ear. Although surgical resection remains the best option for definitive treatment of these tumors, the diagnostic and management algorithms have evolved considerably with the introduction of high-resolution computed tomography, MRI, and genetic testing.

Long term surgical and hearing outcomes in the management of tympanomastoid paragangliomas.

OBJECTIVE: To analyze the long term outcomes after surgery in tympanomastoid paragangliomas. STUDY DESIGN: Retrospective study. METHODS: The charts of 145 patients with tympanomastoid paragangliomas managed between 1988 and 2013 were reviewed. The clinical features, audiological data, pre- and postoperative notes were noted. The tumors were staged according to the modified Fish and Mattox classification. The surgical approaches for all patients were formulated according to the surgical algorithm developed at our center. RESULTS: 34 (23.5%), 46 (31.7%), 22 (15.2%), 18 (12.4%) and 25 (17.2%) patients were diagnosed to have TMP class A1, A2, B1, B2 and B3 tumors respectively. Gross tumor resection was achieved in 141 (97.2%) patients. The facial nerve was uncovered in four patients and infiltrated in three. The cochlea was found eroded in seven cases. The mean follow-up was 48.4 months. Recurrence was seen in one patient (0.7%). In the cases where the facial nerve was preserved (n=143), the nerve function was graded as HB grade 1 in 138 patients (97%). Postoperatively, the mean AC showed an improvement in all categories except in class B2 and B3, which corresponds to the classes that include patients who underwent subtotal petrosectomy. CONCLUSION: We report the long term surgical outcomes in tympanomastoid paragangliomas in the largest series published till date. It is possible to completely eradicate all types of tympanomastoid paragangliomas with minimum sequelae by choosing the correct surgical approach to achieve adequate exposure for individual tumor classes as described in our classification and algorithm. LEVEL OF EVIDENCE: IIb.

Diagnosis and management of multiple paragangliomas of the head and neck.

Paragangliomas (PGs) are slowly growing, usually benign neoplasms. The aim of the study was to analyze the incidence, diagnostic and therapeutic management of patients with multiple paragangliomas of the head and neck. A retrospective review of the records of 84 patients with head and neck PGs, diagnosed and treated in our institution was performed for the years 1983-2013 to identify patients with multiple tumors. Fourteen (16.6 %) patients developed multiple PGs, synchronous or metachronous, within 4-21 years of follow-up. Clinical data of these patients were reviewed to evaluate the diagnosis, location, stage and management strategy. There was a total number of 37 tumors in 14 patients. There were 20/37 (54.0 %) carotid PGs, 9/37 (24.3 %) jugular PGs and 8/37 (21.7 %) vagal PGs. Carotid PGs were observed in 12/14 (86 %) patients and in 8/14 (57 %) cases bilateral tumors occurred. Vagal PGs developed in 7/14 (50 %) patients and bilateral tumors were found in 1/14 (7 %) case. Jugular PGs occurred in 9/14 (64 %) patients. There were 30 synchronous tumors and seven metachronous PGs diagnosed 2-18 years after removal of the first tumor. Single metachronous mediastinal PG occurred. All patients had at least one tumor removed, with histopathological confirmation of the diagnosis. One patient had positive history of familial PGs. Carotid PGs are most common multiple paragangliomas. Radiological survey of the head and neck is required to detect multicentric tumors. Metachronous mediastinal and abdominal tumors may occur. Regular, prolonged follow-up is essential to identify metachronous PGs and possible postoperative gradual ICA occlusion.

Leksell Gamma Knife radiosurgery of the jugulotympanic glomus tumor: long-term results.

OBJECT: Glomus tumors usually display indolent behavior, and the effectiveness of radiation in stopping their growth can be assessed after long-term follow-up. Currently only midterm results of radiosurgery are available, so the authors included patients treated by Gamma Knife at least 10 years ago in this study to obtain a perspective of long-term results. METHODS: During the period from 1992 to 2003, the Gamma Knife was used to treat 46 patients with glomus tumors. The age of the patients ranged from 21 to 79 years (median 56 years). Gamma Knife radiosurgery was the primary treatment in 17 patients (37%). Open surgery preceded radiosurgery in 46% of cases, embolization in 17%, and fractionated radiotherapy in 4%. The volume of the tumor ranged from 0.2 to 24.3 cm(3) (median 3.6 cm(3)). The minimal dose to the tumor margin ranged between 10 and 30 Gy (median 20 Gy). RESULTS: One patient was lost for follow-up after radiosurgery. Clinical follow-up was available in 45 patients and 44 patients were followed with MRI in a follow-up period that ranged from 12 to 217 months (median 118 months). Neurological deficits improved in 19 (42%) of 45 patients and deteriorated in 2 patients (4%). Tumor size decreased in 34 (77%) of 44 patients with imaging follow-up, while an increase in volume was observed in 1 patient (2%) 182 months after radiosurgery and Gamma Knife treatment was repeated. One patient underwent another Gamma Knife treatment for secondary induced meningioma close to the glomus tumor 98 months after initial radiosurgical treatment. Seven patients died 22-96 months after radiosurgery (median 48 months), all for unrelated reasons. CONCLUSIONS: Radiosurgery has proved to be a safe treatment with a low morbidity rate and a reliable long-term antiproliferative effect.

The effects of tympanomastoid paragangliomas on hearing and the audiological outcomes after surgery over a long-term follow-up.

The primary goals of surgery of tympanomastoid paragangliomas (TMPs) are tumor eradication and hearing preservation. Though the surgical management of TMPs has been dealt with widely in the literature, the effects of TMPs themselves on preoperative hearing and the audiological outcomes after surgery have not been analyzed in detail. This article comprehensively evaluates the preoperative hearing and the long-term hearing outcomes after surgery of TMPs. This study is based on a study population of 145 patients which is the largest reported in the literature. The surgical approaches for all patients with TMPs were formulated according to an algorithm developed by the authors. Complete tumor removal with excellent hearing results can be achieved by approaching the tumor classes by the right surgical technique. TMPs could possibly induce sensorineural hearing loss in higher frequencies, and future studies could be directed towards this.

Jugulotympanic paragangliomas: 75 years of evolution in understanding.

Jugulotympanic paragangliomas were first described approximately 75 years ago. Since that time, there has been considerable evolution in knowledge of tumor biology, methods of classification, and appropriate management strategies. This paper attempts to summarize these gains in information.

[Endocrine surgery for neck paraganglioma: operation, radiation therapy or wait and scan?]. / Endokrine Chirurgie zervikaler Paragangliome: Operation, Strahlentherapie oder "wait and scan"?

BACKGROUND: Head and neck paraganglioma (HNP) represent rare endocrine tumors. Therapy is decided on genetic findings, tumor characteristics (e.g. tumor size, localization and dignity), age of patient and symptoms. In terms of local control radiation therapy is as equally effective as surgery but surgical morbidity rates secondary to cranial nerve injuries remain high. PATIENTS: Based on 6 patients with 11 solitary (4 patients) and multiple (2 patients) HNP (8 carotid body tumors, 1 vagal, 1 jugular and 1 jugulotympanic paraganglioma) the specific characteristics of the need for surgery as well as correct choice of treatment in cases of sporadic succinate dehydrogenase (SDH) negative and hereditary SDH positive HNP will be exemplarily demonstrated. RESULTS: A total of 6 carotid body tumors (four sporadic, two hereditary) were resected in 4 patients, five as primary surgery and one as a revision procedure. In one case a preoperative embolization was performed 24 h before surgery. Malignancy could not be proven in any patient. The 30-day mortality was zero. In the patient with bilateral hereditary carotid body tumors, unilateral local recurrent disease occurred. After resection of the recurrent tumor permanent unilateral paralysis of the laryngeal nerve, glossopharyngeal nerve and hypoglossal nerve occurred. All patients were followed-up postoperatively for a mean of 64 months (range 23-78 months) with a local tumor control rate of 100%. The overall survival rate after 5 years was 100%. CONCLUSIONS: Given a very strict indication with awareness of surgical risks selective surgery has a key position with low postoperative morbidity in the treatment of HNPs. We prefer surgery for small unilateral paraganglioma, malignant or functioning tumors.

Function-preserving therapy for jugulotympanic paragangliomas: a retrospective analysis from 2000 to 2010.

OBJECTIVES/HYPOTHESIS: Treatment for jugulotympanic paragangliomas (JTPs) is shifting from radical toward function-preserving surgery. Alternative primary treatments are available, such as stereotactic radiotherapy (SRT) and radiosurgery. The aim of this study was to analyze the results after primary function-preserving surgery with or without adjuvant radiotherapy, or primary SRT, in the treatment of JTPs. STUDY DESIGN: Retrospective analysis. METHODS: From 2000 to 2010, 45 patients (mean age, 62.5 years) received function-preserving treatment for JTPs-four type A paragangliomas (8.9%), 19 type B (42.2%), 13 type C (28.9%), and nine type D (20%) in the Fisch classification. The patients were retrospectively assigned to three groups: primary function-preserving surgery, primary stereotactic radiotherapy, and close follow-up. The end points for analysis were long-term tumor control, cranial nerve function, and hearing. RESULTS: A total of 64.4% of the patients (n = 29) received primary surgery, with complete resection in 18. Eleven patients had surgical tumor reduction, with fractionated postoperative radiotherapy (mean 53.5 Gy; range, 50-56 Gy) in five cases and radiosurgery (18 Gy) in one case; five patients received close follow-up. Twelve patients (26.7%) underwent primary radiotherapy (11 with SRT [mean, 50 Gy]; one with radiosurgery [16 Gy]). Four patients (8.9%) received a wait-and-scan strategy. The mean follow-up was 46.8 months. The overall tumor control rate was 97.2%. CONCLUSIONS: With these high tumor control rates, consistent with the literature, function-preserving therapy for JTPs currently appears to offer the greatest benefit for patients.

A jugulotympanic paraganglioma with craniocervical extension.

Jugulotympanic paragangliomas (JTPs) are rarely encountered benign diseases derived embryonically from the autonomic nervous system. Although JTPs may originate extracranially or intracranially, little has been reported in the literature about large JTPs involving several anatomical structures in the craniofacial regions. Management of large JTPs is controversial. The authors describe a large JTP invading the cranial bones and extending through the neck to the left clavicle. Doppler sonography, computed tomography and magnetic resonance imaging were performed preoperatively to confirm the diagnosis. Combined therapeutic approaches were undertaken with preoperative selective embolization followed by craniofacial resection in cooperation with neurosurgeons.