HSC Section 8_April 2017

Wanna et al

Fig. 6. Glomus jugulare as seen on a contrast-enhanced MRI scan. The arrow designates the tumor with a characteristic salt-and-pepper appearance. ( A ) is an axial cut; ( B ) is a coronal cut.

available substrates ( Fig. 7 ). However, it is important to note that cranial nerve palsy can occur after embolization utilizing liquid and small particle agents such as Onyx. 19 Thus, preoperative patient counseling regarding the potential risks and ben- efits of embolization is warranted. Furthermore, a careful preoperative cranial nerve examination after embolization and immediately before surgery should be performed. Surgery Historically, microsurgery with gross total resection was considered the treatment strategy of choice for JP. Although gross total resection is possible in the majority of cases, it may result in debilitating cranial neuropathy and less commonly, vascular injury. In a study done by Sanna and colleagues, 21 53 patients with Fisch class C or D JP were treated surgically. Gross total resection was achieved in 83% of cases, with a 10% tumor recurrence rate. The presence of new cranial neuropathy varied depending on the presence of intracranial extension, but was as high as 39%. Recently, the same group retrospectively reviewed 122 class C or D tumors. Gross tumor control was achieved in 86% of JPs, though 54% of the patients developed a postoperative lower cranial nerve injury. Cranial nerve IX was most commonly affected at last follow-up. 22 In another study including 119 patients, nearly 75% of patients had tumor control with surgical management, and new cranial neuropathies were noted in approximately 50% of patients after surgery. 23 Lastly, Fayad and colleagues, 3 examined the House Ear Clinic experience with glomus jugulare tumors (GJT), reporting total tumor removal in 81% of surgical cases. In this series, the incidence of postoperative cranial neurop- athy varied according to tumor size. For patients with Fisch classification C4 and lower, the incidence of new cranial nerve injury varied from 8.7% to 13%, whereas for patients with classification of C4 and higher, the deficit ranged from 63.6% to 81.8%. Overall, 26.5% of patients in this series developed tumor recurrence at an average of 26 months. In an effort to minimize morbidity and improve symptoms associated with disease, subtotal resection has been used with increasing frequency by many centers. Subtotal resection may be particularly relevant to older or infirm patients with advanced disease

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