Large Intradural Tympanojugular Paragangliomas. A Contribution on Surgery and Management

Abstract

Large intradural growth of tympanojugular paragangliomas (TJ-PGs) into the cerebellopontine angle is an infrequent condition that can determine an extensive involvement of vessels and brainstem, representing a surgical challenge. The current classifications lack accuracy for defining large intradural TJ-PGs and assessing their operability. This study aims to retrospectively reappraise the management of a large intradural TJ-PGs surgical series, discussing operability criteria, treatment strategies, and resection techniques. Over a series of 63 class D TJ-PGs operated on between 1973 and 2008, patients with large intradural tumors were retrospectively reviewed. Surgical techniques and outcomes with long-term follow-up were analyzed. Seven patients presented with large intradural tumors, ranging from 4 cm to 5.5 cm in diameter. These cases were treated either via a petro-occipital transsigmoid approach in a single-stage resection (4 patients) or via a petro-occipital approach as a second-stage surgery after a previous infratemporal fossa approach on the extradural tumor (3 patients). Complete tumor resection was obtained in 5 cases through wide removal of the petro-occipital skull base and exposure of the dural root of the tumor, which carries its main blood supply and allows preemptive hemostasis. No new postoperative cranial nerve losses were observed. The surgical procedure was aborted in 2 cases because of cerebellar edema and carotid artery tear, respectively. Large intradural TJ-PGs can be effectively surgically managed with an appropriate technique combined with relevant nonsurgical strategies. Thus, operability criteria for these lesions can be extended. To share objective experience on large intradural TJ-PGs, a redefinition of Di3 tumors is recalled.