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Collet-Sicard syndrome (CSS) is the unilateral palsy of the cranial nerves (CN) IX, X, XI, and XII. To our knowledge, no review describes the characteristics of patients diagnosed with CSS. Therefore, this review aims to collect and describe all cases in the literature labeled as CSS. We performed a scoping review of the literature and conducted a database search in Embase and PubMed. We included articles and abstracts with case reports or case series of patients with CSS diagnosis. We classified the cases into two groups: "CSS", referring to patients presenting exclusively with IX-XII nerve involvement, and "CSS-plus", which corresponds to cases with CSS and other neurological impairments. We included 135 patients from 126 articles, of which 84 (67.7%) were male. The most common clinical manifestations reported were dysphagia and dysphonia. The most common etiology was tumoral in 53 cases (39.6%) and vascular in 37 cases (27.6%). The majority of patients showed partial or total improvement, with just over half receiving conservative treatment. The most frequent anatomic space was the jugular foramen (44.4%) and the parapharyngeal retrostyloid space (28.9%). Approximately 21% of the patients had other CN impairments, with the seventh and eighth CN most frequently compromised. We conclude that although there is a need for greater rigor in CSS reporting, the syndrome has a clear utility in identifying the localization of jugular foramen and parapharyngeal retrostyloid space pathology. [ABSTRACT FROM AUTHOR]

Introduction The surgical management that achieves minimal morbidity and mortality for patients with glomus and non-glomus tumors involving the jugular foramen (JF) region requires a comprehensive understanding of the complex anatomy, anatomic variability, and pathological anatomy of this region. Objective The aim of this study is to propose a rational guideline to expose and preserve the lower cranial nerves (CNs) in the lateral approach of the JF. Methods The technique utilized is the gross and microdissection of 4 fixed cadaveric heads to revise the JF's surgical anatomy and high part of the carotid sheath compared with surgical cases to understand and preserve the integrity of lower CNs. The method involves radical mastoidectomy, microdissection of the JF, facial nerve, and high neck just below the carotid canal and the JF. The CNs IX, X, XI, and XII are microscopically dissected and kept in sight up to the JF. Results This study realized well the surgical and applied anatomy of the lower CNs with relation to the facial nerve and JF. Conclusions The JF anatomy is complicated, and the key to safely operate on it and preserving the lower CNs is to find the posterior belly of the digastric muscle, to skeletonize the facial nerve, to remove the mastoid tip preserving the stylomastoid foramen, to skeletonize the sigmoid sinus and posterior fossa dura not only anterior but also posteroinferior to reach and drill the jugular tubercle. [ABSTRACT FROM AUTHOR]

Introduction The surgical management that achieves minimal morbidity and mortality for patients with glomus and non-glomus tumors involving the jugular foramen (JF) region requires a comprehensive understanding of the complex anatomy, anatomic variability, and pathological anatomy of this region.

Objectives: The distinctive bilateral carotid sheaths (CS) reside in the neck region and form part of the deep cervical fasciae. Aspects of the CS anatomy are controversial, most notably its specific attachment sites and fascial makeup, which are key determinants for the spread of tumours and infections and surgical planning. This review aimed to organise the pertinent aspects relating to CS anatomy and pathology, explore their clinical relevance and highlight areas of disagreement in the literature. Methods: A narrative review identified key papers relating to CS anatomy, histology, embryology, pathology and clinical and surgical significance using PubMed and Google Scholar. This was supported by a systematic review focused on the fascia forming the CS which was conducted using PubMed, Web of Science and Core Collection which yielded 22 papers. Results: and Discussion: The CS surrounds the internal carotid artery, internal jugular vein, cranial nerves IX - XII, lymph nodes and nervous plexuses as they course from the jugular foramen superiorly down along into the mediastinum inferiorly. There are contradicting descriptions regarding the CS attachments at the extracranial skull base and within the mediastinum. Author descriptions of the CS fasciae are complex, varied and incongruent. Pathologies affecting the CS include malignancies of the nerves, vascular lesions and utilisation of the CS space as a corridor for the spread of deep neck infections. Conclusion: This paper collates and presents pertinent anatomical and clinical aspects regarding the CS. A proper knowledge of the CS anatomy and structural relationships will optimise surgical approaches and orientation when operating within the region.

Background: Surgical treatment of dumbbell jugular foramen schwannomas can be challenging. The main goals of surgery are maximal resection with preservation of function and overall patient quality of life. Methods: In this paper, we present a step-by-step technical description of a microsurgical resection of dumbbell-shaped JF schwannoma using a modified retrosigmoid infra-jugular approach. Conclusion: The modified retrosigmoid infra-jugular is a safe and suitable approach in selected cases. This technique, however, must be limited only to those tumors with minimal extension into the jugular foramen. [ABSTRACT FROM AUTHOR]

1, Supporting Video 1): The FN was dissected from the genicular ganglion to stylomastoid foramen, the digastric muscle was detached from the digastric ridge and the FN was dissected from the stylomastoid foramen and further dissected to the surface of the styloid process. In a literature review, postoperative grade I or II FN function was achieved in 67.2% of patients who underwent total anterior rerouting.2 Parhizkar et al.4 reported that FN deficits associated with total rerouting of the FN occur may be due to stretching of the nerve or reduced blood supply. Keywords: Jugular foramen paragangliomas; infratemporal fossa type A approach; facial nerve; lower cranial nerves EN Jugular foramen paragangliomas infratemporal fossa type A approach facial nerve lower cranial nerves 2684 2687 4 11/16/21 20211201 NES 211201 INTRODUCTION Jugular foramen paragangliomas (JFPs) are highly vascularized tumors, although JFPs grow slowly and are considered histologically benign, the infiltrative nature of tumors tend to destroy vital neurovascularities adjacent to tumor. Our modified total anterior FN transposition technique not only reduced FN tension but also maintained blood supply of the FN by ensuring minimal FN injury and degeneration, which lead to significant improvement of FN function postoperatively. [Extracted from the article]

Background  Antero-laterally located meningiomas of the foramen magnum (FM) pose significant surgical resection challenges. The effect of FM shape on surgical resection of FM meningiomas has not been previously studied. The present study investigates how FM shape effects the extent of tumor resection and complication rates in antero-lateral FM meningiomas. Materials and Methods  This retrospective study included 16 consecutive patients with antero-lateral FM meningiomas operated on by a single surgeon. FMs were classified as ovoid (n  = 8) and nonovoid (n  = 8) using radiographic evaluation. Results  Sixteen patients were examined: seven males and nine females (mean age of 58.5, and range of 29 to 81 years). Gross total resection was achieved in 81% of patients, with tumor encased vertebral arteries in 44%. Patient characteristics were similar including age, sex, preoperative tumor volume, relationship of vertebral artery with tumor, preoperative Karnofsky performance score (KPS), symptom duration, and presence of lower cranial nerve symptoms. The ovoid FM group had lower volumetric extents of resection without statistical significance (93 ± 10 vs. 100 ± 0%, p  = 0.069), more intraoperative blood loss (319 ± 75 vs. 219 ± 75 mL, p  = 0.019), more complications per patient (1.9 ± 1.8 vs. 0.3 ± 0.4, p  = 0.039), and poorer postoperative KPS (80 ± 21 vs. 96 ± 5, p  = 0.007). Hypoglossal nerve palsy was more frequent in the ovoid FM group (38 vs. 13%). Conclusion  This is the first study demonstrating that ovoid FMs may pose surgical challenges, poorer operative outcomes, and lower rates of extent of resection. Preoperative radiological investigation including morphometric FM measurement to determine if FMs are ovoid or nonovoid can improve surgical planning and complication avoidance. [ABSTRACT FROM AUTHOR]

Lesions arising from the upper parapharyngeal space (UPPS) often involved the jugular foramen region (JFR), occasionally extending into the posterior cranial fossa. This study aims to investigate the surgical anatomy of the JFR and UPPS from the perspective of an expanded endoscopic approach (EEA), tracing the lower cranial nerves from their extracranial foramina to the UPPS. Six cadaveric specimens (12 sides) underwent a transpterygoid EEA to expose the JFR and UPPS. Distances from the medial pterygoid plate (MPP) to the internal carotid artery (ICA), hypoglossal canal (HC), and jugular tubercle (JT) were measured on anonymized Computed tomography angiography images previously obtained from 30 patients with pulsatile tinnitus. Full access to the JFR, and its medial, superior, and anterior aspects, could be adequately achieved via an EEA. Upon exiting the jugular foramen, the glossopharyngeal nerve courses posterior to the ICA, traveling inferiorly into the UPPS between ICA and IJV. The vagus nerve is in close proximity to the hypoglossal nerve traveling posterior to the ICA. The accessory nerve courses lateral to the vagus nerve, running posterior to the IJV. The minimal distances from the MPP to ICA, HC, and JT were 2.52 ± 0.34, 2.86 ± 0.36, and 3.18 ± 0.33 cm, respectively. This anatomical study strongly suggests the feasibility of using an EEA to access to the medial, superior, and anterior aspects of the jugular foramen and the adjacent UPPS. [ABSTRACT FROM AUTHOR]

Background: Lower cranial nerve palsies, or Collet-Sicard syndrome, can be caused by many different etiologies including head trauma, basilar occipital fractures, tumors, and interventions. Few reports describe different presentations of this condition, and we present here a case study to increase awareness of and add to the variable spectrum. Case Description: A 56-year-old who had been hit while diving was admitted to our department. On examination, he was conscious without any signs of lateralization but presented with severe neck pain. CT brain and cervical spine revealed a C1 fracture with bilateral symmetrical fracture of the anterior and posterior arches (Jefferson's fracture) and slight bilateral joint dislocation C1-C2 discreetly predominant on the left. One week later, he presented with dysarthria, dysphonia, swallowing disorder, anisocoria, tongue deviation, and palate deviation (XII, IX, and X). CT Angiography showed dissection of the internal carotid artery immediately after the carotid bulb. He has been treated conservatively with curative anticoagulants with stable symptoms. No surgical intervention had been proposed. Conclusion: Adding to the literature, delayed Collet-Sicard syndrome and lower cranial affection can be caused by missed carotid wall hematoma following severe craniocervical trauma associated with Jefferson's fracture. [ABSTRACT FROM AUTHOR]

This study established novel technique nuances in surgery for ventral foramen magnum meningiomas (vFMMs) via a dorsal lateral approach. From July 2012 to July 2019, 37 patients with vFMMs underwent tumor resection surgery and were operated on with a dorsal lateral approach. Two safe zones were selected as the entrance of the surgical corridor. Safe zone I was located between the dural attachment of the first dental ligament (FDL) and the branches of C1; safe zone II lay between the dural attachment of the FDL and the jugular foramen. The tumor was debulked first through safe zone I and then through safe zone II. The tumor was removed through a trajectory from the caudal to cephalad to allow tumor debulking from below and downward delivery, away from the brainstem and lower cranial nerves. Thirty-three patients underwent gross total resection, and 4 patients underwent subtotal resection. Four patients transiently required a nasogastric feeding tube. All patients recovered within 3 months postoperatively. Three patients (8.1%) developed permanent mild hoarseness and dysphagia as a result of postoperative damage of cranial nerves IX and X. One patient underwent tracheotomy. No patient experienced tumor recurrence during the follow-up period. We established a minimal retraction principle, in which the selection of 2 safe zones as the entrance of the surgical corridor, tumor removal from the inferior to superior direction, and debulking followed by devascularization were the key elements to implement the minimal retraction principle in vFMM surgery. [ABSTRACT FROM AUTHOR]

Background: The surgical removal of the infratemporal parapharyngeal lesions (IPL) is challenging due to its anatomical complexity. Previous surgical approaches have often been too invasive and necessitated sacrifice of normal function and anatomical structures, particularly in the retromandibular nerve region. Therefore, we sought to identify an approach corridor to this area that requires less sacrifice and report an innovative approach through a retromandibular fossa route to the IPL. Methods: Five cadaveric specimens were dissected bilaterally with a trans-tympanic plate and styloid process approach. These specimens were investigated microanatomically and morphometrically to examine the extent of the approach in the parapharyngeal space. The clinical application of this approach was compared to previous approaches to the IPL used in our clinical series of 20 cases. Results: Using this novel approach, the inferior alveolar nerve was identified in all specimens, while the chorda tympani and lingual nerve were identified in 6 (60%) and 4 (40%) dissections, respectively. In all specimens, the petrous portion of the internal carotid artery and the exit of the lower cranial nerve were identified. The average length of the exposed lower cranial nerves was 16.6 ± 3.8 mm (range: 11–25 mm). Conclusions: The described approach is feasible for accessing the IPL at the retromandibular nerve and is less invasive than conventionally used approaches. [ABSTRACT FROM AUTHOR]

Schwannomas encompassing the superior parapharyngeal space are challenging lesions because of the anatomical complexity of this region and the frequent involvement of the neurovascular structures of the jugular foramen. The purpose of this study is to report the technical aspects and the advantages of the anterolateral approach, here proposed for schwannomas of this complex area. The main steps of the anterolateral approach are described in detail, along with the results of a consecutive series of 38 patients with a retrostyloid superior parapharyngeal schwannoma involving the jugular foramen operated on by means of this route between 1999 and 2019. The supine position is generally preferred. The medial border of the sternocleidomastoid muscle, mastoid tip, and superior nuchal line are the landmarks for the hockey-stick skin incision. The accessory nerve is retrieved and mobilized cranially. Detachment of the sternocleidomastoid, digastric, and nuchal muscles allows for a 180° exposure of the extracranial side of the jugular foramen. Three working corridors, namely the pre-carotid, pre-jugular, and retro-jugular, allow access to the deeper part of the jugular foramen area and the superior parapharyngeal space. In the present series, a gross total resection was achieved in 89.4% of the patients. Three recurrences occurred after an average follow-up of 80.5 ± 51 months. The anterolateral approach is highly effective in the treatment of retrostyloid superior parapharyngeal space schwannomas involving the jugular foramen. Its simplicity of execution, versatility, and very low morbidity are among its main strengths. [ABSTRACT FROM AUTHOR]

Objective: We report an association between lower cranial nerve (CN IX/X) vascular compression at the brainstem with laryngeal symptoms utilizing a stepwise algorithm that systematically evaluates and eliminates all other common etiologies. Our experiences with retromastoid craniectomy with lower cranial nerve (LCN) decompression versus non-neurosurgical treatments are detailed.Study Design: Retrospective chart review at a tertiary care academic medical center with follow-up telephone survey.Methods: Baseline demographics, clinical characteristics, quality-of-life surveys, and treatment outcomes were recorded for patients with laryngeal symptoms associated with LCN compression at the brainstem.Results: Forty-nine patients demonstrated LCN compression at the brainstem on imaging and presented with chief complaints of dysphonia (25 of 49, 51%), chronic cough (19 of 49, 39%), dysphoric breathing (3 of 49, 6%), and dysphagia (2 of 49, 4%). Poor initial scores were noted for Voice-Related Quality of Life (V-RQOL), Reflux Symptom Index, and Glottal Closure Index. Twenty-four patients underwent LCN decompression, of which 21 of 24 (88%) reported partial, near-complete, or complete improvement. Major perioperative complications occurred in four of 24 patients (17%). Patients who had undergone decompression were more likely to obtain complete/near-complete symptom resolution (10 of 24 patients, 42%) compared to those undergoing conservative treatments (2 of 25 patients, 8%) (P = 0.02). V-RQOL scores improved more in surgical patients [mean change score, 33.0 (standard deviation [SD], 31.2) than nonsurgical patients (mean change score 9.6, SD 20.9) (P = 0.03) (mean follow-up 3.0 years, SD 2.0).Conclusion: Lower cranial nerve compression at the brainstem should be considered when all other etiologies are excluded. Retromastoid craniectomy with LCN decompression demonstrates an acceptable safety profile.Level Of Evidence: 4 Laryngoscope, 129:2105-2111, 2019. [ABSTRACT FROM AUTHOR]

Introduction: Pediatric schwannomas are rare, and most of them are associated with neurofibromatosis type 2 (NF2) and usually located in the vestibular nerve. Herein, we present the first pediatric case of intracranial schwannoma derived from the IX/X nerve complex unrelated to NF2. Case report: The patient was a 9-year-old boy who presented with a 3-month history of headache and nausea. There was no family history of NF2. Imaging studies revealed a cystic lesion with enhanced wall in the left cerebellomedullary fissure. During the operation, the IX/X nerve complex was strongly adhered to the tumor at the jugular foramen. The tumor was totally excised, and the postoperative MRI demonstrated no residual tumor. Histopathological diagnosis was schwannoma. Genetic analysis revealed no mutation associated with NF2 and schwannomatosis. Conclusion: We reported the first case of pediatric lower cranial nerve schwannoma which was not associated with NF2. The schwannoma should be included as differential diagnosis of pediatric posterior fossa tumors. [ABSTRACT FROM AUTHOR]

Objective To describe microsurgical anatomy of the rhomboid lip (RL) and to consider its role by presenting histology and clinical cases. Methods We examined 10 (20 sides) formalin-fixed adult human cadaveric heads injected with colored silicone. A total of 20 RLs were examined posteriorly. We examined the expansion of the RL in the cerebellopontine cistern. We assessed the relationship between the RL and choroid plexus and the RL and cranial nerve IX and classified the RL. We also observed these relationships in clinical cases during surgeries and examined histologic assessments of the RL. Results The RL was divided into 3 types, non-extension type, lateral extension type, and jugular foramen type, according to the relationship between the RL and choroid plexus. There were many variations of the extension of the RL. The jugular foramen type was rare. Conclusions Histologically, the RL is the remnant of the fourth ventricle covered with ependymal cells. Knowledge of the detailed anatomy and proper dissection of the RL may help surgeons to obtain good visualization of structures around the foramen of Luschka. [ABSTRACT FROM AUTHOR]

Paralysis of the lower cranial nerves is uncommon after closed head injuries. Most cases reported are unilateral and associated with base of skull fractures, usually involving the occipital condyles. Bilateral lower cranial nerve palsy is even less common, with only a handful of cases reported in literature. A 17-year-old girl presented to us after she was involved in a side-on collision with a car while driving a scooter. She sustained traumatic brain injury requiring mechanical ventilation. Detailed neurological evaluation revealed bilateral paralysis of the IXth, Xth, and XIIth cranial nerves with no evidence of a fracture of the base of skull or brain stem injury. A traction type of injury to the nerves arising from a whiplash mechanism may have led to paralysis of the lower cranial nerves in our patient. An exhaustive review of literature revealed 11 reports of bilateral lower cranial nerve palsy associated with closed head injuries; there were only four cases without underlying fracture of the occipital condyles. Our patient made a complete recovery over a period of 4 months. A traction type of injury to the lower cranial nerves may occur due to a whiplash mechanism. This type of injury may be associated with a favorable outcome. [ABSTRACT FROM AUTHOR]

Background: Jugulotympanic paraganglioma (JTP) are benign, high-vascularized lesions that frequently invade the jugular foramen, temporal bone, the upper neck, and the posterior fossa cavity, resulting in a wide variety of clinical symptoms. Methods: In this retrospective study, we assess the clinical symptoms and discuss the individual multidisciplinary treatment and outcome of 22 patients with JTP. Results: In 12 patients, a hearing deficit was the presenting symptom, whereas pulsatile tinnitus and otalgia were present in six and four patients respectively. Facial nerve involvement was seen in six patients (three HB Grade 1-2 and three HB Grade 4-6). Four patients presented with lower cranial nerve impairment. Rare symptoms were ataxia caused by brainstem compression and papilledema due to cerebral sinus obstruction. A new or worsening of the preoperative facial nerve or lower cranial nerve function occurred in two and four patients respectively. Conclusion: The treatment strategy and the surgical approach for JTP should be tailored to the tumor extension and the patient's clinical symptoms. [ABSTRACT FROM AUTHOR]

Background: Lesions lateral to the lower brainstem in an area extending from the foraminae of Luschka to the foramen magnum are rare and include different pathologies. There is no consensus on an ideal surgical approach. Method: To gain access to this area, we use the midline suboccipital subtonsillar approach (STA). This midline approach with unilateral retraction of the cerebellar tonsil enables entry into the cerebellomedullary cistern. Conclusions: The STA offers excellent access with a panoramic view of the cerebellomedullary cistern and its structures and therefore can be useful for a number of different pathologies in the lower petroclival area. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the value of free-run electromyography (f-EMG) monitoring of extraocular cranial nerves (EOCN) III, IV, and VI during expanded endonasal surgery (EES) of the skull base in reducing iatrogenic cranial nerve (CN) deficits. Design We retrospectively identified 200 patients out of 990 who had at least one EOCN monitored during EES. We further separated patients into groups according to the specific CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as Group I and those who did not as Group II. Results A total of 696 EOCNs were monitored. The number of muscles supplied by EOCNs that had SG f-EMG activity was 88, including CN III = 46, CN IV = 21, and CN VI = 21. There were two deficits involving CN VI in patients who had SG f-EMG activity during surgery. There were 14 deficits observed, including CN III = 3, CN IV = 2, and CN VI = 9 in patients who did not have SG f-EMG activity during surgery. Conclusions f-EMG monitoring of EOCN during EES can be useful in identifying the location of the nerve. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of EOCN during EES need to be done with both f-EMG and triggered EMG.

Background The purpose of this study was to share our review of surgical strategies and long-term outcomes in the management of tympanojugular paragangliomas. Methods This was a retrospective study with a literature review. The records of 184 patients with 185 tympanojugular paragangliomas were analyzed for tumor class, surgical procedure, preoperative vascular management, and perioperative sequelae. Results Of class C1, C2, C3, and C4 tumors, we found 46 (24.9%), 95 (51.3%), 41 (22.2%), and 3 (1.6%), respectively. One hundred four (56.2%) tumors had intracranial extensions and 8 (4.3%) involved the vertebral artery. A single-stage procedure was adopted in 158 (85.4%) tumors. The infratemporal fossa type A approach was used in all cases. In 17 patients (9.7%), an intra-arterial stenting of the internal carotid artery was performed. Gross-total tumor removal was achieved in 166 cases (89.7%) and 4 (2.4%) among them developed a recurrence. Conclusion A thorough understanding of skull base techniques and a logical decision-making process in the management of tympanojugular paragangliomas can achieve a high rate of success in terms of recurrences and complications. © 2015 Wiley Periodicals, Inc. Head Neck 38: 871-885, 2016 [ABSTRACT FROM AUTHOR]

Background: Glossopharyngeal neuralgia (GN) is a rare functional disorder representing around 1% of cases of trigeminal neuralgia. Lancinating throat and ear pain while swallowing are the typical manifestations, and are initially treated using anticonvulsants such as carbamazepine. Medically refractory GN is treated surgically. Microvascular decompression (MVD) is reportedly effective against GN, superseding rhizotomy and tractotomy. Methods: We encountered three patients with medically refractory GN who underwent MVD using intraoperative neurophysiological monitoring (IONM). The offending vessels were the posterior inferior cerebellar arteries, which were confirmed intraoperatively via a transcondylar fossa approach to be affecting the root exit zones of the glossopharyngeal and vagus nerves. As IONM, facial motorevoked potentials (MEPs) and brainstem auditory-evoked potentials were monitored during microsurgery in all three patients. Pharyngeal and vagal MEPs were added for two patients to avoid postoperative dysphagia. Results: GN disappeared immediately after surgery with complete preservation of hearing acuity and facial nerve function. Transient mild swallowing disturbance was observed in 1 patient without pharyngeal or vagal MEPs, whereas the remaining two patients with pharyngeal and vagal MEPs demonstrated no postoperative dysphagia. Conclusion: Although control of severe pain is expected in surgical intervention for GN, lower cranial nerves are easily damaged because of their fragility, even in MVD. IONM including pharyngeal and vagal MEPs appears very useful for avoiding postoperative sequelae during MVD for GN. [ABSTRACT FROM AUTHOR]

Eleven patients with jugular foramen lesions with or without extradural extension were operated at University Hospital of Campinas (UNICAMP), in Campinas, Brazil, between 1998 and 2001. Neck dissection, mastoidectomy without transposition of the facial nerve and myofascial flap reconstruction of the cranial base with an especially developed technique were carried out in 7 patients. Four patients were operated using retrosigmoid craniectomy. Total excision was accomplished in 9 cases. All patients did not show evidence of disease progression at least after 2 years follow-up. There was no mortality. New lower cranial nerve deficits occurred in 5 patients. Nine maintain or improved their preoperative status based on Karnofsky and Glasgow Outcome Scale. A complex anatomy of this region demand wide exposures for treat those tumors. For this reason, an adequate approach for curative resection of most lesions and an efficient skull base reconstruction decreasing postoperative morbidity are essential.Onze pacientes com lesões expansivas do forame jugular associadas ou não a componente extradural foram submetidos a ressecção cirúrgica no Hospital das Clínicas da Universidade Estadual de Campinas (UNICAMP) entre 1998 e 2001. Foi utilizada cirurgia combinada com dissecção do pescoço, mastoidectomia sem transposição do nervo facial e técnica de reconstrução miofascial da base do crânio desenvolvida por um dos autores. Quatro pacientes foram operados via craniectomia retrosigmoidea. Ressecção total foi feita em 9 pacientes, subtotal em um e parcial em outro. Nenhum dos 11 pacientes teve progressão da doença em 2 anos de acompanhamento. Não houve mortalidade. Cinco pacientes tiveram déficits adicionais de nervos cranianos baixos. Nove pacientes mantiveram ou melhoraram suas pontuações de acordo com a escala de Karnofsky. Para adequada abordagem do paciente com tumor de forame jugular, são necessários bom conhecimento anatômico da região, exposição cirúrgica ampla, e técnica de reconstrução eficiente para obter cura com baixas taxas de complicações pós-operatórias.

Abstract Primary neurolymphomatosis is an extremely rare tumor. We report the case of a 74-year-old patient presenting with dysphagia and hoarseness. Initial contrast-enhanced computed tomography of the head, neck, and chest did not reveal any lesions. His symptoms improved with short-term administration of prednisone but recurred and deteriorated. Magnetic resonance (MR) imaging revealed a tumor along the ninth and tenth cranial nerves across the jugular foramen. Fluorine-18 fluorodeoxyglucose positron emission tomography indicated this was a primary tumor. Repeated MR imaging after 2 months revealed considerable tumor enlargement. A left suboccipital craniotomy was performed to remove the tumor that infiltrated the ninth and tenth cranial nerves. The histopathologic diagnosis was diffuse large B-cell lymphoma. Although focal radiation therapy was administered to ensure complete eradication of the tumor, the patient died of aspiration pneumonia with systemic metastasis. To our knowledge, this is the first reported case of primary neurolymphomatosis in the lower cranial nerves.

Objectives: The distinctive bilateral carotid sheaths (CS) reside in the neck region and form part of the deep cervical fasciae. Aspects of the CS anatomy are controversial, most notably its specific attachment sites and fascial makeup, which are key determinants for the spread of tumours and infections and surgical planning. This review aimed to organise the pertinent aspects relating to CS anatomy and pathology, explore their clinical relevance and highlight areas of disagreement in the literature., Methods: A narrative review identified key papers relating to CS anatomy, histology, embryology, pathology and clinical and surgical significance using PubMed and Google Scholar. This was supported by a systematic review focused on the fascia forming the CS which was conducted using PubMed, Web of Science and Core Collection which yielded 22 papers., Results: and Discussion: The CS surrounds the internal carotid artery, internal jugular vein, cranial nerves IX - XII, lymph nodes and nervous plexuses as they course from the jugular foramen superiorly down along into the mediastinum inferiorly. There are contradicting descriptions regarding the CS attachments at the extracranial skull base and within the mediastinum. Author descriptions of the CS fasciae are complex, varied and incongruent. Pathologies affecting the CS include malignancies of the nerves, vascular lesions and utilisation of the CS space as a corridor for the spread of deep neck infections., Conclusion: This paper collates and presents pertinent anatomical and clinical aspects regarding the CS. A proper knowledge of the CS anatomy and structural relationships will optimise surgical approaches and orientation when operating within the region., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Radiation-induced cranial nerve palsy (RICNP) is a severe long-term complication in patients with head and neck cancer following high-dose radiation therapy (RT). We present the case report of a patient with bilateral RICNP of the hypoglossal and vagus cranial nerves (XII/X) following postoperative RT in the era prior to the introduction of intensity-modulated RT (IMRT), and an analysis of our IMRT patient cohort at risk including the case of a XII RICNP. A total of 201 patients whose glosso-pharyngeal (IX), X and XII cranial nerves had been exposed to >65 Gy definitive IMRT in our institution between January, 2002 and December, 2012 with or without systemic therapy, were retrospectively identi- fied. A total of 151 patients out of 201 fulfilling the following criteria were included in the analysis: Locoregionally controlled disease, with a follow-up (FU) of >24 months and >65 Gy exposure of the nerves of interest. So far, one of the assessed 151 IMRT patients at risk exhibited symptoms of RICNP after 6 years. The mean/median FU of the entire cohort was 71/68 months (range, 27-145). The results were compared with literature reports. In conclusion, RICNP appears to be a rare complication. However, a longer FU and a larger sample size are required to draw reliable conclusions on the incidence of RICNP in the era of IMRT. [ABSTRACT FROM AUTHOR]

Objective: Lesions of the cerebellomedullary cistern lateral to the lower brainstem in an area extending from the foraminae of Luschka to the foramen magnum are rare and can be caused by various sources. There is no consensus on an ideal surgical approach. We describe the anatomical features and the surgical technique of the midline suboccipital subtonsillar (STA) approach to the cerebellomedullary cistern and its pathologies. Methods: The study was performed on three alcohol (ETOH)-fixed specimens (6 sides), and the technique of the approach was highlighted. The tonsillar retraction needed to view the important structures was measured. Additionally, the records of 31 patients who underwent the STA procedure were evaluated. We provide three clinical cases as examples. Results: Tonsillar retraction of 0.3 cm (SD ± 0.1 cm) exposed the PICA with its telo-velo-tonsillar and cortical branches. Retraction of 0.4 cm (SD ± 0.2 cm) exposed the spinal root of CN XI. Retraction of 0.9 cm (SD ± 0.01 cm) exposed the hypoglossal canal. Retraction of 1.3 cm (SD ± 0.2 cm) exposed the root exit zone of the glossopharyngeal nerve. Retraction of 1.6 cm (SD ± 0.3 cm) exposed the jugular foramen (JF), and retraction of 2.4 cm (SD ± 0.2 cm) exposed the inner auditory canal (IAC). In all of the selected cases, the pathology could be reached and exposed using the STA. Conclusions: We recommend STA as a straightforward, easy-to-learn and therefore time-saving and safe procedure compared with other standard approaches to the cerebellomedullary cistern and its pathologies. [ABSTRACT FROM AUTHOR]

We will evaluate the value of electromyography (EMG) from cranial nerve (CN) V during endoscopic endonasal surgery (EES). EES is a minimally invasive form of skull base surgery. To date, no studies have been conducted examining the technique and value of free-run electromyography (f-EMG) of CN V during skull base surgeries and/or EES.We examined 18 patients who had EMG monitoring of CN V during an EES. A total of 29 CN V nerves were monitored among all the patients. Of those 18 patients, some underwent additional CN monitoring.One patient (5%) had significant EMG activity in the muscles supplied by CN V during the EES and did not have any neurological deficits. Of the other CNs monitored, significant EMG activity was present in CN VII, CN IX, CN X, CN III, and CN VI in 14%, 12%, 21%, 19%, and 5% of all those nerves monitored, respectively. No patients developed postoperative neurological deficits.It is possible to reliably monitor CN V during EES. The value of f-EMG monitoring of the trigeminal nerve during EES seems limited. A larger study of CN V with triggered EMG and f-EMG would be beneficial to evaluating the value of CN V monitoring during EES. [ABSTRACT FROM AUTHOR]

Objective: To discuss the classification of petrous bone cholesteatoma (PBC) and add a subclassification; to review the existing literature and to propose the ideal surgical management of PBC based upon the experience of the largest series published in the literature until now. Study Design: Retrospective analysis. Setting: Quaternary referral neuro-otologic private practice. Materials and Methods: The data of 129 patients who underwent surgery for PBC between 1979 and 2008 were analyzed with respect to the classification, type of the approach used, facial nerve lesion and its management, recurrences and outcome. Results: Out of the 129 PBC cases 64 were supralabyrinthine, 9 infralabyrinthine, 7 infralabyrinthine-apical, 48 massive and 1 apical. The facial nerve was involved in 95% of the cases. Hearing could not be preserved in 82% of the cases due to the extent of the lesions and the surgical approaches used. The internal carotid artery, jugular bulb and the lower cranial nerves were infrequently involved, but demanded careful identification and meticulous care to avoid complications. Obliteration of the cavities provided a safe solution for protection of the exposed dura and the vital neurovascular structures. Recurrences were observed in 5 cases. Conclusion: The classification of PBC is fundamental to choose the appropriate surgical approach; the facial nerve is involved in almost all the cases, radical removal takes priority over hearing preservation and cavity obliteration is important to protect the vital neurovascular structures which may be exposed. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The lower cranial nerves must be identified to avoid iatrogenic injury during skull base and high cervical approaches. Prompt recognition of these structures using basic landmarks could reduce surgical time and morbidity. Methods: The anterior triangle of the neck was dissected in 30 cadaveric head sides. The most superficial segments of the glossopharyngeal, vagus and its superior laryngeal nerves, accessory, and hypoglossal nerves were exposed and designated into smaller anatomic triangles. The midpoint of each nerve segment inside the triangles was correlated to the angle of the mandible (AM), mastoid tip (MT), and bifurcation of the common carotid artery. Results: A triangle bounded by the styloglossus muscle, external carotid artery, and facial artery housed the glossopharyngeal nerve. This nerve segment was 0.06 ± 0.71 cm posterior to the AM and 2.50 ± 0.59 cm inferior to the MT. The vagus nerve ran inside the carotid sheath posterior to internal carotid artery and common carotid artery bifurcation in 48.3% of specimens. A triangle formed by the posterior belly of digastric muscle, sternocleidomastoid muscle, and internal jugular vein housed the accessory nerve, 1.90 ± 0.60 cm posterior to the AM and 2.30 ± 0.57 cm inferior to the MT. A triangle outlined by the posterior belly of digastric muscle, internal jugular vein, and common facial vein housed the hypoglossal nerve, which was 0.82 ± 0.84 cm posterior to the AM and 3.64 ± 0.70 cm inferior to the MT. Conclusions: Comprehensible landmarks can be defined to help expose the lower cranial nerves to avoid injury to this complex region. [ABSTRACT FROM AUTHOR]

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The fundamental goal of skull base surgery is tumor removal with preservation of neurological function. Injury to the lower cranial nerves (LCN; CN 9–12) profoundly affects a patient’s quality of life. Although intraoperative cranial nerve monitoring (IOM) is widely practiced for other cranial nerves, literature addressing the LCN is scant. We examined the utility of IOM of the LCN in a large patient series. One hundred twelve patients underwent 123 skull base operations with IOM between January 1994 to December 1999. The vagus nerve ( n = 37), spinal accessory nerve (n = 118), and the hypoglossal nerve ( n = 83) were monitored intraoperatively. Electromyography (EMG) and compound muscle action potentials (CMAP) were recorded from the relevant muscles after electrical stimulation. This data was evaluated retrospectively. Patients who underwent IOM tended to have larger tumors with more intricate involvement of the lower cranial nerves. Worsening of preoperative lower cranial nerve function was seen in the monitored and unmonitored groups. With the use of IOM in the high risk group, LCN injury was reduced to a rate equivalent to that of the lower risk group ( p > 0.05). The immediate feedback obtained with IOM may prevent injury to the LCN due to surgical manipulation. It can also help identify the course of a nerve in patients with severely distorted anatomy. These factors may facilitate gross total tumor resection with cranial nerve preservation. The incidence of high false positive and negative CMAP and the variability in CMAP amplitude and threshold can vary depending on individual and technical factors. [ABSTRACT FROM AUTHOR]

Owing to their scarcity, location, and intricate neurovascular associations, jugular fossa tumors are among the most challenging pathologies encountered by the neurosurgeon.1 While paragangliomas originate within and often occlude the jugular bulb, schwannomas and meningiomas are extra-bulbar and typically do not impede venous flow.2 Schwannomas typically arise from an extradural origin, expanding the jugular foramen.3-5 Meningiomas are intradural and cause hyperostosis of the jugular tubercle.6 We described and have been exposing and resecting jugular fossa tumors through a presigmoid suprabulbar infralabyrinthine window6 that has been detailed in cadaveric studies.7,8 This approach maintains the patency of the jugular bulb without breaching the labyrinths or manipulating the facial nerve. It is applicable to cases with partially impaired hearing and intact lower cranial nerves. The carotid artery can be identified by neuronavigation and micro-Doppler ultrasonography. This approach provides a direct lateral trajectory with a short distance to the jugular fossa and cerebellopontine angle. Early exposure and central debulking of the tumor minimize manipulation of the exquisitely sensitive lower cranial nerves. The distal aspect of these tumors can be removed with endoscopic assisted techniques.9 The first patient is a 49-yr-old woman with a previously irradiated schwannoma who presented with worsening neurologic deficits-an extradural suprabulbar approach was used to resect this tumor. The second patient is a 27-yr-old woman with an enlarging meningioma and associated neurological dysfunction; this tumor was resected using the suprabulbar approach with opening of the presigmoid dura. Both patients have consented to surgery and publication of images. Image at 2:27 and 6:38 reprinted from Arnautović et al, with permission from JNSPG. Image at 2:50 and 6:45 ©Ossama Al-Mefty 1997, reused with permission., (© Congress of Neurological Surgeons 2021.)

Background  Antero-laterally located meningiomas of the foramen magnum (FM) pose significant surgical resection challenges. The effect of FM shape on surgical resection of FM meningiomas has not been previously studied. The present study investigates how FM shape effects the extent of tumor resection and complication rates in antero-lateral FM meningiomas. Materials and Methods  This retrospective study included 16 consecutive patients with antero-lateral FM meningiomas operated on by a single surgeon. FMs were classified as ovoid ( n  = 8) and nonovoid ( n  = 8) using radiographic evaluation. Results  Sixteen patients were examined: seven males and nine females (mean age of 58.5, and range of 29 to 81 years). Gross total resection was achieved in 81% of patients, with tumor encased vertebral arteries in 44%. Patient characteristics were similar including age, sex, preoperative tumor volume, relationship of vertebral artery with tumor, preoperative Karnofsky performance score (KPS), symptom duration, and presence of lower cranial nerve symptoms. The ovoid FM group had lower volumetric extents of resection without statistical significance (93 ± 10 vs. 100 ± 0%, p  = 0.069), more intraoperative blood loss (319 ± 75 vs. 219 ± 75 mL, p  = 0.019), more complications per patient (1.9 ± 1.8 vs. 0.3 ± 0.4, p  = 0.039), and poorer postoperative KPS (80 ± 21 vs. 96 ± 5, p  = 0.007). Hypoglossal nerve palsy was more frequent in the ovoid FM group (38 vs. 13%). Conclusion  This is the first study demonstrating that ovoid FMs may pose surgical challenges, poorer operative outcomes, and lower rates of extent of resection. Preoperative radiological investigation including morphometric FM measurement to determine if FMs are ovoid or nonovoid can improve surgical planning and complication avoidance., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Primary glioblastoma multiforme tumors of the medulla oblongata are rare, especially in the adult population. Perhaps due to this rarity, we are not aware of any previous reports addressing the resection of these tumors or their clinical outcomes. In this surgical video, we present a 43-year-old man with a 1-month history of left-sided paresthesia. The paresthesia initiated in the left hand, along with weakness and reduced fine motor control, and then spread to the entire left side of the body. He had recent weight loss, imbalance, difficulty in swallowing, and hoarseness in his voice. He also had a diminished gag reflex, and significant atrophy of the right side of the tongue with an accompanying deviation of the uvula and fasciculations of the tongue. MRI showed an infiltrative expansile mass within the medulla with peripheral enhancement and central necrosis. In T2/FLAIR sequences, a hyperintense signal extended superiorly into the left inferior aspect of the pons and left inferior cerebellar peduncle and inferiorly into the upper cervical cord. The decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of this infiltrative expansile intrinsic mass in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials and monitoring of lower cranial nerves IX, X, XI, and XII. A gross-total resection of the enhancing portion of the tumor was performed, along with a subtotal resection of the nonenhancing portion. The surgery and postoperative course were uneventful. Histopathology revealed a grade IV astrocytoma. The patient received radiation therapy. In this surgical video, we demonstrate important steps for the microsurgical resection of this challenging glioblastoma multiforme of the medulla oblongata. The video can be found here: https://youtu.be/QHbOVxdxbeU., Competing Interests: Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication., (© 2019, Sima Sayyahmelli, Jian Ruan, Bryan Wheeler, and Mustafa K. Başkaya.)

Background: Glossopharyngeal neuralgia (GN) is a rare functional disorder representing around 1% of cases of trigeminal neuralgia. Lancinating throat and ear pain while swallowing are the typical manifestations, and are initially treated using anticonvulsants such as carbamazepine. Medically refractory GN is treated surgically. Microvascular decompression (MVD) is reportedly effective against GN, superseding rhizotomy and tractotomy., Methods: We encountered three patients with medically refractory GN who underwent MVD using intraoperative neurophysiological monitoring (IONM). The offending vessels were the posterior inferior cerebellar arteries, which were confirmed intraoperatively via a transcondylar fossa approach to be affecting the root exit zones of the glossopharyngeal and vagus nerves. As IONM, facial motor-evoked potentials (MEPs) and brainstem auditory-evoked potentials were monitored during microsurgery in all three patients. Pharyngeal and vagal MEPs were added for two patients to avoid postoperative dysphagia., Results: GN disappeared immediately after surgery with complete preservation of hearing acuity and facial nerve function. Transient mild swallowing disturbance was observed in 1 patient without pharyngeal or vagal MEPs, whereas the remaining two patients with pharyngeal and vagal MEPs demonstrated no postoperative dysphagia., Conclusion: Although control of severe pain is expected in surgical intervention for GN, lower cranial nerves are easily damaged because of their fragility, even in MVD. IONM including pharyngeal and vagal MEPs appears very useful for avoiding postoperative sequelae during MVD for GN.