Combined approaches for resection of extensive glomus jugulare tumors

Complete resection with conservation of cranial nerves is the primary goal of contemporary surgery for glomus jugulare tumors. This publication reports the value of combined surgical approaches in achieving this goal in 12 patients with extensive tumors. Eleven of these tumors were classified as Fisch Class C and/or D, while eight were categorized as Jackson-Glasscock Grade III or IV. Intracranial (intradural) extension was present in 10 patients; four patients had tumor extension into the clivus and two into the cavernous sinus. The petrous internal carotid artery (ICA) was involved in eight and the vertebral artery (VA) in one. Subtemporal-infratemporal, retrosigmoid, and/or extreme lateral transcondylar approaches were added to the usual transtemporal-infratemporal approach. This improved the exposure, provided early control of the petrous ICA, and facilitated tumor removal from the clivus, cavernous sinus, posterior fossa, and foramen magnum, allowing a single-stage resection in eight patients. Ten patients had a complete microscopic resection with no mortality. The facial nerve was preserved in nine cases, with tumor involvement requiring nerve resection followed by grafting in the remaining three. Mobilization of the facial nerve was avoided in five cases; of these, three had intact function and two had House-Brackmann Grade III function on follow-up review. Only one patient had a mild persistent swallowing difficulty. The ICA was preserved in 10 patients and resected in two, while the VA required reconstruction in one case. There were no instances of stroke, and blood transfusions were required in five patients who had tumors with nonembolizable ICA or VA feeders. While complete resection provides the best possibility for cure, the important role of adjuvant radiation therapy in cases with residual tumor is discussed. The importance of degrees of brain-stem compression and vascular encasement is emphasized in classifying the more extensive tumors.