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Diagnostic and therapeutic problems in extracranial meningiomas
SCIENTIFIC PAPERS
Diagnostic and Therapeutic Problems in Extracranial Meningiomas
James H. Whicker, MD, Rochester, Minnesota Kenneth D. Devine, MD, Rochester, Minnesota Collin S. MacCarty, MD, Rochester, Minnesota
Extracranial meningiomas, either primary or secondary, are often difficult to diagnose and treat. 'Fo establish the common sites of extracranial presentation and to develop guidelines for treatment, we reviewed tile charts of 1,768 patients with meningiomas seen at our clinic from 1946 to 1971. Patients with orbital, cutaneous, spinal, or readily diagnosable intracranial meningiomas were excluded. Sixteen patients had primary extracranial meningiumas or extracranial extensions of intracranial meningiomas that posed unusual diagnostic or therapeutic problems. The cases of ten patients who typify the group are presented. The meningocyte has been confirmed as the cellular origin of meningiomas [1,2]. The meningocytes compose the arachnoid-lining cells that cluster about the tips of the arachnoid villi. The anatomic incidence of meningiomas closely corresponds to the location of the arachnoid villi [3]. Although the mode of occurrence of intracraniai meningiomas is well established, the mode of occurrence of extracranial meningiomas is not uniFrom the Mayo Clinic and Mayo Foundation, Rochester. Minnesota. Reprint requests should be addressed to the Section of Publications, Mayo Clinic, Rochester, Minnesota 55901. Presented at the First Joint Meeting of the Society o ~, Head and Neck Surgeons and the American Society for Head and Neck Surgery, Hot Springs. Virginia, April 30 to May 2, 1973.
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versally accepted. Several theories have been advanced to explain the occurrence of ectopic meningiomas. The more widely accepted theory suggests that meningiomas arise from meningocytic cellular rests [4-6l. These cellular rests have been demonstrated within the sheaths of cranial nerves at their sites of exit through the skull foramina. A second theory, based on the histology of the cellular components of meningiomas, that these tumors may arise directly from meseuehymal cells including meningocytes, fibroblasts, and Schwann cells was proposed by Shuangshoti, Netsky, and Filz-Hugh [7]. These authors regard meningocytes as specialized fibroblasts of mesenchymal origin. The intimate relation among meningocytes, fibroblasts, and Schwann cells occurs because of their common mesen~hymal origin and.explains the diverse histologic features commonly found in meningiomas. This theory explains the occurrence of ectopic meningiomas unrelated either to skull and intravertebral foramina or to cranial sutures [8-I I ]. For ease of comparison and discussion, the ten cases are grouped according to the anatomic site of presentation of the tumor. The anatomic sites include the middle ear, infratemporal fossa, nasopharynx, and parapharyngeal-jugular foramen region.
The American Journal of Surgery
Extracranial Meningiomas
Case Reports The Ear
Case |. A fifty-four year old woman was first examined in December 1945. She complained of tinnitus (two years) and progressive hearing h)ss (three months) in the left ear. A solid, brown tumor filled the external auditory canal, preventing visualization of the tympanic membrane. Although findings on skull roentgenograms were normal, roentgenograms of the mastoid region demonstrated cellular destruction within the mastoid process. On December 12, 1945, radical mastoidectomy revealed a tumor over the horizontal course of the facial nerve. The tumor extended through the antrum into the mastoid, and a finger-like projection extended into the eustachian tube. No intracranial extension was found. The tumor was totally removed, and radium ele m e n t points were inserted for twenty-four hours. The pathologist reported that the lesion was a meningioma with psammoma bodies. After the operation the patient experienced transient facial weakness and aphasia; however, these symptoms cleared completely within two weeks. She was lost to follow-up study after six months, but examination at that time revealed no recurrence. Case |1. A fifty-five year old woman was first seen in April 1957 because of a progressive hearing loss of five years' duration in the right ear. In addition, she had experienced pulsatile tinnitus and vertiginous attacks during the preceding two years. In 1955 and 1957, tissue, reported by the pathologist as chemodectoma, had been removed from the right external canal. Our examination revealed a firm, pink growth in the right external auditory canal. An audiogram demonstrated a mild conductive hearing loss on the right. Findings on roentgenograms of the mastoid region were normal. At surgery "a large portion" of the tumor was removed from the external canal and middle ear. The pathologic diagnosis was meningioma. After the operation she received combined intraoral and external irradiation. At her last examination in 1972, she was free of disease. Case Ill. A forty-two year old woman was first seen in April 1956. She had had pulsatile tinnitus, fullness, and hearing loss in the left ear for two years. Several previous myringotomies had not improved the symptoms. An audiogram demonstrated a mild sensorineural loss above 4,000 Hz in the left ear. A reddish area was seen behind the anterosuperior quadrant of the left tympanic, membrane. In addition, hyperplastie lymphoid tissue filled the left fossa of Rosenmtiller. On April 25, 1956 exploratory tympanotomy revealed only a bluish discoh)ration of tbe promontory. Four days later the nasopharynx was subjected to beta radon applications (50 rag). In September 1956 fluid was aspirated from the left middle ear. In April 1957 she noted trigeminal paresthesias; moreover, a small mass was
Volume 126, October 1973
seen behind the posteroinferior quadrant of the tympanic membrane. Roentgenograms of the mastoid region showed cloudy air cells and periantral sclerosis, with questionable enlargement of the internal auditor). meatus. Roentgenograms of the skull, including base views, showed no abnormalities. On April 5, 1957 modified radical mastoidectomy exposed a tumor surrounding the incus and extending into the antrum. No bony dehiscence of the tegmen was fl)und. The tumor was removed, and 3,000 rads of cobalt 60 irradiation were delivered after the operation. The pathologist reported that the tissue was a meningioma. At postoperative examination in April 1967, there was no tumor recurrence or progression of the trigem!:ml Faresthesias. Roentgenograms of the skull, with Stenver's views, showed only postoperative changes. When re-examined in June 1972 the patient had no recurrence.
Comment. In his review of t e m p o r a l bone m e n i n g i o m a s , N a g e r [3] p o s t u l a t e d t h a t these tumors o r i g i n a t e d from a r a c h n o i d g r a n u l a t i o n s in t h e following locations: (1) the internal a u d i t o r y m e a t u s a l o n g the s h e a t h s of the facial a n d vestibular nerves, (2) the j u g u l a r f o r a m e n s u r r o u n d i n g the glossopharyngeal, vagus, a n d accessory nerves, and (3) along the course of the greater superficial petrosal nerve. He described six p a t i e n t s who had p r o b a b l e m i d d l e ear m e n i n g i o m a s ; however, five of the six p a t i e n t s h a d bony d e s t r u c t i o n of the m i d d l e cranial fossa or the petrous portion of the t e m p o r a l bone, s u g g e s t i n g an i n t r a c r a n i a l c o m p o nent. In his series, follow-up d a t a were e i t h e r brief or not available. Therefore, only one p a t i e n t had an u n d e n i a b l e e c t o p i c m e n i n g i o m a of t h e m i d d l e ear. T w o o t h e r m e n i n g i o m a s of the m i d d l e ear have been described [12,13]. Of the three p a t i e n t s in our series, one h a d no i n t r a c r a n i a l signs or s y m p t o m s . O n e h a d trigeminal p a r e s t h e s i a s ; however, a fourteen y e a r followu p s t u d y revealed no progression of the t r i g e m i n a l neuralgia or d e v e l o p m e n t of o t h e r s y m p t o m s suggestive of i n t r a c r a n i a l i n v o l v e m e n t . O n e p a t i e n t had t r a n s i e n t a p h a s i a in the i m m e d i a t e postoperative period, m a k i n g exclusion of an i n t r a c r a n i a l c o m p o n e n t difficult. O u r three p a t i e n t s h a d tinnitus, u s u a l l y pulsatile, a n d progressive h e a r i n g loss. A c o n s t a n t finding was a reddish brown mass p r e s e n t i n g in the external canal or b e h i n d the t y m p a n i c m e m b r a n e . A u d i o g r a m s revealed c o n d u c t i v e losses in two patients whereas the third h a d a h i g h - f r e q u e n c y sensorineural hearing loss t h a t was p r o b a b l y unrelated to the disease. A m e n i n g i o m a of the m i d d l e ear m a y m i m i c the s y m p t o m s a n d a p p e a r a n c e of a chemodectoma.
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C Figure 1. Case V. Recurrent extracranial meningioma in forty year old woman. A and B, sphenoidal ridge menin. gioma (12 by 20 cm) before operation. C, meningioma after right maxillectomy.
In[rttt ernporal I,'f)ssa C a s e IV. In N o v e m b e r 19t'~ a fifty-four y e a r - o l d woman was initially seen because of right facial p a i n of seven y e a r s ' duration. Because chewing e x a c e r b a t e d the pain, surgical correction of the malocclusion was performed, without henefit, in 1967. l,ocal a n e s t h e t i c injections also failed to relieve the facial pain. E x a m i nation disclosed facial a s y m m e t r y resulting from fullness over the right z y g o m a t i c area. Skull and facial roentgen~grams, including special views of the zygomatic arch, suggested the extension of a sphenoidal ridge m e a i n g i o m a t() the region of t h e right t e m p o r o m a n d i b u l a r joint. T h e t u m o r also involved the lateral a n d inferior walls of the orbit. Sinus roentgenograms gave negative resuhs. On N o v e m b e r 27, 1968 right total p a r o t i d e e t o m y was perfiwmed, exposing and preserving the facial nerve. T h e p a r o t i d e c t o m y incision was then curved anteriorly above the hairline. T h e t e m p o r a l muscle was e l e v a t e d until the tum~w was fi)und invading the muscle and t;one in t h e infratemporal fossa. T h e spaces d e e p to the zygoma and posterior to t h e ant r u m were filled with tumor. T h e m a n d i b u l a r r a m u s a n d t m u o r m a s s were resected en bloc, and the t u m o r was t r a n s e c t e d a t the point where it e x t e n d e d intracranially. T h e pathologist reported that the t u m o r was a m e n i n g i o e p i t h e l i o m a t o u s m e n i n g i o m a (11 by 5 by ;~ cm). On D e c e m b e r 4, 1968 a right retrograde b r a c h i a l angiogram d e m o n s t r a t e d an a v a s c u l a r lesion in the right t e m p o r a l area d i s p l a c i n g the m i d d l e cerebral complex superiorly, posteriorly, a n d medially, with some associated sclerosis of the g r e a t e r wing of the sphenoid bone. On D e c e m b e r 10, 1968 the t u m o r was a p p r o a c h e d through a right t e m p o r a l c r a n i e c t o m y and was found to lie in the m i d d l e fossa e x t e n d i n g to, but not medial to, the foramen ovale. T o t a l removal of the t u m o r was a c c o m p l i s h e d . In a follow-up letter in April 1972 the patient reported t h a t her h e a l t h was normal. C a s e V. A forty y e a r old w o m a n h a d c r a n i o t o m y in 1937 for a ~phenoidal ridge m e n i n g i o m a . Recurrence m a d e necessary the e n u c l e a t i o n of the right eye in
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1941. Recurrent m e n i n g i o m a d i s t o r t i n g the right side of the face p r o m p t e d her visit to us i~a October 1952. (Figure IA and B.) Roentgenograms of the skull sh~)wed an osteomatous reaction involving the right facial a n d frontal btmes a n d the floor of the anterior a n d m i d d l e fossae, T h e previous c r a n i o t o m y hone flap was also involved. Facial views d e m o n s t r a t e d an irregularity of the external surface of the zyg~maatic process of t h e right maxilla. A p n e u m o e n c e p h a l o g r a m revealed a slight shift of the latPral and third ventricles to the left. On O c t o b e r 22. 1952 a s t a n d a r d m a x i l l e c t o m y incision revealed t u m o r filling the orbit, a n t r u m , and r e t r o m a x i l l a r y fossa, and bulging the frontal a n d temporal regions. Because of the size of the t u m o r (t'2 by 20 cm). right m a x i l l e c t o m y was necessary. (Figure 1C.) Persistent hypotension forced t e r m i n a t i o n of the operation. although t u m o r r e m a i n e d in the orbit and at the site of the previous c r a n i o t o m y . T h e p a t i e n t refused a second-stage i n t r a c r a n i a l procedure, h u t on follow-up s t u d y in 1965 (thirteen years after the operation), the p a t i e n t enjoyed excellent h e a l t h with no a p p a r e n t recurrence of the ext racranial c o m p o n e n t . C a s e V l . A forty-six y e a r old woman was seen in 1965 because of fullness in t h e right temporal area a n d slight proptosis of the right eye. T h e p a t i e n t refused further e v a l u a t i o n after the p r e l i m i n a r y e x a m i n a t i o n . In 1966 a t a n o t h e r institution, hiops3 of the t e m p o r a l a r e a was i n t e r p r e t e d as lipoma. She returned to our clinic in ,June 1967. complail.ing of a g r a d u a l increese in size of the t e m p o r a l mass a n d an increase in the proptosis. In a d d i t i o n , she h a d experienced several brief vertiginous episodes a c c o m p a n i e d by nausea. She refused t r e a t m e n t until .lanuary 1968. At t h a t t i m e . the m a n d i b l e devia~ed to the right when she o p e n e d her mouth, and t h e r e was obvious proptosis and fullness in the right t e m p o r a l region. Skull and orbital roentgenog r a m s revealed a m e n i n g i o m a involving the greater and lesser wings of t h e right sphenoid bone a n d t h e lateral wall of the right orbit. On F e b r u a r y 12, 196~ a m e n i n gioma of the right sphenoidal ridge was exposed t h r o u g h
The American Jotirnal of Surgery
Extracranlal Meningiomas
a temporal craniectomy. The lesser wing of the sphenoid and the invaded orbital wall were removed. The pathologist reported the tissue as en plaque (4 by 2 by 0.5 cm) meningioma. In March 1971 the patient returned with recurrent fullness bulging the right cheek. (Figure 2.) Total parotidectomy was performed, preserving the facial nerve. The parotid incision was then extended anteriorly, curving into the hairline. The extracranial component of the tumor was removed intact by working superficial to and deep to the branches of the seventh nerve. Total extirpation of the tumor required removing the zygomatic arch and slitting the buccinator muscle to expose the extension of the tumor beneath the buccal mucosa. The meningioma seemed to extend intracranially through the site of the previous craniectomy. The pathologist reported that the meningioma infiltrated the bone of the lateral orbital wall. The patient did well until August 1971, when she noticed a recurrent lump in the right cheek, involving the malar bone. On October 13, 1971 exploration through an incision in the alveolar buccal sulcus revealed a tumor extensively infiltrating the buccinator and external pterygoid muscles. Subtotal removal of the tumor was accomplished. Six month follow-up study revealed no obvious growth of the residual tumor.
C o m m e n t . E x t e n s i o n s of m e n i n g i o m a s intrO the i n f r a t e m p o r a l fossa have p r e v i o u s l y been r e p o r t e d . B e c a u s e of the insidious n a t u r e of m e n i n g i o m a s , we feel justified in r e m o v i n g e x t r a c r a n i a l extensions. T h e follow-up period in two of our p a t i e n t s is too brief to j u d g e the benefit of the p r o c e d u r e ; however, a t h i r t e e n y e a r follow-up s t u d y in one p a t i e n t reflects t h e l e n g t h of s y m p t o m a t i c relief t h a t m a y be e x p e c t e d in c e r t a i n instances. T h e rem o v a l of e x t r a c r a n i a l m e n i n g i o m a s from t h e infrat e m p o r a l area is g r e a t l y f a c i l i t a t e d by first perf o r m i n g total p a r o t i d e c t o m y to expose the course of t h e facial nerve. T h i s allows safe r e m o v a l of t u m o r superficial a n d d e e p to the facial n e r v e plexus.
Figure 2. Case VI. Extracranial meningioma in fiftythree y e a r old woman.
The meningioma involved the glossopharyngeal, vagus, and accessory nerves and extended from the carotid bulb to the base of the skull. (Figure 3.) The superior extent of the tumor reached the base of the,~skull, but intracranial extension along the carotid artery was uncertain. On February 22, 1962 suboccipital craniotomy was performed, and residual meningioma was dissected from the ninth, tenth, and eleventh nerves just within the jugular foramen. The patient was free of disease when last seen in Jan)aary 1971. C a s e V I I I . A fifteen year old girl was first seen in November 1961 because of lateral neck pain, hoarseness, and diplopia of one year's duration. Two mon~{hs prior to our examination, a paralyze~t" left vocal cord
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Jugular Fora m en-Parapharyngeal Region Case VII. A twenty-two year old man was first seen in February 1962. He had been hoarse for two years, and a mass had been present i n the left side of the neck for two months. T h e referring diagnosis was that of a carotid body tumor. Examination revealed a mass in the left upper neck deep to the sternoeleidomastoid muscle. The mass encroached upon the lateral wall of the pharynx and hypopharynx. The left vocal cord was paralyzed. Cervical and base of the skull roentgenograms were negative. The initial impression was that of either a mixed tumor or a neurofibroma. On February 14, 1962 cervical exploration uncovered a large tumor which biopsy proved was a meningioma. Total par0tidectomy was performed, exposing the seventh nerve.
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1973,
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Figure 3. Case VII. Resected meningioma in twenty-two y e a r old man involving the glossopharyngeal, vagus, and accessory nerves and extending from the carotid bulb to the skufl base.
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had been diagnosed. Dysphagia and weakness of the left trapezius muscle also had been noted. Our examination revealed ~nvolvement of the sixth, ninth, tenth, eleventh, and twelfth cranial nerves. Skull roentgenograms, including stereo views of the base, were negative. Lateral and anteroposterior tomograms of the odontoid demonstrated erosion of the clivus and basioccipital region on the left. In addition, a soft tissue mass was noted in the nasopharynx. On November 18, 1961 the posterior fl)ssa was approached through a hockeystick incision. A meningioma was found invading the muscle between the mastoid tip and the base of the skull. Although the base of the skull was superficially eroded, the tumor did not extend intracranially. The anterior extension of the tumor was such that the tumor could not be removed. The pathologist reported that the lesion was a malignant meningioma with many mitotic figures. Postoperative therapy with cobalt 60 did not affect the tumor, and the patient died within nine months from uncontrolled extracranial ~disease; there was never evidence of intracranial involvement. Case IX. A forty-seven year old woman was first seen in November 1970. For the preceding two years, she had suffered from a sharp, jabbing pain that originated in the left temporal region and extended to the left eye. In October 1969 a left serous otitis had been treated with a ventilating tube. In July 1970 she had noticed trigeminal anesthesia on the left. A generalized convulsion precipitated her visit here in November 1970. Physical examination disclosed Horner's syndrome and trigeminal anesthesia, both on the left. Sagging of the left choana and a soft mass covering the left carotid artery were present. An echoencephalogram demonstrated a 2 mm shift to the right. An audiogram revealed a left conductive loss of 60 decibels. Roentgenograms of the petrous pyramid showed evidence of a mass in the left ethmoid sinus eroding the medial wall of the left orbit. Tomograms of the ~thmoid sinus revealed a mass in the left posterior ethmoid area which destroyed the floor of the middle fossa, the left medial orbital wall, and the superior surface of the left petrous bone. On January 7, 1971 an intranasal ethmoid and sphenoid sinus exploration was performed to obtain diagnostic tissue. Biopsy of the tissue in the sphenoid sinus was insufficient for pathologic diagnosis, but an inactive neoplasin of neural origin was considered likely. On January 13, 1971 an incision was made in the left soft palate, and the pharyngeal constrictor was separated to expose a bluish parapharyhgeal mass. Biopsy of the mass was interpreted as a meningotheliomatous meningioma lacking appreciable mitotic activity. O n ' J a n u a r y 19, 1971, after a positive left common carotid arteriogram, a suboccipital craniotomy exposed a grayish tumor extending from ~the middle fossa to obliterate the left trigeminal nerve. Subtotal removal was accomplished. When last seen ~three months after the operation, the patient had no progression of the tumor.
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Comment. F o u r previous p r i m a r y e x t r a c r a n i a l p a r a p h a r y n g e a l m e n i n g i o m a s h a v e been r e p o r t e d [5, 7,14,15]. T o these, we a d d one case o f p r i m a r y p a r a p h a r y n g e a l m e n i n g i o m a , one of a lesion origin a t i n g j u s t within t h e j u g u l a r foramen, a n d one of p a r a p h a r y n g e a l extension from an i n t r a c r a n i a l m e n i n g i o m a . A l t h o u g h u n c o m m o n in t h e p a r a p h a r y n g e a l areas, m e n i n g i o m a s m u s t be considered in t h e differential diagnosis. Nasopharynx Case X. A fifty-five year old man was first examined at our clinic in June 1962, with findings of left exophthalmos and temporal swelling. Roentgenograms of the skull were normal. In July 1962 the left periorbital and temporal swelling had increased rapidly. In addition, the patient's hearing in the left ear declined. Sinus roentgenograms were negative, but physical examination revealed a nasopbaryngeal lesion located at the posterior tip of the inferior turbinate and impinging on the orifice of the eustachian tube. On July 26, 1962 biopsy of the nasopharynx revealed a meningioma. Neurosurgical consultants believed that the meningioma was inoperable because of its intranasal extension. The patient received cobalt 60 (5,800 rads) therapy, but he returned in December 1962 because of left retro-orbital pain. T h e swelling over the zygomatic arch and temporomandibular joint had increased. There was no hearing in the left ear. Skull roentgenograms showed a soft tissue mass in the nasopharynx which extended to the left sphenoid and posterior ethmold sinuses. The mass eroded the floor of the middle fossa. Symptomatic treatment was instituted, and follow-up study in June 1972 disclosed no further progression of the tumor.
Comment. S p h e n o i d a l ridge m e n i n g i o m a s occasionally s p r e a d into t h e o r b i t a n d n a s o p h a r y n g e a l regions. W h e n c o n f r o n t e d w i t h a n a s o p h a r y n g e a l mass, the otolaryngologist m u s t consider extensions from i n t r a c r a n i a l n e o p l a s m s in his differential diagnosis.
Summary E x t r a c r a n i a l m e n i n g i o m a s , either p r i m a r y or s e c o n d a r y , m a y p r e s e n t in n u m e r o u s sites a b o u t the h e a d a n d neck. We have d e s c r i b e d p r i m a r y e x t r a c r a n i a l m e n i n g i 0 m a s of t h e m i d d l e ear a n d j u g u l a r f o r a m e n - p a r a p h a r y f f g e a l regions. S u r g i c a l e x t i r p a t i o n of s u c h m e n i n g i o m a s s h o u l d provide a good prognosis if r e m o v a l is c o m p l e t e . For t u m o r s in t h e i n f r a t e m p o r a l region, p r e l i m i n a r y t o t a l p a r o t i d e c t o m y exposes the facial nerve So t h a t t h e s u r r o u n d i n g t u m o r m a y be r e m o v e d w i t h o u t inj u r i n g t h e nerve. W i t h p a t i e n t s who h a v e e x t r a -
The American Journal of Surgery
Extracranial Meningiornas
cranial extensions of intracranial meningiomas, the surgeon m a y be reluctant to excise the extracranial component, i,T~wever, follow-up s t u d y of cases in which extracranial excision was performed suggests t h a t long-term relief from pain and disfiguration may be expected. The intracranial component m a y be removed at a second-stage procedure, or in certain instances, the patient may be observed. Consultation with a neurosurgeon is essential in determining the appropriate therapeutic course. References 1. Courville CB, Abbott KH: The histogenesis of meningiomas: with particular reference to the origin of the 'meningothelial' variety. J Neuropathol Exp Neurol 1: 337, 1942. 2. Cushing HW: Meningiomas: Their Classification, Regional Behaviour, Life History, and Surgical End Results. Springfield, III, Thomas, 1938. 3. Nager GT: Meningiomas Involving the Temporal Bone: Clinical and Pathological Aspects. Springfield, III, Thomas, 1964. 4. Craig WMcK, Gogela L3: Intraorbital meningiomas: a
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5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
clinicopathologic study. Am J Ophthalmol 32: 1663, 1949. Hallgrimsson J, Bjornsson A, Gudmundsson G: Meningioma of the neck: case report. J Neurosurg 32: 695, 1970. New GB, Devine KD: Neurogenic tumors of nose and throat. Arch Otolaryngo146:163, 1947. Shuangshoti S, Netsky MG, Fitz-Hugh GS: Parapharyngeal meningioma: with special reference to cell of origin. Ann Otol Rhinol Laryngo180: 464, 1971. Bain GO, Shnitka TK: Cutaneous meningioma (psammoma): report of a case. Arch Dermato174: 590, 1956. Harkin JC, Reed RJ: Tumors of the peripheral nervous system. Atlas of Tumor Pathology, Fascicle 3. Washington, Armed Forces Institute of Pathology, 1969. Benedict WL: Tumors and cysts arising near the apex of the orbit. Am J Ophthalmol 6: 183, 1923. Wiegmann E: Ein Fall yon Psammon der Orbita. Ktin Monatsbl Augenheilkd 82: 232, 1929. Kettel K: Peripheral Facial Palsy: Pathology and Surgery. Springfield, I11,Thomas, 1959. Debain JJ, Siardet J, Francois J, et al: Mbningiome du nerf facial intratympanique. Ann Oto-laryngol (Paris) 83: 397, 1966. Hoye SJ, Hoar CS Jr, Murray JE: Extracranial meningioma presenting as a tumor of the neck. Am J Surg 100: 486, 1960. Suzuki H, Gilbert EF, Zimmermann B: Primary extracranial meningioma. Arch Patho184: 202, 1967.
~,7
Diagnostic and Therapeutic Problems in Extracranial Meningiomas
James H. Whicker, MD, Rochester, Minnesota Kenneth D. Devine, MD, Rochester, Minnesota Collin S. MacCarty, MD, Rochester, Minnesota
Extracranial meningiomas, either primary or secondary, are often difficult to diagnose and treat. 'Fo establish the common sites of extracranial presentation and to develop guidelines for treatment, we reviewed tile charts of 1,768 patients with meningiomas seen at our clinic from 1946 to 1971. Patients with orbital, cutaneous, spinal, or readily diagnosable intracranial meningiomas were excluded. Sixteen patients had primary extracranial meningiumas or extracranial extensions of intracranial meningiomas that posed unusual diagnostic or therapeutic problems. The cases of ten patients who typify the group are presented. The meningocyte has been confirmed as the cellular origin of meningiomas [1,2]. The meningocytes compose the arachnoid-lining cells that cluster about the tips of the arachnoid villi. The anatomic incidence of meningiomas closely corresponds to the location of the arachnoid villi [3]. Although the mode of occurrence of intracraniai meningiomas is well established, the mode of occurrence of extracranial meningiomas is not uniFrom the Mayo Clinic and Mayo Foundation, Rochester. Minnesota. Reprint requests should be addressed to the Section of Publications, Mayo Clinic, Rochester, Minnesota 55901. Presented at the First Joint Meeting of the Society o ~, Head and Neck Surgeons and the American Society for Head and Neck Surgery, Hot Springs. Virginia, April 30 to May 2, 1973.
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versally accepted. Several theories have been advanced to explain the occurrence of ectopic meningiomas. The more widely accepted theory suggests that meningiomas arise from meningocytic cellular rests [4-6l. These cellular rests have been demonstrated within the sheaths of cranial nerves at their sites of exit through the skull foramina. A second theory, based on the histology of the cellular components of meningiomas, that these tumors may arise directly from meseuehymal cells including meningocytes, fibroblasts, and Schwann cells was proposed by Shuangshoti, Netsky, and Filz-Hugh [7]. These authors regard meningocytes as specialized fibroblasts of mesenchymal origin. The intimate relation among meningocytes, fibroblasts, and Schwann cells occurs because of their common mesen~hymal origin and.explains the diverse histologic features commonly found in meningiomas. This theory explains the occurrence of ectopic meningiomas unrelated either to skull and intravertebral foramina or to cranial sutures [8-I I ]. For ease of comparison and discussion, the ten cases are grouped according to the anatomic site of presentation of the tumor. The anatomic sites include the middle ear, infratemporal fossa, nasopharynx, and parapharyngeal-jugular foramen region.
The American Journal of Surgery
Extracranial Meningiomas
Case Reports The Ear
Case |. A fifty-four year old woman was first examined in December 1945. She complained of tinnitus (two years) and progressive hearing h)ss (three months) in the left ear. A solid, brown tumor filled the external auditory canal, preventing visualization of the tympanic membrane. Although findings on skull roentgenograms were normal, roentgenograms of the mastoid region demonstrated cellular destruction within the mastoid process. On December 12, 1945, radical mastoidectomy revealed a tumor over the horizontal course of the facial nerve. The tumor extended through the antrum into the mastoid, and a finger-like projection extended into the eustachian tube. No intracranial extension was found. The tumor was totally removed, and radium ele m e n t points were inserted for twenty-four hours. The pathologist reported that the lesion was a meningioma with psammoma bodies. After the operation the patient experienced transient facial weakness and aphasia; however, these symptoms cleared completely within two weeks. She was lost to follow-up study after six months, but examination at that time revealed no recurrence. Case |1. A fifty-five year old woman was first seen in April 1957 because of a progressive hearing loss of five years' duration in the right ear. In addition, she had experienced pulsatile tinnitus and vertiginous attacks during the preceding two years. In 1955 and 1957, tissue, reported by the pathologist as chemodectoma, had been removed from the right external canal. Our examination revealed a firm, pink growth in the right external auditory canal. An audiogram demonstrated a mild conductive hearing loss on the right. Findings on roentgenograms of the mastoid region were normal. At surgery "a large portion" of the tumor was removed from the external canal and middle ear. The pathologic diagnosis was meningioma. After the operation she received combined intraoral and external irradiation. At her last examination in 1972, she was free of disease. Case Ill. A forty-two year old woman was first seen in April 1956. She had had pulsatile tinnitus, fullness, and hearing loss in the left ear for two years. Several previous myringotomies had not improved the symptoms. An audiogram demonstrated a mild sensorineural loss above 4,000 Hz in the left ear. A reddish area was seen behind the anterosuperior quadrant of the left tympanic, membrane. In addition, hyperplastie lymphoid tissue filled the left fossa of Rosenmtiller. On April 25, 1956 exploratory tympanotomy revealed only a bluish discoh)ration of tbe promontory. Four days later the nasopharynx was subjected to beta radon applications (50 rag). In September 1956 fluid was aspirated from the left middle ear. In April 1957 she noted trigeminal paresthesias; moreover, a small mass was
Volume 126, October 1973
seen behind the posteroinferior quadrant of the tympanic membrane. Roentgenograms of the mastoid region showed cloudy air cells and periantral sclerosis, with questionable enlargement of the internal auditor). meatus. Roentgenograms of the skull, including base views, showed no abnormalities. On April 5, 1957 modified radical mastoidectomy exposed a tumor surrounding the incus and extending into the antrum. No bony dehiscence of the tegmen was fl)und. The tumor was removed, and 3,000 rads of cobalt 60 irradiation were delivered after the operation. The pathologist reported that the tissue was a meningioma. At postoperative examination in April 1967, there was no tumor recurrence or progression of the trigem!:ml Faresthesias. Roentgenograms of the skull, with Stenver's views, showed only postoperative changes. When re-examined in June 1972 the patient had no recurrence.
Comment. In his review of t e m p o r a l bone m e n i n g i o m a s , N a g e r [3] p o s t u l a t e d t h a t these tumors o r i g i n a t e d from a r a c h n o i d g r a n u l a t i o n s in t h e following locations: (1) the internal a u d i t o r y m e a t u s a l o n g the s h e a t h s of the facial a n d vestibular nerves, (2) the j u g u l a r f o r a m e n s u r r o u n d i n g the glossopharyngeal, vagus, a n d accessory nerves, and (3) along the course of the greater superficial petrosal nerve. He described six p a t i e n t s who had p r o b a b l e m i d d l e ear m e n i n g i o m a s ; however, five of the six p a t i e n t s h a d bony d e s t r u c t i o n of the m i d d l e cranial fossa or the petrous portion of the t e m p o r a l bone, s u g g e s t i n g an i n t r a c r a n i a l c o m p o nent. In his series, follow-up d a t a were e i t h e r brief or not available. Therefore, only one p a t i e n t had an u n d e n i a b l e e c t o p i c m e n i n g i o m a of t h e m i d d l e ear. T w o o t h e r m e n i n g i o m a s of the m i d d l e ear have been described [12,13]. Of the three p a t i e n t s in our series, one h a d no i n t r a c r a n i a l signs or s y m p t o m s . O n e h a d trigeminal p a r e s t h e s i a s ; however, a fourteen y e a r followu p s t u d y revealed no progression of the t r i g e m i n a l neuralgia or d e v e l o p m e n t of o t h e r s y m p t o m s suggestive of i n t r a c r a n i a l i n v o l v e m e n t . O n e p a t i e n t had t r a n s i e n t a p h a s i a in the i m m e d i a t e postoperative period, m a k i n g exclusion of an i n t r a c r a n i a l c o m p o n e n t difficult. O u r three p a t i e n t s h a d tinnitus, u s u a l l y pulsatile, a n d progressive h e a r i n g loss. A c o n s t a n t finding was a reddish brown mass p r e s e n t i n g in the external canal or b e h i n d the t y m p a n i c m e m b r a n e . A u d i o g r a m s revealed c o n d u c t i v e losses in two patients whereas the third h a d a h i g h - f r e q u e n c y sensorineural hearing loss t h a t was p r o b a b l y unrelated to the disease. A m e n i n g i o m a of the m i d d l e ear m a y m i m i c the s y m p t o m s a n d a p p e a r a n c e of a chemodectoma.
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C Figure 1. Case V. Recurrent extracranial meningioma in forty year old woman. A and B, sphenoidal ridge menin. gioma (12 by 20 cm) before operation. C, meningioma after right maxillectomy.
In[rttt ernporal I,'f)ssa C a s e IV. In N o v e m b e r 19t'~ a fifty-four y e a r - o l d woman was initially seen because of right facial p a i n of seven y e a r s ' duration. Because chewing e x a c e r b a t e d the pain, surgical correction of the malocclusion was performed, without henefit, in 1967. l,ocal a n e s t h e t i c injections also failed to relieve the facial pain. E x a m i nation disclosed facial a s y m m e t r y resulting from fullness over the right z y g o m a t i c area. Skull and facial roentgen~grams, including special views of the zygomatic arch, suggested the extension of a sphenoidal ridge m e a i n g i o m a t() the region of t h e right t e m p o r o m a n d i b u l a r joint. T h e t u m o r also involved the lateral a n d inferior walls of the orbit. Sinus roentgenograms gave negative resuhs. On N o v e m b e r 27, 1968 right total p a r o t i d e e t o m y was perfiwmed, exposing and preserving the facial nerve. T h e p a r o t i d e c t o m y incision was then curved anteriorly above the hairline. T h e t e m p o r a l muscle was e l e v a t e d until the tum~w was fi)und invading the muscle and t;one in t h e infratemporal fossa. T h e spaces d e e p to the zygoma and posterior to t h e ant r u m were filled with tumor. T h e m a n d i b u l a r r a m u s a n d t m u o r m a s s were resected en bloc, and the t u m o r was t r a n s e c t e d a t the point where it e x t e n d e d intracranially. T h e pathologist reported that the t u m o r was a m e n i n g i o e p i t h e l i o m a t o u s m e n i n g i o m a (11 by 5 by ;~ cm). On D e c e m b e r 4, 1968 a right retrograde b r a c h i a l angiogram d e m o n s t r a t e d an a v a s c u l a r lesion in the right t e m p o r a l area d i s p l a c i n g the m i d d l e cerebral complex superiorly, posteriorly, a n d medially, with some associated sclerosis of the g r e a t e r wing of the sphenoid bone. On D e c e m b e r 10, 1968 the t u m o r was a p p r o a c h e d through a right t e m p o r a l c r a n i e c t o m y and was found to lie in the m i d d l e fossa e x t e n d i n g to, but not medial to, the foramen ovale. T o t a l removal of the t u m o r was a c c o m p l i s h e d . In a follow-up letter in April 1972 the patient reported t h a t her h e a l t h was normal. C a s e V. A forty y e a r old w o m a n h a d c r a n i o t o m y in 1937 for a ~phenoidal ridge m e n i n g i o m a . Recurrence m a d e necessary the e n u c l e a t i o n of the right eye in
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1941. Recurrent m e n i n g i o m a d i s t o r t i n g the right side of the face p r o m p t e d her visit to us i~a October 1952. (Figure IA and B.) Roentgenograms of the skull sh~)wed an osteomatous reaction involving the right facial a n d frontal btmes a n d the floor of the anterior a n d m i d d l e fossae, T h e previous c r a n i o t o m y hone flap was also involved. Facial views d e m o n s t r a t e d an irregularity of the external surface of the zyg~maatic process of t h e right maxilla. A p n e u m o e n c e p h a l o g r a m revealed a slight shift of the latPral and third ventricles to the left. On O c t o b e r 22. 1952 a s t a n d a r d m a x i l l e c t o m y incision revealed t u m o r filling the orbit, a n t r u m , and r e t r o m a x i l l a r y fossa, and bulging the frontal a n d temporal regions. Because of the size of the t u m o r (t'2 by 20 cm). right m a x i l l e c t o m y was necessary. (Figure 1C.) Persistent hypotension forced t e r m i n a t i o n of the operation. although t u m o r r e m a i n e d in the orbit and at the site of the previous c r a n i o t o m y . T h e p a t i e n t refused a second-stage i n t r a c r a n i a l procedure, h u t on follow-up s t u d y in 1965 (thirteen years after the operation), the p a t i e n t enjoyed excellent h e a l t h with no a p p a r e n t recurrence of the ext racranial c o m p o n e n t . C a s e V l . A forty-six y e a r old woman was seen in 1965 because of fullness in t h e right temporal area a n d slight proptosis of the right eye. T h e p a t i e n t refused further e v a l u a t i o n after the p r e l i m i n a r y e x a m i n a t i o n . In 1966 a t a n o t h e r institution, hiops3 of the t e m p o r a l a r e a was i n t e r p r e t e d as lipoma. She returned to our clinic in ,June 1967. complail.ing of a g r a d u a l increese in size of the t e m p o r a l mass a n d an increase in the proptosis. In a d d i t i o n , she h a d experienced several brief vertiginous episodes a c c o m p a n i e d by nausea. She refused t r e a t m e n t until .lanuary 1968. At t h a t t i m e . the m a n d i b l e devia~ed to the right when she o p e n e d her mouth, and t h e r e was obvious proptosis and fullness in the right t e m p o r a l region. Skull and orbital roentgenog r a m s revealed a m e n i n g i o m a involving the greater and lesser wings of t h e right sphenoid bone a n d t h e lateral wall of the right orbit. On F e b r u a r y 12, 196~ a m e n i n gioma of the right sphenoidal ridge was exposed t h r o u g h
The American Jotirnal of Surgery
Extracranlal Meningiomas
a temporal craniectomy. The lesser wing of the sphenoid and the invaded orbital wall were removed. The pathologist reported the tissue as en plaque (4 by 2 by 0.5 cm) meningioma. In March 1971 the patient returned with recurrent fullness bulging the right cheek. (Figure 2.) Total parotidectomy was performed, preserving the facial nerve. The parotid incision was then extended anteriorly, curving into the hairline. The extracranial component of the tumor was removed intact by working superficial to and deep to the branches of the seventh nerve. Total extirpation of the tumor required removing the zygomatic arch and slitting the buccinator muscle to expose the extension of the tumor beneath the buccal mucosa. The meningioma seemed to extend intracranially through the site of the previous craniectomy. The pathologist reported that the meningioma infiltrated the bone of the lateral orbital wall. The patient did well until August 1971, when she noticed a recurrent lump in the right cheek, involving the malar bone. On October 13, 1971 exploration through an incision in the alveolar buccal sulcus revealed a tumor extensively infiltrating the buccinator and external pterygoid muscles. Subtotal removal of the tumor was accomplished. Six month follow-up study revealed no obvious growth of the residual tumor.
C o m m e n t . E x t e n s i o n s of m e n i n g i o m a s intrO the i n f r a t e m p o r a l fossa have p r e v i o u s l y been r e p o r t e d . B e c a u s e of the insidious n a t u r e of m e n i n g i o m a s , we feel justified in r e m o v i n g e x t r a c r a n i a l extensions. T h e follow-up period in two of our p a t i e n t s is too brief to j u d g e the benefit of the p r o c e d u r e ; however, a t h i r t e e n y e a r follow-up s t u d y in one p a t i e n t reflects t h e l e n g t h of s y m p t o m a t i c relief t h a t m a y be e x p e c t e d in c e r t a i n instances. T h e rem o v a l of e x t r a c r a n i a l m e n i n g i o m a s from t h e infrat e m p o r a l area is g r e a t l y f a c i l i t a t e d by first perf o r m i n g total p a r o t i d e c t o m y to expose the course of t h e facial nerve. T h i s allows safe r e m o v a l of t u m o r superficial a n d d e e p to the facial n e r v e plexus.
Figure 2. Case VI. Extracranial meningioma in fiftythree y e a r old woman.
The meningioma involved the glossopharyngeal, vagus, and accessory nerves and extended from the carotid bulb to the base of the skull. (Figure 3.) The superior extent of the tumor reached the base of the,~skull, but intracranial extension along the carotid artery was uncertain. On February 22, 1962 suboccipital craniotomy was performed, and residual meningioma was dissected from the ninth, tenth, and eleventh nerves just within the jugular foramen. The patient was free of disease when last seen in Jan)aary 1971. C a s e V I I I . A fifteen year old girl was first seen in November 1961 because of lateral neck pain, hoarseness, and diplopia of one year's duration. Two mon~{hs prior to our examination, a paralyze~t" left vocal cord
t/
Jugular Fora m en-Parapharyngeal Region Case VII. A twenty-two year old man was first seen in February 1962. He had been hoarse for two years, and a mass had been present i n the left side of the neck for two months. T h e referring diagnosis was that of a carotid body tumor. Examination revealed a mass in the left upper neck deep to the sternoeleidomastoid muscle. The mass encroached upon the lateral wall of the pharynx and hypopharynx. The left vocal cord was paralyzed. Cervical and base of the skull roentgenograms were negative. The initial impression was that of either a mixed tumor or a neurofibroma. On February 14, 1962 cervical exploration uncovered a large tumor which biopsy proved was a meningioma. Total par0tidectomy was performed, exposing the seventh nerve.
Volume 126, October
1973,
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Figure 3. Case VII. Resected meningioma in twenty-two y e a r old man involving the glossopharyngeal, vagus, and accessory nerves and extending from the carotid bulb to the skufl base.
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had been diagnosed. Dysphagia and weakness of the left trapezius muscle also had been noted. Our examination revealed ~nvolvement of the sixth, ninth, tenth, eleventh, and twelfth cranial nerves. Skull roentgenograms, including stereo views of the base, were negative. Lateral and anteroposterior tomograms of the odontoid demonstrated erosion of the clivus and basioccipital region on the left. In addition, a soft tissue mass was noted in the nasopharynx. On November 18, 1961 the posterior fl)ssa was approached through a hockeystick incision. A meningioma was found invading the muscle between the mastoid tip and the base of the skull. Although the base of the skull was superficially eroded, the tumor did not extend intracranially. The anterior extension of the tumor was such that the tumor could not be removed. The pathologist reported that the lesion was a malignant meningioma with many mitotic figures. Postoperative therapy with cobalt 60 did not affect the tumor, and the patient died within nine months from uncontrolled extracranial ~disease; there was never evidence of intracranial involvement. Case IX. A forty-seven year old woman was first seen in November 1970. For the preceding two years, she had suffered from a sharp, jabbing pain that originated in the left temporal region and extended to the left eye. In October 1969 a left serous otitis had been treated with a ventilating tube. In July 1970 she had noticed trigeminal anesthesia on the left. A generalized convulsion precipitated her visit here in November 1970. Physical examination disclosed Horner's syndrome and trigeminal anesthesia, both on the left. Sagging of the left choana and a soft mass covering the left carotid artery were present. An echoencephalogram demonstrated a 2 mm shift to the right. An audiogram revealed a left conductive loss of 60 decibels. Roentgenograms of the petrous pyramid showed evidence of a mass in the left ethmoid sinus eroding the medial wall of the left orbit. Tomograms of the ~thmoid sinus revealed a mass in the left posterior ethmoid area which destroyed the floor of the middle fossa, the left medial orbital wall, and the superior surface of the left petrous bone. On January 7, 1971 an intranasal ethmoid and sphenoid sinus exploration was performed to obtain diagnostic tissue. Biopsy of the tissue in the sphenoid sinus was insufficient for pathologic diagnosis, but an inactive neoplasin of neural origin was considered likely. On January 13, 1971 an incision was made in the left soft palate, and the pharyngeal constrictor was separated to expose a bluish parapharyhgeal mass. Biopsy of the mass was interpreted as a meningotheliomatous meningioma lacking appreciable mitotic activity. O n ' J a n u a r y 19, 1971, after a positive left common carotid arteriogram, a suboccipital craniotomy exposed a grayish tumor extending from ~the middle fossa to obliterate the left trigeminal nerve. Subtotal removal was accomplished. When last seen ~three months after the operation, the patient had no progression of the tumor.
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Comment. F o u r previous p r i m a r y e x t r a c r a n i a l p a r a p h a r y n g e a l m e n i n g i o m a s h a v e been r e p o r t e d [5, 7,14,15]. T o these, we a d d one case o f p r i m a r y p a r a p h a r y n g e a l m e n i n g i o m a , one of a lesion origin a t i n g j u s t within t h e j u g u l a r foramen, a n d one of p a r a p h a r y n g e a l extension from an i n t r a c r a n i a l m e n i n g i o m a . A l t h o u g h u n c o m m o n in t h e p a r a p h a r y n g e a l areas, m e n i n g i o m a s m u s t be considered in t h e differential diagnosis. Nasopharynx Case X. A fifty-five year old man was first examined at our clinic in June 1962, with findings of left exophthalmos and temporal swelling. Roentgenograms of the skull were normal. In July 1962 the left periorbital and temporal swelling had increased rapidly. In addition, the patient's hearing in the left ear declined. Sinus roentgenograms were negative, but physical examination revealed a nasopbaryngeal lesion located at the posterior tip of the inferior turbinate and impinging on the orifice of the eustachian tube. On July 26, 1962 biopsy of the nasopharynx revealed a meningioma. Neurosurgical consultants believed that the meningioma was inoperable because of its intranasal extension. The patient received cobalt 60 (5,800 rads) therapy, but he returned in December 1962 because of left retro-orbital pain. T h e swelling over the zygomatic arch and temporomandibular joint had increased. There was no hearing in the left ear. Skull roentgenograms showed a soft tissue mass in the nasopharynx which extended to the left sphenoid and posterior ethmold sinuses. The mass eroded the floor of the middle fossa. Symptomatic treatment was instituted, and follow-up study in June 1972 disclosed no further progression of the tumor.
Comment. S p h e n o i d a l ridge m e n i n g i o m a s occasionally s p r e a d into t h e o r b i t a n d n a s o p h a r y n g e a l regions. W h e n c o n f r o n t e d w i t h a n a s o p h a r y n g e a l mass, the otolaryngologist m u s t consider extensions from i n t r a c r a n i a l n e o p l a s m s in his differential diagnosis.
Summary E x t r a c r a n i a l m e n i n g i o m a s , either p r i m a r y or s e c o n d a r y , m a y p r e s e n t in n u m e r o u s sites a b o u t the h e a d a n d neck. We have d e s c r i b e d p r i m a r y e x t r a c r a n i a l m e n i n g i 0 m a s of t h e m i d d l e ear a n d j u g u l a r f o r a m e n - p a r a p h a r y f f g e a l regions. S u r g i c a l e x t i r p a t i o n of s u c h m e n i n g i o m a s s h o u l d provide a good prognosis if r e m o v a l is c o m p l e t e . For t u m o r s in t h e i n f r a t e m p o r a l region, p r e l i m i n a r y t o t a l p a r o t i d e c t o m y exposes the facial nerve So t h a t t h e s u r r o u n d i n g t u m o r m a y be r e m o v e d w i t h o u t inj u r i n g t h e nerve. W i t h p a t i e n t s who h a v e e x t r a -
The American Journal of Surgery
Extracranial Meningiornas
cranial extensions of intracranial meningiomas, the surgeon m a y be reluctant to excise the extracranial component, i,T~wever, follow-up s t u d y of cases in which extracranial excision was performed suggests t h a t long-term relief from pain and disfiguration may be expected. The intracranial component m a y be removed at a second-stage procedure, or in certain instances, the patient may be observed. Consultation with a neurosurgeon is essential in determining the appropriate therapeutic course. References 1. Courville CB, Abbott KH: The histogenesis of meningiomas: with particular reference to the origin of the 'meningothelial' variety. J Neuropathol Exp Neurol 1: 337, 1942. 2. Cushing HW: Meningiomas: Their Classification, Regional Behaviour, Life History, and Surgical End Results. Springfield, III, Thomas, 1938. 3. Nager GT: Meningiomas Involving the Temporal Bone: Clinical and Pathological Aspects. Springfield, III, Thomas, 1964. 4. Craig WMcK, Gogela L3: Intraorbital meningiomas: a
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5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
clinicopathologic study. Am J Ophthalmol 32: 1663, 1949. Hallgrimsson J, Bjornsson A, Gudmundsson G: Meningioma of the neck: case report. J Neurosurg 32: 695, 1970. New GB, Devine KD: Neurogenic tumors of nose and throat. Arch Otolaryngo146:163, 1947. Shuangshoti S, Netsky MG, Fitz-Hugh GS: Parapharyngeal meningioma: with special reference to cell of origin. Ann Otol Rhinol Laryngo180: 464, 1971. Bain GO, Shnitka TK: Cutaneous meningioma (psammoma): report of a case. Arch Dermato174: 590, 1956. Harkin JC, Reed RJ: Tumors of the peripheral nervous system. Atlas of Tumor Pathology, Fascicle 3. Washington, Armed Forces Institute of Pathology, 1969. Benedict WL: Tumors and cysts arising near the apex of the orbit. Am J Ophthalmol 6: 183, 1923. Wiegmann E: Ein Fall yon Psammon der Orbita. Ktin Monatsbl Augenheilkd 82: 232, 1929. Kettel K: Peripheral Facial Palsy: Pathology and Surgery. Springfield, I11,Thomas, 1959. Debain JJ, Siardet J, Francois J, et al: Mbningiome du nerf facial intratympanique. Ann Oto-laryngol (Paris) 83: 397, 1966. Hoye SJ, Hoar CS Jr, Murray JE: Extracranial meningioma presenting as a tumor of the neck. Am J Surg 100: 486, 1960. Suzuki H, Gilbert EF, Zimmermann B: Primary extracranial meningioma. Arch Patho184: 202, 1967.
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