Management of a glomus jugulare tumour with internal carotid artery involvement

Abstract

SummaryA previously healthy 40-year-old female presented for surgical resection of a large glomus jugulare tumour with extensive involvement of the carotid siphon and intracranial extension. Conduct of anaesthesia with specijic reference to cerebral protection is discussed. A combination of induced hypothermia, barbiturate therapy, normotension, normocarbia and prior clamping of the distal internal carotid artery was chosen. The role of barbiturates as a therapeutic intervention is debated. Key wordsAnaesthetic management; glomus jugulare tumour. Cerebral protection; hypothermia, barbiturates.Glomus bodies are paraganglia of neural crest origin which occur in relation to the autonomic nervous system. They occur at a variety of sites, but are microscopically identical. The glomus jugulare arises from a constellation of glomus bodies occurring within the temporal bone. These bodies are situated at the dome of the jugular bulb, on the promontory in the middle ear and in the intrabony canaliculi of the auricular and tympanic nerves.Glomus jugulare tumours arising at the jugular bulb may present with a variety of caudal cranial nerve palsies due to involvement of these nerves with tumour at the level of the jugular foramen.Continued extension of the tumour to the ear gives rise to otological symptoms. Invasion may progress into the petrous temporal bone, the base of the skull, and finally intracranial extension may occur. The blood supply of the glomus jugulare tumour is derived from the external carotid artery, but very extensive tumours may also have supplying vessels from the internal carotid artery.Glomus tumours are usually slow-growing neoplasms. The clinical history commonly spans several years.'-4 The management of this tumour is a team project, involving radiologists, surgeons and anaesthetists. During the surgical extirpation of a glomus jugulare tumour with intracranial extension and internal carotid artery involvement, the anaesthetist is required to provide conditions and administer drugs which may protect the brain either prior to an ischaemic event, or possibly soon after such an event has occurred. The combined effect of unilateral internal carotid artery sacrifice and sudden severe blood loss can result in ischaemic brain damage. Case historyA 40-year-old Caucasian woman weighing 60 kg was scheduled for surgical removal of a glomus jugulare tumour. She presented with a 7-year history of progressive vertigo and tinnitus, and a 6-month history of deafness in her right ear. Examination revealed a pulsatile red-blue tumour behind her right tympanic membrane. Computerised t o m~g r a p h y~.~ and carotid angiography5 confirmed a large vascular tumour of the jugular bulb extending into the posterior fossa and the cavernous sinus via the carotid canal in the base of the skull. The wall of the right internal carotid artery was involved with tumour in the carotid canal segment. Crossover blood flow from left to right across the circle of Willis was adequate.In spite of the extent of tumour spread, it was deci...