3- injection of glue in head and neck paraganglioma

BACKGROUND AND PURPOSE:

Substantial intraoperative bleeding during surgical removal of head and neck paragangliomas may be a major problem in the management of these highly vascularized tumors. Traditional preoperative embolization via a transarterial approach has proved beneficial but is often limited by complex vascular anatomy and unfavorable locations. We report our experience with the preoperative devascularization of head and neck paragangliomas by using direct puncture and an intralesional injection of cyanoacrylate.

METHODS:

We retrospectively analyzed nine consecutive patients with head and neck paragangliomas who were referred for preoperative devascularization. Three patients were treated for carotid-body tumors; two for vagal lesions; and four, for jugular paragangliomas. Direct puncture of the lesion was performed by using roadmap fluoroscopic guidance. Acrylic glue was injected by using continuous biplane fluoroscopy. All patients underwent postembolization control angiography and immediate postoperative CT scanning.

RESULTS:

Angiograms showed that complete devascularization was achieved in all cervical glomus tumors, whereas subtotal devascularization was achieved in jugular paragangliomas. In this latter location, the injection of acrylic glue was limited by the potential risk of reflux into normal brain territory via feeders from the internal carotid or vertebral artery. The tumors were surgically removed and histologically examined. No technical or clinical complications related to the embolization procedure occurred.

CONCLUSION:

Percutaneous puncture of paragangliomas in the head and neck region and their preoperative devascularization by intralesional injection of acrylic glue is a feasible, safe, and effective technique.

Paragangliomas, also called glomus tumors, are highly vascularized tumors of neural crest origin that are derived from chemoreceptor organs in the walls of blood vessels or specific nerves in the head and neck area. They can develop in the middle ear (glomus tympanicum), the jugular foramen of the skull base (glomus jugulare), or the head and neck area (glomus caroticum, glomus vagale). Glomus tumors are multiple in 25% of patients and usually benign but locally destructive (1–4). They spread along paths of least resistance and cases of malignancy may occur. Glomus tumors can be treated with surgical excision, radiation therapy, surgery and irradiation, or embolization and surgery. Surgical removal is often associated with a significant intraoperative bleeding rate because of the vascular nature of the tumors (3, 5–11), especially when they are large. To reduce intraoperative blood loss, preoperative devascularization with transarterial embolization has proved beneficial (12–18), but this often remains incomplete because of the extensive angioarchitecture and substantial arteriovenous shunting of these lesions. Alternatively, direct puncture and the injection of acrylic glue have been described (19–22), but these can also be associated with complications (23). We report our experience in nine cases of head and neck paragangliomas treated by means of direct puncture and the intratumoral injection of cyanoacrylate.