see also: Carotid Body and Carotid Sinus -- General Information, Carotid Body Paraganglioma, Carotid Body Tumor Resection, Carotid body tumor resection and vasomotor instability (blood pressure problems)

Clinical Course (modified case example as managed in 2000's)

CC: 28 yo female with tinnitus

HPI: 28 yo female with a history of pulsatile tinnitus (AS>AD) and HL AD for several months. She also has noticed heart racing and palpitations. No hypertension or headaches. No dysphagia, odynophagia, hoarseness, or difficulty breathing. CT at OSH showed bilateral jugular foramen lesions.

Physical Exam:

• TM AD: vascular mass in hypotympanum up to level of stapes
• TM AS: small vascular lesion in the hypotympanum
• Otherwise full head and neck exam was WNL

Audiogram:

• AD: Mild conductive HL rising to WNL @ 2Khz, sloping to mild conductive HL again
• AS: WNL
• Discrim: WNL bilaterally (>96%)

MRI/MRA/MRV

• bilateral jugular foramen paraganglioma
• bilateral carotid body tumors
• IJ bilaterally
• extensive collateral flow

Surgery #1 – Right Side: Embolization followed by tumor resection two days later

• Embolization of multiple feeder arteries in conjunction with Neurosurgery
  • Used PVA 150-250 micron embolic material
  • Injected in to two primary feeders from the occipital artery, a feeder from the ascending pharyngeal artery, and a feeder from the internal maxillary artery
  • Successful embolization of the jugular foramen glomus tumor(s)
• Resection of right glomus jugulare tumor via the infratemporal fossa approach
  • Performed CWR in effort to preserve conductive mechanism of right ear
  • Operative findings:
    • Large jugular foramen glomus tumor
    • Pars nervosa intact
    • Sigmoid packed off below emissary
    • Round window violated inadvertently 
    • Small amount of tumor left behind the carotid
• Post op course: 
  • Noted likely CN VIII loss
  • Course otherwise uncomplicated besides nausea and dizziness
  • Negative reservoir test
  • Mobile vocal cords bilaterally
  • Discharged home on post-op day 7 from embolization on general diet, lifting restrictions, and nasal restrictions.
• 1 month follow up
  • Altered taste
  • Continued imbalance – referred for vestibular therapy
  • Referred for genetics eval for children
  • Audiogram:
    • AD: severe to profound mixed HL
    • AS: left mild SNHL

Surgery #2 – Left Side: Embolization followed by tumor resection two days later

• Embolization of multiple feeder arteries in conjunction with Neurosurgery
  • Multiple branches of the occipital artery and multiple branches of the ascending pharyngeal artery
  • Successful embolization of the jugular foramen glomus tumor(s)
• Resection of the left glomus jugulare tumor via the infratemporal fossa approach
  • Performed CWR in effort to preserve conductive mechanism of left ear
  • Operative findings:
    • Approximate 75% tumor removal
    • CN 9, 10, 11, 12 encased in tumor at medial wall of jugular foramen
• Post op course:
  • Immobile left vocal fold
  • Course complicated by aspiration concerns, dysphagia, and difficulty hearing
  • Swallow study: 
    • Patient exhibits moderate dysphagia.
    • Aspiration: Patient has a moderate risk of aspiration
    • Dysphagia II diet
• 1 month follow up
  • Audiogram:
    • AD: stable bone conduction thresholds but air conduction has decreased 10-15db at all frequencies
    • AS: stable bone conduction thresholds but air conduction has decreased 10-50db at all frequencies
    • Discrim: good AD, excellent AS

Evaluation for Hoarseness – 6 months post op

• Hoarse and breathy voice since surgery

• Denies aspiration of food or liquids

• Occasionally dizzy especially upon standing with multiple episodes of near syncope (see Carotid body tumor resection and baroreflex failure (blood pressure problems))

• PE: significant for slightly diminished gag reflex but palate elevation symmetric, tongue extrudes fully but deviates slightly to the left

Injection laryngoplasty for immobile left vocal fold

• Microscopic direct laryngoscopy with injection

• Anesthesia: General OETT with 4-0 MLT

• Both arytenoids mobile to palpation

• 0.4 cc of radiesse voice led to direct visualization of medialization of left cord