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Jugular Foramen Tumors

last modified on: Tue, 03/06/2018 - 13:03

Jugular Foramen Tumors

 

  • 1Jugular Foramen Tumors
    • 1.1GENERAL CONSIDERATIONS
    • 1.2PREOPERATIVE PREPARATION
    • 1.3NURSING CONSIDERATIONS
    • 1.4ANESTHESIA CONSIDERATIONS
    • 1.5OPERATIVE PROCEDURE
    • 1.6POSTOPERATIVE CARE
    • 1.7SUGGESTED READING

 

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. Glomus jugulare tumor
      2. Nerve sheath tumor
      3. Meningioma
      4. Epidermoid
      5. Chordoma
    2. Contraindications
      1. Asymptomatic (nonenlarging) nerve sheath tumor or meningioma
      2. Poor surgical candidate (inability to tolerate lengthy anesthetic)
  2. PREOPERATIVE PREPARATION
    1. History and Physical Examination
      1. Progression of deficits
      2. Cranial nerve dysfunction and compensation
      3. Brainstem and long tract signs
      4. Decreased color vision, visual acuity, or papilledema caused by hydrocephalus
      5. Signs and symptoms of a catecholamine secreting tumor
        1. Palpitations
        2. Flushing
        3. Hypertension
        4. Diarrhea
    2. Ancillary Testing
      1. Audiogram
      2. ABR (when hearing preservation surgery attempted)
      3. ENG when balance dysfunction present
      4. ENoG/EMG of facial musculature if facial paralysis present
    3. Radiological Evaluation
      1. CT scan of skull base (axial and coronal) is used to delineate bony destruction and assist with characterization of the tumor. Contrast not needed.
      2. MRI (T1 with and without gadolinium, T2) in both the axial and coronal planes to characterize the tumor extent and involvement with intracranial structures and vasculature. MRA/MRV is occasionally useful in determining patency of sigmoid-jugular system bilaterally.
      3. Angiography of carotid and vertebral systems is used to define tumor location and size with respect to major vessels. Performed 1 to 2 days prior to surgery so embolization of the tumor vasculature can be performed if necessary. Balloon test occlusion of the carotid should be performed if involved with tumor.
      4. CXR is done if indicated by concomitant disease processes.
    4. Laboratory Evaluation
      1. Hemoglobin level, PT/PTT, type and cross for 2 to 4 units of blood
      2. Urine for vanillymandelic acid and metanephrine levels and blood for an epinephrine/norepinephrine ratio if a catecholamine-secreting tumor is suspected preoperatively.
      3. EKG in patients over 35 years or if underlying heart disease is present.
    5. Consultation
      1. Neurosurgery consultation is done if large intracranial tumor component is present or hydrocephalus is present preoperatively.
      2. Endocrinology consultation is done if catecholamine-secreting tumor is identified.
    6. Consent for Surgery
      1. Risks inherent to any surgical procedure
        1. Bleeding, infection, scar formation, skin anesthesia, or dysesthesia
        2. Subtotal tumor removal
      2. Risks of anesthesia
        1. Death, pneumonia, pulmonary embolism, deep vein thrombosis
      3. Risks of jugular foramen surgery
        1. Cranial nerve deficits (VII-XII most commonly)
          1. Potential nerve grafting using either the greater auricular nerve or sural nerve
          2. Swallowing dysfunction with potential for aspiration
        2. Hearing loss
        3. Vestibular dysfunction
        4. CSF leak with the potential for meningitis
          1. Need for lumbar drain
          2. Need for revision surgery
        5. Stoke
        6. Seizure
        7. Death
        8. Need for abdominal fat and fascia to close defect
  3. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
        1. Mayfield headrest
        2. CUSA (Cavitron Ultrasonic Aspirator), depending on tumor type and size
        3. Microscope and video unit
        4. NIMS (nerve integrity monitor system) x 2
        5. Hot line unit (for solution irrigation)
        6. Sextet suction caddy
        7. NIMS, nerve integrity monitor system and probes
        8. Nerve stimulator control unit and instrument
    2. Instrumentation and Equipment
      1. Standard
        1. Acoustic Neuroma Instrument Tray
        2. Bien Otologic Electric Drill Tray and burrs
        3. Ear Basic Instrument Tray
        4. Ear Microsurgery Instrument Tray
        5. Fischer Bipolar Instrument Tray
        6. Mastoid Instrument Tray
        7. Midas Rex Drill Tray
      2. Special
        1. Micro Neurotology Instrument Tray
        2. House-Urban Middle Fossa Retractor Tray (MCF approach)
        3. Rongeur Tray, Large (TL approach)
        4. Retractor Tray, Small (for harvesting fat, TL approach)
        5. Jannetta Posterior Fossa Retractor Tray, (translab approach)
        6. Gantz Micro Forceps Instrument Tray (for MCF AN removal)
        7. KLS Oto Trauma Implant - Instrument Tray
        8. Adson cerebellum retractor, 8 in long, 4 x 4, sharp prongs x 2
        9. 5910 Beaver blade
        10. Modified Lahey ligature needle (aneurysm needle)
        11. Bipolar Bayo irrigation forceps, instruments, 8 in, 1.0 mm tip (MCF)
        12. Bipolar irrigating forceps (TL approach)
        13. Neurosurgical cottonoids in a variety in sizes
        14. Bone wax
    3. Medications (specific to nursing)
      1. Antibiotic ointment
      2. Papaverine, 30mg per ml
      3. 1% lidocaine with 1:100,000 epinephrine
      4. Surgicel
      5. Avitene sheet
      6. Ringer's injection, 1,000 ml bag x 6 for irrigation
      7. Ringer's irrigation solution, 1,000 ml bottles, in warmer x 4
    4. Prep and Drape
      1. Prep
        1. Shave ipsilateral cranium 10 cm circumferentially, left lower abdomen for fat graft, and ipsilateral lower extremity for possible sural nerve graft
        2. 10% providone iodine to ipsilateral hemicranium, face, neck, and left lower quadrant; 10% providone iodine to ipsilateral lower leg if sural nerve graft anticipated preoperatively
      2. Drape
        1. Head drape (leave ipsilateral face free of tape)
        2. Towels around head
        3. Surgeon places NIMS needle electrodes
        4. Clear plastic drape over ipsilateral face and neck, split sheet around cranium leaving entire ipsilateral face visible, and drainage bag placed 1 cm behind intended incision
        5. Split sheet around cranium leaving the entire ipsilateral face visible
        6. Clear plastic drape over left lower quadrant site and ipsilateral lower leg (if sural nerve graft is anticipated); cover with a towel and hemostat for easy identification when needed, then cover with separate full sheet
    5. Drains and Dressings
      1. Antibiotic ointment to incision, then adaptic, fluffs x 3, and Kerlix 4 in x 2
      2. Antibiotic ointment to abdomen, then fluffs, and Elastoplast (for TL only)
    6. Special Considerations
      1. Preparation of patient
        1. Pad patient with foam and tuck both arms with elbow guards.
        2. Strap patient to bed securely and test roll from side to side to ensure stability.
        3. Draw parabolic incision on scalp beginning 6 cm superior to pinna, extending to 7 cm posterior to pinna, and ending in a skin crease approximately 5 to 6 cm inferior to pinna.
        4. Place NIMS electrodes in the orbicularis oris and orbicularis oculi musculature, as well as 2 grounding electrodes in the forehead to monitor the facial nerve.
        5. Place NIMS electrodes in the ipsilateral tongue and soft palate to monitor cranial nerves IX and XII.
        6. Place electrodes and earphones for ABR monitoring if hearing preservation is being attempted.
      2. Clavicle is prepped for possible nerve graft; nerve graft will be done with nylon suture (either 8-0, BV130-4, or 10-0, BV75-4).
      3. When requested to watch face for movement, do not stop observing until told to do so by surgeon.
      4. Ringer's injection should be warm (98 to 102°F).
      5. Have papaverine, 30 mg per ml, on table for all hearing restoration cases.
      6. Ringer's Injection should be used for irrigation during drilling and setup to run through the hot lint unit.
      7. When positioning patient, pad patient with foam and tuck both arms with elbow guards. Strap patient to bed securely and test roll side to side to ensure stability. Then surgeons will place NIMS electrodes in the orbicularis oris and orbicularis oculi musculature, as well as 2 grounding electrodes in the forehead to monitor the facial nerve.
  4. ANESTHESIA CONSIDERATIONS
    1. General anesthetic without muscle relaxant
    2. Xomed endotracheal tube with monitoring electrodes for cranial nerve X +ace electrodes into second NIMS device
    3. Table rotated 180° from anesthesia personnel
    4. Central lines and arterial lines per anesthesia (should be made aware of the high potential for significant blood loss)
    5. Cephazolin 1 g preoperative (repeat every 8 hours)
    6. Decadron 6 mg preoperative (repeat every 6 hours)
  5. OPERATIVE PROCEDURE
    1. Incision and Elevation of Skin Flaps
      1. Raise skin and subcutaneous tissue flaps anteriorly to level of ear canal, and tail of parotid. Preserve greater auricular nerve for grafting if necessary.
      2. Raise large Palva flap (from linea temporalis to mastoid tip) up to level of ear canal.
      3. Dissect skin of EAC circumferentially, 2 to 3 mm medial to the bony-cartilaginous junction, and transect.
      4. Elevate the skin laterally out of the bony canal.
      5. Continue raising flaps anteriorly to the level of the parotid fascia, just posterior to the masseter muscle.
    2. Neck Exposure
      1. Identify and place vascular loops around the internal and external carotid arteries as well as the jugular vein.
      2. Identify the lower cranial nerves (IX, X, XI, XII).
      3. Separate the sternocleidomastoid and digastric muscles away from the mastoid tip anteriorly.
      4. Remove the soft tissue overlying the jugular foramen to establish continuity between the jugular vein and bulb.
    3. Facial Nerve
      1. Identify facial nerve at anterior aspect of digastric ridge, inferior to tragal cartilage pointer.
      2. Trace facial nerve out through parotid distal to the pes anserinus by 1 cm.
      3. The facial nerve should be freed from the medial surface of the parotid fascia using sharp dissection.
    4. Mastoidectomy
      1. Complete mastoidectomy with skeletonization of the dura from 2 cm posterior to the sigmoid sinus up to the bony labyrinth and down to the jugular bulb. The entire sigmoid, jugular bulb, and jugular vein should be completely decompressed.
      2. Skeletonization of the posterior bony canal and facial nerve to the stylomastoid foramen. Continue to remove all of the bone 270° around the facial nerve using a diamond burr from the stylomastoid foramen to the posterior semicircular canal.
      3. Remove mastoid tip lateral to the digastric ridge.
      4. The digastric muscle tendon inserts into the nerve sheath. To prevent injury to the nerve, remove a cuff of tissue with the nerve. Sharp dissection with Mayo scissors is required.
      5. Remove bone anterior to the lower vertical segment of the facial nerve (hypotympanic bone) avoiding entrance into the external auditory canal (EAC).
      6. Remove bone medial to the facial nerve; a bridge of bone housing the facial nerve is thus created. In small tumors, this may be all the exposure required (fallopian bridge technique).
    5. Partial Rerouting of the Facial Nerve
      1. Mobilization of the facial nerve anterior and lateral is required for most large tumors that involve the jugular bulb.
      2. This allows preservation of the EAC and conductive hearing, as well as allowing for normal postoperative facial function in most cases.
      3. A suture is place through the cuff of soft tissue surrounding the facial nerve up to the skin flaps for retraction purposes.
    6. Total Facial Nerve Reroute
      1. For extensive jugular foramen tumors that invade the inner ear, a subtotal petrosectomy is required.
      2. Remove the posterior and inferior tympanic ring.
      3. Skeletonize the facial nerve from the pes to the genu.
      4. Reroute the decompressed facial nerve (with the soft tissue cuff at the stylomastoid foramen) anteriorly.
      5. The eustachian tube must be obliterated. Drill away the mucosa medially; pack the lumen with a combination of muscle, fascia, and bone wax.
      6. Remove the contents of the middle ear, including the mucosa, tympanic membrane, and ossicles.
    7. Vascular Control
      1. Ligate the sigmoid sinus distal to the vein of Labbe with a doubled 2-0 silk suture on an aneurysm needle.
        1. Small incisions are made in the dura anterior and posterior to the sigmoid sinus.
        2. The aneurysm needle is passed medial to the sigmoid exiting the cerebellar dura in the mastoid.
        3. The suture is threaded on the needle, and it is withdrawn with the suture.
      2. Double suture ligate the jugular vein in the neck and divide.
      3. Ligate and divide the ascending pharyngeal artery.
      4. In large tumors with extensive blood supply, the external carotid artery may need to be divided in the neck.
      5. Open sigmoid sinus, jugular bulb, and jugular vein in continuity.
    8. Tumor Removal
      1. Remove tumor from lumen of sigmoid and jugular vein. Profuse bleeding from the 4 to 8 openings of the inferior petrosal sinus into the jugular bulb should be controlled with gentle packing with Oxycel.
      2. Remove tumor from the hypotympanum and middle ear.
      3. Remove tumor from the inner ear if present.
      4. Follow tumor medially at jugular bulb to remove tumor from lower cranial nerves. Proceed superiorly removing tumor from inferior internal auditory canal (IAC) to cerebellopontine angle (CPA) if present.
      5. Follow jugular bulb anteromedially to remove tumor from the vertical segment (and possibly the horizontal segment) of the carotid artery.
        1. Leave bipolared tumor capsule on carotid artery rather than risk injury to lumen if densely adherent.
        2. Remove any intradural tumor present.
    9. Closure
      1. Dura
        1. Any large dural defects should be closed in a water tight fashion if possible using either temporalis fascia, fascia lata, or rectus fascia.
        2. Exposed brain should be covered with fascia, even if suture approximation is not possible.
        3. Large dural repairs require a temporary lumbar drain (5 days).
      2. Ear canal
        1. Release the facial nerve tacking suture and replace into a protected site within the temporal bone when partial rerouting has been performed.
        2. Facial nerve may remain in situ if complete rerouting has been performed.
        3. If subtotal petrosectomy has been performed, the EAC skin is everted out of the cartilaginous ear canal and oversewn with 3-0 vicryl suture. Use the Palva flap as a second layer of closure.
        4. If EAC is preserved:
          1. Place drill holes through bony EAC anteriorly, superiorly and inferiorly.
          2. Sew the EAC skin into position in the bony canal with 4-0 vicryl suture.
      3. Mastoid/cranial defect
        1. Use left lower quadrant abdominal fat and fascia to close the defect in the mastoid and cranium.
        2. Alternatively, the temporalis muscle and Palva flap can be rotated into the defect.
        3. Alternatively, a superiorly based SCM flap may be rotated into the defect.
        4. A combination of all 3 may be necessary for large defects.
      4. Skin/subcutaneous tissues
        1. Close the Palva flap if not used for obliteration of the defect or closure of the ear canal.
        2. Place a suction drain in the neck.
        3. Close in layers (3-0 vicryl in the subcutaneous tissues and 4-0 nylon in the skin).
        4. Close the abdominal wound over a Penrose drain.
      5. Pack the EAC with Iodoform Nugauze soaked in bacitracin ointment to stent open the canal (7 to 10 days).
      6. Bulky mastoid-type dressing with adequate pressure.
      7. Nasogastric feeding tube placed if CN X sacrificed or injured.
  6. POSTOPERATIVE CARE
    1. Surgical Intensive Care Unit Overnight
      1. Neurological monitoring
      2. Extensive anesthetic time
      3. Hemoglobin level, blood chemistry ordered
      4. NG to suction if present
      5. Lumbar drain at ear level
    2. Postoperative Day 1
      1. Transfer from unit to general floor
      2. Remove Foley catheter, arterial lines, supplemental oxygen, EKG leads
      3. Hemoglobin level if extensive blood loss intraoperatively
      4. Up to chair (QD) (unless at bed rest for lumbar drainage)
      5. Clear liquids if no NG present (monitor first feed for aspiration)
      6. Ambulate with assistance (QD) (unless at bed rest for lumbar drainage)
    3. Postoperative Day 2
      1. Remove abdominal Penrose drain
      2. Change mastoid dressing
      3. Advance diet if no NG
      4. Begin tube feeds if NG present
    4. Postoperative Day 3
      1. Swallow study if NG or aspiration present with oral feeds
      2. Consider TVC medialization procedure if CN X sacrificed; NG tube feeds for several weeks if simply injured
    5. Postoperative Day 4
      1. MRI scan of operative field to assess completeness of tumor removal and as a baseline to follow the patient for recurrence
      2. Remove suction drain in neck when output less than 30 cc per day
      3. Discharge planning
    6. Postoperative Day 5
      1. Discharge home if tolerating oral feeds and ambulating independently
      2. Remove lumbar drain if present, and begin ambulation; discharge when ambulating independently
    7. Postoperative Days 7 to 10
      1. Remove stitches in neck and scalp
      2. Remove ear packing
  7. SUGGESTED READING
    1. Eisele DE, Netterville JL, Hoffman HT. Gantz BJ. Parapharyngeal space masses. Head Neck. 1999;21:154-159.
    2. Fisch U. Infratemporal fossa approach for glomus tumors of the temporal bone. Ann Otol Rhinol Laryngol. 1982;91:474-479.
    3. Freidman M, ed. Management of jugular foramen tumors. Operative Techniques Otolaryngol Head Neck Surg. 1996;7:89-219.
    4. Holliday MJ, Nachlas N, Kennedy DW. Uses and modifications of the infratemporal fossa approach to skull-base tumors. Ear Nose Throat. 1986;65:101-106.