Digital Subtraction Angiography of Glomus Tympanicum and

263
Digital Subtraction Angiography of Glomus Tympanicum
and Jugulare Tumors
Raymond F. Carmody,' Joachim F. Seeger,' William W. Horsley, ' Janice R. L. Smith ,' and Roger W. Miller 2
Radiologic procedures used to evaluate patients with suspected glomus tumor have included plain skull radiography ,
temporal bone tomography , computed tomography , and cerebral
angiography. Of these, only angiography has proven reliable as
a screening procedure for small glomus tympanicum and jugulare tumors. Digital subtraction angiography was used as the
initial examination for suspected paraganglioma in 14 patients.
Intravenous digital subtraction angiography proved to be an
acceptable screening tool for these highly vascular tumors. Also ,
intraarterial digital subtraction angiography proved very satisfactory for mapping of tumor blood supply, which greatly simplified
preoperative embolization. Effectiveness of therapy was readily
ascertained by serial follow-up intravenous digital subtraction
angiography.
Glomus tympanicum or jugulare tum ors usually present c linically
with pulsatile tinnitu s. hearin g loss. or lower cranial nerve deficit
[1J. These lesions can often be detected by otoscopi c exa mination ,
but the extent of the tum or usually ca nnot be predicted . Sku ll
radiography and tomog raphy are not effective for diagnosing small
glomus tumors. Similarly. computed tomography (CT) is in sensiti ve
lor small paragangliomas in the temporal reg ion. Convention al
selective ce rebral angiograph y is a sensiti ve means of diagnosing
glomus tum ors. but is not a suitable screening procedure because
of its ri sks and cost. For 2 years . we have screened possible glomu s
tu mor suspects with digital subtraction angiog raphy (DSA). Thi s
procedure ca n be performed safely on an outpati ent basis .usually
in less th an 30 min.
Materials and Methods
Fourteen patients with suspected glomus tumor or with pulsatile
tinnitus of unknown etiology were referred by the otolaryngology
service for DSA examinati on. Th e techniqu e of examinati on is as
follows: A 5-6 Frenc h pigtail catheter is introduced into the superi or
vena cava . Forty ml of a 76% iod inated co ntrast medium is injected
at a rate of 20-30 ml / sec. One or two images are obtained per
secon d . Th e imaging sequence must be long enoug h to evaluate
the veno us sinuses.
Two projections are usually sufficient for screen ing purposesa half-axial view (fi g . 1) and an Arcelin (or Sten ver) view (fig . 2) .
The Arcelin projection is especiall y helpful because it opens up th e
gen u of th e petrou s ca rotid artery and th e distal sig moid sinus. A
slightly rotated lateral view to separate th e petrous bones is an
alternative projection . Th e co mm on ca rotid bifurcation is inc luded
in th e image to rul e out an assoc iated ca rotid or vag us body tum or.
Results
Thirteen patients who presen ted c linica ll y with pul sati le tinnitu s
all had tech nicall y good or excellent intravenous DSA examinations.
Fi ve of these had negative physical examinati ons. no hearing loss.
an d normal DSA studi es. Three pati ents with a red mass in the
middle ear cav ity and a fourth wi th severe ex tern al otiti s had DSA
finding s typi ca l of paragangliom a; namely. a hype rvascular. inten sely staining lesion in th e temporal bon e wi th ea rl y veno us
shunting . On e of th ese was felt to be a glomu s tympanic um lesion .
and three had features of glomus jugulare tum ors (fig . 3). On e oth er
patient w ho had a red mass in th e middle ear cav ity was th oug ht to
have a large glomus tympani c um tumor on th e basis of the intravenous DSA study . th e co nven tion al angiogram. and th e CT scan.
but surgical exploration disclosed metastatic thyroid ca rcinoma to
the petrous bone.
In a 30-year-o ld woma n with a pul satin g noise in her ri ght ear.
DSA showed a large right frontal lobe arteriovenous malform ati on.
In a 71-year-old wo man wi th pul satile tinnitu s th at abated wi th
mastoid compression. DSA showed an occluded d istal jugular ve in
reconstituted by multiple coll ateral ve nous channe ls. Thi s was believed to be th e resu lt of the use of a previous intern al jugular vein
central ve nous pressure catheter.
In a 3 1-year-old woman w ith pu lsatile tinnitus but no abnormal
physical findings . DSA showed a larg e jugular bu lb on th e affli c ted
side. Th is finding was of doubtfu l significa nce ..
An 8-year-old boy had an otoscopic exam inati on suggestive of a
very small glomus tympanic um tumor. In order to maximize th e
likelihood of detecting a small vascu lar lesion. we elected to perform
intraarteri al rath er than intravenous DSA (fig . 4). No angiog raphi c
abnormaliti es we re seen. Surg ical explorati on d isclosed a c holesterol granuloma on th e tymp anic membrane.
Discussion
Intravenous DSA has been shown to be an effec tive screening
tool for ce rtain intracranial vasc ular lesions [2 . 3]. and it is also
, Department of Rad iology. Section o f Neurorad iology . University of Arizona Health Sciences Center . Tucson. AZ 85724 . Address reprint req uests to R. F.
Carmody.
2 Department of Surgery . Section of Otolaryngology. University of Arizona Health Sciences Center . Tucson . AZ 85724 .
AJNR 4:263-265, May/ June 1983 0195-6108 / 83 / 0403-0263 $00.00 © American Roentgen Ray Soc iety
264
DIGITAL RADIOGRAPHY AND DSA
AJNR :4 , May/ June 1983
Fig. 1.-Norm al intrac ranial intrave nous
DSA, anteroposteri or Towne projec tion. Art erial
(A) and ve nous (6) phases.
Fig. 2. -Norm al intrac rani al in travenou&
DSA , Arce lin projection. A, Arterial phase. Re·
gion of middl e ear cavity ( arrow) . 6 , Ve nous
ph ase. Small right jugul ar bulb (arrow ).
Fig . 3. - 42-yea r-old wo man w ith pulsatile tinnitus and hearing loss , ri ght ear. Anteroposteri or (A) and Arcelin (6) projec tion s, art eri al ph ase . Lar Je
hyperv asc ul ar mass in ri ght temporal bone. C, Anteroposterior projection , venous ph ase. Patency but compression of right intern a l jugular vein (arrow ) dUE 10
large glomus jugulare tumor .
DIGITAL RADIOGRAPHY AND DSA
AJNR:4, May/ June 1983
Fig. 4. -N orma l intraa rt eri al DSA , Arcelin projection . Vascular resolution approaches conventional angiography.
SUSPECTED GLOMUS TYMPANI CUM
or JUGULARE TUMOR
~
OTOLOGIC EVALUATION
~
PETROUS BONE X-RAYS
~
'"
IV OSA
/
NEGATIVE
STOp/
POSITIVE
PLANN~O
RA
" " CT
/
~
FOLLOW WITH
IV OSA
""
~~~NNED
~~~
POL nOMOGRAPHY
+
IA OSA, ? EMBOLIZATION
Fig . 5.-Protocol for evalu ating patients wi th suspected glomus tumor . IV
DSA = intravenous DSA ; IA DSA = intraarterial DSA; RA R. = rad iation
Iherapy .
proving to be useful in otolaryngologic radiology [4 , 5]. With spatial
resolution of 1-2 line pairs / mm, as well as excellent co ntrast
resolution , DSA is an efficient means of screening patients with
suspected paragangliomas of the head and neck .
Our protocol for the evaluation of ihe patient with a suspected
glomus tumor is illu strated in figure 5. After th e indi vidua l is seen
265
by an otologist and appropriate plain radiographs are obtained, we
generally proceed directly with DSA . If th e stud y is negati ve, th e
radiologic workup is termin ated . If positive, high -resolution enhanced CT can be performed immediately after th e DSA . CT ca n
demonstrate both bon e destru c tion and intrac rani al extension. Pluridirecti ona l tomography , whi le c urrentl y still helpful in se lec ted
cases, may eventu all y be totall y rep laced by hig h-resolution CT
scanning w ith multipl anar reform atting capab ilit y .
Follow in g surgical and / or radi ation th erapy, th e size and vasc ularity of th e paragangliom a can be co nvenientl y reevaluated by
DSA. Two of our pati ents have had serial foll ow- up studi es.
Th e use of digital fluorosco py for intraarteri al studi es appea rs to
provid e consistent ly exce llent im ages, even with half th e usual
doses of co ntrast material , with little loss of spati al resolution . Once
a glomus tumor has been di scovered or co nfirmed by intravenous
DSA, intraarterial DSA ca n be done to define better th e feeding
vessels and angioarchitecture of the lesion . Intraarterial DSA also
proved to be a very helpful adjunct to therapeutic emboli zati on of
these lesions in three of our cases . Th e avail ability of in stantaneous
subtraction images co nsiderably shortens th e cath eter tim e for thi s
proced ure.
It is possible th at so me glomus tumors may have been mi ssed by
DSA in our seri es, but th e quality of th e images makes thi s seem
unlikely. All patients with glomus tumors diagnosed by DSA subsequen tl y had conventional angiog raphy to " map out " tum or bl ood
supply. Although conven ti ona l angi ograp hy defined th e feed in g
vesse ls much more c learly, th e appearance of the tumor stain was
virtu ally identica l in the se two studi es. We co uld not ju stify subjec tin g our patients to th e ri sks of a co nvention al art eri og ram merely to
confirm negative DSA examinations.
To summarize, DSA is an effic ient , safe, and cost-effec ti ve
sc reening test for glomus tympanicum and jugulare tum ors. Other
vascu lar lesion s that may present with pulsatile tinnitus, such as
arteriovenous malformations, dural arteriovenous fistula e, ec tati c
carotid arteries, or aneurysms presenting in the middle ear cav ity ,
shou ld be detectable by this technique.
REFERENCES
1. Britton BH. Glomus tympanicum and glomus jugulare tum ors.
Radiol Clin North Am 1974;12: 543-55 1
2. Modic MT , Wein stein MA , Chilcote WA , et al. Di gital subtrac ti on
angiog raphy of th e intracranial vascular system: co mp arative
stud y in 55 patients. AJR 1982; 138 : 229-306
3. Carmody RF, Smith JRL, Seeger JF, Ovitt TW , Capp MP .
Intracran ial applicati ons of digital intravenou s subtraction angiography . Radiology 1982; 144 : 529-534
4. Kinney SE, Modic MT, Weinstein MA , Starnes D, Du c hesneau
PM . Digital subtraction angiography of lesions o f th e head and
neck. Laryngoscope 1982 ;92:55 7-561
5 . Miller RW, Carmody RF , Seeger JF, Coulthard SW, Smith JRL,
Koopman CF Jr. Digital subtraction angiography: appli cati ons
in otolaryngology-head and neck surgery. Head Neck Surg
1983 (in press)

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