Surgical Management of Tympanojugular Paragangliomas with Intradural Extension, with a Proposed Revision of the Fisch Classification

Abstract

Background: Tympanojugular paragangliomas (TJPs) with intradural extension can be successfully treated by a single or staged procedure with low surgical morbidity. Objectives: To present the clinical findings and treatment methods used for surgically treating TJP with intradural extension, as well as to discuss the complications of treatment and the relative merits of single versus staged surgery by using a comprehensive literature review comparing objective outcome measures. Study Design: A retrospective case review of 45 cases of TJP with intradural extension. Setting: A quaternary skull base and neurotologic center. Materials and Methods: The charts of 45 patients with Fisch classification class C or D TJP with intradural extension, who were operated on from April 1988 to April 2010, were analyzed. Clinical findings and preoperative lower cranial nerve (LCN) palsy as well as postoperative totality of resection, postoperative LCN palsy and complications were studied. The types, indications, and distribution of staged procedures were also analyzed. Results: Out of 45 cases, 22 were C3di2. The IX and X cranial nerves were the commonest nerves affected preoperatively. Preoperative internal carotid artery management was performed in 16 cases. Twenty-nine cases had a single procedure and 16 had a staged procedure. The main indication for staged procedures was intradural extension of 2 cm or more. The infratemporal fossa approach (ITFA) type A was the main procedure in all cases. Overall, total resection was achieved in 68.8% of cases with postoperative cerebrospinal fluid leak in 4.4% cases. Postoperative House-Beckmann grade I–III facial nerve status was maintained in 80% of cases, and overall LCN preservation rate was 56.9%. There were no cases requiring tracheostomy, and 3 cases required delayed phonosurgical procedures to improve their voice. Conclusions: TJP with intradural extension can be successfully managed with the judicious use of staged procedures to reduce the incidence of postoperative cerebrospinal fluid leak. The ITFA did not cause an excessively high rate of facial nerve palsy, and the overall total resection and LCN preservation rate compares very favorably with previously published data.

Diagnosis and management of multiple paragangliomas of the head and neck

“…To avoid lower cranial nerve palsy, incomplete resection of large tumors in the jugular foramen with postoperative radiotherapy may be justified. Sivalingam et al [21] apply two stage removal of tumors with intradural extension, e.g. neurosurgical and infratemporal fossa approach.…”

The Role of Wait-and-Scan and the Efficacy of Radiotherapy in the Treatment of Temporal Bone Paragangliomas

“…Patients who were lost for follow-up and case sheets with incomplete records were excluded from the study. The TBPs were classified according to the modified Fisch classification (1,2). The age, sex, presenting complaints, clinical findings, side and site of the tumors and cranial nerve status were noted.…”

“…Progression in glomus tumors can be so slow that ongoing neurologic deficits may undergo simultaneous compensation or go unnoticed by the patient (66). There are many articles that point toward the fact that the improvement in LCN deficits can be attributed to compensation mechanism by contralateral nerves (15,66Y68), which usually takes place a few weeks after the palsy occurs, especially in younger patients (1,69). In our series, we had 2 patients in the waitand-scan group who compensated well after an LCN palsy because the slow growth of the tumor allowed the patient to adapt to the deficits.…”

“…Key Words: Lower cranial nerve palsyVRadiotherapyVStereotactic radiosurgeryV Temporal bone paragangliomasVTympanojugular paragangliomasV Tympanomastoid paragangliomasVWait-and-scan. Temporal bone paragangliomas (TBPs), including tympanomastoid paragangliomas (TMPs; modified Fisch Class A and B) and tympanojugular paragangliomas (TJPs; modified Fisch Class C and D) (1,2), are benign tumors involving the middle ear cleft and the skull base for which 3 distinct treatment modalities are currently in practice: microsurgery, radiotherapy (RT), and waitand-scan. In the past, RT was offered as the treatment of choice for Class C and D TJPs because they were deemed inoperable (3,4).…”

Infratemporal fossa approach type a with transcondylar‐transtubercular extension for Fisch type C2 to C4 tympanojugular paragangliomas

“…1 These tumors tend to grow along the planes of least resistance ( Figure 1) by following preexisting pathways in the skull base (ie, vascular channels, neural foramina, and air cell tracts). [3][4][5] The jugular foramen area was not completely under surgeon control until the introduction of the infratemporal fossa approach type A (IFTA-A) by Ugo Fisch in 1978. The surgical management of these lesions remains particularly challenging as a result of the complex anatomic location and potential intraoperative and postoperative complications.…”