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. |