The patient  was admitted to Shmaisani hospital from Palestine with complains of left ear pain for more than one month with hearing loss in the left ear and Horner syndrome left side and strider and swallowing difficulty.

On examination, the patient was alert cooperative, walking normally with stable Romberg stance with slight weakness of the left upper limb with no sensory deficit. He has miosis of the left eye with enophthalm and ptosis of the left eye and slight congestion of the left eye (Horner sign). The vision is not affected nor the oculomotor nerves. The hearing of the left ear was severely impaired. There is slight weak muscles of the left facial nerve. The gag reflex is impaired from the left and the uvula is sagging from the left side. The left side of the tongue is atrophied and shift to the left when protruding it anterior. The patient is suffering from swallowing difficulty and has hiccup. The condition is progressing every day and the condition is deteriorating. There is hard mass elevating the lobule of the left ear and extending down to the bifurcation of the common carotid artery.

The patient was sent for investigations and MRI performed 31-May-2012 showing huge mass occupying the left temporal region, involving the middle part of the petrous bone, extending into the middle ear and to the jugular fossa, medially to the left parapharyngeal space and laterally to the parotid area and subareolar space. MRA showed no flow signal of the left ICA in the neck and brain. Multiple vascular branches are seen supplying the mass from the left ECA. The extracranial MRV showed no flow signal from the left jugular vein and the sigmoid, which could be explained by low flow.

The patient was given Dexamed before surgery, after what the hearing became normal and the mass decrease in  size.

Using Inomed ISIS 32 channel, INAV Medtronic navigation, and facility for angiography, the patient was put in prone position with head rotated maximally to the right with fixation of the head with Mayfield fixator, incision anterior to the left sternocliedomastoid muscle was done to expose the common carotid, ICA, ECA and the mastoid tip. The hypoglossal and the glossopharyngeal nerves were exposed and preserved. The tumor was hard in consistency and filling the left jugular vein. Venography of the jugular vein was performed to see if it is patent and showing any flow tot eh sigmoid or inferior petrosal vein. It was negative and only bush of contrast was seen at the most superior part of the tumor. Stepwise dissection of the tumor was performed from the most distal up to the base of the skull. The jugular vein was ligated by silk. The occipital, ascending pharyngeal and the maxillary arteries were the main feeders of the mass. They were followed and coagulation or ligation was performed to decrease the bleeding and facilitated the tumor removal. The involved tumorous jugular vein was followed until it was reaching the jugular foramen. The anterior parts of the tumor were removed by piece-meal fashion, until the dura of the middle fossa was noted. During this part, the distorted posteriorly facial nerve was seen and preserved. It was possible to find this because of Inomed technology. Subtotal resection of the tumor was achieved leaving intentionally a part in the sigmoid sinus to avoid catastrophic sequel. A big piece of surgicele was applied over the remaining part of the tumor. There was minimal blood loss and the patient did not require blood transfusion.

Routine closure of the wound. Smooth postoperative recovery. Horner sign immediately disappeared and no cranial nerve deterioration was noted.

The patient is a child with rapidly progressive deterioration. Surgical intervention is the best solution in this case.

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Considering that the hearing is preserved and the young age of the patient all efforts were directed so as not to violate the bony structures of the left ear and try with all means to remove the tumor from the performed approach, to avoid hearing disturbances.

The patient was discharged from ICU 04-June-2012 with rapidly recovering preoperative neurologic deficits. Horner sign disappeared and swallowing improved and no hiccup or strider and the patient telling that hearing is normal and the facial nerve function became normal.