eMedicine Specialties > Radiology > Head/Neck

Glomus Tumor (Head and Neck): Follow-up

Author: Robert A Koenigsberg, DO, MSc, FAOCR, Director of Neuroradiology, Professor, Department of Radiology, Drexel University College of Medicine
Coauthor(s): Cyrus Dastur, BS, Department of Neuroradiology, MCP Hahnemann University; Robert Kim, BS, Department of Neuroradiology, Hahnemann University Hospital
Contributor Information and Disclosures

Updated: Jan 29, 2008

Intervention

The preferred method of treatment for glomus tumors of the head and neck is surgery. However, because most paragangliomas are slow-growing and benign, radiation treatment alone or no treatment at all is preferred in elderly patients in whom the risks of surgery are relatively high and the tumor is unlikely to cause serious morbidity or mortality. If the patient is young, surgery is the best available option because it is the only option that allows total cure.4,5,6,7,8,9,12,15,16,17,18,22,23,24

Radiation therapy

Gamma-knife irradiation is commonly used in patients who are poor candidates for surgical excision or embolization because of their age or disease state or because of unacceptable morbidity. This procedure is expensive, and clear remission is not reported to date. However, gamma-knife irradiation may be of some use in controlling the tumor and, thereby, in preventing it from growing larger.5,6,7,8,9,12

Embolization

Embolization is a common technique used as the lone treatment option or as a precursor to surgical excision. As a result of the highly vascular nature of these neoplasms, embolization is an effective technique that is aimed at starving the lesion of its blood supply and inducing necrosis. This is the primary and, at times, the only treatment option for glomus jugulare tumors because of the difficulty in excising many of the tumors. In combination with surgical excision, embolization is often used to reduce blood loss, and it has been proven to be highly effective.

In bilateral lesions, especially of the vagale type, embolization is often required as the sole course of treatment for 1 of the lesions, in tandem with surgical excision of the other. This approach is used because of the proximity of the lesion to the vagus nerve and the occasionally inevitable perioperative damage to the nerve during excision.

As a result of their inherent neovascularity, catheter-directed embolization is appropriate in the treatment of chemodectomas, particularly if surgical removal is contemplated. The use of microcatheters allows precise delivery of embolic agents into masses and embolization of multiple, small, feeding trunks. Although glomus tumors may arise from multiple arterial territories, embolization is typically limited to the feeders of the external carotid branch artery.

Typically, the author performs glomus tumor embolization by using polyvinyl alcohol, starting with 50-µm particles and progressing to 250- to 300-µm particles as warranted. Rarely, highly vascular shunts in the glomus tumors may require the use of liquid-adhesive embolic agents to close any rapidly forming fistulae. Occlusive coils implanted along feeding arterial pedicles can be helpful in closing feeders in difficult complex tumors; however, the author tends to use these devices sparingly. In the author's practice, glomus tumor embolization is performed in a preoperative setting. Nevertheless, some authors suggest that embolization alone may be beneficial in the treatment of these tumors.

Surgery

Surgical excision is the treatment of choice, and current techniques are highly successful with relatively low morbidity rates: blood loss and CN neuropathies are the major complications. Depending on the specific type and location of the tumor, different surgical approaches are required.4,9,15,16,18,22,23,24

Most otologists can excise an intratympanic and/or intramastoid tumor via a transmeatal or transmastoid approach. Jugular bulb tumors require excision by surgeons experienced in neck and mastoid surgery. Tumors invading the carotid canal require an infratemporal approach; expertise in skull-base surgery is required. The treatment of transdural glomus tumors requires neurosurgical expertise.

Tumors involving the cavernous sinus or the foramen magnum may be unresectable, and any combination of subtotal resection, radiation therapy, and embolization may be required.

As a result of the highly vascular nature of glomus tumors, preoperative embolization is commonly used to reduce surgical blood loss. The only exception is in patients with glomus tympanicum tumors, in whom surgical blood loss is typically limited.

Medicolegal Pitfalls

  • Whenever external carotid embolization is performed, care must be taken to avoid inadvertent extracranial-intracranial embolization and the subsequent risk of stroke.
  • Occult occipital-vertebral connections may be present or open, or they may become apparent on angiograms, only after partial embolization is performed.
  • Pterygopalatine–internal carotid collaterals, as well as middle meningeal–middle cerebral communications, may exist. These should be recognized prior to embolization.
  • The ophthalmic artery should be identified prior to external carotid embolization, and care should be taken to identify any existing ethmoidal-ophthalmic arterial communications.

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More on Glomus Tumor (Head and Neck)

Overview: Glomus Tumor (Head and Neck)
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Follow-up: Glomus Tumor (Head and Neck)
Multimedia: Glomus Tumor (Head and Neck)
References
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References

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Further Reading

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Keywords

chemodectoma, nonchromaffin paraganglioma, glomus body tumors, paraganglioma, glomus jugulare tumors, glomus tympanicum tumors, glomus vagale tumors, carotid body glomus tumors, carotid body tumors

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Contributor Information and Disclosures

Author

Robert A Koenigsberg, DO, MSc, FAOCR, Director of Neuroradiology, Professor, Department of Radiology, Drexel University College of Medicine
Robert A Koenigsberg, DO, MSc, FAOCR is a member of the following medical societies: American Osteopathic Association, American Society of Interventional & Therapeutic Neuroradiology, American Society of Neuroradiology, and Radiological Society of North America
Disclosure: Nothing to disclose.

Coauthor(s)

Cyrus Dastur, BS, Department of Neuroradiology, MCP Hahnemann University
Cyrus Dastur, BS is a member of the following medical societies: American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Robert Kim, BS, Department of Neuroradiology, Hahnemann University Hospital
Disclosure: Nothing to disclose.

Medical Editor

Barton F Branstetter IV, MD, Assistant Professor of Radiology and Otolaryngology, University of Pittsburgh; Director of Head and Neck Imaging, Associate Director of Informatics, Department of Radiology, Division of Neuroradiology, University of Pittsburgh Medical Center
Barton F Branstetter IV, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Pennsylvania Medical Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

C Douglas Phillips, MD, Professor, Departments of Radiology, Neurosurgery, and Otolaryngology, University of Virginia Health Sciences Center
C Douglas Phillips, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Lawrence M Davis, MD, Assistant Professor of Diagnostic Imaging (Clinical), Department of Diagnostic Imaging, Brown Medical School
Lawrence M Davis, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, Radiological Society of North America, and Rhode Island Medical Society
Disclosure: Nothing to disclose.

 
 
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