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The use of jugular bulb catheterization (JBC) in neurologically injured patients to monitor adequacy of cerebral blood flow and metabolism is increasing. However little is written about the technique, success rate and complications. We describe our method and the results of JBC in 60 consecutive children.

Forty-six cases of glomus tumor involving the middle ear are presented. The average follow-up period is 7.1 years. Surgical success rate is 73 percent and radiation is 20 percent. As a secondary modality of therapy for persistent or recurrent tumors, the surgical success rate was 71 percent and radiation was 40 percent. The therapeutic failures are described by anatomic location. There were two tumor related deaths. The treatment of choice for glomus tumors and for tumor recurrences or persistences, providing that they do not invade the intracranial cavity, is surgical. A wide excision (including a jugular bulb and vein resection when indicated) is advocated.

The simultaneous effects of right ventricular pacing on cerebral blood flow (CBF) and cardiac function in complete heart block have not been reported. Catheters in the jugular bulb, right ventricle, and pulmonary and brachial arteries of five patients, aged 49 to 78 years, allowed studies at initial rates of 30 to 40 and during the tenth minute of pacing at 60, 70, 90, and 100 per minute. Mean initial cardiac output (CO) was 2.8 L per minute and increased 29% to 3.6 at a rate of 60 per minute ( P P P

One of the most important sequelae of middle-ear infections is phlebitis or thrombosis of some of the venous drains of the head, and particularly when such pathologic conditions occur, as they usually do, in the sigmoid bend of the lateral sinus. Disease of this nature is found not only in the sigmoid sinus, but also in the lateral sinus proper, the superior and inferior petrosal sinuses, the cavernous sinus, the jugular bulb, the internal jugular vein and its connections, etc. The sigmoid sinus is, however, its favorite location on account of its vascular connections with the tympanic cavity and adjoining cells and its close contiguity to these frequently infected structures. As the jugular bulb is located directly beneath the tympanic cavity, an unusually high dome to the bulb, or necrosis of the tympanic floor, or congenital dehiscences in the floor, will assist in the conveyance of infection. This will occur

Tumors of the glomus jugularis have only recently been recognized, and few cases have been reported. A brief review of the literature, summary of the clinical characteristics and the presentation of an additional case are the purpose of this report. REVIEW OF LITERATURE Guild 1 in 1941 reported his discovery in the temporal bone of a minute structure, which he termed glomus jugularis. It is histologically identical with the carotid body and is situated in the adventitia of the dome of the jugular bulb covered by the bone of the hypotympanum. Its innervation and blood supply are the glossopharyngeal nerve and ascending pharyngeal artery. In this respect also it is similar to the carotid body, which has the same blood and nerve supply. Rosenwasser 2 in 1945 made the first report of a tumor of the glomus jugularis. Additional cases have since been reported by Kipkie, 3 Le Compte and associates, 4

Radiographic demonstration of glomus jugulare tumours may be difficult using plain films of the petrous bone, tomography and carotid arteriography, which are the usual means employed. The tumour is usually situated in the region of the jugular bulb and invasion and compression of the internal jugular vein at this level sometimes occur. From a surgical point of view, it is of value to know the extent of tumour spread and, bearing this in mind, internal jugular venography may be of help. This investigation can conveniently be carried out on an anaesthetised patient at the same time as carotid arteriography. A new technique of demonstrating the sigmoid sinus and jugular bulb is described. It does not appear to have been reported previously in the British literature, but there are two references in the Swedish literature (Gejrot and Lauren, 1964; Gejrot and Lindbom, 1960).

Introduction THE GLOMUS JUGULARE, a normal structure first described by Guild, 3 lies in the dome of the jugular bulb just below the floor of the middle ear. The "glomus" is quite small, 0.5 × 0.25 mm, and is composed of nonchromaffin staining paraganglia cells arranged in an organoid pattern. No physiological function has yet been proved, but neoplasms of this tissue are the most frequent type of middle ear tumor 12 and were first described by Rossenwasser. 9 Much confusion as to the nomenclature, clinical signs and symptoms, instance of metastases, and proper therapy of these tumors remains. The purpose of this report is to review the nine cases of glomus tumors with metastases and to record an additional instance of distant spread to the lungs. Material and Methods Medical literature was reviewed for reports on cases of metastatic glomus tumors. The more interesting features of the nine

IT HAS become apparent to me and I have said so repeatedly at lectures and in publications, 1,2 that a rational mode of therapy can logically be proposed if one attempts to classify these tumors into stages based on clinical empirical estimation of the underlying pathology, at the time they are first seen. One must realize that for many reasons it is most difficult to evaluate a modality of therapy in glomus jugulare tumors, whether it be surgery, irradiation, or a combination of both, when it is generally known that these tumors, untreated, have changed very slowly over the years. Bickerstaff and Howell 3 reported a patient who had a glomus jugulare tumor untreated for 42 years. Twenty-five years ago, I removed a huge glomus tumor from the middle ear, mastoid, and jugular bulb area. I left tumor attached to the jugular bulb and gave irradiation postoperatively (5,500 rads, 200

Nonchromaffin paragangliomas 1 as a group are histologically like the carotid-body tumors and are in essence blood-vessel tumors with interspersed epithelioid cells. I shall limit my remarks to those tumors which originate within the middle ear and the dome of the jugular bulb and I shall attempt to segregate them by their specific sites of origin to tympanic tumors of the middle ear2 and glomus jugulare tumors arising from the jugular bulb. Published case reports are limited to approximately 100 cases. I feel that some tumors of this classification have been missed for lack of specific pathological identification. The objective of this study of a few cases in the Vancouver area is an attempt to make a special effort to emphasize early symptoms and early diagnosis. Tumors originating from the nonchromaffin paraganglioma vary according to their particular point of origin, such as the tympanic plexus or the adventitia of the jugular

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Summary1. The values for cerebral blood flows, arterial-cerebral venous oxygen and glucose differences were not significantly different on the two sides in 18 simultaneous bilateral observations in 12 subjects. 2. Three subjects with unilateral cerebral disease also had similar values on the two sides. 3. The assumption that blood obtained from one internal jugular bulb is representative of mixed cerebral venous blood appears to be correct.

Abnormal electroencephalographic patterns occurred in some patients during clinical testing of a new general anesthetic, Ohio 347 (Ethrane; 2-chloro-l, l, 2-trifluoroethyl difluoromethyl ether). Despite these patterns, recovery from general anesthesia was prompt, and no mental or psychological sequelae were detected. In view of the other advantages of the agent, the decision was made to continue clinical testing and attempt to define the cerebral effects of the drug more quantitatively. With this in mind the following studies were undertaken.

High-resolution computed tomography (HRCT) has become the primary radiologic method for evaluation of paragangliomas of the temporal bone. The HRCT evaluation of the integrity of certain bony landmarks has a profound effect on selection of surgical approach. The most important landmarks are the bony walls separating the carotid artery and the jugular bulb from the middle ear. Arteriography is not necessary if the lesion is confined to the middle ear. However, it is indicated in tumors that have eroded the above landmarks or in those patients with related neurologic symptoms.

• A 10-year-old boy had conductive deafness caused by a highly situated enlarged jugular bulb in contact with the lenticular process of the incus. Results of jugular phlebography showed that nearly all the venous return from the dural sinuses was via the ipsilateral transverse sinus and jugular vein. (Arch Otolaryngol102:430-431, 1976)

THESE interesting tumors, which presumably arise from the adventitia of the jugular bulb in the floor of the mastoid antrum and also possibly from other paraganglionic cells that occur in the middle ear, went unrecognized until 1945, when Rosenwasser, of New York, described the first case. Since then, further cases have been described from time to time, but they are still by no means common. In the classical review by Lattes and Waltner, inCancer, May, 1949, in which eight more cases were reported, it was suggested that the original descriptions as carotid body-like tumor and glomus jugulare tumor be jettisoned in favor of the more correct name of nonchromaffin paraganglioma. The case reported below, which presented certain quite characteristic features, is the first known to have occurred at St. Luke's Hospital in New York. REPORT OF CASE The patient was a Negro woman, aged 46, in apparently good health

GUILD first described a carotid-bodylike structure which is found above the jugular bulb. This structure is associated with the tympanic branch of the glossopharyngeal nerve and the tympanic branch of the ascending pharyngeal artery. The function of this organ is not known, but presumably it functions similarly to the carotid body and is an organ sensitive to the degree of oxygen saturation of the arterial blood. In 1945 Rosenwasser first described a tumor of this structure. Following his description there have been some 40 to 50 case reports of glomus jugularis tumors. Winship and associates reported 11 cases, 7 of which were benign and 4 malignant. Winship and Louzan reviewed the literature in 1951 and reported a case of their own. They reviewed 42 cases of glomus jugularis tumors in the literature and reported that the incidence of the disease is 80% in females, with a mortality rate of 34%.

This case is reported not with the thought that it will be particularly instructive, but more because it represents an unusual circumstance, in that a diagnosis of a septicemia of otitic origin was made with as much certainty as is the rule and that the patient recovered without operative intervention. It again raises the question relative to the ease with which surgical sinus thrombosis should be recognized. Cases of septicemia apparently complicating acute surgical mastoid disease are seen. Likewise, there are cases in which a diagnosis is made, but at operation disease of the sinus is not disclosed. Experience with such cases and the one about to be reviewed would tend to make one feel less certain of recognizing sinus thrombosis, that is, in cases requiring a mastoid operation, with or without the sinus and jugular operation following. R. H., aged 6, on June 5, 1926, during an

Five patients had unilateral tinnitus from increased intracranial pressure of different etiologies. In each case, the tinnitus was produced by a venous bruit and could be decreased by Valsalva's maneuver, head turning to the ipsilateral side, or by light pressure over the ipsilateral jugular vein. Correction of the increased intracranial pressure obliterated the tinnitus. Turbulence, created as blood flows from the hypertensive intracranial portion into the low pressure of the jugular bulb, is proposed as the mechanism producing the tinnitus.

The popularization of skull base approaches for lesions at the jugular foramen requires a thorough understanding of the normal anatomic features of this region. We present a series of color photographs with a review of the vital structures at the skull base in the region of the jugular foramen exposed via the infratemporal fossa approach. The jugular bulb and its relationship to the ninth, tenth, eleventh, and twelfth cranial nerves and to the internal carotid artery and otic capsule are demonstrated. All relationships are described in the lateral surgical position. The clinical usefulness of a thorough understanding of these anatomic associations is discussed.

To the Editor. —Adler and Ropper have noted an important association between cranial venous bruit, and enlarged, high-jugular bulb. 1 In our previous reports of venous bruit with increased intracranial pressure, we noted that increased jugular flow occurred on the side of the bruit. 2,3 However, we did not report the association of the anatomical variant (ie, enlarged, high-jugular bulb). In retrospect, we found that two of our patients, in whom tomograms, and/or jugular venograms were available, did have enlarged jugular bulbs on the side of the bruits. The enlarged, displaced jugular bulb helps explain the unilateral location of the self-audible bruit. It may even contribute to the objective bruits we described, by producing turbulence. However, it alone cannot explain the low incidence of the bruit in the general population, considering the relative frequency of this anatomical variant, and it does not explain the direct correlation of the bruit with

To the Editor.— The neurologic features of a large group of patients with glomus tumors of the head and neck were recently well delineated by G.J. Spector et al ( Arch Neurol 33:270, 1976). In their series of 75 patients, 57 tumors arose from the jugular bulb, 11 from the middle ear, and 7 from the vagus nerve. However, similar tumors of the carotid body (glomus caroticum) were not included in their presentation. In contrast to the glomus tumors (chemodectomas) of their group with a high incidence of neurologic manifestations, chemodectomas of the carotid bifurcation are usually not very symptomatic. The majority of carotid chemodectomas are benign and slow growing, with minimal associated symptoms; most patients with chemodectomas of the carotid bifurcation are asymptomatic except for the presence of a painless cervical mass. 1 The angiographic features of chemodectomas of the carotid bifurcation are well established and diagnostic for the average

To the Editor. —We read with interest the article by Drs Adler and Ropper regarding pulsatile tinnitus and abnormalities of the jugular bulb. 1 We have had an interest in pulsatile tinnitus, and, over the last seven years, have seen 25 patients with this unusual complaint (Table). 2 In our experience, patients with objective pulsatile tinnitus (heard by the patient and examiner alike) are likely to have angiographic evidence of an arterial abnormality, such as a dural arteriovenous malformation, affecting the transverse venous sinus or significant intra- or extracranial arterial occlusive disease. In comparison, subjective pulsatile tinnitus (heard only by the patient) may fluctuate with maneuvers, such as head turning or light Results of Evaluation in 25 Patients With Pulsatile Tinnitus Objective pulsatile tinnitus Normal 2 Arteriovenous malformation Dural (transverse sinus) 5 Pial (parietal cortex) 1 Total 6 Occlusive arterial disease Ipsilateral siphon stenosis 3 Ipsilateral carotid stenosis 2 Contralateral carotid occlusion 2

Osseous hemangiomas are distinctly unusual tumors of the skull base. They clinically mimic other, more common lesions in this region, and their diagnosis is rarely made preoperatively with currently available techniques. Three cases of osseous hemangiomata, 2 involving the geniculate region and 1 arising from the jugular bulb, are described in relation to the perioperative assessment and management of these lesions. A review of 21 previously reported skull base hemangiomas is included.

Une femme de 22 ans a consulte pour une surdite droite remontant a plusieurs annees, des acouphenes pulsatils unilateraux remontant a 6 mois et une autophonie droite remontant a deux mois. Au niveau de l'hypotympan droit on a note une grosse masse bleue deplacant lateralement le 1/3 inferieur du tympan. Une tomodensitometrie de haute resolution a revele un golfe de la jugulaire dehiscent. L'angiographie a montre un sinus occipital droit dominant avec un petit sinus transverse droit. Le sinus transverse gauche n'etait pas visualise

The diagnosis and mode of development of thrombophlebitis of the lateral sinus are usually fairly clear. A septic temperature and chills in the course of purulent otitis media, with or without evidence of mastoiditis, suggest thrombosis either of the lateral sinus or of the jugular bulb. Positive results of blood cultures at this time, as pointed out by Libman, 1 are of great significance and usually indicate that operative treatment is imperative. In all such cases the otitic infection is the start. In contrast to sinus thrombosis secondary to otitis media, I have observed two children and have been interested in a third child in whose case I believed that the source of sinus thrombophlebitis was not an otitic infection. In one case the condition was due to the spreading of a thrombus from the left lateral sinus to the healthy right side, and in the other two it was

The infrequency with which double traumatic injury of the jugular bulb occurs, or is mentioned in the medical literature, prompts me to relate an experience I had with one of my patients. March 26, 1928, the mother of a girl, aged 13, came to me for a prescription for double acute otitis media. She did not bring her daughter with her, but gave me the usual history of a typical case of two weeks' duration in which both ears were discharging following an attack of earache. She lived in a nearby town, 4 miles distant, so I advised her to sponge out the ears well with cotton, put in warm glycerin, and bring the girl in for examination. March 28, the patient was brought in and I found perforations in both tympanic membranes and a discharge from each. Attention being indicated, I treated her ears for three days by modern methods. At the end of