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available substrates (
Fig. 7
). However, it is important to note that cranial nerve palsy
can occur after embolization utilizing liquid and small particle agents such as
Onyx.
19
Thus, preoperative patient counseling regarding the potential risks and ben-
efits of embolization is warranted. Furthermore, a careful preoperative cranial nerve
examination after embolization and immediately before surgery should be performed.
Surgery
Historically, microsurgery with gross total resection was considered the treatment
strategy of choice for JP. Although gross total resection is possible in the majority
of cases, it may result in debilitating cranial neuropathy and less commonly, vascular
injury. In a study done by Sanna and colleagues,
21
53 patients with Fisch class C or D
JP were treated surgically. Gross total resection was achieved in 83% of cases, with a
10% tumor recurrence rate. The presence of new cranial neuropathy varied depending
on the presence of intracranial extension, but was as high as 39%. Recently, the same
group retrospectively reviewed 122 class C or D tumors. Gross tumor control was
achieved in 86% of JPs, though 54% of the patients developed a postoperative lower
cranial nerve injury. Cranial nerve IX was most commonly affected at last follow-up.
22
In another study including 119 patients, nearly 75% of patients had tumor control with
surgical management, and new cranial neuropathies were noted in approximately
50% of patients after surgery.
23
Lastly, Fayad and colleagues,
3
examined the House
Ear Clinic experience with glomus jugulare tumors (GJT), reporting total tumor removal
in 81% of surgical cases. In this series, the incidence of postoperative cranial neurop-
athy varied according to tumor size. For patients with Fisch classification C4 and
lower, the incidence of new cranial nerve injury varied from 8.7% to 13%, whereas
for patients with classification of C4 and higher, the deficit ranged from 63.6% to
81.8%. Overall, 26.5% of patients in this series developed tumor recurrence at an
average of 26 months.
In an effort to minimize morbidity and improve symptoms associated with disease,
subtotal resection has been used with increasing frequency by many centers. Subtotal
resection may be particularly relevant to older or infirm patients with advanced disease
Fig. 6.
Glomus jugulare as seen on a contrast-enhanced MRI scan. The arrow designates the
tumor with a characteristic salt-and-pepper appearance. (
A
) is an axial cut; (
B
) is a coronal
cut.
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