Otology & Neurotology

32:291Y296 2011, Otology & Neurotology, Inc.

Hearing Results After Hypotympanotomy for Glomus

Tympanicum Tumors
*Konstantinos Papaspyrou, *Torsten Mewes, *Miklos Toth, Irene Schmidtmann,
Ronald G. Amedee, and *Wolf J. Mann
*Department of Otorhinolaryngology, Head and Neck Surgery, and Institute for Medical Biostatistics,
Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz,
Germany; and Ochsner Health System, Department of OtolaryngologyYHead and Neck Surgery,
New Orleans, Louisiana, U.S.A.

Objective: We postulate, that glomus tympanicum tumors

(GTTs) may be safely removed without interference with the
ossicular chain via a hypotympanotomy approach.
Study Design: Prospective, nonrandomized anatomic and
clinical study.
Setting: Tertiary referral center.
Patients: All 17 patients between 1989 and 2009 with GTTs
without involvement of the lumen of the jugular bulb.
Interventions: We used a modified hypotympanotomy approach. Our technique is a modification of the one first published by Shambaugh (1955). Pure-tone audiograms were
performed in all patients. Preoperative and postoperative audiograms were modeled in a linear mixed model evaluating
hearing threshold for air and bone conduction and air-bone gap
at 500, 1,000, 2,000, and 3,000 Hz. In an effort to preserve the
normal sound conducting apparatus and hearing, we used a
retroauricular approach, exposing widely the jugular bulb, the

carotid artery, the protympanum, and even the bony part of the
Eustachian tube via a hypotympanotomy. Three formalin-fixed
and one macerated temporal bones were dissected step by step
under the operating microscope to demonstrate the approach in
cadaver dissections.
Main Outcome Measure: To evaluate if GTTs can be completely resected without interference with the ossicular chain to
improve conductive hearing loss.
Results: We found a substantial improvement of hearing
threshold after surgery at all frequencies in air conduction. For
bone conduction, there was only a slight gain within random
variation. The air-bone gap decreased significantly after surgery.
Conclusion: Our approach demonstrated a safe avenue for
complete tumor removal without interference with the continuity of the ossicular chain. Key Words: Glomus tympanicum
tumorVHearingVHypotympanotomyVOssicular chain.
Otol Neurotol 32:291Y296, 2011.

In 1955, Shambaugh (1) first described the technique

of hypotympanotomy for removal of early glomus jugulare tumors confined to the hypotympanum and tympanic
cavity in an effort to gain adequate exposure of the tumor
without sacrificing the hearing. This approach to the
tympanic cavity had not been described before, although
Rosen (2) suggested that Bin cases where the tumor arises
from the promontory, it might be possible to excise the
entire tumor by simply elevating the tympanic membrane.[ Brown (3) detailed that Bit may be possible to

remove a small hypotympanic tumor through an incision

in the floor of the external auditory canal, whereby the
lower half of the drum membrane could be turned up and
the tympanum exposed.[
MATERIALS AND METHODS
Temporal Bones
One macerated temporal bone and 3 formalin-fixed bones
were dissected step by step under the operating microscope to
demonstrate the hypotympanotomy approach for glomus tympanicum tumor removal (Fig. 1).

Address correspondence and reprint requests to Konstantinos

Papaspyrou, M.D., Department of Otorhinolaryngology, Head and
Neck Surgery, University Medical Center of the Johannes Gutenberg
University Mainz, Langenbeckstr. 1, D-55101 Mainz, Germany; E-mail:
papaspyrou@hno.klinik.uni-mainz.de
K. P. and T. M. contributed equally to this work.

Patients
We prospectively evaluated, in a nonrandomized study, 17
patients who had a hypotympanotomy approach for glomus tympanicum tumor (GTT) removal between 1989 and 2009; there
were 12 women and 5 men. All patients underwent preoperative

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292

K. PAPASPYROU ET AL.
the ossicular chain into the aditus ad antrum were candidates
for this approach, extended upward or downward according
to the individual situation. The therapeutic concept included
no angiography or embolization for these isolated tympanic
GTTs (4,5). Pure-tone audiograms were performed in all
patients. This study was reviewed and approved by the institutional review board.
In an effort to preserve the normal sound conducting
mechanism and hearing, the following technique was used to
expose the tympanic cavity widely via the hypotympanum, once
hypotympanic involvement was demonstrated by preoperative
imaging (Fig. 1): after a retroauricular incision, the skin of the
posterior meatal wall was incised. A supplementary incision
through the skin of the inferior and anterior meatal wall along
the outer edge of the osseous meatus follows. The skin of the
anterior, inferior, and posterior osseous meatal wall was elevated as a tube to the sulcus tympanicus, thus exposing almost
the entire extent of the tympanic bone. After elevation of the
tympanomeatal flap that ensures the visualization of the superior
part of the tumor and identifies the position of the auditory
ossicles, the surgical procedure should include circumferential
enlargement of the bony external canal by drilling inferiorly as
far as the tympanic sulcus. The inferior osseous meatal wall was
thinned down with a burr so as to widen and enlarge inferiorly
and anteriorly the osseous meatus. During further drilling
inferiorly and medially, the vertical portion of the carotid canal
should be identified. This represents the anterior border of the
surgical field. The carotid canal makes a sharp angle with the
dome of the jugular bulb. After identification, the jugular dome
is progressively exposed as far as the styloid prominence. This
structure always lies in front of the facial canal; that is, the
preservation of the styloid prominence, which is the cranial end
of the styloid process, impedes injury to the FN during drilling.
The position of the FN in the posterior meatal wall where it
emerges from the stylomastoid foramen must be kept in mind.
By removing the floor of the meatus anterior to, but not beyond,

FIG. 1. A, Macerated temporal bone after exposure of the

hypotympanic cells (right side, lateral view) using a transcanal
approach. B, The same anatomic situation in a formalin-fixed
specimen with the tympanic membrane in its normal position but
with the hypotympanon drilled down, so exposing the jugular bulb
and the internal carotid artery if needed. C, Same anatomic
situation with the tympanic membrane now reflected after complete tumor removal. The remaining bony defect is filled with fascia
and muscle. ICA indicates internal carotid artery; JB, jugular bulb;
P, promontory; Sp, styloid process; TM, tympanic membrane;
white arrow, umbo; black arrow, round window niche.

computed tomography (CT) (Fig. 2) and/or magnetic resonance

imaging (MRI) and/or magnetic resonance angiography. This
way, a glomus jugulare tumor could be ruled out. Once a glomus jugulare tumor was excluded based on imaging findings,
patients with glomus tympanicum tumors even extending around

FIG. 2. Preoperative CT of a patient with a left-sided glomus

tympanicum tumor. (This figure is courtesy of Prof. W. MullerForell, Department of Neuroradiology, Mainz.)

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HYPOTYMPANOTOMY FOR GLOMUS TYMPANICUM

a vertical line through the posterior edge of the sulcus tympanicus, the facial nerve (FN) is safely avoided. After correct
removal of all bony overhangs around the styloid prominence,
there is direct visualization into the round window niche. The
superior limit of the surgical field is the promontory just below
the semicanal of the tensor tympani muscle. For sufficient
exposure of the hypotympanum, it also is necessary to lower the
anterior wall of the external canal formed by the tympanic bone.
It allows not only the exposure of the carotid canal but also the
identification of the caroticotympanic artery. The complete
exenteration of the angle between the carotid canal and the
jugular dome permits removal of the infralabyrinthine cells in
the event of tumor involvement.
The anulus tympanicus is elevated from its sulcus anteriorly,
inferiorly, and posteriorly. This permits the pars tensa to be
folded upward upon itself, exposing all of the tympanic cavity
and the tumor within it. After complete tumor removal, the
defect in the hypotympanon is filled with muscle and fascia,
and the tympanic membrane and meatal skin are folded back
into position.

Statistical Methods
Mean and standard deviations for the hearing thresholds
observed in air conduction and in bone conduction at the main
speech frequencies of 500, 1,000, 2,000, and 3,000 Hz both
before and after surgery were computed. This included the airbone gap between air conduction and bone conduction at each
frequency before and after surgery.
We assumed that hearing threshold and air-bone gap were
normally distributed. The dependence of hearing threshold and
air-bone gap on type of conduction, frequency, time (before/
after surgery), and duration of follow-up was modeled in a linear
mixed model, thereby taking into account possible dependencies
because of repeated measurements. In the first model, hearing
threshold was the dependent variable whereas the type of

FIG. 3.

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conduction, frequency, and time were categorical covariates.

Duration of follow-up was modeled as continuous covariate. In
the second model, the air-bone gap was the dependent variable,
whereas frequency and time were categorical covariates.
p values for F tests of main effects and interaction terms are
given. Furthermore, we present p values of t tests testing for
specific differences of interest. These tests were performed in
an explorative fashion; therefore, p values are descriptive.
Descriptive statistics were obtained using SPSS 15.0 (SPSS,
Inc., Chicago, IL, USA). Modeling was performed using PROC
MIXED from SAS 9.2 (SAS Institute Inc., Cary, NC, USA).

RESULTS
Follow-up time, including audiologic data, ranged
from 1 to 236 months (mean, 43.3 mo).
Patients most recent audiograms were selected. Hearing
threshold depended on type of conduction ( p G 0.0001),
frequency ( p G 0.0001), and time of audiometry ( p G
0.0001); duration of follow-up was not associated with
hearing threshold ( p = 0.3976).
The hearing threshold improved, on average, by 3.6 dB
at 500 Hz ( p = 0.2138), by 4.7 dB at 1,000 Hz
( p = 0.1091), by 5.9 dB at 2,000 Hz ( p = 0.0434), and by
8.5 dB at 3,000 Hz ( p = 0.0039). For bone conduction,
we found only a slight improvement in hearing threshold
that is within random variation with a mean increase
of 1.2 dB at 500 Hz ( p = 0.6733), of 1.6 dB at 1,000 Hz
( p = 0.5740), 3.5 dB at 2,000 Hz ( p = 0.2367), and a
marginally significant improvement in hearing threshold
of 5.4 dB at 3,000 Hz ( p = 0.0686). A composite preoperative and postoperative audiogram is depicted in
Figure 3. The air-bone gap decreased, on average, after

Hearing threshold before and after surgery for air and bone conduction.
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FIG. 4.

K. PAPASPYROU ET AL.

Air-bone gap before and after surgery.

surgery by 2.4 dB at 500 Hz ( p = 0.1645), by 3.1 dB at

1,000 Hz (p = 0.0787), by 2.5 dB at 2,000 Hz ( p =
0.1546), and 3.2 at 3,000 Hz ( p = 0.0680) (Fig. 4).

DISCUSSION
In patients with glomus tympanicum tumors, we routinely use a retroauricular approach because these tumors
often are not adequately demonstrated on CT or MRI;
thus, their real extent often is determined intraoperatively.
Of course, as Shambaugh (1)(p597) points out, the preservation of hearing should not be at the risk of incomplete removal of the tumor. This speaks in favor of a
retroauricular instead of a transcanal approach. In addition, if the surgeon finds that hypotympanotomy does not
fully and adequately expose the tumor or enters the
jugular bulb, there is the possibility to proceed with exposure and occlusion of the jugular bulb via a radical
mastoidectomy approach. In 1967, Farrior (6) described
a postauricular hypotympanoplasty technique for the
removal of glomus tumors similar to the one we used in
this study. House and Glasscock (7) maintained that
virtually all tympanicum tumors could be safely removed
surgically either by transcanal exposure or through an
extended facial recess approach, preserving the posterior
external auditory canal.
Glasscock et al. (8) state that, when the tumor is limited
to the promontory and all margins can be clearly defined
through the intact tympanic membrane, a transcanal
(tympanomeatal flap) procedure is the method of choice.
A large glomus tympanicum lesion filling the middle ear

and hypotympanum would best be removed by a postauricular approach using an extended facial recess exposure of the middle ear and hypotympanum. However,
this often poses a greater risk to the FN. We prefer the
postauricular transcanal approach without facial recess
exposure. With this technique, the FN is safely avoided.
Glasscock et al. reported approximately 35 tympanicum
tumor removals, 30 of which were removed by the
transcanal or extended facial recess approach, thereby
preserving the posterior canal wall in 30 cases, the tympanic membrane in 24, and the ossicular chain in 24.
Six patients in this series, however, required tympanic
membrane grafting and ossicular reconstruction. Five
patients underwent radical mastoidectomy. There were
no Bdead[ ears in this group, and in all cases, preoperative hearing was maintained or improved. FN function
was spared in all 35 cases, and to date, no patient has
demonstrated any sign of recurrent disease. In our study,
the tympanic membrane, the ossicular chain, and the
FN function were preserved in all cases.
Pensak and Jackler (9) describe the creation of a fallopian bridge with preservation of the FN while removing
tumors that arise within or juxtaposed to the jugular fossa
reporting on 35 patients, 13 of which had glomus jugulare
tumors. The vertical segment of the FN was skeletonized
from the stylomastoid foramen to the second genu. An
extended facial-recess exposure was performed. Bone
lying anterior to the FN was burred down, hugging
the anterior surface of the fallopian canal to optimize
visualization of the posterior mesotympanum and hypotympanum. Perilabyrinthine cells were widely exenterated in both the infralabyrinthine space and the retrofacial

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HYPOTYMPANOTOMY FOR GLOMUS TYMPANICUM

air-cell system. In the authors_ experience, in selected
cases, leaving the FN in situ has neither compromised
the extent of tumor resection nor increased the liability
toward neurologic injury.
OLeary et al. (10) reported on 64 patients. Surgical
approaches were classified as either transcanal or transmastoid. One fifth of the cases were small enough for
transcanal removal. Approximately 70% of these tumors
were removed transmeatally and 30% via a postauricular
incision. Lesions in this latter group usually required
increased access anteriorly. The remaining 80% of cases
required a transmastoid/facial recess approach. A radical
mastoidectomy with removal of the posterior canal wall
was performed in 3 patients. The preoperative mean airbone gap of 10 dB was reduced to a mean gap of 4 dB
postoperatively. This improvement in conductive hearing
was accompanied by a slight worsening of bone conduction postoperatively, with a rise in the mean bone PTA
from 24 to 32 dB. Our method, on the contrary, reached
substantial hearing improvement at 2,000 and 3,000 Hz
in air conduction, a slight gain within random variation
for bone conduction with a marginally significant improvement at 3,000 Hz, and a significant decrease of
the air-bone gap after surgery at 3,000 Hz. Three tympanic membrane perforations failed to heal and required
secondary tympanoplasty. A cholesteatoma developed
postoperatively in 1 patient and was treated by revision
mastoidectomy. In another case, an FN weakness noted
postoperatively prompted reexploration and FN decompression. The patient experienced a mild (IINI) permanent weakness. In our study, as already mentioned, such
complications did not occur.
Gjuric et al. (11) report on 11 glomus tympanicum
tumors. All patients were treated surgically with apparent
complete removal of the tumor. The surgical approach
was either the transcanal (endaural or retroauricular)
or the classic retroauricular transmastoid approach. The
transcanal approach (performed on 7 patients) was reserved for tumors confined to the tympanic cavity, and it
included resection of the floor of the external auditory
meatus for visualization of the tumor margins. If necessary, the FN was exposed in its mastoid portion, and the
dome of the jugular bulb and the internal carotid artery
were inspected. The evaluation of hearing was available
for 10 patients. In 4 instances, the ossicular chain was
temporarily disarticulated, for exposure purposes, and in
1 patient, a canal wall down procedure was performed.
Three patients required a second-stage tympanoplasty.
The air-bone gap closed postoperatively to within 10 dB
in 3 patients, to within 20 dB in 6 patients, and to more
than 30 dB in 1 patient (average of 0.5, 1, 2, and 4 kHz).
Two minor complications occurred. One patient had a
temporary facial palsy, and another patient had a persistent defect of the external meatal wall, requiring closure.
Comparing with our study, additionally to the 2 minor
complications, there are no detailed, statistically analyzed
results regarding air and bone conduction and air-bone
gap, and the 4 kHz frequency was preferred instead
of 3 kHz.

295

There are 4 reports in the literature of using lasers for

GTT removal totaling 13 patients. Durvasula et al. (12)
used a Diode or KTP laser. Postoperatively, none of the 9
patients had sensorineural hearing loss or neural deficit;
there was no recurrence but an increase in the air-bone
gap of 10 dB was observed in 2 patients. Molony et al.
(13) also used the KTP laser, whereas Robinson et al. (14)
used the Nd YAG laser, and Kouzaki et al. (15) used a
potassium titanyl phosphate laser, the feeding vessels
having been embolized the previous day. In the authors_
experience, laser excision can be performed with minimal bleeding and morbidity, and it provided excellent
tumor control in glomus tympanicum surgery to shrink
and coagulate the tumor progressively with minimal
hemorrhage, avoiding ossicular disarticulation and, sometimes, the need for extended facial recess or hypotympanotomy surgery. According to Robinson et al. (14), care
should be taken to avoid accidental energy transmission
to the cochlea. However, the same authors report sensorineural hearing loss of 20 dB after the excision of the
tumor.
Salami et al. (16) used a piezoelectric device in 10
patients affected by type A glomus tympanicum tumors
(Fisch classification). The piezoelectric device confirmed
its safety on soft tissues; during unintentional contact
with the mass, no side effects were detected. Postoperatively, all 10 patients had no evidence of sensorineural
hearing loss, neural deficit, or recurrence. In all the
patients, 1 month, 6 months, and 1 year after surgery and
at the end point, pure tone audiometry showed a mean
hearing improvement of at least 16.4 dB of audibility
threshold.
Blood loss was not an issue, neither in the present study
nor in any of the other series referred to above. Only
OLeary et al. (10)(p1039) reported a significant intraoperative blood loss in their series of 64 surgically removed tumors.
The remaining air-bone gap between 9 and 3 dB in our
patients was possibly related to distortion of the drum or
enlargement of the tympanic ring inferiorly. As the
middle ear ventilation was not affected in none of the
cases, Eustachian tube function was not impaired.

CONCLUSION
We have demonstrated that our hypotympanotomy
approach for removal of glomus tympanicum tumors
modified from Shambaugh_s description provided for
substantial hearing improvement at 2,000 and 3,000 Hz in
air conduction, a slight gain within random variation for
bone conduction with a marginally significant improvement at 3,000 Hz, and a significant decrease of the airbone gap after surgery at 3,000 Hz. This approach
allowed for a safe approach for complete tumor removal
without interference of the continuity of the ossicular
chain while providing excellent exposure of the jugular
bulb, the carotid artery, the protympanum, and even the
bony part of the Eustachian tube.
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K. PAPASPYROU ET AL.
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