Jugular bulb and skull base pathologies: proposal for a novel classification system for jugular bulb positions and microsurgical implications

OBJECTIVEThere is no definitive or consensus classification system for the jugular bulb position that can be uniformly communicated between a radiologist, neurootologist, and neurosurgeon. A high-riding jugular bulb (HRJB) has been variably defined as a jugular bulb that rises to or above the level of the basal turn of the cochlea, within 2 mm of the internal auditory canal (IAC), or to the level of the superior tympanic annulus. Overall, there is a seeming lack of consensus, especially when MRI and/or CT are used for jugular bulb evaluation without a dedicated imaging study of the venous anatomy such as digital subtraction angiography or CT or MR venography.METHODSA PubMed analysis of “jugular bulb” comprised of 1264 relevant articles were selected and analyzed specifically for an HRJB. A novel classification system based on preliminary skull base imaging using CT is proposed by the authors for conveying the anatomical location of the jugular bulb. This new classification includes the following types: type 1, no bulb; type 2, below the inferior margin of the posterior semicircular canal (SCC), subclassified as type 2a (without dehiscence into the middle ear) or type 2b (with dehiscence into the middle ear); type 3, between the inferior margin of the posterior SCC and the inferior margin of the IAC, subclassified as type 3a (without dehiscence into the middle ear) and type 3b (with dehiscence into the middle ear); type 4, above the inferior margin of the IAC, subclassified as type 4a (without dehiscence into the IAC) and type 4b (with dehiscence into the IAC); and type 5, combination of dehiscences. Appropriate CT and MR images of the skull base were selected to validate the criteria and further demonstrated using 3D reconstruction of DICOM files. The microsurgical significance of the proposed classification is evaluated with reference to specific skull base/posterior fossa pathologies.RESULTSThe authors validated the role of a novel classification of jugular bulb location that can help effective communication between providers treating skull base lesions. Effective utilization of the above grading system can help plan surgical procedures and anticipate complications.CONCLUSIONSThe authors have proposed a novel anatomical/radiological classification system for jugular bulb location with respect to surgical implications. This classification can help surgeons in complication avoidance and management when addressing HRJBs.

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Anatomical considerations of high jugular bulb in lateral skull base surgery

The Journal of Laryngology & Otology ◽

10.1017/s0022215100137247 ◽

1997 ◽

Vol 111 (4) ◽

pp. 333-336 ◽

Cited By ~ 14

Author(s):

Asim Aslan ◽

Maurizio Falcioni ◽

Alessandra Russo ◽

Giuseppe De Donato ◽

Fatih Ridvan Balyan ◽

...

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Nerves ◽

Internal Auditory Canal ◽

Jugular Bulb ◽

Mastoid Process ◽

High Jugular Bulb ◽

Lateral Skull Base ◽

Significant Difference ◽

Temporal Bones

AbstractIn order to study high jugular bulb management in lateral skull base surgery, an anatomical study was conducted on 30 temporal bones by examining the relationship between the internal auditory canal (IAC) and the jugular bulb. The following parameters were measured: 1) Height of the jugular bulb (H) … distance between the level of the jugular bulb dome and the line passing through the confluence of the sigmoid sinus with the jugular bulb (SS-JB), 2) Mastoid length (ML) … distance between the mastoid process and middle cranial fossa dura, 3) Distance between the most inferior part of the porus acousticus and jugular bulb dome (A), 4) Distance between the porus acousticus and SS-JB (B). The jugular bulb was defined as high when it occupied more than two thirds of (B). The incidence of a high jugular bulb was 23 per cent in this study. When the jugular bulb was high, the mean (H) and (A) were 9.4 ± 1.9 mm and 2.7 ± 0.5 mm, respectively. (H) was higher on the right side than on the left side. No statistically significant difference was found between small and large mastoids (t-test: p>0.05). It was concluded that when a high jugular bulb was encountered during lateral skull base surgery, the jugular bulb position allows a very small working area inferior to the IAC. In these cases, a 3 or 4 mm depression of the jugular bulb is necessary in order to expose the lower cranial nerves. This can be accomplished by lowering the jugular bulb with the technique already described.

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A rare case of meningeal carcinomatosis and internal auditory canal metastasis presenting with the deafness for gastric cancer

Surgical Case Reports ◽

10.1186/s40792-020-01018-1 ◽

2020 ◽

Vol 6 (1) ◽

Author(s):

Takayuki Tanaka ◽

Kengo Kanetaka ◽

Takahiro Ikeda ◽

Shun Yamaguchi ◽

Syunsuke Kawakami ◽

...

Keyword(s):

Gastric Cancer ◽

Rare Case ◽

Abdominal Cavity ◽

Internal Auditory Canal ◽

Imaging Study ◽

Meningeal Carcinomatosis ◽

Systemic Examination ◽

Metastatic Sites ◽

Blood Biopsy ◽

Type 3

Abstract Background Meningeal carcinomatosis is a very rare metastatic site of gastric cancer and meningeal carcinomatosis without other metastatic sites is much extremely rare. Herein, we report our experience with a very rare case of meningeal carcinomatosis which was difficult to diagnose the recurrence by general systemic examination and was found due to the deafness despite the sustained high tumor markers. Case presentation A 68-year-old man consulted a hospital with vomiting and hematemesis. Laboratory tests revealed severe anemia. He was referred to our hospital and underwent an emergency gastroscopy, which revealed Borrman type 3 tumor and oozing of blood. Biopsy specimen showed gastric cancer. After several examinations, total gastrectomy was performed and tegafur-gimeracil-oteracil potassium (S-1) was initiated as adjuvant chemotherapy one month after surgery. Tumor marker levels (CEA and CA19-9) remained high for three months after surgery. S-1 was continued while shortening the imaging study follow-up period. Nine months after surgery, he noticed difficulty in hearing with facial paralysis, dizziness, tinnitus, and appetite loss. He was diagnosed with meningeal carcinomatosis and bilateral internal auditory canal metastasis. He died approximately two months later. Conclusion Meningeal carcinomatosis should be considered if bilateral deafness and vestibulopathy develop after gastrectomy, even if no recurrence is apparent in the abdominal cavity.

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The High Jugular Bulb in Lateral and Posterolateral Skull Base Surgery

Skull Base ◽

10.1055/s-2005-916515 ◽

2005 ◽

Vol 15 (S 2) ◽

Author(s):

Petr Vachata ◽

M. Sames

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Jugular Bulb ◽

High Jugular Bulb

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Multi-Disciplinary Skull Base Conference and its Effects on Patient Management

Annals of Otology Rhinology & Laryngology ◽

10.1177/00034894211021251 ◽

2021 ◽

pp. 000348942110212

Author(s):

Nathan Kemper ◽

Scott B. Shapiro ◽

Allie Mains ◽

Noga Lipschitz ◽

Joseph Breen ◽

...

Keyword(s):

Skull Base ◽

Medical Center ◽

Academic Medical Center ◽

Significant Proportion ◽

Internal Auditory Canal ◽

Patient Characteristics ◽

Management Plan ◽

Case Review ◽

Retrospective Case ◽

Lateral Skull Base

Objective: Examine the effects of a multi-disciplinary skull base conference (MDSBC) on the management of patients seen for skull base pathology in a neurotology clinic. Methods: Retrospective case review of patients who were seen in a neurotology clinic at a tertiary academic medical center for pathology of the lateral skull base and were discussed at an MDSBC between July 2019 and February 2020. Patient characteristics, nature of the skull base pathology, and pre- and post-MDSBC plan of care was categorized. Results: A total of 82 patients with pathology of the lateral skull base were discussed at a MDSBC during an 8-month study period. About 54 (65.9%) had a mass in the internal auditory canal and/or cerebellopontine angle while 28 (34.1%) had other pathology of the lateral skull base. Forty-nine (59.8%) were new patients and 33 (40.2%) were established. The management plan changed in 11 (13.4%, 7.4-22.6 95% CI) patients as a result of the skull base conference discussion. The planned management changed from some form of treatment to observation in 4 patients, and changed from observation to some form of treatment in 4 patients. For 3 patients who underwent surgery, the planned approach was altered. Conclusions: For a significant proportion of patients with pathology of the lateral skull base, the management plan changed as a result of discussion at an MDSBC. Although participants of a MDSBC would agree of its importance, it is unclear how an MDSBC affects patient outcomes.

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Otopathologic Abnormalities in CHARGE Syndrome

Otolaryngology ◽

10.1177/01945998211008911 ◽

2021 ◽

pp. 019459982110089

Author(s):

Rafael da Costa Monsanto ◽

Renata Malimpensa Knoll ◽

Norma de Oliveira Penido ◽

Grace Song ◽

Felipe Santos ◽

...

Keyword(s):

Facial Nerve ◽

Middle Ear ◽

Spiral Ganglion ◽

Internal Auditory Canal ◽

Semicircular Canals ◽

Charge Syndrome ◽

University Of Minnesota ◽

Bony Canal ◽

Ganglion Neurons ◽

Temporal Bones

Objective To perform an otopathologic analysis of temporal bones (TBs) with CHARGE syndrome. Study Design Otopathologic study of human TB specimens. Setting Otopathology laboratories. Methods From the otopathology laboratories at the University of Minnesota and Massachusetts Eye and Ear Infirmary, we selected TBs from donors with CHARGE syndrome. These TBs were serially sectioned at a thickness of 20 µm, and every 10th section was stained with hematoxylin and eosin. We performed otopathologic analyses of the external ear, middle ear (middle ear cleft, mucosal lining, ossicles, mastoid, and facial nerve), and inner ear (cochlea, vestibule, internal auditory canal, and cochlear and vestibular nerves). The gathered data were statistically analyzed. Results Our study included 12 TBs from 6 donors. We found a high prevalence of abnormalities affecting the ears. The most frequent findings were stapes malformation (100%), aberrant course of the facial nerve (100%) with narrow facial recess (50%), sclerotic and hypodeveloped mastoids (50%), cochlear (100%) and vestibular (83.3%) hypoplasia with aplasia of the semicircular canals, hypoplasia and aplasia of the cochlear (66.6%) and vestibular (91.6%) nerves, and narrowing of the bony canal of the cochlear nerve (66.6%). The number of spiral ganglion and Scarpa’s ganglion neurons were decreased in all specimens (versus normative data). Conclusions In our study, CHARGE syndrome was associated with multiple TB abnormalities that may severely affect audiovestibular function and rehabilitation.

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P–331 The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis

Human Reproduction ◽

10.1093/humrep/deab130.330 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

J Keckstein ◽

H Gernot

Keyword(s):

Classification System ◽

Working Group ◽

Complex Disease ◽

Diagnostic Methods ◽

Anatomical Location ◽

Ovarian Endometriosis ◽

Deep Endometriosis ◽

Non Invasive ◽

Complete Mapping

Abstract Study question Is there a classification for a complete mapping of endometriosis, including anatomical location, size of the lesions, and degree of involvement that can be used with both, diagnostics and surgery? Summary answer #Enzian classification improves in both, non-invasive diagnostic methods and surgical therapy for endometriosis as a universally usable classification system for all aspects of the disease. What is known already The most commonly used r-ASRM classification has certain limitations due to its incomplete description of DE, the complexity of the classification, and lack of reproducibility. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable for the description of DE. However, since it does not include peritoneal and ovarian lesions and lacks a description of tubo-ovarian adhesions, it has not gained full acceptance. A combination of classification with different systems such as r-ASRM, EFI score and Enzian, may complicate classification of the disease due to overlaps and time-consuming documentation. Study design, size, duration The result is a consensus of a panel of renowned clinicians (working group), gynaecological surgeons and sonographers with extensive expertise in diagnosis and therapy of endometriosis. A first draft was written in 2019 by a joint effort of the first and last author and sent to all working group members. Taking all comments into account, a revised draft was then sent to all coauthors and repeated until a consensus was reached (9 revisions). Participants/materials, setting, methods Criteria used to invite the experts to participate in this consensus process included their having significant peer-reviewed publications in the field of diagnosis and management of endometriosis. Main results and the role of chance Our current proposal is the first of its kind to universally describe superficial and deep endometriosis, ovarian endometriosis, adenomyosis and adhesions by using a classification system that can be applied by gynaecologists, surgeons, sonographers and radiologists following the same principles. The correlation between preoperative and surgical staging, on the basis of the Enzian scheme, allows for consistent and clear classification of endometriosis, especially DE. Endometriosis can be mapped completely with one single classification system enabling the use of one common language. Limitations, reasons for caution This classification system is anatomically logical and should be easy to use. Further studies are ongoing and are needed to provide proof for the applicability, reproducibility and accuracy of the #Enzian classification for the description of endometriosis. Wider implications of the findings: #Enzian classification now enabled better coverage of various endometriosis localizations. The possibility of using this system preoperatively as well as postoperatively within the framework of diagnostics offers clinicians a significant improvement in the care of patients with such a complex disease. Trial registration number Not applicable

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FIBROMA ARISING FROM THE JUGULAR BULB AND INVADING THE MIDDLE EAR AND EXTERNAL AUDITORY CANAL

The Laryngoscope ◽

10.1288/00005537-192804000-00004 ◽

1928 ◽

Vol 38 (4) ◽

pp. 232???243

Author(s):

GEORGE W. MACKENZIE

Keyword(s):

Middle Ear ◽

External Auditory Canal ◽

Jugular Bulb

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Polytomography and Congenital Anomalies of the Ear

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348948209100503 ◽

1982 ◽

Vol 91 (5) ◽

pp. 480-484 ◽

Cited By ~ 2

Author(s):

J. William Wright ◽

George Hicks

Keyword(s):

Temporal Bone ◽

Congenital Anomalies ◽

Internal Auditory Canal ◽

Semicircular Canals ◽

Conventional Radiography ◽

Jugular Bulb ◽

External Ear ◽

Tympanic Cavity ◽

Axial Tomography ◽

Computerized Axial Tomography

Conventional radiography and even high resolution computerized axial tomography leave much to be desired in demonstrating the minutiae of the anatomy of the temporal bone. Multidirectional tomography remains the examination of choice radiographically in cases of congenital anomalies of the temporal bone. Details of the inner, middle and even external ear in the presence of atresia are more clearly delineated by this method than any other to date. Such information is of inestimable value to the surgeon in the diagnosis and surgical correction of anomalies of the temporal bone. Important features of the vestibule, semicircular canals, cochlea, facial nerve, internal auditory canal, temporomandibular joint, pneumatization of the temporal bone, tegmen, tympanic cavity, ossicles, oval and round windows, jugular bulb and carotid artery and the external ear canal are discerned most clearly by multidirectional tomography.

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A Novel Country Classification System for Choosing International Business Locations

International Business Research ◽

10.5539/ibr.v13n1p29 ◽

2019 ◽

Vol 13 (1) ◽

pp. 29

Author(s):

Mikidadu Mohammed ◽

Jean Marie Luundo

Keyword(s):

Political Economy ◽

International Business ◽

Classification System ◽

New Classification ◽

International Investments ◽

Doing Business ◽

Legal Risks ◽

Political Economic ◽

Type 3

This paper introduces a novel country classification system that rates the political economy risks of countries for the purpose of conducting international business. It is intended to provide investors, multinational companies, and business researchers a quick and efficient way of gauging the extent of political, economic, and legal risks associated with doing business in different countries. The study covers over 170 countries and identifies 24 country types. At the extremes are Type 1 countries (least risky) and Type 24 countries (most risky). Overall, the new classification system suggests that political economy risks associated with doing international business are relatively mild in Type 1, Type 3, and Type 4 countries. However, international businesses should temper their investment decisions with caution in Type 19, Type 20, Type 22, Type 23, and Type 24 countries due to high political, economic, and legal risks, especially Types 23 and 24 where these risks are excessive. At the same time, international businesses may want to refocus their attention to Type 11 countries who are now havens for international investments due to drastic reduction in political, economic, and legal risks associated with doing business. The twenty-four country types identified in this new classification system are time-invariant. Thus, countries may move up or down due to improvements or deteriorations in certain aspects of their political economy.

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