Turkish Neurosurgery 3: 128· 133. 1993 Erongun: 1n1Iatemporal Approac1i

Infratemporal Approach For Jugular Foramen Meningioma

UGUR ERONGUN. YAVUZ UYAR. BiLGE ÇAKIR. ALI UYGUN. YALÇIN KOCAOGULLAR.

Selçuk University Medical School Departments of Neurosurgery (UE. AU. YK).Otorhinolaryngology (YU)and Radiology (BÇ)Konya. TÜRKIYE

Abstract : The properties of tumours of the jugular foramen arepresented and the details of the infratemporal A approach. a newtechnique for neurosurgeons. are discussed.

INTRODUCTION

The jugular foramen is a canal in the skull basebetween the lateral aspect of the occipital bone andthe inferiomedial part of the petrous pyramid andis divided anatomically into two parts by a bone orfibrous septum. anteriody the pars nervosa andposteriorly the pars venosa. While the inferiorpetrousal sinus and the N. glassopharingeus are pass·ing through the pars nervosa. the V. jugularis inter­na. N. vagus. N. accessorius. ascendant pharingealartery and meningeal branches of the occipital arterypass though the pars venosa. The foramen jugularewhich has such a complicated structure. is affectedby congenitaL. vascular and. most frequently.tumoural lesions and these lesions reveal various

clinical syndromes. Most often encountered tum­mours in the foramen jugulare region are glomusjugulare tumour. neuroma. meningioma. metastaticcarcinoma. chondroma.· nasopharynx carcinoma andcarcinoma of the tympanic cavity. Symptomatologyof these tumours may be primarily otological orneurological or a combination ofboth (3.7). The mostencountered initial symptoms are loss ofhearing. tin­nitus. otorrhoea. facial paralysis. pain and 9th. lOth.IIth aanial nerve paralysis. Paralysis of these nervesis called Syndrome of the jugular fossa or Vernet'ssyndrome and is characterized by loss of taste sen­sation in the posterior third of the tongue. paralysis

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Key Words Jugular foramen. Meningioma. InfratemporalA approach.

of the vocal cords and soft palate and weakness ofthe trapezius and sternocleidomastoid muscles. Iftumours of the foramen jugulare region extendmedial1y to the hypoglossal canal and causehypoglossal nerve paralysis. the clinical presentationis known as Collet-Sicard syndrome.

CASE REPORT

This 42-year-old female was admitted to the ENTclinic on 2l January 1992 with a complaint ofhoarseness. After questioning the patient it wasrevealed that the prasent complaint started 9 monthspreviously and had inaeased since then and duringthe pa st two months headache and difficulty inswallowing were added. General physical examina­tion reve ale d no significant finding. Afterotoneurolaryngological examination. it was foundthat the right vocal cord was fixed in the paramedianline. the uvula was retracted to the left and the gagreflex was lost.

Routine laboratory studies and plain X-rays show­ed no significant abnormality. Although clinical1ythere was no neurological deficit related to the IIthcranial nerve. EMG revealed partial denervation ofthe sternocleidomastoid muscle. Electrophysiologicalevaluation of the facial muscles. audiogram and elec­tronystagmogram were within normal limits.

Turkish Neurosurgery 3: 128 - 133. 1993

After an axial and coronal CT investigation of thebasis cranU an 18x22x20 mm mass origiriating in thejugular canal was found. The mass had enlarged thecanal by filling the lumen and showed ex­tracanaliculary extension at the caudal part. Themass, which had a dumb-bell configuration extend­ed along the posterior contour of the petrous boneto the cerebello-pontine angle obliterating thecerebello-pontine dstern. There were amorphouscaldfications inside and around the mass. CT after

administration of contrast material show ed slightenhancement. There was no perifocal oedema. Thewidth of the internal acoustic canal was normaL. The

right lateral recess of the 4th ventric1e was compress­ed. (Fig1.2)Although the morphological appearance

Fig. 1a.b: Axia] and coranal CT showing a mass Eillingenlargingthe jugu1ar foramen with extracanaliculary extension.

Erongun: Infratempora] Approach

Fig.2a.b : On postoperative axia]and corana] CT, complete removelof the tumuor.

of the mass on CT was meningioma, it was thoughtthat it could be a neurogenic tumour due to its con­figuration so from that standpoint. the infratemporalA approach developed by Fisch. was chosen for com­plete removal of the mass.

Endotracheal general anestheisa was performed.A skin indsion in the shape of an inverse "S" wasmade beginning in the right temporal region andpassing through the postauricular area and extendingdownward to the hyoid bone at the neck. The ind­sion was carried down to the mastoid periosteum.A periosteal flap in connection with the externalauditory canal was prepared from mastoidperiosteum. The external auditory canal was

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incised. the skin was turned back and stitched. The

entran ce of the external auditory canal was occlud­ed using a periosteal flap. The branches of the facialnerve in the parotid gland was exposed. Then atten­tion was directed to the neck and the vessel-nerve

sheath was exposed. The internal jugular vein. com­mon carotid artery. external and internal carotidarteries were found and tracks of the N. vagus. N.glossopharingeus and N. accessorius were identified.Mastoidectomy was performed. The sigmoid sinus.digastric ridge. facial nerve and bony labyrinthinewere exposed by removing retrosigmoid. retrofadal.retrolabyrinthine. supralabyrinthine. infralabyrin­thine. pericarotid and supratubal cells. At the sametime the posterior bone wall of the external auditorycanal was removed so that a bridge was made. Thetympanic membrane and ossicle chain were remov­ed. A new fallopian canal beginning around thegeniculate ganglion and passing along the anteriorwall of the external auditory canal was made andthe facial nerve was elevated from its normal posi­tion and transported to this new canaL.(Fig 3) Themastoid apex and bony laminas on the sigmoid sinus

Erongun: Infratempora1 Approach

were removed. Small dural indsions were made in

front and behind the sigmoid sinus and then thesigmoid sinus was ligated with a pair of sutures.The vertical portion of the ICA was exposed on themedial wall of the middle ear. The tube efEustachian

was obliterated with bone-wax. The styloid processwas excised and using a high speed drill the inferiorpart of the tympanic bone was removed so that thejugular bulb. sigmoid sinus. V. jugularis interna andcervical segment of the ICA and its vertical segmentin the temporal bone were completely exposed. Thejugular bulb was partially filled by a tumoural mass.The V. jugularis interna was ligated in the neck andthe tumour was exposed by opening the bulbus ofthe jugular vein. During this period massive bleedingfrom the petrousal sinuses was contrelled. Thetumour had enlarged the jugular foramen and com­pressed the 9th. lOth and iIth aanial nerves. Bonystructure around the jugular foramen was remove dby drilling and 2x2 cm of the dura was exposed. Afteropening the dura mater the cerebello-pontine anglewas exposed. When the abnormally thickenedarachn9id walls of the dsterns were opened it was

Fig. 3 : View of the operation Field after fadal nerve transposition (anterior reroruting)

1- Fadal nerve (at the tip of miaodissector)L· Bony labyrinthine3- The segment of the ICA in temporal bone.4- 1nternal jugular vein.5- Sigmoid sinus6- Middle cranial fossa

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Turkish Neurosurgery 3: 128 - 133. 1993 Erongun: Infratemporal Approach

Fig. 4 : Tumoral tissue at the tip of the aspiration tube and cerebellum immediately above are seen.

Fig. 5 : The seventh and eight aanial nerves. brain stem. PICA and cerebellum at the tip of the bipolaryforcep after total exdsion of the tumour.

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Turkish Neurosurgery 3: 128 . 133. 1993

seen that the operative field was completely occupiedby the tumour which had an epiarachnoidal deavagewith the cerebellum. (Fig 4) It was recognized thatthe tumour was macroscopically a meningiomarather than aneuroma. It was impossible to identifyany vital vascular and neural structure in theoperative field. so to achieve mobilization of the massinternal decompression was dissected from the 7thand Sth cranial nerves on the superior pole. Afterdissection was completed. both the cranial nerveswere visible. Preserving the epiarachnoidal deavagebetween the tumour and the brain stern. thetumoural mass was reduced in size and mobilizedfrom the nest it had made on the brain stern. At last

the PICA was dissected from the inferio-posteriorportion of the tumour and total tumour excision wasachieved. (Fig 5) The dural opening was covered bya musculo-facial graft from temparalis musde. Thecavity was packed using fat harvested from theanterior abdominal wall and a temporalis flap wasdesigned to cover the cavity completely.

The patient had no additional neurologic deficitsduring the postoperative period. Pathology revealedangioblastic meningioma.

DlSCUSSION

Radical surgical management of jugular faramentumours has made great progress in parallel with ad­vances in neuroradiological investigations. Particular­ly the introduction of CT. NMR and DSA hasprovided considerable aid. The complexity of theanatomical structure in the jugular faramen region.the close proximity of the jugular foramen to veryimportant neurovascular structures like the ICA,jugular bulb. the seventh and eighth cranial nervesand the brain stern. and the possibility of an in­tracranial mass extending to the extracranial spaceor an extracranial one to the intracranium have in­

creased the importance of surgical treatment ofjugular foramen tumours.

First of all. it should be determined whether

tumours of the jugular fararnen are purely intraaanialor solely extraaanial or have both extraaanial andintracranial components (5). After location thetranslabyrinthine. infratemporal A, transsigmoid.transmandibular. retrosigmoid or suboccipital surgicalapproaches can be used. depending upon the symp­tomatology. size and extension of the tumour.

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With the translabyrinthine approach. due tolabyrinthectomy. permanent total sensorineural hear­ing loss occurs postoperatively. For this reason. it canbe performed in cases with hearing loss. AlthoughHorn and House (4) postulated that this approach pro­vided direct access to the jugular bulb and posteriorfossa. existence of the facial nerve superficially overthe jugular faramen limits surgical manipulations inthis region. Because the area exposed is limited.radical excision of intracranially located tumours isimpossible.

The transsigmoid appoach for jugular faramentumours was desaibed by Mann and et aL.(S).Withthis technique. the jugular foramen is exposedwithout performing facial nerve transposition andlabyrinthectomy thus cochleavestibular function isprotected. After mastoidectomy. the sigmoid sinusis found and the jugular bulb exposed. The disad­vantage of this approach is limited exposure of thejugular fararnen so removal oflarge tumours and par­ticularly their intracranial components. is dillicult.

With the transmandibulary approach anasteotomy is performed on the mandible at themidline (6). The parapharyngeal area is enteredthrough the floor of the mouth and the jugularforamen is exposed by retracting half the mandiblelaterally. But this type of approach is not practicalbecause as the area is deeply situated it is very dil­ficult to reach the intradural portion and haemostasismay be a surgical problem due to inability to con­trol the sigmoid sinus.

The infratemporal A approach as performed byFisch provides direct access to the jugular foramen(i). The details of this technique were discussed inthe case report. The most important advantage of thisapproach is that it provides wide exposure of thefaramen jugulare region because transposition of thefacial nerve is possible and the intraaanial compo­nent can be exposed easily. The most importantdisadvantage is permanent conductive deafness sincethe bony chain of the middl,e ear and externalauditory way are excised and obliteration occurs, buthearing aids are effective. Despite the risk of paresisor paralysis after facial nerve transposition, this com­plication is rare and transient with meticuloussurgical manipulation. This technique of Fisch isalso prefered in tumours which have excessive ex­tracranial extension since the neck has been expos­ed to the level of the hyoid bone.

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The subocdpital approach is preferred fortumours purely intraaanial in location which don'tcause hearing loss. This methot is advised for exd­sion of tumours greater than 2 cm in diameter. it re­quires long-standing retraction of the cerebellum andto expose the extraaanial part of the tumour is dif­ficult. On this appro;;ichcontrol of bleeding has somedifficulties related to surgical technique. However.with the infratemporal approach, the sigmoid sinusand internal jugular vein are ligated and profusebleeding from petrousal sinuses can easily be con­trolled (9).

Following examination of the techniques discuss­ed above. the infratemporal A appoach was chosenfor our patient for three reasons:

1. The most direct and widest possible exposureof the jugular foramen is afforded due to transposi­tion of the fadal nerve.

2. Bleeding can be controlled by haemostasis ofthe important sinuses and veins in the region.

3. It is also possible to expose the intracranialcomponent of the tumour.

Fisch. who developed the infratemporal A ap­proach. described the removal of tumours greaterthan 2 cm in diameter in two stages (1.2). A1.thoughthe tumour was greater than 2 cm in diameter. in ourpatient complete removal was accomplished usinga one-staged surgical approach.

Erongun: Infratemporal Approach

Correspondence: Asso. Prof. Dr. Ugur ErongunSelçuk University, Medical schoolNeurosurgery DepartmentKonya - TÜRKIYE

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