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Objective The intraforaminal component of jugular foramen tumors is difficult to access surgically, as it requires complex approaches for radical removal and leads to a high recurrence due to residual tumor. The retrosigmoid suprajugular approach, intradural drilling of the roof of the jugular foramen, has been recently proposed for removal of such intraforaminal component without sacrificing the sigmoid-jugular venous system or requiring additional approaches. This study presents our experience with this approach and introduces the use of intraoperative continuous vagus nerve monitoring. Methods Nineteen patients (14 with neuromas and 5 with meningiomas) were operated using this approach over a 12.5-year period. In the more recent 14 cases, continuous vagus nerve monitoring was performed with a ball-type electrode placed on the proximal vagus nerve. Results More than 95% of the tumor removal was achieved in all but the first neuroma case. Extubation immediately after surgery and oral feeding within a week postoperatively was achieved in all patients. Seven of 9 patients with preoperative hearing disturbance symptomatically improved after surgery. All but the first case had no signs of recurrence during the follow-up period (average of 58 months). Conclusions The retrosigmoid suprajugular approach is safe and effective for removal of tumors extending into the jugular foramen, maintaining a chance of hearing improvement. Intraoperative continuous vagus nerve monitoring is useful to avoid postoperative complications in such surgeries.

OBJECTIVESurgery for tumors around the jugular foramen has significant risks of dysphagia and vocal cord palsy due to possible damage to the lower cranial nerve functions. For its treatment, long-term tumor control by maximum resection while avoiding permanent neurological damage is required. To accomplish this challenging goal, the authors developed an intraoperative continuous vagus nerve monitoring system and herein report their experience with this novel neuromonitoring method.METHODSFifty consecutive patients with tumors around the jugular foramen (34 jugular foramen schwannomas, 11 meningiomas, 3 hypoglossal schwannomas, and 2 others) who underwent microsurgical resection under continuous vagus nerve monitoring within an 11-year period were retrospectively investigated. Evoked vagus nerve electromyograms were continuously monitored by direct 1-Hz stimulation to the nerve throughout the microsurgical procedure.RESULTSThe average resection rate was 96.2%, and no additional surgery was required in any of the patients during the follow-up period (average 65.0 months). Extubation immediately after surgery and oral feeding within 10 days postoperatively were each achieved in 49 patients (98.0%). In 7 patients (14.0%), dysphagia and/or hoarseness were mildly worsened postoperatively at the latest follow-up, but tracheostomy or gastrostomy was not required in any of them. Amplitude preservation ratios on intraoperative vagus nerve electromyograms were significantly smaller in patients with postoperative worsening of dysphagia and/or hoarseness (cutoff value 63%, sensitivity 86%, specificity 79%).CONCLUSIONSIntraoperative continuous vagus nerve monitoring enables real-time and quantitative assessment of vagus nerve function and is important for avoiding permanent vagus nerve palsy, while helping to achieve sufficient resection of tumors around the jugular foramen.

Jugular foramen tumors, particularly those that are triple dumbbell-shaped with intracranial, intraforaminal, and extracranial extensions, are difficult to access surgically. However, advances in neuroimaging, neuromonitoring, and skull base surgery have enabled their safe resection with lower rates of morbidity and mortality. We share our experience with the surgical technique for the management of triple dumbbell-shaped jugular foramen schwannomas. The infralabyrinthine transjugular transsigmoid approach with high cervical exposure under continuous vagus nerve monitoring enables gross total resection of triple dumbbell-shaped jugular foramen schwannomas, aiming at surgical cure of these benign tumors for appropriately selected patients.

Classical surgical management of jugular foramen (JF) tumors usually requires facial nerve rerouting which results in permanent facial palsy in most patients. The purpose of the article is to study the outcomes of different rerouting techniques, and to discuss their indications.We retrospectively reviewed 98 patients with JF tumors operated at our center between January 2008 and December 2016 using different surgical approaches with the following procedures for facial nerve management: total anterior rerouting (TR), partial anterior rerouting (PR), and fallopian bridge (FB) technique. The data for facial nerve management, surgical outcome and postoperative facial nerve function were collected from the medical records.In the study, there were 48 males and 50 females. Of them, 61 (62.2%) were jugular paragangliomas, 22 (22.4%) schwannomas, and 15 (15.3%) meningiomas. Total tumor removal was achieved in 95 (96.9%) patients, while near-total removal was achieved in 3 (3.1%) paragangliomas. TR was applied in 31 (31.6%) patients with PR in 26 (26.5%) patients, and FB in 41 (41.8%) patients. The mean follow-up duration was 39.4±22.6 months, and 2 recurrences of paragangliomas were observed. Seventy-five patients (76.5%) had good facial function (HB I-II) at 1 year after surgery, the patients who received a TR approach presented significantly less HB I-II FN function (48.4%) than those with PR (82.6%, P0.05) or those with FB technique (95.1%, P0.001). 21 patients (21.4%) presented new-onset lower cranial nerve dysfunction of which 13 recovered at 1 year after surgery.Facial nerve management in JF tumors should be tailored individually. No-rerouting methods, such as the fallopian bridge technique, bring significantly better results in terms of facial nerve function, which might be performed first during surgery; its indication is based mainly on the tumor type and extent.

This issue has been devoted to the management of jugular foramen tumors and has been commissioned by our guest editor, Mislav Gjuric. Tumors that arise in or around the jugular foramen like paragangliomas, schwannomas, and meningiomas have always caused both surgeons and their patients very significant problems. Their resection is certainly not for the occasional skull base surgeon or indeed the faint hearted. It demands the ultimate attention to detail and, like much of what we do, the very highest levels of competence and skill. Recent data on the natural history of many of these lesions suggests that their growth rate can be extremely slow and therefore a conservative approach can be adopted for some. Advances in imaging make this entirely appropriate as the growth rate can be monitored accurately at intervals. At the same time, recognition of the genetic defect that gives rise to the paraganglioma syndromes has reinforced the wisdom of this approach for several patients. Through screening programs in susceptible pedigrees, paragangliomas are now being detected at a stage long before they would normally have been found in days gone by. For those unfortunate patients with multiple paragangliomas there is no room for error in management planning or its subsequent execution. The workhorse approach to the jugular foramen developed by Ugo Fisch remains the gold standard for most large jugular foramen paragangliomas. However, smaller tumors can be removed by other techniques and there is also a role for radiotherapy in some patients. The control of the internal carotid artery has also been improved by interventional radiological techniques. All in all, it is time to reconsider the management of jugular foramen tumors, and the papers in this issue will reignite the debate.

Radiation therapy may be required after surgical removal of jugular foramen tumors. Even in cases of benign lesions such as paragangliomas and meningiomas, radical removal may not be possible and postoperative adjuvant treatment may be necessary. Radiosurgery is the most used modality of postoperative irradiation and long-term tumor growth control is achieved in the majority of cases. Radiosurgery may also be indicated as primary treatment in cases of small tumors, especially in elderly patients. Fractionated stereotactic radiotherapy is recommended for larger tumors. Preservation of cranial nerves function is very high. Irradiation with protons and carbon ions are indicated in cases of chordomas and chondrosarcomas. Comparison of results with various modalities of postoperative irradiation therapy for different tumor types is presented.

Tumors of the jugular foramen remain challenging lesions despite advances in surgical technique and medical technology. Tumors with extensive extra- and intracranial components necessitate both radical neck dissection maneuvers combined with skull base approaches. We present a single surgeon’s perspective in managing these difficult tumors.

Jugular foramen tumors are rare cranial base lesions that present diagnostic and management difficulties. Paragangliomas were the most frequent lesions, followed by schwannomas and meningiomas. These tumors have characteristic radiological features. Radical resection of these tumors with preservation of the lower cranial nerves is the treatment of choice. Despite the advances in skull base surgery, new postoperative lower cranial nerve deficits still represent a challenge.

The jugular foramen (JF) is an anatomically complex region where important bony, neural, and vascular structures converge. Tumors are the primary cause of JF pathology and often present therapeutic challenges. In this article we discuss the clinical and pathologic aspects of JF tumors. These aspects include the classic JF clinical syndromes, imaging characteristics of specific JF tumors, and gross pathologic and histopathologic features. The three most common and important JF tumors, glomus jugulare tumors, meningiomas, and schwannomas, are discussed in depth. A wide variety of tumors can occur in the JF. Nonetheless, our current clinical and radiographic knowledge usually allows a clinician to ascertain the pathology of a JF tumor preoperatively with a high degree of certainty. Doing so allows the clinician not only to formulate the most effective treatment plan but also to provide accurate and thorough preoperative counseling to patients harboring these serious lesions.

Many approaches have evolved to deal with removal of jugular foramen tumors. The most commonly employed are the Fisch type infratemporal fossa approaches. Traditionally, these approaches are associated with significant degrees of morbidity in addition to that associated with tumor removal. Various modifications of these approaches have been developed to decrease morbidity but still provide adequate visualization and exposure for tumor removal. The various modifications and combinations are described. The approach developed and most utilized by the authors is presented in detail.

This article discusses the use of radiosurgery in the treatment of tumors of the jugular foramen, including glomus tumors; schwannomas involving cranial nerves (CNs) IX, X, and XI; and meningiomas. The appropriate role of radiosurgery, stereotactic radiotherapy, or both in the management of these tumors is controversial. Radiosurgery may be used as a primary treatment modality or as an adjunct after subtotal or partial extirpation of a tumor. Although long-term follow-up for as long as 7 years does not conclusively demonstrate the efficacy of radiosurgery in controlling tumors, results have been comparable to those achieved with conventional radiotherapy. Furthermore, radiosurgical outcomes compared favorably with CN morbidity and mortality of surgical series and with radiation-induced morbidity in radiotherapy series. Finally, the limitations and disadvantages of radiosurgery in the treatment of these lesions are discussed.

This article discusses the epidemiology, presentation, and diagnostic work-up of nonparaganglioma jugular foramen tumors, and the management options and predicted outcomes. Paragangliomas are the most common jugular foramen tumors, but other nonparagangliomas are important to consider in a differential for jugular foramen tumors. This article specifically focuses on jugular foramen schwannomas, meningiomas, metastatic disease, and regional pathologies that may extend to the jugular foramen, such as endolymphatic sac tumors, chordomas, and chondrosarcomas. Operative approaches to these tumors are also reviewed.

ne of the challenges of contemporary neurosurgery is to continue dealing with extremely complex situations O with increasing ease, making difficult choices comprehensible to patients, avoiding all functional, cosmetic, and psychological complications. To meet this challenge is very complicated. It means, on many occasions, to restrain our own vanity, combining a very difficult neurosurgical operation with alternative solutions, including endovascular treatments and radiotherapy, always aiming at a multidisciplinary approach. The ability to choose such a “judicious” combination of procedures is particularly important in specific neurosurgical pathologies, including lesions of the jugular foramen.

The jugular foramen is particularly susceptible to surgical trauma of cranial nerves during resection of skull base tumors, both benign and malignant. Treatment decisions rely heavily on accurate diagnosis and knowledge of the relevant anatomic structures. This article describes the clinical presentation of jugular foramen tumors, and discusses the roles of imaging and laboratory tests in diagnosis.

The preoperative evaluation and management of the patient with a jugular foramen tumor comprises a series of clinical, biochemical, radiographic, and endovascular studies. The selection and order of necessary studies are dictated by the suspected tumor type as suggested by the initial clinical and radiographic evaluation. Catecholamine testing and balloon test occlusion, for example, may be necessary in the management of a glomus jugulare tumor, but do not constitute part of the preoperative evaluation of a jugular foramen schwannoma. We review the studies and procedures used in the preoperative evaluation and management of the patient with a jugular foramen tumor. Included in this discussion is an introduction to CT/MRI holography, a newly designed method of three-dimensional image display, which is still in the developmental stage.

To describe the diagnosis, management, and treatment outcome of jugular foramen (JF) tumors.Retrospective chart review.Charts of the 83 patients diagnosed with JF tumors between January 1997 and May 2008 were reviewed. Presenting symptoms, otologic and neurotologic examination, audiologic thresholds, treatment procedure, surgical technique, tumor size and classification, and postoperative complications were recorded. Facial nerve function was graded using the House-Brackmann scale. Extent of tumor removal was determined at time of surgery, followed by routine radiographic follow-up.The mean age of patients with JF tumors was 48.5 years (standard deviation, 16.3 yr), and women (79.5%) outnumbered men (20.5%). Most had glomus jugulare (GJ) tumors (n = 67, 80.7%); 9 patients had lower cranial nerve schwannomas (10.8%), and 7 patients had meningiomas (8.4%). The most frequent initial symptoms included pulsatile tinnitus (84.3%), conductive hearing loss (75.9%), and hoarseness (34.9%). Sixty-one patients (73.5%) underwent surgery, 18.1% had radiotherapy, and 8.4% were observed. Total tumor removal was achieved in 81% of surgery cases. New lower cranial nerve (CN) deficits occurred after surgery in 18.9% of GJ, 22.2% of schwannoma, and 50% of the 4 meningiomas. At last follow-up, 88.1% of surgical patients had normal or near-normal (House-Brackmann I or II) facial function.Total resection of GJ tumors, meningiomas, and lower CN schwannomas can be a curative treatment. However, subtotal removal may be required to preserve CN function, vital vascular structures, and the brainstem. Postoperative radiotherapy is used to control residual tumor. When postoperative complications develop in patients, early rehabilitation is important to decrease mortality and morbidity. Therefore, patients should be closely followed.

The most significant objection to the proposal of lateral transtemporal cranial base surgery for the treatment of jugular foramen tumors is the perceived lasting morbidity attendant to aggregate cranial nerve loss. As techniques become more standardized and earlier diagnosis generates smaller tumors for treatment, outcome has become more predictable. Surgery has become the recognized management preference for these cranial base lesions. The purpose of this article is to assess the role of surgery in the treatment of jugular foramen lesions, as well as to review some of the technical highlights of conservation surgery, its clinical prerequisites, and reasonable expectations. We review 100 lateral skull base surgical cases of lesions involving the jugular foramen. The majority of these lesions--77 of 100--were paragangliomas. For these glomus tumors, cranial nerve preservation correlated well to tumor size and location. The diversity of the remaining 23 cases prevented any substantive conclusions.

Aims: To assess the size and bridging patterns of jugular foramina of adult human skulls. Materials and Methods: The study was conducted on 56 adult North - Indian skulls procured from Department of Anatomy of Santosh Medical College, Ghaziabad. The jugular foramina were observed by naked eye and with magnifying lens to assess the variations in size and bridging patterns. Results: The jugular foramen was larger on the right side in 53.5% skulls and on the left side in 7.1% skulls. In the remaining skulls (39.4%) it was equal on both sides. Complete tripartite division was observed in 10.7% cases. Incomplete division was seen in 7.1% cases on right side and 3.5% cases on the left side. Incomplete division was never observed bilaterally. An additional accessory foramen was observed to be communicating with posterior condylar canal. Conclusion: The variations observed in present study are of immense value to ENT surgeons while performing middle ear surgeries for various jugular foramen tumors. Also, the bridging patterns cause compression to structures passing through this foramen hence accentuating the clinical presentations of Glomus jugulare.

✓ The authors describe a widened transcochlear approach for large tumors of the jugular foramen with intrapetrous, intracranial, and infratemporal extensions. This approach complements the transcochlear and infratemporal approaches by enlarging the route of access to the region with disinsertion of the sternocleido-mastoid, digastric, and stylohyoid muscles, by removing petrous bone in order to displace the facial nerve, by resection of the auditory canal, and by subluxation of the temporomandibular joint and zygomatic process. The use of this approach is described in seven patients.