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Viet Pham, M.D.
Dayton Young, M.D. The University of Texas Medical Branch (UTMB Health)
Department of Otolaryngology
Grand Rounds Presentation
May 29, 2012
Glomus Tumors
of the Temporal Bone: Synopsis of Glomus Tympanicum and Jugulare
Glomus Tumors
of the Temporal Bone
All images obtained via Google search unless otherwise
specified. All images used without permission.
Viet Pham MD
Dayton Young MD
Synopsis of Glomus Tympanicum and Jugulare
(http://www.explosm.net)
May 29, 2012
Paraganglia
Paraganglioma
Presentation
Diagnostics
Classification
Treatment
Outline
(http://w
ww
.diz
zin
ess-a
nd-b
ala
nce.c
om
)
(http://me.hawkelibrary.com) (http://my.clevelandclinic.org) (Swartz 2009)
Glomus bodies
Clusters of chief cells
Identical to carotid body
Similar to adrenal autonomic ganglia
“Zellballen” network with arterioles and
venules
Chief cells
Arise from neural crest cells, migrate with
sympathetic ganglia (Gulya 1993)
Neurosecretory modulators of vascular
activity
Dopamine
Norepinephrine
Physiology Paraganglia
(http://me.hawkelibrary.com)
Oxygen baroreceptors
Cell clusters
Type I
Chief cells
Catecholamines
Dark cell type
Light cell type
Type II
Sustentacular cells
Modified Schwann cells
Physiology Temporal Bone Paraganglia
(http://f
lylib
.com
/books/e
n/2
.953.1
.20/1
/)
Type I cell Type II cell (Rao 1999)
Physiology Temporal Bone Paraganglia
Tympanic
Paraganglioma
Anterior Jugular
Paraganglioma
Posterior Jugular
Paraganglioma
(Swartz 2009)
Third branchial arch (Zak 1982)
Two or three present, maybe more in fifth decade
Nonchromaffin, lack chromium salt affinity
Distinction from adrenal neuroendocrine
system
Location
Two typical regions
Anterolateral jugular fossa
Within middle ear
Jugular bulb adventitia
Jacobson nerve (cranial nerve IX)
Arnold nerve (cranial nerve X)
Third branchial arch (Zak 1982)
Two or three present, maybe more in fifth decade
Nonchromaffin, lack chromium salt affinity
Distinction from adrenal neuroendocrine
system
Location
Two typical regions
Anterolateral jugular fossa
Within middle ear
Jugular bulb adventitia
Jacobson nerve (cranial nerve IX)
Arnold nerve (cranial nerve X)
Physiology Temporal Bone Paraganglioma
Glomus jugulare
Glomus tympanicum
Extratemporal Paraganglioma
Carotid body tumor
Glomus vagale
First described by Gould in 1941 (O’Leary 1991)
Most common true neoplasm of middle ear
Most common pathologic condition of jugular foramen
Second most common tumor of the temporal bone
Rare overall, 0.012% in 600,000 (Bertrand 1976, Balatsouras 1992)
More frequent in Caucasians
Usually on left side
Female:Male ratio 6:1
Peak incidence in fifth decade
Aggressive in younger patients
Commonly multifocal
Likely to secrete vasoactive substances
Temporal Paraganglioma Epidemiology
(N Engl J Med 2010; 362:e66.)
Multiple tumors in 5-10%
Familial autosomal dominant disorder
Less than 10% of cases
Multicentricity in 30-50% affected
Associated with defects on chromosome 11q23 (Petropoulous 2000)
Metastasis in 3-4% (Pluta 1994, Motegi 2008)
Lymph nodes
Lung
Liver
Spleen
Bone
Temporal Paraganglioma Epidemiology
(J N
ucl M
ed
2012; 53:2
64-2
74.)
Slow-growing, firm red mass
Bleeds profusely with manipulation
Neurological deficits in advanced cases
Dysphagia, dysarthria (hypoglossal canal)
Facial hypesthesia (petrous apex)
Ataxia, imbalance (posterior fossa, cerebellum)
Chief cells
Clusters, “zellballen”
Nuclear pleomorphism
and hyperchromatism
Store catecholamines
Actively secrete norepinephrine in 1-3%
More likely to be secreted by glomus jugulare
Temporal Paraganglioma Characteristics
(http://m
e.h
aw
kelib
rary
.com
)
(Rao 1
999)
Temporal Paraganglioma Symptomatology
Hearing loss (80%)
Pulsatile tinnitus (60%)
Aural fullness (18%)
Rupture through
tympanic membrane (7%)
Otalgia
Otorrhagia
Vertigo/dizziness (9%)
Headache (4%)
Hearing loss (80%)
Pulsatile tinnitus (60%)
Aural fullness (18%)
Rupture through
tympanic membrane (7%)
Otalgia
Otorrhagia
Vertigo/dizziness (9%)
Headache (4%)
Temporal Paraganglioma Symptomatology: Secreting Tumors
Flushing
Diarrhea
Palpitations
Headache
Labile hypertension
Orthostasis
Diaphoresis
Temporal Paraganglioma Physical Examination
Reddish-blue mass on otoscopy
Medial to inferior tympanic membrane
Pulsatile
Blanching with positive pressure
(Brown sign)
Decreased pulsations with
carotid compression
(Aquino sign)
Audible bruit auscultated
(objective tinnitus)
Mastoid
Infra-auricular region
(http://w
ww
.explo
sm
.net)
(http://w
ww
.youtu
be.c
om
)
Hearing loss
Typically conductive (52%)
Sensorineural if labyrinth invaded (5%)
Mixed hearing loss (17%)
Neurological
Facial nerve palsy
Vernet syndrome
Jugular foramen syndrome
Cranial nerves IX, X, XI
Villaret syndrome
Jugular foramen and Horner syndromes
Miosis, ptosis, anhydrosis
Ataxia
Temporal Paraganglioma Physical Examination
(AJN
R 2
002 2
3: 929
-931)
(Arq
. N
euro
-Psiq
uia
tr 2
006; 64: 603-6
05.)
(http://p
tjourn
al.apta
.org
)
Uncommon otologic symptom
Vascular pathophysiology
Increased vascular blood flow
Vascular lumen stenosis
Nonvascular
Sensorineural hearing loss
Superior semicircular canal dehiscence
Myoclonic contractions
Tensor veli palatini
Levator veli palatini
Salpingophayrngeus
Superior constrictor
Pulsatile Tinnitus Differential Diagnosis
(Radio
Gra
phic
s 2
006; 26:1
15
-124)
Carotid atherosclerosis
Intracranial vascular
abnormalities
Dural arteriovenous fistula (AVF)
Arteriovenous malformation (AVM)
Aneurysm
Anterior inferior cerebellar
artery
Internal carotid artery
Vertebral artery
Tortuous internal carotid
artery
Fibromuscular dysplasia
Pulsatile Tinnitus Arterial Etiologies
(J Neurol Neurosurg
Psychiatry 2004; 75:993)
(J NeuroIntervent
Surg 2010; 2:202-207)
(RadioGraphics
2004; 24:1637-1653)
Idiopathic intracranial
hypertensive syndrome (IIH)
Jugular bulb abnormalities
High jugular bulb
Jugular bulb dehiscence
Jugular diverticula
Abnormal condylar and mastoid
emissary veins
Pulsatile Tinnitus Venous Etiologies
(http://w
ww
.radio
log
yassis
tant.nl)
(Radio
logy 2
000; 216:3
42-3
49)
(Int J P
edia
tr O
torh
inola
ryngol
2012; 76:4
47-4
51)
(India
n J
ourn
al of O
tolo
gy
2011; 17:1
23
-126)
Pulsatile Tinnitus Physical Examination
Otoscopy
Inspect oral cavity and pharynx for contractions
Wide oral opening may decrease contractions
Fiberoptic nasopharyngoscopy
Venous pulsatile tinnitus
Decreases with internal jugular vein compression
Decreases with head rotation ipsilaterally
Neurological
Audiological
Carotid Duplex ultrasound
Computed tomography
angiography (CTA)
Magnetic resonance
venography
Carotid angiography if
suspect AVF/AVM
Lumbar puncture if suspect IIH
CTA temporal bone and neck if abnormal otoscopy
Pulsatile Tinnitus Diagnostics
(Sismanis 2011)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Angiography
Serum catecholamines
Urinary vanillylmandelic acid
Urinary metanephrine
Positron emission tomography (Hoegerle 2003)
Octreotide scintigraphy (Bustillo 2004)
Temporal Paraganglioma Diagnostics
(http://m
e.h
aw
kelib
rary
.com
)
(http://emedicine.medscape.com)
(Radio
Gra
phic
s 2
009; 29:1
877-1
896)
Bony partition between jugular fossa and hypotympanum
Glomus jugulare erodes jugular fossa
Glomus tympanicum occupies middle ear
Jugular foramen
Enlargement if length + width greater than 20mm
Bony erosion with decalcification
Diagnostics CT
Glomus Tympanicum Glomus Jugulare
(Rao 1999)
(Swartz 2009)
(http://me.hawkelibrary.com)
Caroticojugular spine
Separates jugular bulb from
petrous carotid artery
Erosion with glomus jugulare
Intracranial extension
Invasion of fallopian canal
Other vascular abnormalities
High jugular bulb
Aberrant carotid artery
(Rao 1999)
(Imaging 2007; 19:55-70)
(Radiology Case Reports 2009; 4(4))
(http://me.hawkelibrary.com)
Diagnostics CT
Smooth erosion of jugular foramen
Glomus erosion typically irregular margins
Diagnostics CT Differential: Schwannoma
(AJR
2004; 182:3
73
-377)
(AJN
R 2
000; 21:1
139-1
144)
May be difficult to distinguish from
schwannomas
Tend to infiltrate bone around
jugular foramen
Diagnostics CT Differential: Meningioma
(http://www.medscape.com) (Indian J Pathol Microbiol 2011;54:398-9) (Iran J Radiol 2011;8:176-81)
Vascular
“Salt and pepper” flow voids
Intraluminal involvement of
petrous carotid artery
Occlusion of jugular vein and
sigmoid sinus
Intracranial extension
Intradural
Extradural
Screen for multiple tumors
Assess for glomus vagale tumor
Diagnostics MRI
(http://sumerdoc.blogspot.com)
Smooth contoured mass
T1-weighted images
Iso-intense without contrast
Significant gadolinium enhancement
High signal intensity on T2-weighted images
Diagnostics MRI Differential: Schwannoma
(http://r
adio
paedia
.org
)
T1- and T2-weighted imaging
Iso-intense to grey matter
Increased intensity with contrast
“Dural tails”
Diagnostics MRI Differential: Meningioma
(Surgical Neurology 2001; 56:8-20) (Iran J Radiol 2011;8:176-81)
Diagnostics CT versus MRI
CT usually sufficient imaging alone
Jugular bulb major preoperative consideration
Supplants venography to assess jugular bulb
MRI when diagnosis or extent is questioned
Delineates neoplastic and native tissue
Good for intradural tumors
T1 images may overestimate
tumor extent (Brackmann 2010)
Petrous apex best imaged with
CT and MRI (Arriaga 1991)
Magnetic resonance angiography
typically inadequate
Better assess larger tumors
Identify multicentric disease
Preoperative embolization
Performed 1-2 days before surgery
Polyvinyl alcohol or intravascular coils
Decrease intraoperative blood loss
Balloon occlusion if anticipate
carotid sacrifice
Carotid sacrifice morbidity (Linskey 1994)
Cerebral infarction 26%
Fatality 46%
Diagnostics Angiography
(http://www.aneurysm-stroke.com)
Better assess larger tumors
Identify multicentric disease
Preoperative embolization
Performed 1-2 days before surgery
Polyvinyl alcohol or intravascular coils
Decrease intraoperative blood loss
Balloon occlusion if anticipate
carotid sacrifice
Carotid sacrifice morbidity (Linskey 1994)
Cerebral infarction 26%
Fatality 46%
Diagnostics Angiography
Before Embolization After Embolization
(http://me.hawkelibrary.com)
Primary supply
Inferior tympanic artery (from
ascending pharyngeal artery)
Stylomastoid artery
Occipital artery (60%)
Posterior auricular artery (40%)
Other contributors (Hesselink 1981)
Middle meningeal artery
Internal carotid artery
External carotid artery
Angiography Arterial Supply
(AJNR 2006; 27:1820-1822)
Ascending
Pharyngeal
Contributors
Internal maxillary
Middle meningeal
Posterior auricular
Vascular compartments ` (Moret 1980, Moret 2982, Russel 1986, Young 1988)
Inferomedial
Posterolateral
Anterior
Superior
Each compartment
hemodynamically
independent
Multicompartmental in
85% glomus tumors
Angiography Arterial Supply
(http://www.interventionalneuroradiology.net)
Contributors
Occipital
Posterior auricular
Angiography Arterial Supply
Compartment Location Blood Supply
Inferomedial Jugular bulb,
Hypotympanum
Inferior tympanic branch of
ascending pharyngeal
Posterolateral Posterior tympanic cavity,
Mastoid Stylomastoid
Anterior Protympanum,
Pericarotid area
Anterior tympanic branch
of internal maxillary,
Caroticotympanic branch
of internal carotid
Superior Epitympanum,
Supralabyrinthine
Superior tympanic branch
of middle meningeal artery
(Alerstone 1996)
(Minor 1994)
“Danger zone” around jugular bulb (Minor 1994)
Inferior petrosal sinus
Internal jugular vein
Sigmoid sinus
Protympanum
Hypotympanum
Mesotympanum
Intracranial extension
Radiograhic diagnosis 14-20% (Rigby 1996)
Up to 50% with dural involvement intraoperatively (Spector 1976, Andrews 1989, Jackson 1990)
Glomus Tumors Pattern of Spread
Patterns of Spread Protympanum
Facial
Nerve
Jugular
Vein Internal
Carotid
Carotid canal
Middle cranial fossa
Most common route for
intracranial extension via
protympanum
Eustachian tube
Nasopharyngeal mass
Epistaxis
Peritubal cell tract
Petrous apex
(Minor 1994)
Patterns of Spread Hypotympanum
Facial
Nerve
Jugular
Vein Internal
Carotid
Sigmoid sinus lumen
Internal jugular lumen
Inferior petrosal sinus
Neural foramina
at skull base
(Minor 1994)
Patterns of Spread Mesotympanum
Facial
Nerve
Jugular
Vein Internal
Carotid
Antrum and
epitympanum
Laterally
External auditory canal
Round window
Erode cochlea
Internal auditory canal
(Minor 1994)
Facial recess
Sinus tympani
Mastoid
Classification Glasscock-Jackson
TYPE CHARACTERISTICS
I Limited to the promontory
II Completely fills the middle ear space
III Fills the middle ear and extends to mastoid
IV Extend into external auditory canal
May extend anterior to internal carotid artery
GLOMUS TYMPANICUM
Classification Glasscock-Jackson
TYPE CHARACTERISTICS
I Involves jugular bulb, middle ear, and mastoid
II Extends underneath internal auditory canal
May have intracranial extension
III Extends into petrous apex
May have intracranial extension
IV Extends into clivus and infratemporal fossa
May have intracranial extension
GLOMUS JUGULARE
Classification Fisch
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
GLOMUS TUMORS
Classification Fisch
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
GLOMUS TUMORS
(Fisch 1988)
Classification Fisch
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
GLOMUS TUMORS
(Fisch 1988)
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
GLOMUS TUMORS
Classification Fisch
TYPE CHARACTERISTICS
C1 Limited involvement of
vertical portion of carotid canal
C2 Invades vertical portion
of carotid canal
C3 Invades horizontal portion
of carotid canal (Fisch 1988)
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
GLOMUS TUMORS
Classification Fisch
TYPE CHARACTERISTICS
C1 Limited involvement of
vertical portion of carotid canal
C2 Invades vertical portion
of carotid canal
C3 Invades horizontal portion
of carotid canal (Fisch 1988)
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
GLOMUS TUMORS
Classification Fisch
TYPE CHARACTERISTICS
C1 Limited involvement of
vertical portion of carotid canal
C2 Invades vertical portion
of carotid canal
C3 Invades horizontal portion
of carotid canal (Fisch 1988)
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
GLOMUS TUMORS
Classification Fisch
TYPE CHARACTERISTICS
C1 Limited involvement of
vertical portion of carotid canal
C2 Invades vertical portion
of carotid canal
C3 Invades horizontal portion
of carotid canal
(Fisch 1988)
GLOMUS TUMORS
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
Classification Fisch
TYPE CHARACTERISTICS
D1 Intracranial extension less than 2cm
D2 Intracranial extension greater than 2cm
GLOMUS TUMORS
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
Classification Fisch
TYPE CHARACTERISTICS
D1 Intracranial extension less than 2cm
D2 Intracranial extension greater than 2cm
(Fisch 1988)
GLOMUS TUMORS
TYPE CHARACTERISTICS
A Limited to middle ear cleft
B Limited to tympanomastoid complex
No infralabyrinthine involvement
C Involves labyrinthine compartment
Extends to petrous apex
D Intracranial involvement
Classification Fisch
TYPE CHARACTERISTICS
D1 Intracranial extension less than 2cm
D2 Intracranial extension greater than 2cm
(Fisch 1988)
Temporal Paraganglioma Treatment
Excision
Definitive treatment in 90%
Staged for larger tumors
Laser or bipolar cautery for excision
and hemostasis
Alpha- and beta- blockade
secreting tumors
Radiation
Adjuvant therapy if incomplete
resection
Poor or unwilling surgical
candidates
Transcanal approach
Small tumors on promontory
Drill canal for hypotympanum access
Facial recess approach for middle ear
and mastoid
Transmastoid-transcervical for glomus
jugulare
Modified infratemporal approach for
larger tumors
Unresectability (Jackson 1982, Rufini 2006)
Foramen magnum
Cavernous sinus
Treatment Surgery
(Minor 1994)
Treatment Transmastoid-Transcervical
Complete mastoidectomy Open facial recess
Identify vasculature
and nerves
(Minor 1994)
Treatment Transmastoid-Transcervical
Amputate mastoid tip and
ligate internal jugular vein
(Minor 1994)
Pack sigmoid sinus and
transpose facial nerve
Postauricular approach to infratemporal fossa
Type A
Type B
Type C
Treatment Fisch Surgical Approach
(Snow 2009)
Postauricular approach to infratemporal fossa
Type A
Type B
Type C
Treatment Fisch Surgical Approach
Radical mastoidectomy
Anterior transposition of facial nerve
Explore posterior infratemporal fossa
Cervical dissection
Jugular bulb
Vertical petrous carotid
Posterior infratemporal fossa
Postauricular approach to infratemporal fossa
Type A
Type B
Type C
Treatment Fisch Surgical Approach
Explore petrous apex
Mid-clivus
Horizontal internal carotid artery
Superior infratemporal fossa
Postauricular approach to infratemporal fossa
Type A
Type B
Type C
Treatment Fisch Surgical Approach
Nasopharynx
Peritubal space
Rostral clivus
Parasellar area
Cavernous sinus
Pterygopalatine fossa
Anterosuperior infratemporal fossa
Foramen rotundum
Treatment Modified Infratemporal Approach
Similar postauricular
incision
External auditory canal (EAC)
is transected and oversewn
EAC, tympanic membrane,
midldle ear contents resected
Facial nerve mobilized (Canalis 2000)
(Glasscock 2003)
Treatment Modified Infratemporal Approach
Resect eustachian tube
Expose internal carotid artery
Access
ο Middle and posterior cranial fossa
ο Nasopharynx
ο Foramen rotundum
ο Clivus
ο Cavernous sinus (Canalis 2000)
(Glasscock 2003)
Anterosuperior extension
Resect zygoma and
temporomandibular joint
Reflect temporalis inferiorly
Dislocate mandibular
anteroinferiorly
Treatment Transcondylar/Suboccipital
Intracranial tumors near foramen
magnum
Supplement intratemporal approach
Trans-sigmoid exposure
Trans-labyrinthine exposure
Exposures cranial cervical junction
(Brackmann 2010)
Treatment Transcondylar/Suboccipital
Identify vertebral artery
Posterior and inferior to mastoid tip
On transverse process of C1
vertebra
Expose occipital condyle and
jugular tubercle
Access hypoglossal nerve
Access cranial cervical junction
Cervical stabilization procedure
if more than half of condyle
resected (Brackmann 2010)
Leave tumor portion if adherent
to internal carotid
Cranial nerve preservation
enhanced if medial wall of
jugular bulb preserved
Intradural involvement
Commonly at jugular bulb
En-bloc resection if blood loss less
than 2000mL
Otherwise staged procedures
Treatment Surgical Considerations
Cerebellum PICA Pons
(Bra
ckm
ann 2
010)
PICA – posterior inferior cerebellar artery
Bleeding
Facial paresis/paralysis
Cranial nerve palsy
Hoarseness
Dysphagia
Dysarthria
Cerebrospinal fluid leak
Tympanic membrane
perforation (O’Leary 1989, Forest 2001)
Cholesteatoma (O’Leary 1989, Forest 2001)
Treatment Surgical Complications
External beam
Stereotactic
Not ablative
Obliterative endarteritis in tumor vessels
stops growth
Tumor control in over 90% (Maarouf 2003, Krych 2006)
Regrowth possible after 10-15 years (Brackmann 2010)
Comparable to surgery
Tumor control
Recurrence
Morbidity
Treatment Radiotherapy
Indications
Elderly
Poor surgical candidates
Some multicentric lesions
Patient preference
Dual-modality treatment with
surgery
Limit cranial neuropathies
Adjuvant therapy after near-total
resection
No long-term data
Treatment Radiotherapy
Surveillance (Swartz 2009)
Residual mass
Stabile or decreased size
Decreased enhancement on CT
Reduced T2-weighted signal on MRI
Diminished flow voids
Morbidity
Cranial nerve deficit
Osteoradionecrosis
Tumor regrowth
Radiation-induced malignancy (Lustig 1997)
Treatment Radiotherapy
Most common tumor of middle
ear but rare
Pulsatile tinnitus and hearing
loss classic symptomatology
Characteristic radiographical
features
Surgery most definitive treatment
Transcanal for small tumors
Transmastoid-transcervical for larger
ones
Radiation acceptable alternative
for nonsurgical candidates
Conclusion Glomus Tumors of Temporal Bone
(http://www.smbc-comics.com)
References
Alberstone CD, Anson JA. Preoperative evaluation and management of jugular foramen tumors. Operative Techniques in Otolaryngology 1996; 7:106-112.
Andrews JC, Valavanis A, Fisch U. Management of the internal carotid artery in surgery of the skull base. Laryngoscope 1989; 99:1224-1229.
Arriaga MA, Brackmann DE. Differential diagnosis of primary petrous apex lesions. Am J Otol 1991; 12:470-474.
Bailey BJ, Johnson, JT, Newlands SD, eds. Head and Neck Surgery – Otolaryngology, 4th Ed. Philadelphia: Lippincott, 2006. pp 2003-2007.
Balatsouras DG, Eliopoulos PN, Economou CN. Multiple glomus tumours. J Laryngol Otol 1992; 106:538-543.
Bertrand RA, Mansour S. Cochlear-vestibular manifestations of jugular foramen pathologies. J Otolaryngol 1976; 5:44-54.
Brackmann DE, Shelton C, Arriaga MA. Otologic Surgery, 3rd Ed. Philadelphia: Saunders, 2010. pp 551-567.
Bustillo A, Telischi FF. Octreotide scintigraphy in the detection of recurrent paragangliomas. Otolaryngol Head Neck Surg 2004; 130:479–482.
Canalis RF, Lambert PR. The Ear: Comprehensive Otology. Philadelphia: Lippincott Williams and Wilkins, 2000. pp 813-830.
Carrasco V, Rosenman J. Radiation therapy of glomus jugulare tumors. Laryngoscope 1993; 103:23-27.
Fisch U, Mattox D. Microsurgery of the Skull Base. New York: Thieme, 1988. pp 149-220.
Flint PW, et al, eds. Cummings Otolaryngology: Head and Neck Surgery, 5th Ed. Philadelphia: Mosby Elsevier, 2010. ch 176.
Forest JA III, Jackson CG, McGrew BM. Long-term control of surgically treated glomus tympanicum tumors. Otol Neurotol 2001; 22:232-236.
Glassock ME, Gulya AJ. Surgery of the Ear, 5th Ed. Hamilton: BC Decker, 2003. pp 715-738.
Gottfried ON, Liu JK, Couldwell WT. Comparison of radiosurgery and conventional surgery for the treatment of glomus jugular tumors. Neurosurg Focus 2004; 17:E4.
Gulya AJ. The glomus tumor and its biology. Laryngoscope 1993; 103:7-15.
Hesselink JR, Davis KR, Taveras JM. Selective arteriography of glomus tympanicum and jugulare tumors: technique, normal and pathologic anatomy. AJNR 1981; 2:2890-2897.
Hoegerle S, Ghanem N, Altehoefer C, et al. 18F-DOPA positron emission tomography for the detection of glomus tumours. Eur J Nucl Med Mol Imaging 2003; 30:689–94.
Jackson CG. Skull base surgery. Am J Otol 1981: 3:161-171.
References
Jackson CG, Glasscock ME III, Harris PF. Glomus tumors. Diagnosis, classification, and management of large lesions. Arch Otolaryngol 1982; 108:401-410.
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