Jugular Foramen Tumors: Diagnosis and Treatment

Introduction: The outcome and surgical complications of a series of 105 jugular foramen tumors, surgically treated between January 1987 and November 2004, are presented. All tumors were operated on using the same multidisciplinary otoneurosurgical approach. Total removal with preservation of cranial nerves and vessels was the goal to be achieved with surgery.

Material and Methods: One hundred five patients with jugular foramen tumors were surgically treated between January 1987 and November 2004 at the Instituto de Neurologia de Curitiba (INC) and State University of Campinas (UNICAMP), Brazil. There were 79 women (75%) and 26 men (25%). In the group of paragangliomas there were 49 women and 11 men (approximately a 4:1 ratio of female-to-male incidence), with a mean age of 42.5 years ± 12.0 (range: 18–72 years). Two patients presented bilateral JF paragangliomas and two tumors secreted catecolamines (norepinephrine). Three patients related familial history of JFT or carotid body tumors. In the meningiomas group, two cases were histologically malignant and four presented malignant behavior. Eleven patients (10.7%) had been operated elsewhere before. Embolization was performed 3 to 5 days prior surgical procedure. High-flow saphenous bypass to reconstruct the ICA was performed in two cases before tumor removal and sacrifice of this vessel. All patients were operated on through the same otoneurosurgical approach. Radiotherapy was performed for malignant and invasive tumors.

Results: Paraganglioma was the most frequent JFT in this series was (60 cases, 56.8%) followed by low cranial nerve schwannomas (18 cases, 16.6%) and meningiomas (10 cases, 9.8%). Pulsatile tinnitus and hearing loss were the most frequent initial clinical symptoms of paragangliomas. Aggressive and malignant tumors as well as the meningiomas presented initially with low cranial nerves palsy and pain in the ear and mastoid region. Total removal was possible in 77 cases (73%) and in 87% of benign tumors. Radical removal of paragangliomas was possible in 47 patients (78%). In 13 paragangliomas (22%), total resection was not possible due to invasion of lower cranial nerves and/or brainstem. Radical removal was possible in all cases of schwannomas and in 5 patients with benign meningiomas. Low cranial nerves deficit was the most common (10 patients = 9.7%) and also the most dangerous complication. It was permanent in 6 patients. Postoperative facial nerve and cochlear nerve paralysis occurred in 8 cases (7.8%). Facial nerve palsy was temporary in 3. Four patients (3.9%) developed CSF leakage. Four patients (3.9%) died after surgery. Cause of death was surgical damage of lower cranial nerves complicated with aspiration pneumonia and septicemia (2 patients), pulmonary embolism (1 patient), and cerebral hypoxia due a large cervical hematoma causing tracheal deviation (1 patient).

Conclusions: Total resection of benign tumors (schwannomas, benign meningiomas, noninfiltrative paragangliomas) is possible with low mortality and morbidity. Radical resection of malignant and invasive tumors with preservation of cranial nerves is not possible. Size, biological behavior, histology, invasion of cranial nerves and bone of the cranial base, and extension into the cavernous sinus, clivus, and brainstem were factors limiting radical resection. Surgical damage of lower cranial nerves is the most dangerous complication related to surgery.