CASE 18522 Published on 10.04.2024

Angioembolisation as the best palliative treatment for glomus jugulare – A case report

Section

Interventional radiology

Case Type

Clinical Case

Authors

Mohamed Rafi Kathar Hussain, A. L. Periyakaruppan

Department of Imaging Science and Interventional Radiology, Tamil Nadu Government Multi Super Speciality Hospital, Chennai, India

Patient

49 years, female

Categories
No Area of Interest ; No Imaging Technique
Clinical History

A 49-year-old female patient came with complaints of right ear tinnitus and right-sided headache for the past 1 year. She is a known case of hypothyroidism on treatment. CT and MRI were performed outside the institute, and she came for further evaluation and management.

Imaging Findings

CT shows an ill-defined soft tissue mass lesion noted in the right jugular bub region with an associated moth-eaten pattern of bony destruction. In contrast, the lesion shows significant contrast enhancement (Figures 1a and 1b). In MRI, a T2 heterogeneous hyperintense avidly enhancing mass lesion was noted in the right jugular foramen (Figures 2a, 2b and 2c). The lesion is antero-medially abutting the right carotid canal, posteriorly right sigmoid sinus.

Six-vessel DSA shows extensive tumour blush with feeders arising from the tympanic branches of the right ascending pharyngeal artery and right internal maxillary arteries (Figures 3a and 3b). After excluding the dangerous anastomosis, embolisation was done using the PVA particles (100 to 300mm) in both branches. Postoperative angiogram shows a significant reduction of tumour vascularity (Figure 4). In the immediate postoperative period, patient tinnitus is significantly reduced. The patient is not willing for surgery due to concerns about postoperative complications. After tumour embolisation, there was a significant improvement in the quality of life.

Discussion

Glomus jugulare is one of the slow-growing head and neck region paragangliomas or chemodectomas that arise in the jugular foramen [1]. The incidence is about 1 case per 1.3 million people [2]. Paragangliomas are of two types: parasympathetic and sympathetic. Most of the head and neck paragangliomas are parasympathetic types. They arise from the paraganglia cell in an adventitia layer of the jugular fossa. They are slow-growing, benign, locally destructive, highly vascular tumours. Three to six times more common in females than males, 80% are sporadic and less than 1% functionally active [3]. More common in 4 to 6 decades, with an average doubling time of 4.2 years. Malignancy is seen in 1% to 5% of the cases, and metastasis is usually rare. Metastasis can occur in lymph nodes, lungs, liver, and bones. Paragangliomas located in carotid bifurcation, superior vagal ganglion, inferior vagal ganglion and auricular branch of the vagus are known as carotid body tumour (44% to 48%), glomus jugulare tumour (16% to 24%), glomus vagale tumour (8%) and glomus tympanicum, respectively (20%) [3].

Clinically it can cause jugular foramen syndrome due to the involvement of multiple cranial nerves depending upon the extent of involvement of cranial nerves [4]. Surgery is the treatment if complete resection is feasible. Major complications are haemorrhage, cranial nerve deficits, and CSF/endolymphatic leak. Recurrence ranging from 4050% of cases. Mortality rate is 1.2% to 6.4%. Most cervical paragangliomas are relatively radioresistant except the base of skull paragangliomas. Stereotactic radiosurgery also plays a non-invasive, effective treatment role in the management of glomus tumours.

The first report of glomus jugulare tumour embolisation was done by Hekster with autologous muscle in 1973. The first PVA particle embolisation was described by Schic in 1980. Combined arterial and venous preoperative embolisation was described by Jacob et al. [5]. Tumour embolisation is the essential pre-operative procedure to decrease the intra-operative bold loss, or it can be palliative, as in our case, but not curative [1]. Various embolic agents used are n-butyl cyanoacrylate, polyvinyl alcohol, vinyl alcohol polymer, beed block, and coils. Coils are used when there is a dangerous anastomosis exists. Percutaneous direct puncture may close the arterial supply and venous drainage, but it is practically difficult to gauge the embolisation. Occlusion of the inferior petrosal sinus was done in case of transvenous embolisation. Total embolisation is sometimes difficult to achieve due to the multiple arterial feeders. A minor complication is cranial nerve palsy due to tumour oedema or ischemic occlusion of vasa nervorum or transient aphasia or fever [6,7]. The worst complication is cerebellar or brainstem infarct due to non-target embolisation [4]. Severe hypertension in case of functional tumours. Palliative management will improve the quality of life with significant improvement in clinical symptoms, especially vertigo and tinnitus, as in our case.

Differential Diagnosis List
Schwannoma
Neurofibroma
Meningioma
Metastasis
Glomus jugulare
Primitive neuroectodermal tumour
Final Diagnosis
Glomus jugulare
Case information
URL: https://eurorad.org/case/18522
DOI: 10.35100/eurorad/case.18522
ISSN: 1563-4086
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