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CT evaluation of a tympanic-jugular chemodectoma : A case report
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Computerized Radio/. Vol. 7, No. 4, pp. 251-255. 1983 Printedin the U.S.A. All rights reserved
Copyright
0 Pergamon
Press Ltd
CT EVALUATION OF A TYMPANIC-JUGULAR CHEMODECTOMA: A CASE REPORT I.
PANDOLFO, E. SCRIBANO, M. LONCO, L. LAVAGNINI Istituto
and S.
TERMINI
di Scienze Radiologiche dell’Universita di Messina, Italy
(Rrceiued 22 April 1982; in reuisedfirm
22 April 1982; receivedfor publicatiou 23 December 1982)
Abstract-The authors describe a case of a chemodectoma involving the tympanic-jugular region, studied by means of Computed Tomography. They underline the utility of this method in spatial evaluation of such tumors. Chemodectoma
Computed tomography
INTRODUCTION
The chemodectoma or non-chromaffin paraganglioma is a neoplasm which is rarely found. It can appear in any region where chemoreceptor tissue is present. The most frequent starting points are the regions of jugular bulb, middle ear (glomus timpanicum), carotid body and intravagal glomus [l-7]. The tympanic-jugular area seems to be statistically the most favoured as it has the highest percentage of glomic tissue [2,8]. There is no doubt that the term tympanic-jugular tumor is rather vague and mainly due to the impossibility of defining, in most cases, the real starting point of the mass (middle ear, jugular gulf or intravagal glomus), after it has reached a certain volume. Such tumors are not particularly aggressive, represented by slight tendency to metastasize and very slow growth. The development of chemodectoma from a clinical point of view is easily mistaken for rather nonspecific symptoms of otological and neurological order. The non-specific symptoms and the slow growth render the early diagnosis very difficult of such neoplasms which, when diagnosed, appear rather extended and thus render surgery difficult. During their development, tympanic-jugular chemodectomas preferably follow certain pathways, destroying the structures they come in contact with. The most common way of propagation is the expansion along the external acoustic meatus after spreading through the tympanic membrane [S]. Less common is the posterior-superior extension through the tegmen tympani and posterior part of the base of the skull, with subsequent involvement of the posterior and/or middle cranial fossa [S]. More rarely found is the medial extension with invasion of the structures of the internal ear and growth towards the rhinopharynx [6-S]. Also, the cervical invasion with growth along the carotidjugular axis [8] is considerably rare. The purpose of this paper is to furnish the CT evidence of the distribution of a chemodectoma involving the tympanic-jugular area, with particular reference to the pathways followed by the tumor in its development. CASE
REPORT
R.R. is a female who is 60 years of age. For some years the patient has complained of headache, cervical pains, increasing hypoacusia, tinnitus and vertigo. A sudden and modest episode of hemorrhage from the left ear indicated the patient’s need for an otoscopy which revealed the destruction of the tympanic membrane on the left side. The membrane seemed to have been replaced by a polypoid brownish tissue, which bled easily. A neurologic examination evidenced a slight deficiency of the X, IX and XII ipsilateral cranial nerves. The diagnostic suspicion of chemodectoma was later confirmed by examination of a fragment of tissue removed at biopsy (Fig. 1). The patient was then sent to us for CT examination for better spatial evaluation of the neoplasm. 251
252
I. PANDOLFO er al.
Fig. 1.
The examination was carried out by a Pfizer 0450 scanner (5”). The axial slices through the facial bones (Figs 2-3), indicated the presence of a mass of density similar to the soft tissues. There was an extrinsic impression on the wall of the rhinopharinx flattening the Rosenmuller fossa. The mass developed in the left retrostyloid fossa thus causing the lateral displacement of the styloid process (see arrows in Figs 2 and 3). Moreover, it appeared separated from the pterygoid muscles by a fat plane (arrowheads, Figs 2 and 3). In the lower slices it was possible to follow the tumor as far as the hyoid region where an extrinsic impression on the pharynx was still visible (Fig. 4). The coronal slices provided further definition in the evaluation of both the development of the mass (in the parapharyngeal area) and the relationship between the tumor and the pterygoid muscles (Fig. 5). The CT furnished evidence of the destruction of the medial two-thirds of the petrous bone and the posterior part of the base, with subsequent spread of the mass into the middle and posterior cranial fossa (Figs 6 and 7).
Fig. 2
CT evaluation of a tympanic-jugular
253
chemodectoma
Fig. 4.
Fig. 3.
The intravenous administration of contrast medium (100 ml of a solution of sodium and methylglucamine diatrizoate 60%) caused a marked enhancement of the neoplasm (which is expression of an hypervascularity characteristic of these tumors). Finally a slice through the mastoid processes showed persistent opacity of the left sigmoid sinus which appeared to be expanded by probable neoplastic invasion (arrows Fig. 8). DISCUSSION During its slow growth, the chemodectoma tend to develop in various directions, reaching regions extremely different from one another (base of the skull, posterior and middle cranial fossa, the neck, facial bones) [S-S].
Fig. 5.
Fig. 6.
254
I. PAND~LFO
et al.
Fig. I.
Fig. 8.
This characteristic was the cause of numerous difficulties in the spatial evaluation of such tumors, before CT was available. By means of this examination, it is in fact possible to make an accurate evaluation of the extension of the tumor in its intracranial spread, and visualizing, as in our case, regions which would not be otherwise explorable [3-53. In the study of the chemodectomas of the tympanic-jugular region, CT is therefore an essential and irreplaceable preangiographic diagnosis medium. Moreover, it appears to be the most appropriate method in the follow-up of the patients treated with embolization or radiotherapy.
REFERENCES 1. S. T. Eraso, Roentgen and clinical diagnosis of glomus jugular tumors. Four cases and a new radiographic technique, Radiology, 77, 252-256 (1961). 2. S. R. Guild, Glomus jugulare, a nonchromaffin paraganglioma in man, Ann. Otol., Rhin. Lar. 62, 1045-1071 (1953). 3. J. R. Hesselink, P. F. G. New, K. R. Davis, A. L. Weber, G. H. Roberson and J. M. Taveras, Computed tomography of the paranasal sinuses and face: Part I normal anatomy, .I. Comput. assist. Tomogr. 2, 559-567 (1978). 4. J. R. Hesselink, P. F. G. New, K. R. Davis, A. L. Weber, G. H. Roberson and J. M. Taveras, Computed tomography of the paranasal sinuses and face: Part II pathological anatomy, J. comput. assist. Tomogr. 2, 568-576 (1978). 5. E. M. Miller and D. Norman, The role of computed tomography in the evaluation of neck masses, Radiology, 133, 145-149 (1979). 6. P. A. Riemenscheider, G. D. Hoople, D. Brewer, D. Joned, A. Ecker, Roentgenorgraphic diagnosis of tumors of the glomus jugularis, Am. J. Roentg. 69, 59-65 (1953). 1. R. P. and C. B. Holman, Roentgenographic manifestations of the glomus jugulare (chemodectoma), Am. J. Roentg. 89, 1201-1208 (1963). 8. T. N. Rucker, Radiology of glomus jugulare tumors in the temporal bone, Radiology, 81, 807-816 (1963). About the Author-I. PANDOLFO was born in Messina in 1947 and took a degree in medicine at University in 1972. Since 1972, he has been assistant radiologist at the School of Sciences in Radiology at the University where he studies general radiodiagnostics. He has written many publications and he is a partner in the Italian Society of Radiology and Nuclear Medicine (SIRMN). About the Author-E. SCRIBANO was born in Messina in 1947 and took a degree in medicine at University in 1972. Since 1972, he has been assistant radiologist at the School of Sciences of Radiology at the University where he studies general radiodiagnostics He has written publications and is a partner of the Italian Society of Radiology and Nuclear Medicine (SIRMN). Ahout the Author-M. LONGO was born in Messina in 1952 and he took a degree in medicine in 1975. Since 1975 he has been assistant at the School of Neurosurgery at the University of Messine. When he obtained
CT evaluation
of a tympanic-jugular
the Speciahsation in Neurosurgery in 1978, he became of Radiology at the University of Messine.
assistant
255
chemodectoma
neuroradiologist
at the School
of Sciences
About the Authors-L. LAVAGNINI and S. TERMINI took a degree in medicine in 1978 and they attend the Specialisation in Radiology Course at the School of Sciences of Radiology, University of Messine. They have published five articles.
Computerized Radio/. Vol. 7, No. 4, pp. 251-255. 1983 Printedin the U.S.A. All rights reserved
Copyright
0 Pergamon
Press Ltd
CT EVALUATION OF A TYMPANIC-JUGULAR CHEMODECTOMA: A CASE REPORT I.
PANDOLFO, E. SCRIBANO, M. LONCO, L. LAVAGNINI Istituto
and S.
TERMINI
di Scienze Radiologiche dell’Universita di Messina, Italy
(Rrceiued 22 April 1982; in reuisedfirm
22 April 1982; receivedfor publicatiou 23 December 1982)
Abstract-The authors describe a case of a chemodectoma involving the tympanic-jugular region, studied by means of Computed Tomography. They underline the utility of this method in spatial evaluation of such tumors. Chemodectoma
Computed tomography
INTRODUCTION
The chemodectoma or non-chromaffin paraganglioma is a neoplasm which is rarely found. It can appear in any region where chemoreceptor tissue is present. The most frequent starting points are the regions of jugular bulb, middle ear (glomus timpanicum), carotid body and intravagal glomus [l-7]. The tympanic-jugular area seems to be statistically the most favoured as it has the highest percentage of glomic tissue [2,8]. There is no doubt that the term tympanic-jugular tumor is rather vague and mainly due to the impossibility of defining, in most cases, the real starting point of the mass (middle ear, jugular gulf or intravagal glomus), after it has reached a certain volume. Such tumors are not particularly aggressive, represented by slight tendency to metastasize and very slow growth. The development of chemodectoma from a clinical point of view is easily mistaken for rather nonspecific symptoms of otological and neurological order. The non-specific symptoms and the slow growth render the early diagnosis very difficult of such neoplasms which, when diagnosed, appear rather extended and thus render surgery difficult. During their development, tympanic-jugular chemodectomas preferably follow certain pathways, destroying the structures they come in contact with. The most common way of propagation is the expansion along the external acoustic meatus after spreading through the tympanic membrane [S]. Less common is the posterior-superior extension through the tegmen tympani and posterior part of the base of the skull, with subsequent involvement of the posterior and/or middle cranial fossa [S]. More rarely found is the medial extension with invasion of the structures of the internal ear and growth towards the rhinopharynx [6-S]. Also, the cervical invasion with growth along the carotidjugular axis [8] is considerably rare. The purpose of this paper is to furnish the CT evidence of the distribution of a chemodectoma involving the tympanic-jugular area, with particular reference to the pathways followed by the tumor in its development. CASE
REPORT
R.R. is a female who is 60 years of age. For some years the patient has complained of headache, cervical pains, increasing hypoacusia, tinnitus and vertigo. A sudden and modest episode of hemorrhage from the left ear indicated the patient’s need for an otoscopy which revealed the destruction of the tympanic membrane on the left side. The membrane seemed to have been replaced by a polypoid brownish tissue, which bled easily. A neurologic examination evidenced a slight deficiency of the X, IX and XII ipsilateral cranial nerves. The diagnostic suspicion of chemodectoma was later confirmed by examination of a fragment of tissue removed at biopsy (Fig. 1). The patient was then sent to us for CT examination for better spatial evaluation of the neoplasm. 251
252
I. PANDOLFO er al.
Fig. 1.
The examination was carried out by a Pfizer 0450 scanner (5”). The axial slices through the facial bones (Figs 2-3), indicated the presence of a mass of density similar to the soft tissues. There was an extrinsic impression on the wall of the rhinopharinx flattening the Rosenmuller fossa. The mass developed in the left retrostyloid fossa thus causing the lateral displacement of the styloid process (see arrows in Figs 2 and 3). Moreover, it appeared separated from the pterygoid muscles by a fat plane (arrowheads, Figs 2 and 3). In the lower slices it was possible to follow the tumor as far as the hyoid region where an extrinsic impression on the pharynx was still visible (Fig. 4). The coronal slices provided further definition in the evaluation of both the development of the mass (in the parapharyngeal area) and the relationship between the tumor and the pterygoid muscles (Fig. 5). The CT furnished evidence of the destruction of the medial two-thirds of the petrous bone and the posterior part of the base, with subsequent spread of the mass into the middle and posterior cranial fossa (Figs 6 and 7).
Fig. 2
CT evaluation of a tympanic-jugular
253
chemodectoma
Fig. 4.
Fig. 3.
The intravenous administration of contrast medium (100 ml of a solution of sodium and methylglucamine diatrizoate 60%) caused a marked enhancement of the neoplasm (which is expression of an hypervascularity characteristic of these tumors). Finally a slice through the mastoid processes showed persistent opacity of the left sigmoid sinus which appeared to be expanded by probable neoplastic invasion (arrows Fig. 8). DISCUSSION During its slow growth, the chemodectoma tend to develop in various directions, reaching regions extremely different from one another (base of the skull, posterior and middle cranial fossa, the neck, facial bones) [S-S].
Fig. 5.
Fig. 6.
254
I. PAND~LFO
et al.
Fig. I.
Fig. 8.
This characteristic was the cause of numerous difficulties in the spatial evaluation of such tumors, before CT was available. By means of this examination, it is in fact possible to make an accurate evaluation of the extension of the tumor in its intracranial spread, and visualizing, as in our case, regions which would not be otherwise explorable [3-53. In the study of the chemodectomas of the tympanic-jugular region, CT is therefore an essential and irreplaceable preangiographic diagnosis medium. Moreover, it appears to be the most appropriate method in the follow-up of the patients treated with embolization or radiotherapy.
REFERENCES 1. S. T. Eraso, Roentgen and clinical diagnosis of glomus jugular tumors. Four cases and a new radiographic technique, Radiology, 77, 252-256 (1961). 2. S. R. Guild, Glomus jugulare, a nonchromaffin paraganglioma in man, Ann. Otol., Rhin. Lar. 62, 1045-1071 (1953). 3. J. R. Hesselink, P. F. G. New, K. R. Davis, A. L. Weber, G. H. Roberson and J. M. Taveras, Computed tomography of the paranasal sinuses and face: Part I normal anatomy, .I. Comput. assist. Tomogr. 2, 559-567 (1978). 4. J. R. Hesselink, P. F. G. New, K. R. Davis, A. L. Weber, G. H. Roberson and J. M. Taveras, Computed tomography of the paranasal sinuses and face: Part II pathological anatomy, J. comput. assist. Tomogr. 2, 568-576 (1978). 5. E. M. Miller and D. Norman, The role of computed tomography in the evaluation of neck masses, Radiology, 133, 145-149 (1979). 6. P. A. Riemenscheider, G. D. Hoople, D. Brewer, D. Joned, A. Ecker, Roentgenorgraphic diagnosis of tumors of the glomus jugularis, Am. J. Roentg. 69, 59-65 (1953). 1. R. P. and C. B. Holman, Roentgenographic manifestations of the glomus jugulare (chemodectoma), Am. J. Roentg. 89, 1201-1208 (1963). 8. T. N. Rucker, Radiology of glomus jugulare tumors in the temporal bone, Radiology, 81, 807-816 (1963). About the Author-I. PANDOLFO was born in Messina in 1947 and took a degree in medicine at University in 1972. Since 1972, he has been assistant radiologist at the School of Sciences in Radiology at the University where he studies general radiodiagnostics. He has written many publications and he is a partner in the Italian Society of Radiology and Nuclear Medicine (SIRMN). About the Author-E. SCRIBANO was born in Messina in 1947 and took a degree in medicine at University in 1972. Since 1972, he has been assistant radiologist at the School of Sciences of Radiology at the University where he studies general radiodiagnostics He has written publications and is a partner of the Italian Society of Radiology and Nuclear Medicine (SIRMN). Ahout the Author-M. LONGO was born in Messina in 1952 and he took a degree in medicine in 1975. Since 1975 he has been assistant at the School of Neurosurgery at the University of Messine. When he obtained
CT evaluation
of a tympanic-jugular
the Speciahsation in Neurosurgery in 1978, he became of Radiology at the University of Messine.
assistant
255
chemodectoma
neuroradiologist
at the School
of Sciences
About the Authors-L. LAVAGNINI and S. TERMINI took a degree in medicine in 1978 and they attend the Specialisation in Radiology Course at the School of Sciences of Radiology, University of Messine. They have published five articles.