GLOMUS TUMORS OF THE TEMPORAL BONE May 2012

TITLE: GLOMUS TUMORS OF THE TEMPORAL BONE:

SYNOPSIS OF GLOMUS TYMPANICUM AND JUGULARE
SOURCE: Grand Rounds Presentation, Department of Otolaryngology
The University of Texas Medical Branch (UTMB Health)
DATE: May 29, 2012
RESIDENT PHYSICIAN: Viet Pham, MD
FACULTY PHYSICIAN: Dayton Young, MD
DISCUSSANT: Dayton Young, MD
SERIES EDITOR: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Quinn, MSICS

"This material was prepared by resident physicians in partial fulfillment of educational requirements established for
the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was
not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a
conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty
and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."

INTRODUCTION
First described by Gould in 1941 (O’Leary 1991), glomus tumors of the temporal bone
are a rare occurrence overall, estimated to affect approximately 0.012% in 600,000 (Bertrand
1976, Balatsouras 1992), but happen to be the most common true neoplasm of the middle ear. In
particular, it is the most common pathologic condition of the jugular foramen and second most
commonly diagnosed neoplasm of the temporal bone behind vestibular schwannomas.

PHYSIOLOGY
In actuality, the nomenclature “glomus” is a misnomer because these bodies derive from
neural crest elements that are felt to migrate with sympathetic autonomic ganglion cells to form
paraganglia (Gulya 1993). As a whole, the paraganglia constitute part of the neuroendocrine
system found within the adrenal and extraadrenal systems. Glomus bodies in general are
comprised of clusters of chief cells intertwined with arterioles and venules in a “zellballen”
network, often serving as neurosecretory modulators of the vascular activity via he release of
dopamine and norepinephrine.
In the temporal bone, paraganglia are felt to derive from the third branchial arch (Zak
1982) and perform as oxygen baroreceptors. One anatomical distinction from the adrenal
neuroendocrine system is their nonchromaffin nature, lacking an affinity for chromium salts on
histological analysis. Temporal bone paraganglia are composed of clusters of type I and type II
cells. Chief cells constitute type I cells are have been divided into light and dark cell types,
while type II cells are composed of supportive, sustentacular or modified Schwann cells.
On average, people possess two or three paraganglia in the temporal bone typically
located in either the anterolateral jugular fossa or within the middle ear, although some have
noted more paraganglia present when individuals reach the fifth decade of life. Temporal bone
paraganglia are usually associated with the jugular bulb adventitia and the Jacobson and Arnold
nerves. Paragangliomas originating from the glomus bodies affiliated with the jugular bulb are

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designated as glomus jugulare while those arising from the middle ear are referred to as glomus
tympanicum.

TEMPORAL BONE PARAGANGLIOMA

Temporal bone paragangliomas tend to affect Caucasians in the fifth decade of life.
There is a higher female preponderance at a ratio of 6:1, and many tumors occur on the left side.
Those that manifest in younger individuals tend to exhibit more aggressive behavior by either
presenting with multifocal disease or actively secreting vasoactive substances. Multicentricity is
generally present in only 5-10% of cases, but the incidence can increase to 50% in those affected
by a familial autosomal dominant disorder. This disorder is associated with defects on
chromosome 11 (Petropoulous 2000) but occurs in less than 10% of all paraganglioma cases.
Metastasis occurs rarely at a rate of 3-4% but tends to involve regional lymph nodes, the lung,
liver, spleen, and bone (Pluta 1994, Motegi 2008).
Histologically, paragangliomas have a cellular architecture similar to native paraganglia
with clusters of chief cells arranged in the zellballen fashion. Most cells will demonstrate some
degree of nuclear pleomorphism and hyperchromatism. Approximately 1-3% of tumors will
actively store and secrete catecholamines, which is more common with glomus jugulare.

PRESENTATION
Hearing loss is the most common symptom individuals complain of, and it is usually
conductive in nature, although some will exhibit sensorineural or mixed hearing loss if there is
some invasion of the labyrinth. Others will experience pulsatile tinnitus, which typically
manifests sooner with glomus tympanicum as compared to glomus jugulare. Other symptoms
include aural fullness, vertigo, and headaches. Given its high propensity to bleed with even the
slightest manipulation, otorrhagia may result if the tumor protrudes through the membrane.
In more locally advanced cases, there may be some accompanying neurological deficits
depending on what anatomical structures are involved. Intrusion into the fallopian canal will
result in a facial nerve palsy, while ataxia may arise with extension into the cerebellum at the
posterior fossa. Some patients may complain of facial hypesthesia when there is tumor present at
the petrous apex. Vernet syndrome arises with compression of cranial nerves IX, X, and XI at
the jugular foramen, which can manifest with dysarthria, dysphagia, or shoulder weakness. The
addition of Horner syndromic findings such as miosis, ptosis, and anhydrosis would suggest
compression of the cervical sympathetic chain that constitutes Villaret syndrome.
Although the incidence of actively secreting temporal bone paragangliomas is
significantly low, the presence of one can present similarly as an individual with a
pheochromocytoma. Patients with this clinical picture typically present with flushing and
diaphoresis, palpitations, labile hypertension, orthostatic changes, headaches, and diarrhea. A
clinical suspicion for this warrants further investigation with measuring serum catecholamines
and a 24-hour urinary collection of vanillylmandelic acid and metanephrine.
On physical examination, a glomus tumor classically presents as a reddish-blue or
violaceous mass medial to the tympanic membrane. Smaller ones tend to be visualized in the
inferior quadrants of the tympanic membrane, while a magnified view with either binocular
microscopy or endoscopic otoscopy may reveal some pulsations to the tumors. Blanching of the
mass with application of positive pressure with pneumatic otoscopy is known as the Brown sign,

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and the Aquino sign is the observation of decreased pulsations with carotid compression.
Auscultation over the mastoid or infra-auricular region may appreciate a bruit, otherwise referred
to as objective tinnitus.

RADIOLOGY
Radiographical imaging with at least computed tomography (CT) constitutes the
mainstay of working up a glomus tumor. The primary focus with CT is assessing the bony
partition between the jugular fossa and hypotympanum as that typically helps distinguish
between a glomus jugulare from a glomus tympanicum. Specifically, a glomus jugulare often
erodes through the jugular fossa while a glomus tympanicum occupies the middle ear with
general preservation of the bony partition. In a similar fashion, CT imaging is able to evaluate
for any erosion to the caroticojugular spine which separates the jugular bulb from the petrous
carotid artery. As with the jugular fossa, a glomus jugulare can erode through this bony
landmark to raise clinical suspicion for possible carotid involvement by the neoplasm.
Given its superiority in assessing the bony anatomy compared to magnetic resonance
imaging (MRI), CT is useful to determine if there is any intracranial extension or invasion of the
fallopian canal housing the facial nerve. Furthermore, other vascular abnormalities such as a
high jugular bulb or an aberrant carotid artery can be ruled out with a CT, which is important as
these two conditions can masquerade in a similar presentation as a glomus tumor. A dehiscent
jugular bulb is typically darker blue in color and located more posteriorly than a glomus tumor
on otoscopy, while an aberrant carotid lies more anteriorly and is paler in appearance.
Glomus tumors classically present with characteristic flow voids on MRI that resemble a
mixture of “salt and pepper.” Similarly, MRI is better suited than CT at evaluating for
intraluminal involvement of the petrous carotid artery and for occlusion of either the jugular vein
or sigmoid sinus by the neoplasm. Although not as well-suited to evaluate bony structures, the
advantage of MRI over CT lies in its ability to better delineate soft tissues so as to ascertain
between paraganglioma and native tissue. Consequently, the utility of MRI in evaluating
intracranial involvement is demonstrated by determining either intradural or extradural
extension.
Other tumors that can manifest in the jugular fossa and should be ruled out include
schwannomas and meningiomas, which are the second and third most frequently occurring
neoplasms at that site behind glomus jugulare, respectively. Schwannomas can enlarge and
erode the jugular foramen on CT similar to a glomus tumor, but the erosion typically presents
with smooth borders as opposed to the irregular margins associated with a glomus jugulare.
They tend to be isointense on T1-weighted imaging and hyperintense in T2-weighted imaging
with significant gadolinium enhancement on MRI. Meningiomas are often difficult to
distinguish from schwannomas on CT with its propensity to infiltrate the bone around the jugular
foramen. They are isointense on both T1-weighted and T2-weighted MRI imaging, but they
exhibit characteristic “dural tails” not found with schwannomas.
CT is often sufficient in imaging many glomus tumors since the main preoperative
consideration is the status of the jugular bulb, and consequently, CT has supplanted venography
to evaluate the jugular bulb. MRI is generally employed whenever the diagnosis or extent of the
mass is in question. Given its ability to delineate native and neoplastic tissue, MRI is
particularly useful when assessing intradural tumors. Caution is warranted when acquiring MRI

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as it can overestimate tumor extent on T1-weighted imaging (Brackmann 2010), especially at the
petrous apex as the marrow in that bone is hyperintense and indistinguishable from enhanced
neoplasm in that same area. As such, evaluating the petrous apex radiographically is best
achieved with both CT and MRI.
Magnetic resonance angiography is generally felt to be inadequate for assessing glomus
tumors, and the utility of CT angiography is still under debate. The role of positron emission
tomography (Hoegerle 2003) and octreotide scintigraphy (Bustillo 2004) is currently being
investigated.

ANGIOGRAPHY
Angiography plays an important role in both the diagnostic workup of glomus tumors and
in treating them with preoperative embolization via polyvinyl alcohol or intravascular coils.
Occluding the blood supply to a glomus tumor approximately 1-2 days prior to surgical excision
will improve intraoperative blood loss and even shrink the mass to assist with removal.
Angiography is capable of assessing large tumors and identifying multicentric disease, but it also
provides an opportunity to perform a balloon occlusion test to evaluate for adequate collateral
intracranial blood flow if carotid sacrifice is anticipated. This possibility is important to consider
and plan for in light of the significant morbidity associated with such an intraoperative decision
including cerebral infarction and fatality (Linskey 1994).
The primary blood supply for most glomus tumors arises from either the inferior
tympanic branch from the ascending pharyngeal artery or from the stylomastoid artery. The
stylomastoid artery typically originates from either the occipital or posterior auricular arteries.
Other arterial contributors include the middle meningeal artery and carotid arteries. Together,
they form four major hemodynamically independent vascular compartments by which glomus
tumors can derive from. The inferior tympanic branch of the ascending pharyngeal artery
constitutes an inferomedial compartment, while the stylomastoid artery is the source of a
posterolateral one. An anterior compartment may be formed from either the anterior tympanic
branch of the internal maxillary artery or caroticotympanic branch of the internal carotid artery,
and a branch from the middle meningeal artery creates a superior compartment. While
individual and separate from one another, multiple compartments can contribute to a glomus
tumor in up to 85% of cases.

PATTERN OF SPREAD
Glomus tumors, particularly glomus jugulare, tend to spread around the venous sinuses
surrounding the jugular bulb. Sometimes collectively referred to as the “danger zone,” the
venous sinuses most commonly involved include the inferior petrosal sinus, internal jugular vein,
and the sigmoid sinus (Minor 1994). From here, these tumors can extend toward and beyond the
protympanum, hypotympanum, mesotympanum, or intracranial cavity. Of note, while
intracranial extension is suspected radiographically in approximately 14-20% of cases (Rigby
1996), up to 50% are pertinent for intraoperative findings of some degree of dural involvement
(Spector 1976, Andrews 1989, Jackson 1990).
Neoplastic spread from the protympanum is often facilitated with involvement of the
peritubal cell tracts toward the petrous apex, the carotid canal toward the middle cranial fossa, or
the Eustachian tube toward the nasopharynx. Extension from the hypotympanum often results in
luminal invasion of either the sigmoid sinus or internal jugular vein or spread toward the inferior
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petrosal sinus or neural foramina at the skull base. A glomus tumor at the mesotympanum has a
similar spread pattern as that of a cholesteatoma. It may reach toward the antrum and
epitympanum or more posteriorly toward the facial recess, sinus tympani, or mastoid air cells.
While it may extend laterally through the tympanic membrane toward the external auditory
canal, a glomus tumor could proceed more medially through the round window and erode the
cochlea and internal auditory canal.

CLASSIFICATION
There have been a number of schema proposed to describe the size and associated
anatomical involvement of glomus tumors, with the first being the one described by Alford and
Guilford in the early 1960’s that based their classification on the surgical approach employed to
remove the tumor. The more commonly cited ones currently include those developed by
Glasscock and Jackson and by Fisch (Brackmann 2010).
The Glasscock-Jackson classification scheme divides into two separate systems, one for
glomus tympanicum and another one for glomus jugulare, which are detailed in Tables 1 and 2,
respectively. A superscript connotates the extent of intracranial extension if present.
Table 1. Glasscock-Jackson Glomus Tympanicum Classification

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Table 2. Glasscock-Jackson Glomus Jugulare Classification

In contrast, Fisch’s system utilizes a single system that is applicable to both types of
glomus tumors which is presented in Table 3. It has been associated closely with related
mortality and morbidity.

Table 3. Fisch Classification

For type C tumors, it is further divided into three possibilities depending on the degree of
invasion of the carotid canal. There is limited involvement of the vertical portion of the carotid
canal with C1 tumors but frank invasion of that segment in C2 tumors. Extension into the
horizontal portion of the carotid canal constitutes C3 tumors. In a similar fashion, type D tumors
are subdivided into D1 and D2 tumors, depending on whether or not the degree of intracranial
extension exceeds two centimeters, respectively.

SURGERY
Classically, surgical excision is regarded as the definitive treatment modality for glomus
tumors although there has been a growing role for radiotherapy, especially in poor surgical
candidates or cases of incomplete resection. For the rare occurrence of a vasoactively secreting
tumor, it is important to include alpha- and beta-blockade as part of the treatment plan.
In general, a transcanal approach is sufficient for small glomus tympanicum tumors on
the promontory whose borders are all clearly visible through the tympanic membrane. A portion

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of the external auditory canal may be drilled as needed to access the hypotympanum. Exposing
the facial recess is often necessary for glomus tympanicum tumors that extend from the middle
ear toward the mastoid region. In contrast, a combined transmastoid-transcervical approach is
required to adequately access and remove a glomus jugulare. Larger tumors are better addressed
with a modified infratemporal approach. Neoplastic invasion of the foramen magnum and
cavernous sinus are typically regarded as unresectable cases (Jackson 1982, Rufini 2006).
While individual cases may warrant specific intraoperative alterations, a transmastoid-
transcervical approach to a glomus jugulare involves performing a complete mastoidectomy and
opening the facial recess. The dissection is extended more inferiorly toward the upper cervical
neck to identify vasculature and lower cranial nerves. The facial nerve is carefully dissected out
as it courses through the temporal bone and toward the parotid, and the mastoid tip is amputated.
For most glomus jugulare tumors, the facial nerve is often transposed anteriorly to facilitate full
exposure of the neoplasm prior to removal with subsequent ligation of the internal jugular vein
and packing the sigmoid sinus.
Fisch developed three general approaches for tumors that involve the infratemporal fossa.
A Type A approach is similar in methodology to a transmastoid-transcervical approach and
provides access to the jugular bulb, vertical petrous carotid artery, and posterior aspect of the
infratemporal fossa. There is more exposure anteriorly with a Type B approach that facilitates
exploration of the petrous apex and allows access to the mid-clivus, horizontal internal carotid
artery, and the superior infratemporal fossa. A Type C approach essentially provides the most
exposure with its extent to the anterosuperior infratemporal fossa with the potential to reach the
nasopharynx, rostral clivus, cavernous sinus and parasellar area, pterygopalatine fossa, and
foramen rotundum.
Although the exact surgical plan will need to be tailored to the individual patient, the
initial steps to conducting a modified infratemporal fossa approach share a resemblance to those
taken with a transmastoid-transcervical procedure. A similar postauricular incision with
extension toward the upper neck is created, and the facial nerve is dissected and transposed. One
significant difference is that the external auditory canal is transected and oversewn, and the canal
itself along with the tympanic membrane and middle ear contents lateral to the stapes are
mobilized. To reach the anterosuperior infratemporal fossa, the zygoma and temporomandibular
joint would typically need to be resected and the temporalis reflected inferiorly to dislocate the
mandible anteroinferiorly.
Intracranial tumors near the foramen magnum may require a transcondylar, suboccipital
approach to fully expose and subsequently remove them. The first major step involves
identifying the vertebral artery posterior and inferior to the mastoid tip and along the transverse
process of the first cervical vertebra. The bony occiput is removed to expose the occipital
condyle and jugular tubercle, which allows access to the hypoglossal nerve and cranial-cervical
junction. It is important to consider performing a cervical stabilization procedure if more than
half of the condyle is resected.
In general, it is typically advised that any tumor adherent to the internal carotid be left
alone to avoid potentially devastating hemorrhage. Especially for glomus jugulare, preservation
of cranial nerves is enhanced if the medial wall of the jugular bulb is left intact. Intradural
involvement is observed most commonly at the jugular bulb, and proceeding forth with en-bloc
resection is usually pursued if intraoperative blood loss by that point is less than 2000mL. Most

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surgeons will opt to perform staged procedures to remove intracranial tumors if the blood loss is
higher or for profoundly large neoplasms.
Patients need to be counseled extensively on potential complications related to surgical
excision. In addition to bleeding-related problems, the close proximity with lower cranial nerves
prompts discussion of the possibility of facial nerve injury, hoarseness, dysphagia, or dysarthria.
Cerebrospinal fluid leak may arise from removing tumors with intracranial extension. Some
late-onset sequelae include tympanic membrane perforations and cholesteatoma (O’Leary 1989,
Forest 2001).

RADIOTHERAPY
Stereotactic, external beam radiotherapy is an increasingly attractive alternative for
individuals who are poor surgical candidates or reluctant to undergo surgery. Furthermore,
radiotherapy has been found to be effective in an adjuvant role for multimodality treatment often
rendered for incompletely resected or multicentric tumors.
Radiotherapy appears to be comparable to surgery in regards to tumor control, recurrence
rates, and morbidity. An important distinction is that radiotherapy is not an ablative treatment;
rather, it induces obliterative endarteritis in tumor vessels to halt neoplastic growth but with the
aspiration that it results in less cranial neuropathies with the avoidance of potential injury during
surgery. Tumor control rates with this method has been estimated at over 90% (Maarouf 2003,
Krych 2006), although regrowth has been reported 10-15 years after treatment (Brackmann
2010).
Consequently, patients must be counseled that they essentially would “live in
coexistence” with a glomus tumor addressed with radiotherapy. Regular surveillance includes
serial radiographical imaging, which should reveal a residual mass that is either stable in
appearance or even reduced in size. There should be decreased enhancement on CT and
decreased T2-weighted enhancement with diminished flow voids on MRI (Swartz 2009). As
alluded to earlier, regrowth of irradiated glomus tumors is possible, but other potential
complications include damage to other cranial nerves, osteoradionecrosis, and even radiation-
induced malignancies (Lustig 1997). The incidence of these long-term effects is still being
investigated.
Ultimately, the main question is whether a glomus tumor is likely to result in significant
morbidity or mortality in the natural course of the patient’s remaining life. It would be
reasonable to opt for surgical excision in a younger, healthier individual as compared to an
elderly one with medical co-morbidities who might be better addressed with nonsurgical
endeavors (Glasscock 2003).

CONCLUSION
Glomus tumors are the most common neoplasm in the middle ear and second-most of the
temporal bone, but they are still uncommonly encountered overall. There are certain symptoms
and physical examination findings that are classically associated with these tumors, and they
commonly exhibit characteristic radiographical features. Although surgery is considered the
most definitive treatment option, radiotherapy has been found to be an acceptable alternative for
nonsurgical candidates.

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Discussant’s comments by Dr. Dayton Young:

Thank you Dr. Pham. That was a good presentation, very extensive and well covered.
The first thing to keep in mind is that they are rare tumors and they are benign tumors. They
can be very slow growing but they can also be very destructive tumors. There is controversy
about how to manage these tumors especially if they are very big. Typically they grow from
three different location, the jugular bulb, just below the jugular bulb in the neck, and in the
middle ear, and they spread out, into the middle ear and down into the neck. If the tumor is
starting in the ear it is usually detected early, and if it is small, it is taken out. If it is in the neck it
is usually found out early and also taken out. It’s the ones that start in the jugular bulb that can
go a long time without being noticed. These tumors spread via the routes of least resistance but
they usually grow up into the ear and the mastoid. A common route is along the carotid artery
which is why the resection techniques go along that artery, up into the petrous apex and
toward the cavernous sinus, or along the jugular vein and into the middle ear or the posterior
fossa.
When they are a small they are easy to take out. When they are big they involve taking
something out of the neck, rerouting the facial nerve, cutting the ear canal. To get along the
carotid artery you have to move the temporomandibular joint forward, drill down the anterior
wall of the ear canal, drill through the back wall of the TMJ, find the Eustachian tube, drill
through the Eustachian tube, find the carotid artery, and there’s the tumor on the other side of
that. In cutting the Eustachian tube you are taking out the whole middle ear system. Then you
start following the carotid artery up towards the carotid artery, and you have a big risk of
stroke.
These things are technically feasible, as we have advanced considerably of the past
twenty years but it’s also controversial as to how far to take that in a patient because the cure
may be worse than the disease, and that’s where you have to tailor this to the patient. For
example, the House group has a 20% risk of facial nerve sacrifice. About 20% are losing their
vagus nerve, you have a decent percentage of stroke, and sometimes you have to sacrifice the
carotid artery, and of course this is preceded by a balloon occlusion test.
Radiotherapy is, of course, an option, but it is the vascular tissue around the tumor that
responds to it, not really the tumor tissue itself. We know that it will shrink the tumor, but we
have learned that with external beam radiation we can expect the tumor to begin to grow again
after about fifteen or twenty years. We’ve got good results with stereotactic radiation therapy
but our followup is only out to thirteen or fifteen years, so we really don’t know what’s going to
happen. It is, therefore, controversial whether to palliate these patients, use radiation, or
operate on them, which, of course, is the definitive cure.

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