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Glomus Jugulare Tumor

Fisch type C2

Infratemporal Fossa Approach Type A

1. Planning the incision. 2. Creation of a periosteal flap for use in the obliteration of the external acoustic meatus.
3. Preparation for the complete dissection of the external acoustic meatus. 4. Complete cut of the external acoustic meatus. Dissection of the digastric muscle.
5. Dissection of the main stem of the facial nerve. 6. Dissection of the large vessels and the lower cranial nerves.
7. Dissection of the external carotid artery. 8. Dissection and ligation of the ascending pharyngeal artery.
9. Suture-ligation and section of the external carotid artery. 10. Cutting the attachment of the sternomastoid muscle to the mastoid tip.
11. Preparation for the cross section of the digastric muscle. 12. Preparation for mastoidectomy. Glomus tumor is seen protruding into the external acoustic meatus through a preexisting tympanic perforation.
13. Mastoidectomy and antrotomy. Incus is seen. (g, glomus; i, incus). 14. Tumor shrinkage through cauterization.
15. Removal of the posterior buttress. (i, incus). 16. Disarticulation of the incus. (g, glomus; i, incus; m, malleus).
17. Continuing tumor shrinkage. Stapes is seen. (s, stapes). 18. Cutting the tendon of the tensor tympani muscle. (tt, tendon of the tensor tympani muscle).
19. Cutting the tendon of the stapedius muscle. (sm, stapedius muscle). 20. Extension of the tumor into the area of the round window is seen. (rw, round window).
21. Exposure of the facial nerve. (lsc, lateral semicircular canal; ms, mastoid segment; ts, tympanic segment). 22. Continuing the exposure of the facial nerve. (lsc, lateral semicircular canal; eg, external genu; smf, stylomastoid foramen).
23. Removal of eggshell bony fragments from the area of the stylomastoid foramen. (lsc, lateral semicircular canal; smf, stylomastoid foramen). 24. Complete exposure of the facial nerve. (p, parotid; smf, stylomastoid foramen; g, glomus jugulare).
25. Creation of a new fallopian canal (curved line) for the reception of the facial nerve. (et, eustachian tube ostium). 26. Elevating the facial nerve (tympanic segment). (et, eustachian tube ostium).
27. Elevation of the mastoid segment of the nerve. (p, parotid; smf, stylomastoid foramen). 28. Section of the branch of the facial nerve for the digastric muscle. (dmb, branch for the digastric muscle).
29. Mobilization of the intraparotid segment of the facial nerve. 30. Anterior transposition of the facial nerve into the new fallopian canal.
31. Dissection of the lower cranial nerves to preserve them while removing the tumor. 32. Continuing the dissection from the previous stage.
33. The anterior displacement of the mandible with the introduction of the infratemporal fossa retractor facilitates the dissection of the glossopharyngeal nerve. 34. Starting drilling for the exposure of the sigmoid sinus and the posterior fossa dura. (s, sigmoid sinus; pcf, posterior cranial fossa; mcf, middle cranial fossa).
35. Thinning and removing the bone over and around the sigmoid. 36. Passing the aneurysm needle along the posterior wall of the sigmoid sinus. (s, sigmoid sinus).
37. Placement of an absorbable suture. 38. Withdrawal of the needle and the suture.
39. One stage before the ligation of the sigmoid sinus. 40. Double ligation of the sigmoid sinus.
41. Internal jugular vein is ligated, cut, and elevated to be dissected and removed with the tumor. 42. Working across the wall of the vein towards the tumor. (ijv, internal jugular vein; hn. hypoglossal nerve).
43. Entering the sigmoid and dissecting the tumor using as plane of cleavage the inner wall of the sinus. (ss, sigmoid sinus; gj, glomus jugulare). 44. Removing the tumor from the round window.
45. All tumor growths inside the openings of the inferior petrosal sinus are removed and the openings are plugged with surgicel. 46. Removal of the tumor from the carotid canal, great part of which has been eroded. (ijv, internal jugular vein; ica, internal carotid artery; g, glomus tumor).
47. The wall of the internal jugular vein is opened and a finger-like extension of the tumor is found. (g, glomus tumor). 48. The finger-like extension of the tumor inside the internal jugular vein. (gj, glomus jugulare).
49. General view of the finger-like extension of the tumor inside the internal jugular vein. 50. Continuing the elevation of the tumor using as plane of cleavage the inner wall of the sigmoid sinus. (ss, sigmoid sinus).
51. Completion of the dissection of the tumor. (gj, glomus jugulare). 52. General view of the surgical field. Mobilization of the temporalis muscle.
53. Obliteration of the postoperative cavity with adipose tissue. 54. Suturing the wound.