C. Gary Jackson

Vascular anomalies of the middle ear

The patient presenting with a red mass behind the eardrum and a pulsating tinnitus may well have a vascular tumor. One must be ever mindful, however, that the mass may represent a congential vascular anomaly. The most common one seen is the uncovered jugular bulb in which the vessel extends superiorly into the middle ear to or above the incudostapedial joint. More rare is the uncovered and posteriorly displaced carotid artery.

A systematic approach to the surgical management of acoustic neuroma.

Contemporary otomicrosurgical techniques have made total removal of acoustic tumor with preservation of the seventh and sometimes the eighth cranial nerves possible. The four approaches currently used in acoustic tumor surgery are the middle cranial fossa, the translabyrinthine, the suboccipital, and the combined translabyrinthine‐suboccipital. This review examines the surgical results in the removal of more than 600 acoustic tumors and outlines a rationale for the choice of approach. Tumor size on computed tomographic scan and auditory reserve establish the parameters used in planning the surgical procedure. The translabyrinthine exposure is used most frequently followed by the combined translabyrinthine‐suboccipital. The middle fossa and suboccipital approaches are used when preservation of hearing is attempted. Total removal of tumor was accomplished in more than 99% of patients with a mortality rate of less than 1%. Anatomic preservation of the facial nerve, which is directly related to tumor size, was achieved in more than 80% of patients. Preservation of hearing is unlikely when the tumor is larger than 2 cm; anatomic preservation of the cochlear nerve was successful in 73% of hearing preservation procedures.

Malignant Glomus Tumors

Objectives/Hypothesis: To ascertain the incidence of malignancy in a large glomus and skull base series and to compare the clinical course of such patients with those who do not have malignant skull base lesions. Study Design: Retrospective review of all skull base surgery cases treated at the Otology Group between 1970 and 1995. Results: In a series of 175 jugulotympanic glomus tumors, 9 cases (5.1%) were identified. The surgery required for their extirpation is more extensive than nonmalignant glomus tumors. Attendant deficits and mortality from these procedures are accordingly greater. Five‐year survival in this limited population was 72%. Prolonged periods of survival are possible with distant metastases. Conclusions: This rate of malignancy should advocate against a watchful, waiting approach. Radiation therapy is not advocated as a primary modality for this type of tumor, as it may lead to recurrence/persistence with either subsequent malignant degeneration and metastases or local recurrence.

Lateral skull base surgery for glomus tumors: long-term control.

Objective The age of modern microsurgery has made resection of glomus tumors with extensive skull base involvement possible. Resection of extensive lesions is not without risk of major complication or new cranial nerve deficit. Because glomus tumors are rare and slow growing, data reflecting recurrence risk after resection using modern skull base techniques are lacking. These factors complicate the accurate definition of efficacy of surgical resection and its functional cost. The object of this review is to determine the current incidence of major complications, the surgical cranial nerve deficit, the long-term control rate, and the recurrence risk in patients undergoing surgical resection of glomus jugulare tumors. Study Design Retrospective case review. Setting Private practice tertiary referral center. Patients and Interventions One hundred seventy-six patients with glomus tumors underwent 182 lateral skull base resections between 1972 and 1998. Main Outcome Measures Major complications, tumor recurrence, postoperative functional capacity, and factors affecting the incidence of each were assessed. Results Complete surgical control was achieved in 85% of cases. There were nine cases of recurrence, for a recurrent rate of 5.5% (9/164). Cerebrospinal fluid leakage occurred in 4.5% of cases with intracranial extension. New deficits for cranial nerves IX, X, XI, and XII occurred in 39%, 25%, 26%, and 21% of cases, respectively. Satisfactory functional recovery was achieved in an overwhelming majority of cases. The mortality rate was 2.7% (5/182). Conclusions Surgical resection of glomus tumors is established as an effective technique with good functional outcomes and long-term control.

Acoustic Neuroma: A Cost-Effective Approach

A cost-effective approach to the diagnosis and treatment of acoustic neuromas continues to evolve as diagnostic methods improve. In the past 7 months, since gadolinium-enhanced magnetic resonance imaging (MRI) has become available in our practice, our screening and presurgical workup has changed. The purpose of this article is to outline the current philosophy of the senior authors in relation to acoustic neuroma management on the basis of 72 patients diagnosed from July 1988 to February 1989. With more sensitive diagnostic means, older less sensitive studies may be eliminated from the routine workup, thus maintaining cost-effectiveness while preserving the highest standard of patient care. The body of this article will review our current use of the many available diagnostic options and emphasize a cost-effective approach.

Facial paralysis of neoplastic origin: Diagnosis and management

The individual with a progressive (weeks to months) facial weakness should be considered to have a tumor involving the facial nerve until proved otherwise.

Postauricular undersurface tympanic membrane grafting: A follow‐up report

The authors review 1,939 chronic ear surgeries in which 1,556 underwent some form of tympanic membrane grafting. The overall take rate was 93%. There was no selection of cases with regard to presence of infection, cholesteatoma, polyps, or granulation tissue at the time of surgery. There appeared to be no difference in the take rate based upon age of the patient, presence of infection, or cholesteatoma. Autogenous and homograft fascia performed well and there was no significant difference in take rate. Complications were minimal and were related more to the disease process than the grafting technique per se.

Glomus tympanicum and glomus jugulare tumors

The ideal management of most paragangliomas is complete surgical excision. Because of technical advances, issues of resectability have given way to issues of functional outcome and postsurgical quality of life. This article reviews the surgical strategy for craniocervical paragangliomas. Intracranial extension, defect reconstruction, and cranial nerve rehabilitation are addressed.

Diagnosis and management of paragangliomas of the skull base

In appropriately selected patients, glomus tumors of the head and neck are best treated surgically. Unresectability is not a factor in therapeutic planning for local disease control. Existing techniques and exposures for tumor removal can be reliably applied to these paragangliomas, with acceptable morbidity and mortality. A team approach to this problem is mandatory.

Surgical management of brain tissue herniation into the middle ear and mastoid.

In the well pneumatized temporal bone, the temporal lobe of the brain is separated from the middle ear and mastoid process by a thin layer of bone known as the tegmen. Congenital defects, infection, and trauma can alter this structure in such a way that cerebral tissue herniates into the ear. This unusual condition may precipitate numerous otologic problems such as hearing loss, trapped squamous epithelium, and the potential for meningitis or encephalitis.