Jugular Foramen Research Articles

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

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. 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. 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.

Step-by-Step Stereotactic Radiotherapy Planning of Glomus Jugulare: A Guide to Radiation Oncologists—Dr Kanhu’s ROSE (Radiation Oncology from Simulation to Execution)

Background Glomus jugulare is a rare, slow-growing tumor that arise within the jugular foramen of the temporal bone. In the past, surgery was the primary modality of treatment for glomus Jugulare, but it leads to many complications and increased mortality. Radiotherapy was indicated in adjuvant setting in post-operative residual disease. But, with the advent of highly conformal radiation planning, stereotactic radiosurgery (SRS), is now one of the main modalities of radiation treatment in glomus jugulare. Objective To describe the procedural steps for radiation planning of SRS of glomus jugulare. Methods The step-by-step procedure for stereotactic planning of glomus jugulare has been described using a clinical scenario of glomus jugulare. Results The stereotactic radiation planning of glomus jugulare starts with the basic history and relevant clinical evaluation, that is, visual testing. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain is the imaging modality of choice. The radiation planning of glomus jugulare starts with CT simulation. MRI of brain should be done in the prescribed format to achieve uniformity in radiation planning. After CT and MRI image fusion, contouring of target, organs at risk (OAR) and radiation planning should be done. The plan evaluation includes target and OAR coverage index, conformity, homogeneity and gradient index, and beam arrangement. After radiation plan evaluation, treatment is delivered after quality assurance and dry run. Conclusion The paper highlights the sequential process of radiation planning for SRS in glomus jugulare—starting from simulation, planning, evaluation of plan, and treatment.

Abnormal jugular valves are not the sole explanation of an impaired outflow from the cranial cavity through the internal jugular veins: results of <I>in silico</I> studies

Background. Currently, pathological jugular valves are thought to be the main cause of altered hemodynamics in the internal jugular veins, the so-called chronic cerebrospinal venous insufficiency. The alternative interpretation of flow disturbances in these veins is that the main source of abnormal outflow are nozzle-like strictures in their upper parts, at the level or just below the jugular foramen, for example, caused by an enlarged transverse process of the atlas and/or styloid process of the temporal bone.1 These in silico studies were aimed at validation of this hypothesis.
 Methods. With the use of computational fluid mechanics software: the Flowsquare+ and the COMSOL multiphysics, we simulated blood flow in the models of internal jugular veins that exhibited different morphologies (Figure 1). With the Flowsquare+ software, we performed 3-dimensional simulations for the assessment of relevance of the strictures at the level of jugular foramen, while the COMSOL multiphysics software, which was used in 2-dimensional mode, gave us more detailed insight into the behavior of the jugular valve. Results. There was a normal unidirectional flow, with the centrally positioned centerline velocity and no flow separation in modeled veins, which were not narrowed or presented with gradual narrowings. On the contrary, in a majority of models with nozzle-like strictures located at the beginning of the studied veins, abnormal flow patterns were revealed, with significant flow separation and regions with reversed flow. The most severe flow abnormalities were not seen in the models with nozzles of a small cross-sectional area, but rather in those positioned asymmetrically. Abnormal valves (with reversed or asymmetric leaflets) further impaired the flow in models with symmetrically positioned nozzles, but had no significant impact on the flow in a case of an already altered flow evoked by the asymmetric nozzles.1 Importantly, simulations performed with the COMSOL multiphysics revealed that flow disturbances evoked by significant stenosis in the upper part of the internal jugular vein distort leaflets of the jugular valve. This was not seen as a case of a minor stenosis.
 Conclusions. We demonstrated that our working hypothesis is credible and that impaired outflow from the brain through the internal jugular veins is likely to be primarily caused by pathological strictures in the upper parts of these veins, instead of pathological jugular valves that, as of yet, were the main target of clinical research. In addition, pathology of the jugular valves may be secondary to the strictures in the upper segments of the internal jugular veins.

Multiple Meningocele in Klippel-Feil Syndrome: Case Report

Klippel–Feil syndrome (KFS) is a rare congenital skeletal malformation characterized by the fusion of various cervical and occasionally thoracic and lumbar vertebrae. It may be seen as the fusion between two vertebras of all cervical vertebras, Congenital cervical fusion occurs as a result of failure in normal segmentation of cervical summits. Cause of this failure is unknown and occurs at second-eight weeks of gestation. 25 years old, patient presented to our counseling center with a 4-month history of progressive dysphagia. Ent exam showed a soft retropharyngeal mass displacing the left tonsil measuring a little about 6 cm with no sign of ulceration or local inflammation, a short neck was noted with a limitation of flexion and extension movement and low-lying hairline with a psychomotor retardation; which raises the suspicion of Klippel Feil syndrome undiagnosed. Cervical magnetic resonance imaging (MRI) was done which showed a cervical cystic formation compressive oval well limited with regular contours and fluid content with dark aspect in T1 weighted sequences and bright in T2 weighted sequences with regular wall enhanced after injection of gadolinium measuring 8.2*4.3 cm spread over 8.9 cm high This formation appears to continue with the subarachnoid spaces of the posterior cerebral fossa through the hypoglossal nerve canal with doubt about involvement of the jugular foramen. Thoracic CT scan demonstrated a lateral cystic mass exiting out of the intervertebral foramen of T6-T7 showing the same characteristics as the cervical formation above. Klippel-Feil syndrome is a rare congenital skeletal malformation characterized by fusion of several cervical and sometimes thoracic and lumbar vertebrae, leading to a low hairline and a short neck. The pathological feature is congenital fusion of two or more cervical vertebrae. The fusion is thought to be associated with reduced expression of the Pax gene in sclerotomes during chondrification of the vertebra. Klippel-Feil syndrome is usually diagnosed in childhood. However, associated abnormalities may delay diagnosis. The challenge for the specialist is to recognize concomitant abnormalities and perform the appropriate work-up for the diagnosis of Klippel-Feil syndrome.

ODP041 Hearing Loss Reveals Dopamine-secreting Metastatic Paraganglioma

Abstract Background Paragangliomas are neuroendocrine tumors arising from chromaffin cells in extra-adrenal parasympathetic or sympathetic tissues. Frequently they produce catecholamines such as epinephrine and norepinephrine which cause adrenergic symptoms. Rarely, paragangliomas produce only dopamine. These tumors carry a worse prognosis than other types of paragangliomas, especially when associated with loss of SDH-B. Case A 41 year old African American female with developmental delay, allergic rhinitis, OSA, and obesity presented to a primary care clinic for evaluation of hearing loss and left ear pain. Patient was treated for acute otitis media but symptoms failed to resolve. She was referred to audiology where she was found to have a mixed conductive and sensorineural hearing loss on the left. Despite using hearing aids, a year later the patient presented to an ENT clinic with several weeks of worsening left aural fullness and decreased hearing. On otoscopy, a mass was visualized in the middle ear. CT scan identified a lytic lesion at the jugular foramen extending into the middle ear; MR of the inner auditory canal was concerning for a paraganglioma. PET CT revealed widely metastatic disease including FDG avid cervical and supraclavicular lymph nodes, pulmonary nodules, hepatic lesions, and sclerotic lesions in the vertebral column and right humerus. Biopsy of an hepatic lesion confirmed metastatic paraganglioma with loss of SDH-B. Labs were consistent with dopamine excess. A 24 hour urine dopamine was 1020 mcg/24 hour (normal 65-400) with plasma dopamine elevated at 191 pg/mL (normal <30). A 24 hour urine norepinephrine level was mildly elevated at 85 mcg/24 hours (normal 15-80) but plasma norepinephrine and epinephrine were both normal. The patient denied any history of palpitations, flushing, headaches, or chest pain. She was briefly started on doxazosin but this was later discontinued as metanephrines and normetanephrines were not significantly elevated. The tumor was not amenable for surgery. Ultimately after discussion with oncology, the patient opted to proceed with temozolomide and capecitabine chemotherapy. Discussion It is important to recognize differences in treating dopamine secreting paragangliomas compared with other catecholamine producing tumors. Preoperative alpha blockade is not routinely recommended as it may cause hypotension and postoperative cardiovascular collapse. While chemotherapy with Cyclophosphamide–dacarbazine–vincristine has historically been used for metastatic paragangliomas, temozolomide is now showing benefit in cases with SDH-B mutation. Sources cited: Foo, S. H., et al. "Dopamine-secreting phaeochromocytomas and paragangliomas: clinical features and management." Singapore Med J 51.5 (2010): e89-e93. Hadoux, J., Favier, J., Scoazec, J. -Y., et al (2014),SDHB mutations are associated with response to temozolomide in patients with metastatic pheochromocytoma or paraganglioma. Int. J. Cancer, 135: 2711-2720. https://doi.org/10.1002/ijc.28913. Presentation: No date and time listed

Morphometric comparison of Fisch type A and endoscopic endonasal far-medial supracondylar approaches to the jugular foramen.

The jugular foramen (JF) is one of the most complex and challenging skull base regions to approach surgically. The extreme medial approach to access the JF provides the approach angle from an anterior direction and does not require dissection and sacrifice of the jugular bulb (JB) to reach the pars nervosa. The authors compared the Fisch type A approach to the extreme medial approach to access the JF and evaluated the usefulness of the extreme medial approach. This study was performed at the Anatomical Laboratory for Visuospatial Innovations in Otolaryngology and Neurosurgery of The Ohio State University. For the comparison of surgical maneuverability and visualization, two angles were measured: 1) the angle of attack (AoA), defined as the widest angle of movement achieved with a straight dissector; and 2) the angle of endoscopic exposure (AoEE), defined as the widest angle of movement in the nasal cavity. The differences in eustachian tube (ET) management, approach angle, surgical maneuverability, and surgical application of the Fisch type A approach to the extreme medial approach were compared. There was no difference between ET mobilization and transection regarding cranial-caudal (CC) or medial-lateral (ML) AoA (p = 0.646). The CC-AoA of the Fisch type A approach was significantly wider than the CC-AoA of the extreme medial approach (p = 0.001), and the CC-AoEE was significantly wider than the CC-AoA of the extreme medial approach (p < 0.001). There was no significant difference between the CC-AoA of the Fisch type A approach and the CC-AoEE. The ML-AoA of the Fisch type A approach was significantly wider than the ML-AoA of the extreme medial approach (p = 0.033), and the ML-AoEE was significantly wider than ML-AoA in the extreme medial approach (p < 0.001). The ML-AoEE was significantly wider than the ML-AoA in the Fisch type A approach (p = 0.033). The surgical maneuverability of the extreme medial approach was not inferior to that of the Fisch type A approach. The extreme medial approach can provide excellent surgical field visualization, while preserving the JB. Select cases of chordomas, chondrosarcomas, and JF schwannomas should be considered for an extreme medial approach. These two approaches are complementary, and a case-by-case detailed analysis should be conducted to decide the best approach.

Role of hybrid operating room in management of low-velocity penetrating brain injury

Penetrating brain injuries (PBIs) are a severe subtype of traumatic brain injuries (TBIs), where an object pierces the cranium and meninges. Based on the speed of penetration, it can be classified into high and low-velocity penetration. Low-velocity penetrating injury (LVPBI) cause lacerations to the scalp, depressed skull fractures as well as localized brain tissue and blood vessel damage along the object's path of travel. There have been many case reports and small case series published describing these events. However, there is no standardized guideline for general management to improve patient outcomes. In this report we discuss our experience of using the hybrid theatre to manage such cases. We present the clinical management of a 10-year-old boy who was shot in the head with a harpoon. Computed Tomography Angiography (CTA) demonstrated that the harpoon punctured through the jugular foramen and had a high probability of internal jugular vein (IJV) and internal carotid artery (ICA) involvement. The surgery was performed seven days after injury in a hybrid operating room (OR). We used intraoperative digital subtraction angiogram (DSA) to guide our decision to permanently occluded the IJV and ICA. The patient had a good postoperative recovery and was sent home after three weeks of observation in the hospital. Despite the high cost, intraoperative cerebral angiography in hybrid theatre for selected patients with penetrating brain injury where major blood vessel damage is anticipated might benefit overall patient outcome.

Preliminary Study of the Treatment Strategy for Retaining Traumatic Foreign Bodies Involving the Carotid Artery.

Craniomaxillofacial trauma is usually accompanied by indwelling foreign bodies, and some of those are close to the carotid artery, which increases the risks and difficulties of surgical treatment. The introduction of interventional radiology combined with image-guided surgical navigation may be a good solution for precise surgery to remove foreign bodies. Four patients were included in the study. All patients underwent digital subtraction angiography and enhanced computed tomography before surgery. The patients were divided into 3 categories (A, B, and C) according to the presence of carotid artery damage and its positional relationship with the foreign body, and 3 corresponding treatment strategies were developed. Treatments were completed using interventional radiology and surgical navigation systems. All foreign bodies were completely removed, except for 1 remaining in the jugular foramen in a patient. The prognosis of all patients was good, and no systemic complications occurred. The combined interventional radiology and surgical navigation method proposed in this study is an effective method to improve the accuracy and safety of foreign body removal surgery.

Staged Surgery for Intra-Extracranial Communicating Jugular Foramen Paraganglioma: A Case Report and Systematic Review

Staged surgery strategy was preferred for patients with intra-extracranial communicating jugular foramen paraganglioma (IECJFP). A female patient who presented mild tinnitus, headache, and dizziness, together with preoperative related imaging, was diagnosed with a left intra-extracranial communicating jugular foramen lesion in November 2015 and accepted an initial operation for the intracranial tumor by retrosigmoid approach. The pathologic report was paraganglioma. In November 2021, a subtotal resection of the extracranial tumor was conducted for prominent lower cranial nerves (LCNs) deficit and middle ear involvement by infratemporal approach. In patients with IECJFP accompanied by LCNs deficit and middle ear involvement, an initial surgery for extracranial lesion and a second procedure for intracranial tumor were appropriate. However, the first operation for the intracranial lesion was preferred in IECJFP cases without LCNs deficit and middle ear involvement, as it could remove compression to the neurovascular structure and brain stem, clarify a pathological diagnosis, avoid a CSF leak, and prevent a severe neurological disorder from extracranial lesion excision. Subtotal resection of the extracranial tumor would be performed when lesion became larger combined with obvious LCNs disorder and tympanic cavity involvement. Consideration of specific staged surgical strategy for IECJFP in accordance with preoperative LCNs deficit and tympanic cavity involvement could prevent critical postoperative neurological deficit and improve quality of life in the long term.

Quantitative Anatomic Comparison of the Extreme Lateral Transodontoid vs Extreme Medial Endoscopic Endonasal Approaches to the Jugular Foramen and Craniovertebral Junction.

Large, destructive intracranial and extracranial lesions at the jugular foramen (JF) and anterior craniovertebral junction (CVJ) are among the most challenging lesions to resect. To compare the extreme lateral transodontoid approach (ELTOA) with the extreme medial endoscopic endonasal approach (EMEEA) to determine the most effective surgical approach to the JF and CVJ. Seven formalin-fixed cadaveric heads were dissected. Using neuronavigation, we quantitatively measured and compared the exposure of the intracranial and extracranial neurovascular structures, the drilled area of the clivus and the C1 vertebra, and the area of exposure of the brainstem. The mean total drilled area of the clivus was greater with the EMEEA than with the ELTOA (1043.5 vs 909.4 mm 2 , P = .02). The EMEEA provided a longer exposure of the extracranial cranial nerves (CNs) IX, X, and XI compared with the ELTOA (cranial nerve [CN] IX: 18.8 vs 12.0 mm, P = .01; CN X: 19.2 vs 10.4 mm, P = .003; and CN XI, 18.1 vs 11.9 mm, P = .04). The EMEEA, compared with the ELTOA, provided a significantly greater area of exposure of the contralateral ventromedial medulla (289.5 vs 80.9 mm 2 , P &lt; .001) and pons (237.5 vs 86.2 mm 2 , P = .005) but less area of exposure of the ipsilateral dorsolateral medulla (51.5 vs 205.8 mm 2 , P = .008). The EMEEA and ELTOA provide optimal exposures to different aspects of the CVJ and JF. A combination of these approaches can compensate for their disadvantages and achieve significant exposure.

Differentiation between anatomical slenderness and acquired stenosis of the internal jugular veins.

Background and PurposesDifferentiating between acquired stenosis (pathologic) and anatomical slenderness (physiologic) of internal jugular vein (IJV) remain ambiguous. Herein, we aimed to compare the similarities and differences between the two entities.MethodsPatients who underwent head and neck computer tomography (CT) and brain magnetic resonance imaging (MRI) were enrolled in this case‐control study from January 2016 through October 2021.Results1487 eligible patients entered final analysis totally. 803 patients had bilateral IJVs imaging without IJV stenosis‐related symptoms and presented in three ways: right IJV slenderness (10.5%, n = 85), left IJV slenderness (48.4%, n = 388), and symmetric IJVs (41.1%, n = 330). In patients with asymmetric IJVs, their bilateral jugular foramina were also asymmetric. All involved asymmetric IJVs presented as slenderness without surrounding abnormal collaterals and credible cloudy‐like white matter hyper‐intensity (WMH). Their cerebral arterial perfusion statuses on brain MR‐PWI maps were normal.In contrast, the major patients with IJV stenosis presented with signs and symptoms such as headaches, head noise, etc. In CE‐MRV maps, local stenosis of the IJV was surrounded by abnormal venous collaterals in contrast to the lack of abnormal venous collaterals for patients with IJV slenderness. And in CTV maps, the caliber of jugular foramina was mismatched with the transverse diameter of IJV. Moreover, in MRI maps of most of these patients, a cloudy‐like WMHs were distributed symmetrically in bilateral periventricular and/or centrum semi vales. These patients also had symmetrical cerebral arterial hypo‐perfusion. Seven patients underwent stenting of the IJV stenosis correction, their WMHs attenuated or disappeared subsequently.ConclusionsImaging features in addition to clinical symptoms can be used to differentiate between physiologic IJV slenderness and pathologic IJV stenosis. Notable imagine‐defining features for IJV stenosis include local stenosis surrounded by abnormal venous collaterals, cloudy‐like WMHs, and mismatch between the transverse diameter of IJV and the caliber of the jugular foramina.

Transotic Approach for Resection of Expansile Endolymphatic Sac Tumor.

Objectives and Design Endolymphatic sac tumors (ELSTs) are rare and indolent tumors that arise from the endolymphatic sac in the posterior petrous ridge. We present a video case report illustrating the use of a transotic approach for resection of an expansile ELST. Setting and Participants A 25-year-old male presented with a multiyear history of worsening left-sided hearing loss, vertigo, and headaches. Otoscopy revealed a red mass behind an intact tympanic membrane. Computed tomography revealed a large, locally aggressive mass centered in the posterior petrous temporal bone. Magnetic resonance imaging demonstrated a heterogeneously enhancing 2.4 × 3.1 × 2.4 cm tumor that exerted mass effect on the cerebellar surface with extension into the jugular foramen, tympanic cavity, internal auditory canal, and cistern of the cerebellopontine angle. A transotic approach was planned to obtain the necessary generous exposure. Main Outcome Measures and Results Preoperative angiography revealed arterial supply via the ascending pharyngeal and tumor embolization with Onyx was performed. Surgical resection began with a blind-sac closure created from the external auditory canal. The tympanic membrane and malleus were removed and the incustapedial joint was transected. A subtotal petrosectomy was performed for partial tumor exposure. The facial canal and sigmoid sinus were carefully skeletonized and a labrynthectomy was performed. The tumor was resected using a combination of bipolar cautery and blunt and sharp dissection. For closure, an abdominal fat graft was secured with overlying resorbable mesh followed by sequential closure of all skin layers. Histopathologic analysis revealed an ELST. Conclusion The transotic approach offers wide exposure and facilitates large, complex tumor removal. The link to the video can be found at https://youtu.be/YvhyN8iVi44 .

Ultrasound-guided extracardiac vagal stimulation-New approach for visualization of the vagus nerve during cardioneuroablation.

Fluoroscopy-guided extracardiac vagal stimulation (ECVS) from the internal right and left jugular veins (RIJV and LIJV) is routinely used to document vagal response (sinus arrest and/or atrioventricular block) during cardioneuroablation. Ultrasound-guided ECVS allows direct visualization and selective stimulation of the vagus nerve (VN). The objectives of this study were to assess the feasibility of ultrasound-guided ECVS and to compare it with fluoroscopy-guided ECVS. The study group consisted of 48 patients (25 men [52%]; mean age 38 ± 15 years) in whom fluoroscopy-guided ECVS and ultrasound-guided ECVS were performed. For fluoroscopy-guided ECVS, a pacing electrode was introduced into the RIJV and into the LIJV up to the level of the jugular foramen under fluoroscopic guidance. For ultrasound-guided ECVS, the VN and electrode were visualized using ultrasonography. Partial vagal response was defined as induction of sinus arrest or atrioventricular block, whereas full vagal response was defined as induction of both. ECVS was performed in all patients from the RIJV and in 45 from the LIJV. Visualization of the VN using ultrasound was possible in 44 patients (92%). During ECVS from the RIJV, partial vagal response was obtained in 39 (81%) using fluoroscopy-guided ECVS vs 45 (94%) using ultrasound-guided ECVS (not significant) whereas full vagal response was obtained in 27 patients (56%) using fluoroscopy-guided ECVS vs 40 (83%) using ultrasound-guided ECVS (P = .0071). For ECVS from the LIJV, partial vagal response was achieved in 40 (89%) vs 44 (98%) patients (not significant) whereas full vagal response was achieved in 30 (67%) vs 40 (89%) patients (P = .021) (fluoroscopy-guided ECVS vs ultrasound-guided ECVS, respectively). Ultrasound-guided ECVS is feasible and full vagal response is achieved significantly more frequently than using fluoroscopy-guided ECVS.

Jugular foramen schwannoma: A rare tumor treated by stereotactic radiosurgery

Jugular foramen schwannomas (JFS) are rare benign tumors located in the jugular foramen. They can present with various symptoms depending on the extent of involvement of the tumor such as hearing loss, tinnitus, headache, and ataxia. Surgical resection has been considered as the primary treatment option for JFS. Stereotactic radiosurgery (SRS) offers an equally good treatment in patients with small and residual tumors after surgery with the advantage of being non-invasive with minimal complication rates. Herein, we present a rare case of JFS treated by SRS in our institution.

Surgical Management of Craniovertebral Junction Schwannomas: A Systematic Review.

Background: Craniovertebral junction (CVJ) schwannomas are rare, with surgery and stereotactic radiosurgery (SRS) being effective yet challenging options. We systematically reviewed the literature on CVJ schwannomas. Methods: PubMed, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA statement to include studies reporting CVJ schwannomas. Clinical features, management, and outcomes were analyzed. Results: We collected 353 patients from 101 included articles. Presenting symptoms were mostly neck pain (30.3%) and headache (26.3%), with most cranial neuropathies involving the XII (31.2%) and X (24.4%) nerves. Most tumors originated from C2 (30.9%) and XII (29.4%) nerves, being extracranial (45.1%) and intradural-extradural (44.2%). Erosion of C1–C2 vertebrae (37.1%), the hypoglossal canal (28.3%), and/or jugular foramen (20.1%) were noted. All tumors were operated, preferably with the retrosigmoid approach (36.5%), with the far-lateral approach (29.7%) or with the posterior approach and cervical laminectomy (26.9%), far-lateral approaches (14.2%), or suboccipital craniotomy with concurrent cervical laminectomy (14.2%). Complete tumor resection was obtained most frequently (61.5%). Adjuvant post-surgery stereotactic radiosurgery was delivered in 5.9% patients. Median follow-up was 27 months (range, 12–252). Symptom improvement was noted in 88.1% of cases, and cranial neuropathies showed improvement in 10.2%. Post-surgical complications occurred in 83 patients (23.5%), mostly dysphagia (7.4%), new cranial neuropathies (6.2%), and cerebrospinal fluid leak (5.9%). A total of 16 patients (4.5%) had tumor recurrence and 7 died (2%), with median overall survival of 2.7 months (range, 0.1–252). Conclusions: Microsurgical resection is safe and effective for CVJ schwannomas. Data on SRS efficacy and indications are still lacking, and its role deserves further evaluation.

The surgical management of benign tumors of the lateral skull base with intracranial invasion: experience from a single centre over ten years

Objective: To investigate the clinical features, pathological types, imaging features, and surgical strategies of lateral skull base benign tumors with intracranial invasion. Methods: From January 2011 to March 2021, 36 patients of lateral skull base benign tumors with intracranial invasion were included in this retrospective study. Among the 36 patients, 14 cases were male, 22 cases were female, the aged range from 20-67, with the median age of 48. The clinical manifestations, characteristic imaging findings, pathological types, surgical approach selection, and prognosis were analyzed. Results: 36 cases of lateral skull base tumors with intracranial invasion were all accepted surgeries. 23 cases were neurogenic tumors, facial nerve tumors (n=8), neurogenic tumors in jugular foramen with unknown origin(n=6), hypoglossal schwannoma (n=3), transotic intralabyrinthine schwannoma (n=3), vestibular schwannoma involving the middle ear(n=2), vagal nerve schwannoma(n=1). Other types of tumors included meningioma (n=10) and paraganglioma (Di 1 or 2,n=3). Different pathological types of tumors had different clinical manifestations and imaging manifestations. Sixteen cases were subjected to primary resection, while, other 20 cases underwent staged operation. Among the patients with staged operation, 10 patients had completed the second stage operation, five patients were waiting for the second stage operation, the other five patient's residual intracranial tumor were significantly reduced and the space between tumor and brain tissues widened after the first stage operation, so, the following up with "wait and scan"policy was suggested. The total resection rate of tumors was related to the pathological nature, in which neurogenic tumors were 15/17, and meningiomas were 5/8. The main postoperative complications were cerebrospinal fluid leakage and infection in the operation area. There were two cases of postoperative intracranial infection, and three cases of cerebrospinal fluid leakage occurred in non staged operation cases. Conclusions: Lateral skull base tumors with intracranial invasion are rare. The most common pathological type is schwannoma, followed by meningioma and paraganglioma. For this type of tumor, if there is infection in the operation area and neck invasion is large, it is suggested to choose staged surgery, which can reduce the risk of intracranial infection and the incidence of cerebrospinal fluid leakage. Staged surgery strategy can also reduce the difficulty of second stage surgery, so the operation is much safer than non staged surgery.

Application of internal carotid artery stent in skull base surgery

Objective: To report the experience of the application of internal carotid artery stent in skull base surgery, and to clarify the important role of internal carotid artery stent in skull base surgery. Methods: A retrospective study of 22 cases with skull base neoplasms implanted with internal carotid artery stents in the Department of ENT Head and Neck Surgery at the Sixth People's Hospital affiliated with Shanghai Jiao Tong University between July 2019 and January 2021 was conducted. Among them, 17 were male and 5 were female, aged between 33 and 75 years. There were 5 cases on the left, 16 cases on the right, and 1 case on both sides. Of these, there were 4 cases of jugular paraganglioma, 1 case of chondrosarcoma in the jugular foramen, 1 case of carotid body paraganglioma, and 16 cases of nasopharyngeal carcinoma after radiotherapy. Results: The degree of internal carotid artery erosion was assessed by computed tomography angiography (CTA), magnetic resonance imaging and digital subtraction angiography (DSA) images in 22 patients before surgery. It was found that the internal carotid artery was involved to varying degrees in all patients, so internal carotid artery stents were implanted before surgery. Tumor tissue was found to surround the internal carotid artery to varying degrees. Total or subtotal tumor resection was performed in all patients, and no intraoperative and postoperative complications occurred. The postoperative follow-up was 5 months to 2 years, and all patients had no complications such as spontaneous bleeding and pseudo aneurysm. There were no signs of stenosis or occlusion of the internal carotid artery stent segment in all cases. Conclusions: For patients with skull base tumors, preoperative imaging indicates the limited involvement of the internal carotid artery, and internal carotid artery stent implantation before surgery is a safe and effective treatment.

Clinical presentations and management of paraganglioma in the jugular foramen

颈静脉孔区副神经节瘤（即颈静脉球瘤）起源于颈静脉球血管外膜的神经嵴细胞，其起病隐匿，临床症状不典型，早期易被忽视。病变可累及中耳、外耳道、面神经、颈静脉球、后组颅神经、颈内动脉甚至颅内，并引起相应临床症状。影像学检查以及SDHx相关基因检测对疾病的诊断和治疗方案的确立至关重要。处理策略包括随访观察、手术切除及立体定向放射治疗。治疗方案的制定需根据患者年龄、病变范围、全身情况及患者意愿等多方面综合考虑，制定个体化治疗方案，其手术治疗是耳鼻咽喉头颈外科领域最具挑战性手术之一。.

The surgical procedures for tension-free anterior rerouting of facial nerve in infratemporal fossa type A approach

Infratemporal fossa type A approach is the classical approach for resection of tumors in the jugular foramen, and the anterior rerouting of the facial nerve is an important procedure to facilitate tumor exposure. Dysfunction of facial nerve in patients following anterior facial nerve rerouting is great challenge to surgeons and patients. The author made great efforts to modify the surgical management of the facial nerve to improve facial nerve function. After dissection the facial nerve from the fallopian canal and the digastric muscle from the digastric ridge and styloid process, then the digastric muscle and parotid gland were suture with the inferior margin of temporal muscle. A long articulated retractor was placed at an angle of 45° to push the posterior belly of the digastric muscle and the parotid gland anteriorly and superiorly to further minimize the distance from the genicular ganglion to the main trunk of the facial nerve in the parotid gland. All the procedures resulted in tension free anterior rerouting of the facial nerve. Tension-free anterior rerouting of facial nerve not only reduces the tension of the facial nerve, but also preserves the maximal blood supply of the facial nerve, which are beneficial with the recovery of facial nerve function, postoperatively.

Morphology of the groove of the inferior petrosal sinus: application to better understanding variations and surgery of the skull base.

Although adequate venous drainage from the cranium is imperative for maintaining normal intracranial pressure, the bony anatomy surrounding the inferior petrosal sinus and the potential for a compressive canal or tunnel has, to our knowledge, not been previously investigated. One hundred adult human skulls (200 sides) were observed and documented for the presence or absence of an inferior petrosal groove or canal. Measurements were made and a classification developed to help better understand their anatomy and discuss it in future reports. We identified an inferior petrosal sinus groove (IPSG) in the majority of specimens. The IPSG began anteriorly where the apex of the petrous part of the temporal bone articulated with the sphenoid part of the clivus, traveled posteriorly, in a slight medial to lateral course, primarily just medial to the petro-occipital fissure, and ended at the anteromedial aspect of the jugular foramen. When the IPSGs were grouped into five types. In type I specimens, no IPSG was identified (10.0%), in type II specimens, a partial IPSG was identified (6.5%), in type III specimens, a complete IPSG (80.0%) was identified, in type IV specimens, a partial IPS tunnel was identified (2.5%), and in type V specimens, a complete tunnel (1.0%) was identified. An improved knowledge of the bony pathways that the intracranial dural venous sinuses take as they exit the cranium is clinically useful. Radiological interpretation of such bony landmarks might improve patient diagnoses and surgically, such anatomy could decrease patient morbidity during approaches to the posterior cranial fossa.