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__�"_____`E`E�"___�E____��������������������������������������������������������������������GK_________�H::MALIGNANT TUMORS INVOLVING THE JUGULAR FORAMEN: CLINICAL CASES AND SURGICAL CONSIDERATIONS

Daniele Marchioni MD, Elena Rigoni MD, Alessia Rubini MD

Otolaryngology-Head and Neck Surgery Department, University Hospital of Verona, Piazzale Aristide Stefani, 1 37126 Verona, Italy

Corresponding author:
Dr Alessia Rubini, MD
Otolaryngology-Head and Neck Surgery Department, University Hospital of Verona, Piazzale Aristide Stefani, 1 37126 Verona, Italy
Tel: +39-0458122330
Fax: +39-0458122313
Email: ele.rigoni@gmail.com

All of the authors have read and approved the manuscript. None of them has any financial relationship to disclose.
Conflict of Interest: None

Running title: Malignant tumors of jugular foramen

Keywords: jugular foramen, malignant tumor, infratemporal approaches

INTRODUCTION
The jugular foramen is divided into three compartments: two venous and a neural or intrajugular compartment. The venous compartments consist of a larger posterolateral venous channel, the sigmoid part, which receives flow from the sigmoid sinus, and a smaller anteromedial venous channel, the petrosal part, which receives drainage from the inferior petrosal sinus. The petrosal part empties into the sigmoid part through an opening in the medial wall of the jugular bulb between the glossopharyngeal nerve anteriorly and the vagus and accessory nerves posteriorly. The intrajugular or neural part, through which the glossopharyngeal, vagus, and accessory nerves course, is located between the sigmoid and petrosal parts at the site of the intrajugular processes of the temporal and occipital bones, which are joined by a fibrous or osseous bridge. The glossopharyngeal, vagus, and accessory nerves penetrate the dura on the medial margin of the intrajugular process of the temporal bone to reach the medial wall of the internal jugular vein.6
Tumor involvement in the jugular foramen is quite rare, and benign lesions are most frequently present in this anatomically complex area. Paragangliomas and schwannomas are the most common tumors of the jugular foramen and their treatment is now well established. In rare cases, a malignant tumor can involve the jugular foramen. Metastases and malignant tumors arising from adjacent anatomic structures (nasopharynx, parotid, and temporal bone), in advanced stages, may spread to the jugular foramen. These invasive tumors may present with lower cranial nerve deficits or palsy associated with pain in the ear and temporal region as the initial symptoms.
Surgical approaches that access various aspects of the foramen and adjacent areas are the postauricular transtemporal, retrosigmoid, extreme lateral transcondylar, and preauricular subtemporal-infratemporal approaches.
The aim of this study is to describe clinical cases of malignant tumors with jugular foramen involvement, and the associated surgical considerations.

MATERIALS AND METHODS
A retrospective analysis was performed: patients with malignant tumors involving the jugular foramen were included in the study. Initial symptoms, radiological assessment, staging, therapeutic strategy, complications and follow-up are reported.
The surgical approach adopted in our series was tailored according to the extent of the tumor in the neck, the temporal bone, infratemporal fossa and parotid gland.
Preoperative assessment
All of the patients were evaluated with a temporal bone CT scan and maxillofacial and neck MRI before treatment to aid surgical planning. Cranial nerves, in particular the facial nerve and lower cranial nerves (CN IX, X, XI), were evaluated before and after surgery and during the follow-up period.
Incision and neck management (Figure 1)
After induction of general anesthesia, the patient was placed in the supine position with the head turned 45� to the opposite side. Intraoperative monitoring of the facial nerve was performed in all cases. A C-shaped skin incision was made approximately 3 cm behind the ear, starting in the temporal region over the ear and running as far as the neck over the anterior border of the sternocleidomastoid muscle. The great auricular nerve was identified and preserved as far as the cranial bifurcation so it could be used as a graft to reconstruct the facial nerve if required at the end of tumor excision.
The dissection in the temporal area was continued in the plane of the temporal fascia; the external auditory canal was cut at the osteocartilaginous junction and then closed in two layers using the posterior auricular muscle in order to obtain a watertight closure of the external auditory canal. When necessary, the skin flap was elevated anteriorly, completely exposing the parotid gland until the facial muscles were identified.
A neck dissection was then performed; the anterior border of the sternocleidomastoid and the digastric muscle were dissected at the base of the skull until the major vessels of the neck were identified and initially preserved. The internal jugular vein and the common carotid artery with its internal and external branches were carefully dissected and exposed in the neck as far as the base of the skull. The lower cranial nerves were identified at the base of the skull, in particular, the vagus and the sympathetic trunk were isolated latero-inferiorly to the common carotid artery. The hypoglossal nerve was isolated in between the main trunk of the internal jugular vein posteriorly and the common trunk anteriorly; this nerve was isolated and preserved from the neck to the skull base.
Dissection of the lateral process of C-1 and the superior and inferior oblique muscles was performed. In accordance with the staging, the extent and histology of the disease, a radical or selective neck dissection was also performed. At the end of the neck dissection, the internal carotid artery was isolated as far as the base of the skull and the external carotid artery was ligated just over the bifurcation.
Facial nerve management
The posterior belly of the digastric muscle was isolated as far as its mastoid insertion; the tympanomastoid suture was also identified and both anatomical structures were used as landmarks to isolate the main trunk of the facial nerve at the stylomastoid foramen.
Depending on the extent of the lesion, a total parotidectomy was performed and, wherever possible, the facial nerve was isolated and preserved; a rerouting of the seventh cranial nerve was performed in order to better expose the jugular foramen and the extent of the tumor. When a radical parotidectomy was required, the facial nerve was isolated as far as its most peripheral branches in order to isolate the ocular and buccal trunks, to prepare the facial nerve for reconstruction at the end of tumor excision if required.
When required, depending on the extent of the tumor, the digastric and stylohyoid muscles were removed; the stylohyoid process was drilled and removed at the base of the skull, and the posterior margin of the mandible was isolated.
When the tumor involved the facial nerve or when a close relationship was found between the tumor and the nerve, sacrifice of the facial nerve was mandatory in order to completely remove the lesion with safe margins. When a facial nerve resection was necessary, the main trunk of the nerve was isolated into the temporal bone, drilling the mastoid canal of the facial nerve and isolating the nerve as far as the geniculate ganglion.
Subtotal petrosectomy and access to the jugular foramen (Figure 2)
Radical mastoidectomy was necessary in the case of a tumor with involvement of the jugular foramen into the mastoid or when the middle ear and intra-temporal facial nerve were involved by the tumor. In these cases, a subtotal petrosectomy was performed: the skin of the external auditory canal was removed along with the eardrum, and the ossicular chain was removed maintaining just the stapes; the inferior and posterior bony walls of the external auditory canal were removed and the facial nerve was skeletonized into the temporal bone from the stylomastoid foramen to the geniculate ganglion. The mastoid cells were drilled completely, exposing the dura of the middle and posterior fossa. The sinodural angle was identified and the sigmoid sinus was exposed from the superior petrosal sinus to the jugular bulb at the base of the skull into the jugular foramen. The labyrinthine block was preserved, and the internal carotid artery was isolated into the tympanic cavity just under the orifice of the eustachian tube.
The sigmoid sinus was closed inferiorly to the superior petrosal sinus, packing the vascular lumen with Surgicel (absorbable hemostat) and pressing the vein onto the mastoid bone. The internal jugular vein was double-ligated at the neck and cut. The jugular foramen was so exposed and the intraluminal portion of the tumor was isolated. In this case, a tumor which presented with extradural extent was dissected. The lesion was dissected from the jugular foramen trying wherever possible to preserve the lower cranial nerves previously isolated. In the case of lower cranial nerve involvement by the tumor, the sacrifice of one or more of these nerves was necessary to completely remove the tumor. In this step during tumor resection, bleeding from the inferior petrosal sinus was controlled with Surgicel. When an anterior extent of the tumor over the internal carotid artery was found, a careful dissection was performed under microscopic view in order to remove the tumor from the major vascular structures.
Facial nerve reconstruction
After tumor removal and when facial nerve reconstruction was required, an auricular nerve graft was collected. The main trunk of the facial nerve had been isolated previously and the ocular and buccal trunks of the facial nerve were detected in the cheek region. The reconstruction was performed using a cable graft interposition acquired from the great auricular nerve and placed between the main trunk and the peripheral branches of the facial nerve (Figure 3). When a subtotal petrosectomy was performed, a fragment of temporal muscle was used to close the orifice of the Eustachian tube into the tympanic cavity, and a fat pad was collected from the abdomen and used to obliterate the mastoid cavity; a pedicled temporal muscle flap was rotated to separate the skull base from the neck.
Postoperative care
A nasogastric tube was put in place and a tracheotomy was performed at the end of surgery. Intensive care unit monitoring was necessary. The function of the lower cranial nerves was carefully examined during the postoperative period. Nasogastric tube removal was carefully evaluated when a good swallowing function was assured. Tracheotomy removal was evaluated after careful examination of cranial nerve function and avoiding swallowing difficulty and recurrent aspiration.
All of the patients underwent a brain CT scan on the day after surgery. An MRI scan was also planned after 1�2 months. Antibiotic therapy (third-generation cephalosporin) was administered for 48 hours after surgery.

RESULTS
Between January 2015 and December 2015, 120 patients underwent anterior and lateral skull base surgery at Verona University Hospital. The final study group was composed of seven patients, four male and three female (Table 1) affected by malignant lesions involving the jugular foramen. Their median age was 65.8 years. The group of patients was composed of four with malignant tumors of the parotid gland, one with temporal bone carcinoma, one with metastasis from thyroid cancer, and one with metastatic cancer from an unknown primary site.
All operations were video recorded and stored in the clinic�s digital database.

Tumor histology (Table 1)
Four patients had primary extensive malignant tumors of the parotid gland: squamous cell carcinoma (patient 1 and patient 7) (Figure 4), squamous carcinoma recurrence (patient 5), and adenoid cystic carcinoma (patient 2). One patient (patient 3) (Figure 5) was affected by infiltrative squamous carcinoma of the temporal bone, one patient (patient 4) was affected by metastasis of a papillary thyroid carcinoma located in the jugular foramen, and one patient (patient 6) was affected by metastatic cancer from an unknown primary site with an extension into the jugular foramen.
Symptoms
In two patients (patients 1 and 7), the only sign or symptom was a painless swelling in the parotid region which had progressively increased in size over a 5-month and 9-month period. One patient (patient 2) presented with a sudden facial paralysis on the right side. One patient (patient 3) had undergone previous transtemporal surgery for squamous cell carcinoma of the temporal bone. She had a painful swelling mass in the retroauricular region and temporal pain. One patient (patient 4) showed dysphagia, right vocal cord paralysis and hemifacial pain on the right side. One patient (patient 5) was affected by squamous cell carcinoma of the parotid gland and 1 year earlier, he had undergone a total parotidectomy with facial nerve sacrifice and a selective neck dissection. He presented with pain when opening his mouth and had a small crusted cutaneous lesion in the preauricular area.
One patient (patient 6) was affected by left metastatic cancer with unknown primary site and 6 years earlier, he had undergone a radical neck dissection on the left side and adjuvant radiation therapy. He presented with a 2-month history of a rapidly growing painless mass in the right neck.
Surgical procedures and intraoperative findings (Table 2)
In six out of seven patients, a Fisch type A infratemporal fossa approach was adopted together with a subtotal petrosectomy. In one of these seven subjects, a transotic approach in association with a type A infratemporal fossa approach was performed since the tumor extended into the otic capsule (patient 3 with middle ear carcinoma).
Four out of seven patients underwent a total parotidectomy and dissection: one of these three patients (patient 5) had undergone a total parotidectomy previously.
In 6/7 subjects, a total macroscopic resection of the tumor was performed.
Despite the extensive surgical approach, a subtotal resection of the tumor was possible in one of the six patients (patient 3) since there was an adventitial infiltration of the vertical and horizontal portions of the internal carotid artery.
A dural infiltration of the middle cranial fossa was found in one of the six patients (patient 3), and a dural removal was mandatory in order to remove the tumor.
In all the patients was possible to remove the tracheostomy tube during the post-operative course. In the 3rd -4th post-operative day, patients started rehabilitation for swallowing. The tracheostomy tube was removed subsequently to the achievement of a satisfactory patient�s eating and swallowing without inhaling. In our series patients maintained tracheotomy for an average of 15 days after surgery.
Cranial nerve outcome
Regarding the cranial nerves, in one patient, the facial nerve was rerouted anteriorly and preserved. Since there was infiltration of the nerve by the tumor in six of the seven patients, the facial nerve was sacrificed, and in three of these six patients, the nerve was reconstructed with a great auricular cable graft interposed between the proximal stump of the facial nerve and its peripheral branches. Since the dissection created a large defect in three of these patients, reconstruction of the facial tension-free primary repair nerve was not possible.
In 1/7 subjects, infiltration of the lower cranial nerves was found, and the nerves were sacrificed in order to achieve clear margins.
Facial nerve
Three out of seven patients presented a postoperative grade IV on the House-Brackmann (HB) scale, one out of seven patients presented with HB grade V, and three patients showed a HB grade VI.
Lower cranial nerves
One out of seven patients presented normal postoperative function of the lower cranial nerves, one patient presented a postoperative deficit of cranial nerve (CN) X, and three patients presented a deficit of CN XI. One out of seven patients showed paralysis of the lower cranial nerves because it was not possible to dissect the neoplasm from these nerves. One patient presented with CN XI and XII dysfunction after the operation.
Follow-up
The mean follow-up period was 5 months (range 1�12 months) for six patients. One out of seven patients (patient 3) died during the hospitalization because of internal carotid artery rupture due to tumor infiltration.

DISCUSSION
Malignant tumors involving the jugular foramen are rare; the jugular foramen is an exceptionally rare location for primitive malignant tumors, and in the literature, there are few documented cases arising primarily in the jugular foramen, mostly chondrosarcoma or chordoma of the skull base. Metastatic tumors spreading into the jugular foramen are described, particularly arising from the prostate, lung, breast and kidney.
Primary malignant tumors of the jugular foramen should be distinguished from secondary tumors that spread into the jugular foramen; in those cases, the tumors arise from surrounding anatomical areas such as the mastoid bone, parotid gland, infratemporal fossa and rhinopharynx, involving the lateral skull base.
In malignant tumors of the parotid gland, involvement of the facial nerve may be the first symptom, destructive processes generally occurring in the extratemporal segments of the facial nerve, and the nerve may provide a route for spreading along which extratemporal malignancies extend into the skull base with possible involvement of the jugular foramen. The mechanisms of neural involvement include direct invasion along the perineural space and within the substance of the nerve, direct compression, and stretch of nerve fibers.
Regarding the symptoms, patients with lesions of the jugular foramen most commonly present with combinations of cranial nerve palsies (CN VII, IX, X, XII), pulsatile tinnitus, and hearing loss. Patients may present with jugular foramen syndrome (Vernet syndrome), which is characterized by loss of taste in the posterior one-third of the tongue (CN IX), vocal cord paralysis and dysphasia (cranial nerve X), and weakness of the sternocleidomastoid and trapezius (CN XI). Larger tumors may also be indicated by nonspecific symptoms (e.g. headache, increased intracranial pressure) or symptoms due to compression of adjacent structures such as the cerebellum and brain stem (e.g. nystagmus, ataxia, disequilibrium, long tract signs). If the mass extends into the middle ear cavity, clinical examination may reveal the mass to be retrotympanic.1
From the literature, a common consensus is found with regard to radiological assessment of these lesions, in particular, CT scan and MRI are required for the complete delineation of these malignant tumors. Detailed radiographic imaging of any lesions involving the skull base and jugular foramen is crucial before deciding on therapeutic strategy. The CT scan may show erosion of the jugular foramen, but this detail could also be present in other benign lesions such as paragangliomas and meningiomas. MRI is mandatory to study the relationship between the tumor, the brain and the dura mater, and to understand the real extent of the disease in the jugular foramen and surrounding structures. The vascular encasement or vessel displacement secondary to tumor involvement is a crucial detail to be analyzed in the preoperative assessment. Arteriography, when performed, has demonstrated a characteristic avascularity of the lesion, in contrast to vascular lesions, which are the more frequent lesions of the jugular foramen (paraganglioma). But when a primary malignant tumor of the jugular foramen is found, there are no typical radiological signs that may help to distinguish benign from malignant lesions.
However, when a secondary lesion is present spreading into the jugular foramen (for example, from the nasopharynx or parotid), the possibility for the patient to undergo fine needle aspiration or biopsy is much greater because the lesion is directly accessible. Therefore, in this case, a histological diagnosis can allow adequate planning of treatment.
As a result of the different histology, biological behavior, extent and location of these malignant tumors of the jugular foramen, there is still no general consensus on the optimum strategy for their treatment. We have to remember that most of these malignant tumors invading the jugular foramen are radioresistant to common radiotherapy, and for this reason, total surgical removal represents the primary treatment of choice. Furthermore, a combination of surgery and postoperative radiotherapy should be considered in these lesions, as well as in the case of residual tumors after surgery where a high risk of recurrence is expected. Radiotherapy as the primary therapy should be considered to be a viable alternative to surgery in selected cases where a contraindication to surgery is found.
As is well known, in head and neck malignant tumors, the status of the surgical margin is significantly correlated with overall survival. Also in these lesions, we should bear in mind that patients with negative margins may have a significantly better survival than patients with positive margins. For this reason, surgical treatment should be attempted in all cases for total removal of the tumor with safe margins wherever possible.3
Due to the anatomical complexity of the jugular foramen, when a malignant tumor involves this area, total removal of the lesion remains a challenging procedure; in most cases, an en bloc resection is not possible, but a piecemeal resection may be mandatory. This surgical detail is crucial since the final histological examination to understand if clear margins were reached may be very difficult, and thus removing the possibility to determine the real prognosis of the patient.
Regarding the surgical treatment, some important considerations must be borne in mind for tumors arising from adjacent anatomical areas, and spreading into the jugular foramen. In particular, for aggressive tumors arising from the parotid gland with a posterior extension to the ear and lateral skull base, and confined to the jugular foramen, a transtemporal approach to the jugular foramen should be attempted and planned with the goal of achieving clear surgical margins.
In their work, Leonetti et al. observed that circumferential growth of parotid malignant neoplasms may involve the external auditory meatus posteriorly, the floor of the middle cranial fossa superiorly, and the neurovascular structures of the jugular foramen medially. For this reason, the authors suggested a subtotal petrosectomy approach combined with radical parotidectomy exposing the jugular foramen, since the high risk of inadequate tumor resection in these anatomically complex regions may result in local disease recurrence at the lateral skull base.5
Furthermore, the histotype of these tumors represents an important prognostic factor for skull base involvement; as in adenoid cystic carcinoma of the parotid gland, the natural anatomic pathways along fascial planes, nerve sheaths, vascular structures, or bony foramina allow the tumor to involve the infratemporal fossa, the temporomandibular joint, the external auditory canal, or the jugular foramen.4
Chong and Fan observed jugular foramen involvement from a nasopharyngeal carcinoma. The authors observed that a posterolateral extension of this tumor may infiltrate the lower cranial nerves directly in the carotid space within the jugular foramen.2
In our case series, we observed three malignant tumors arising from the parotid gland spreading into the lateral skull base with stylomastoid foramen and jugular foramen involvement, one metastatic cancer with unknown primary site, one metastasis, and one temporal bone carcinoma spreading into the jugular foramen.
Regarding the surgical approaches, we used a type A infratemporal fossa approach in six cases, and in one case, a type A infratemporal fossa approach was used in association with a transotic approach. In four cases, a type A infratemporal fossa approach was required with associated radical parotidectomy and different types of neck dissection depending on the extent of the disease.
Clearly, a transtemporal approach is necessary in all malignant tumors with extension to the jugular foramen and requiring otological skills. If the tumor is arising from adjacent anatomical areas, competence in head and neck oncology is required in order to perform the radical parotidectomy and radical neck dissection depending on the extent of the tumor.
We believe that, in the treatment of these kinds of lesion, a multidisciplinary surgical team is required composed of an otorhinolaryngologist, maxillofacial surgeon and neurosurgeon for safe management of the patient during surgery and the postoperative period.
The main disadvantages of the type A infratemporal fossa approach are related to postoperative conductive hearing loss resulting from ear canal closure and facial nerve paresis related to the anterior rerouting or sacrifice of the nerve. Facial nerve palsy is common in the management of malignant tumors since there is often involvement of the nerve by the lesion. Despite these disadvantages, a type A infratemporal fossa approach permits optimal exposure of the jugular foramen, when the tumor is located there, allowing control of the vascular-nervous structures running through this area.
Control of neural structures in the jugular foramen is mandatory, and postoperative morbidity mainly depends on this surgical step. Given the anatomical conformation of the jugular foramen and since preservation of cranial nerves is not always possible during radical resection of malignant tumors in this area, postoperative morbidity and mortality related to lower cranial nerve damage must be considered in therapeutic planning.
In the surgical management of benign lesions involving the jugular foramen, when cranial nerve infiltration is found, a subtotal removal of the tumor could be adopted in order to maintain the functions of the nerves. In these cases, a fragment of the tumor is left around these nerves, maintaining their integrity and function. In the postoperative follow-up, a radiotherapy strategy may be applied to the residual tumor to maintain good control of the disease.
During the management of malignant lesions, the surgical protocol is to avoid leaving residual tumor in place wherever possible, but some considerations must be made: first, the malignant tumors may present no clear cleavage planes with crucial anatomical structures such as the internal carotid artery, the middle and posterior fossa, and for this reason, total tumor removal could be extremely difficult or impossible; second, for radical excision, sacrifice of the lower cranial nerves is mandatory in most cases. Since mortality is usually associated with damage to the lower cranial nerves, a subtotal or near-total resection of the tumor may be considered avoiding cranial nerve injury, in association with postoperative radiotherapy. Further studies must be performed comparing the different surgical procedures with respect to overall survival.

CONCLUSIONS
Jugular foramen involvement by malignant tumors presents some controversial issues; first, the presence of multiple tumor types, each of which has a different pathologic behavior, prevents the formulation of a common therapeutic strategy; second, due to the complexity of this anatomical area, a total resection of the tumor is almost always impossible. This latter aspect unfortunately leads to the possibility of poor control of some of these lesions. Furthermore, morbidity related to cranial nerve injury during surgery must be considered before deciding on the optimum therapeutic plan, and careful counseling with the patient is mandatory in order to decide the treatment of choice.



REFERENCES
1. Caldemeyer KS, Mathews VP, Azzarelli B, Smith RR: The jugular foramen: a review of anatomy, masses, and imaging characteristics. Radiographics 17:1123�1139, 1997
2. Chong VF, Fan YF: Jugular foramen involvement in nasopharyngeal carcinoma. J Laryngol Otol 110:987�990, 1996
3. Gidley PW, Thompson CR, Roberts DB, DeMonte F, Hanna EY: The oncology of otology. Laryngoscope 122:393�400, 2012
4. Leonetti JP, Marzo SJ, Agarwal N: Adenoid cystic carcinoma of the parotid gland with temporal bone invasion. Otol Neurotol 29:545�548, 2008
5. Leonetti JP, Smith PG, Anand VK, Kletzker GR, Hartman JM: Subtotal petrosectomy in the management of advanced parotid neoplasms. Otolaryngol Head Neck Surg 108:270�276, 1993
6.  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/?term=Rhoton%20AL%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=10983311" Rhoton�AL Jr: Jugular foramen.  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/10983311" \o "Neurosurgery." Neurosurgery 47(3 Suppl):S267�S285, 2000



Figure Legends

Figure 1. Patient 2. Right side: Panel A: cervical dissection in subject with parotid tumor involving the jugular foramen: the major vessels were isolated at the base of the skull. Panel B: the mastoid bone was uncovered and the lower cranial nerves were exposed at the base of the lateral skull. Panel C: a subtotal petrosectomy was performed, the mastoid portion of the facial nerve and jugular bulb were exposed. Panel D: the jugular foramen was exposed after mastoid tip removal, following the facial nerve into the stylomastoid foramen; the tumor was now visible in the jugular foramen.
ca: carotid artery; jv: jugular vein; mat: mastoid tip; fn: facial nerve; tum: tumor

Figure 2. Patient 2. Right side: Subject affected by parotid gland tumor involving the jugular foramen. Panel A: the jugular vein and lower cranial nerves were exposed at the base of the lateral skull; the styloid prominence and inferior rim of the mandible were detected; the tumor was seen in the stylomastoid foramen involving the jugular foramen. Panel B: a subtotal petrosectomy was performed; the tip of the mastoid was removed exposing the jugular foramen; the tumor was infiltrating the facial nerve at the stylomastoid foramen. Panel C: a rerouting of the facial nerve with the residual tumor was performed. Panel D: final cavity after tumor removal; the jugular foramen was completely exposed.
jv: jugular vein; mat: mastoid tip; fn: facial nerve; tum : tumor; sty: styloid process; eat: external auditory canal; jb: jugular bulb.

Figure 3. Patient 2. Panel A-B: facial nerve reconstruction by auricular nerve interposition between the main trunk and peripheral branches of the facial nerve.
bb: buccal branch; ob: orbital branch; gag: great auricular graft; fn: facial nerve
Figure 4. Patient 1. Cervical MRI, sagittal view: a massive solid heterogeneous expansive lesion is present involving almost all of the right parotid gland, and also involving the lateral skull base, the carotid canal and jugular foramen.

Figure 5. MRI (coronal view) of subject affected by mastoid carcinoma (patient 3) involving the infratemporal fossa and jugular foramen.


Tables Legend
Table 1. Patient demographics
Table 2. Surgical procedures, and preoperative, intraoperative and postoperative findings



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