Embolization

Preoperative intra-arterial embolization represents a major advancement in the management of glomus jugulare tumors as an adjunct to intraoperative hemostasis, reduced operative time, and facilitation of complete tumor excision.44,47,68 One retrospective study of 35 patients who underwent surgery for glomus jugulare tumors (18 with preoperative embolization, 17 without) demonstrated that embolization reduced blood loss (by > 50%) and reduced operative time, but did not affect hospitalization time or cranial nerve morbidity.69 Some surgeons do not advocate preoperative intra-arterial embolization on the grounds that the intraoperative blood loss is primarily venous (from IPS and sigmoid sinus),61,70 but they probably represent the minority opinion. These surgeons do not feel that the benefits of embolization warrant the risks of stroke or other complications from the use of this technique.

Preoperative catecholamine screening is performed routinely for detection of secretory types of glomus jugulare tumors that require particular perioperative and anesthetic precautions.

Elevation of catecholamine concentrations three or more times above normal requires screening for pheochromocytoma. As renal vein sampling may be required for this purpose, catecholamine screening should be performed before bilateral carotid angiography.

Management of Jugular Foramen Tumors

In recent decades, the management of lesions of the jugular foramen has evolved. During the 1940s and 1950s, surgical exposures were often limited to mastoidectomies; therefore, high recurrence rates and postoperative facial nerve deficits were common. Thus, radiotherapy was the treatment of choice. With the development of tomograms and, later, CT, and with refinements in surgical techniques, the 1960s and 1970s saw concentrated efforts toward gross total resections of lesions of the jugular foramen. The addition of intra-arterial embolization and MRI in the 1980s further advanced the capabilities of the surgical management of these lesions. For patients with acceptable surgical risk, complete surgical resection is generally desired for tumors of the jugular foramen. We generally reserve radiotherapy for patients with advanced age, significant comorbidities, or postoperative residual tumor or recurrence.

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