Extreme lateral infrajugular transtubercular exposure for resection of a glomus jugulare: Microsurgical operative video.

Abstract

Background: Glomus jugular tumors (GJTs), a subset of paragangliomas, are highly vascularized neoplasms arising in the jugular foramen, typically affecting middle-aged women. Although benign, GJTs often present with critical cranial neuropathies such as hearing loss, swallowing disturbances, and facial weakness and can cause venous outflow obstruction from jugular vein compression. In symptomatic cases, early intervention is warranted and involves surgical resection. Approaches include transmastoid approach, juxtacondylar approach, infratemporal approaches, transotic approach, extreme lateral infrajugular transtubercular exposure (ELITE), or a combination thereof. Due to the highly vascularized nature of these tumors and the relative fragility of nearby cranial nerves, significant bleeding and neurological deficits can occur as a consequence of resection. Intraoperative bleeding, however, can be reduced with preoperative embolization.

Case description: We present the case of a 57-year-old woman with a right-sided GJT extending into the jugular foramen and compressing the facial nerve. Given her progressive symptoms, we felt that radiosurgery was not an ideal treatment. The goals of the procedure were to decompress the facial nerve and achieve maximal safe tumor resection. We utilized the ELITE approach with tailored mastoidectomy, allowing anterolateral access to the tumor. The mastoidectomy allows skeletonization of the sigmoid sinus and jugular bulb as well as the fallopian canal housing the facial nerve. To minimize postoperative cranial nerve palsies, neuromonitoring was used to limit facial nerve manipulation, and an intrabulbar dissection approach was employed to avoid iatrogenic injury to other neurovascular structures. The patient consented to the procedure and the publication of her images.

Conclusion: This case highlights a surgical approach that prioritizes both tumor resection and cranial nerve protection and offers insights into strategies for optimizing outcomes in GJT management. Furthermore, this case underscores the importance of tailored, precise techniques to minimize surgical morbidity for patients with these challenging lesions.