Correspondence

The Journal of Craniofacial Surgery

size, length, and course of branches of the external carotid artery

(ECA) and the transverse cervical artery (TCA). Nonionic contrast
medium (100 mL) was injected at a rate of 4.0 mL/s through an
antecubital vein with an automatic power injector. A bolus-tracking
technique was used to select the individual start delay for the arterial phase. The scan volume included the superior margin of the
aortic arch to the superior margin of the orbit for the arterial phase
scan. Image processing was done on a workstation (ZIOSTATION;
ZIOSOFT, Tokyo, Japan) using the volume-rendering technique.
Three-dimensional vascular models including the TCA in the neck
can be visualized in this way preoperatively (Fig. 1). Rotation of
three-dimensional CTA images and the ability to view the anatomy
from any desired angle can facilitate preoperative assessment and
planning. The branches of the ECA sometimes show rare variations,
which are almost discovered incidentally during surgery. In our
experience, preoperative three-dimensional CTA in a patient with
recurrence of right mandibular gingival carcinoma revealed the
thyrolingual trunk arising from the common carotid artery (Fig. 2).
Without preoperative information on the origin of the lingual artery,
the artery may be ligated needlessly during surgery. Understanding
of the patterns of individual variability in the course of the ECA and
its branches is very vital for neck dissection or microsurgical reconstruction. Furthermore, we have sometimes encountered oropharyngeal cancer patients with stenosis or calcification of the carotid artery,
which are risk factors of complications such as cerebral infarction and
free flap failure. Preoperative three-dimensional CTA findings of the
stenosis and calcification can help to change treatment planning as
well as avoid severe complications. Therefore, we routinely perform
three-dimensional CTA as well as contrast-enhanced CT at once for
vascular assessment before head and neck surgery.
Generally, the branches of the ECA such as the superior thyroid
artery or the facial artery are used as recipient arteries.3,4 However,
prior radiotherapy and/or superselective intra-arterial chemotherapy
can cause damage to the branches of the ECA, and these arteries
might be resected by primary surgery. In double-free-flap reconstruction, not only the branches of the ECA but also the TCA are
sometimes required as recipient arteries.4 When the branches of the
ECA as recipient arteries cannot be used in microsurgical reconstruction after primary surgery, radiotherapy, and/or superselective
intra-arterial chemotherapy, the TCA should be basically selected
in the ipsilateral side because the TCA is generally spared during
neck dissection and is relatively outside previously irradiated field.
Furthermore, The TCA is less affected by atherosclerosis than the
carotid artery. However, so far, several authors have reported threedimensional visualization of only branches of the ECA before head
and neck microsurgical reconstruction using CTA and showed no
visualization of the TCA.1,2 Although Yu5 reported the TCA as recipient vessels in microsurgical reconstruction for previously treated head
and neck cancer patients, there was no preoperative assessment of
the TCA. Patients undergo more invasiveness if contralateral recipient vessels are used, when surgeons found intraoperatively that
TCA cannot be used because of insufficient size or absence. We

& Volume 23, Number 4, July 2012

FIGURE 2. The thyrolingual trunk (arrow) arising from the common carotid
artery identified by three-dimensional CTA.

commonly select the TCA first as recipient artery after preoperative

vascular assessment using three-dimensional CTA for microsurgical
reconstruction in oropharyngeal cancer patients with previous treatments, because the branches of the ECA after superselective intraarterial chemoradiotherapy have severe damage, and reanastomosis
from the branches of the ECA to the TCA is sometimes performed
for insufficient blood flow.
Three-dimensional CTA allows the surgeon to reliably assess
critical vascular anatomy in the neck. In addition, the simultaneous
display of the internal and external jugular veins or bone is possible.
To assess the location, size, length, and course of the branches of the
ECA and the TCA three-dimensionally and decrease potential vessels injury or severe complications in oropharyngeal cancer patients
who had undergone prior operation, radiotherapy, and/or superselective intra-arterial chemotherapy, we recommend the preoperative use of three-dimensional CTA, which carries no risk of cerebral
infarction compared with digital subtraction angiography.
Toshinori Iwai, DDS
Iwai Tohnai, DDS
Department of Oral and Maxillofacial Surgery
Yokohama City University Hospital
Yokohama, Kanagawa, Japan
iwai104oams@yahoo.co.jp

REFERENCES
1. Kramer M, Variaktaris E, Nkenke E, et al. Vascular mapping of
head and neck: computed tomography angiography versus
digital subtraction angiography. J Oral Maxillofac Surg
2008;66:302Y307
2. Thurmuller P, Kesting MR, Holzle F, et al. Volume-rendered
three-dimensional spiral computed tomographic angiography as
a planning tool for microsurgical reconstruction in patients
who had operations or radiotherapy for oropharyngeal cancer.
Br J Oral Maxillofac Surg 2007;45:543Y547
3. Yazar S. Selection of recipient vessels in microsurgical free
tissue reconstruction of head and neck defects. Microsurgery
2007;27:588Y594
4. Yazar S, Wei FC, Chen HC, et al. Selection of recipient vessels in
double free-flap reconstruction of complete head and neck defects.
Plast Reconstr Surg 2005;115:1553Y1561
5. Yu P. The transverse cervical vessels as recipient vessels for
previously treated head and neck cancer patients.
Plast Reconstr Surg 2005;115:1253Y1258

Glomus Tympanicum:
An Unusual Cause of Epistaxis
FIGURE 1. Three-dimensional CTA for vascular assessment before head and
neck microsurgical reconstruction. Arrow indicates the TCA.

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To the Editor: A 72-year-old woman presented with a history of

intermittent predominantly right-sided epistaxis of several months in
duration. The patient was seen by an otorhinolaryngologic surgeon
* Mutaz B. Habal, MD

Copyright 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 23, Number 4, July 2012

during outpatient examination. A nasopharyngeal endoscopic examination revealed a reddish mass bulging into the nasopharynx from the
right eustachian tube (Fig. 1). A conductive moderate hearing loss
was detected in pure-tone audiometry on the right side. She had no
smoking history, and other medical history was unremarkable. A
contrast-enhanced magnetic resonance image showed a hypervascular
mass extending superiorly up the eustachian tube and filing middle ear
cavity (Fig. 2). Digital subtraction angiography was performed. The
mass was vascularized by ascending pharyngeal and occipital branches
of external carotid artery. These findings supported a glomus tumor.
We recommended surgery or radiation therapy, but the patient accepted
radiation therapy. The patient was subsequently referred for radiotherapy. At her most recent follow-up examination, 6 months after completing radiotherapy, she reported no recurrence of her epistaxis and
control magnetic resonance images showed reduction in tumors size.
Paragangliomas are hypervascular, benign neoplasm embryologically derived from neural crest cells of the autonomic nervous system.1
They were previously nominated as chemodectomas or glomus
tumors, but the term paraganglioma is more accurate. Cervical paragangliomas are described by their site of origin and are often given
special names: carotid paraganglioma, glomus tympanicum, glomus
jugulare, vagal carotid paraganglioma, and other rare paragangliomas.
Malignant forms are uncommon. The main criterion for malignancy
is the presence of metastasis to the cervical lymph nodes or distant
sites.2 Glomus tympanicum tumors are the most common primary
neoplasms of the middle ear.3 The origin is typically along the tympanic branch of the glossopharyngeal nerve (Jacobson nerve). Clinically, glomus tympanicum tumors most often present with pulsatile
tinnitus. This is followed by hearing loss, otalgia, and aural fullness.3
In our case, the patient presented with epistaxis secondary to its extension to the nasopharynx through the eustachian tube. In considering the differential diagnoses of lesions along the eustachian tube,
one needs to include diseases extending from both the middle ear
cavity and nasopharynx. Squamous cell carcinoma, vascular lesions
such as hemangioma, and lymphoma may involve the nasopharynx. A
computed tomographic scan will show an enhancing mass. Magnetic
resonance imaging is more sensitive than computed tomographic for
lesions involving the skull base or extending within the cranial vault.4
The criterion standard regarding detection of small paragangliomas
is still digital subtraction angiography.5Y10 A number of treatment
options are available for patients presenting with glomus tumors of
the head and neck. Because of the benign nature of these tumors,
some authors recommend follow-up only for small asymptomatic
lesions.11 Surgical resection of paragangliomas can be complicated by
profuse bleeding because of their high vascularity. Preoperative embolization can significantly reduce intraoperative blood loss. Radiation
therapy and radiosurgery may be indicated. Both classic fractionated
RT and stereotactic radiosurgery (eg, gamma knife surgery) are successful in long-term control of tumor growth. Radiation treatment is
advised as the unique treatment modality for older or infirm, symptomatic patients, especially those with extensive or growing tumors.

FIGURE 1. A mass bulging into the nasopharynx from the right eustachian tube.

Correspondence

FIGURE 2. T1-weighted contrast-enhanced magnetic resonance image

showing the mass extending into the eustachian tube.

Metin Ibrahimov, MD, Mehmet Yilmaz, MD,

Marlen Mamanov, MD, Nazim Korkut, MD,
Istanbul University Istanbul, Turkey
metinibrahimov@gmail.com

REFERENCES
1. Jensen NF. Glomus tumors of the head and neck: anesthetic
considerations. Anesth Analg 2002;78:112Y119
2. Da Silva AD, ODonnell S, Gillespie D, et al. Malignant carotid
body tumor: a case report. J Vasc Surg 2000;32:821Y823
3. OLeary MJ, Shelton C, Giddings NA, et al. Glomus tympanicum
tumors: a clinical perspective. Laryngoscope 1991;101:1038Y1043
4. Pelliteri P, Rinaldo A, Myssiorek D, et al. Paragangliomas of the
head and neck. Oral Oncol 2004;40:563Y575
5. van den Berg R, Verbist BM, Mertens BJA, et al. Head and neck
paragangliomas: improved tumor detection using contrast-enhanced
3D time-of-flight MR angiography as compared with fat-suppressed
MR imaging techniques. AJNR Am J Neuroradiol 2004;25:863Y870
6. Olsen WL, Dillon WP, Kelly WM, et al. MR imaging of
paragangliomas. AJR Am J Roentgenol 1987;148:201Y204
7. Phelps PD, Stansbie JM. Glomus jugulare or tympanicum? The role
of CT and MR imaging with gadolinium DTPA. J Laryngol Otol
1988;102:766Y776
8. Van Gils APG, Van den Berg R, Falke THM, et al. MR diagnosis of
paraganglioma of the head and neck: value of contrast enhancement.
AJR Am J Roentgenol 1994;162:147Y153
9. Vogl TJ, Bruning R, Schedel H, et al. Paragangliomas of the
jugular bulb and carotid body: MR imaging with short sequences
and Gd-DTPA enhancement. AJNR Am J Neuroradiol 1989;10:823Y827
10. Vogl TJ, Juergens M, Balzer JO, et al. Glomus tumors of the skull
base: combined use of MR angiography and spin-echo imaging.
Radiology 1994;192:103Y110
11. van der Mey AG, Frijns JH, Cornelisse CJ, et al. Does intervention
improve the natural course of glomus tumors? A series of 108 patients
seen in a 32-year period. Ann Otol Rhinol Laryngol 1992;101:635Y642

Rare Bleeding After Tooth

Extraction: A Timely Reminder
To the Editor: Nonsteroidal anti-inflammatory drugs (NSAIDs) are
now widely used in anti-inflammation and analgesia for patients
receiving invasive dental procedures. Currently, we found most literatures support that NSAIDs after tooth extraction are safe.1Y3 This
letter reports a rare bleeding in a healthy man after a single tooth
extraction relating to low-dose NSAIDs.
A 59-year-old man complaining of a recurrent hemorrhage after
his left first maxillary molar, which was diagnosed as periapical
periodontitis, being extracted 18 days previously, was admitted to
our hospital on March 13, 2011. We were informed that he had

* Mutaz B. Habal, MD

Copyright 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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