What I'm going to talk about, or it's really an historical commentary because the faculty up here in the front realize that a lot of the things I'll be talking about, we don't really get to operate on these tumors very much anymore, particularly the jugular foramen tumors like the glomus tumors. That was a particular tumor that when I was coming along, which was a long time ago, that was a surgical case. And today, the majority of those are being treated with gamma knife radiosurgery very effectively. So you just, we're not seeing those to operate on. And there's just a number of tumors that we don't get to do very much with at the jugular foramen level because, again, these are benign, slow-growing tumors. And I'm going to make some comments about just the management because if you do get in a situation where you've got to manage these tumors, you've got to ask yourself specific questions. And if you're not prepared to answer in a way that you appear to know what you're doing, then you better pass on these because you can get in trouble. The bottom line of the questions I've got here, and these are just really looking at the broad perspective of management of jugular foramen tumors, carotid space tumors, and the experience I've had for a number of years, and that's really should the surgery be done at all. I mean, you know, if you're looking at a situation where you've got a tumor that's a benign tumor, and particularly in an older person or even in a middle-aged person who's neurologically intact and somebody finds this thing incidentally, you've got to be very careful about, you know, what you recommend in terms of how to manage this. The other aspect of this is so many times it's really odd to realize this, but you can have a significant tumor that is a benign tumor, and yet these people still have cranial nerve function. I mean, the lower cranial nerves are working, and so should you sacrifice a cranial nerve in order to remove a benign tumor that was found incidentally? You really have to ask yourself that. There was a time when people would go after the glomerular tubular tumors and other tumors of this area, and they would not, I mean, they wouldn't blink an eye. They'd sacrifice the carotid because that tumor just had to come out, and that's just kind of never did really sit well with me, and that's another question that, when should you ever consider sacrificing a carotid artery? And if you do get into some sort of trouble where you wind up with a lower cranial nerve deficit, facial nerve palsy, do you have a plan to manage that patient, or are you just going to send the patient away and say, you've got to live with that deficit? That's absolutely the wrong thing to do. You ought to have a plan for facial reanimation, for lower cranial nerve deficits, particularly 10th nerve. You know, you need to know what to do about that in order to alleviate that problem, which can be really a life-changing and potentially life-threatening situation, particularly with lower cranial nerves. Also, the fact is that when you have somebody that comes to you with cranial nerve deficits that have been present for years, they've compensated, and those people can very easily be managed surgically with really no impact on their functionality, although you need to realize if somebody has a 10th nerve palsy, but the 12th nerve is working, 11 is okay, but they've got the hoarseness, but they've compensated, they've had some swelling difficulty, but they're doing pretty good, if you go in and give them one more lower cranial nerve deficit, you may create a totally bad situation. They'll decompensate. So chronic cranial nerve deficits, if you can operate on somebody and not give them a further deficit on top of that, they usually do pretty good, but the chronic deficits versus the acute deficits, obviously the acute deficits are much more difficult to deal with, and really over the last 30 years, you know, we've gone from radical removal of tumors, all of these tumors have to be removed, which is the way I was taught in the 70s and operated in the 80s until the last real 25 years. It's really more of a conservative approach, certainly the use of radiation, specifically radiosurgery to manage these. So these are just questions that you really need to consider. All the guys on the front row have heard all these points before and they've seen these cases, but I'm going to run through some cases because, again, most of you probably have never seen anything like some of these tumors, and I'm just going to show you a couple of cases, but just to get you oriented in terms of the pathology. So the critical thing about any lower cranial nerve, potential lower cranial nerve tumor or jugular foramen region tumor is you want to evaluate them and understand the clinical things that you'll be looking for. Obviously, a tumor such as this, which is a glomerulus jugularis, you know, this guy presented with hearing loss, dizziness, facial weakness. So any cranial nerve, depending upon the growth of the tumor and the extent of the tumor, you can have lower cranial nerves, you can have facial nerve, hearing loss, et cetera. All of those things can be involved depending upon the size and the location of the tumor. Obviously, the lower cranial nerve deficits are obvious with a 12th cranial nerve deficit. Always examine somebody when you suspect this. Take the shirt off. Look at the shoulder girdle musculature, the trapezius, as well as your sternocleidomastoid and 11th cranial nerve palsy. Many of these people, particularly young people, oftentimes will present with a neck mass, and they may have no cranial nerve deficit. They may, but, you know, somebody presenting with a neck mass may wind up having a benign carotid space, jugular frame, and type tumor. And, of course, this is just, you know, articles and points to emphasize that if you've got a neck mass, you know, you may have a dumbbell tumor that may be an intracranial mass, such as meningiomas in particular, but the benign tumors can do this. If you're going to look at these tumors, always be aware of the vascular to around the tumor because it can get you in some serious troubles. You've got to understand where your internal carotid artery is in relationship to the tumor. Knowing that the tumors can, like in this particular case, this is a meningioma that's, look at the vascularity of this, both with the external circulation primarily, but in some of the cases, like the glomus tumors, they've got a significant blood supply from the internal, but understand what the vascularity is before you go after these tumors. Imbolization is critical if it's primarily externally supplied by the external carotid. But this carotid, the carotid artery is critical. I mean, this is a benign, two examples of benign nerve sheath tumors. These are both cases of ninth nerve sheath tumors, but look what we have. In this case, the carotid artery is sitting anterior, but in this case, the vessels are on the lateral margin of this thing. So if you don't recognize that, particularly if you go into a young person, if you're operating on a 15-year-old or a young person in their 20s, they've got normal vessels, you come down on this, and that carotid's sitting on the surface, the lateral margin of that tumor, and so many of these people have got normal blood pressure, soft vessels, and you, you know, it'll be sort of flattened out, and you're dissecting around, and you really won't recognize that, and you can try to palpate the vessel, and if anesthesia went to sleep and the blood pressure's kind of running low, you may just walk right into the carotid simply because you didn't know about it pre-op. So in all of these cases, I want to know where the internal carotid, external carotid vessels are, and it's really critical. In a case like this infratemporal fossa tumor, the reason that the ENT people want us involved with those cases is because what happens to the carotid in that, as you would expect, infratemporal fossa tumor, the vessels are going to be posterior. So anterior, lateral, posterior, but know where that carotid's at because, again, if these people get in trouble, if somebody else is doing the case, you're going to be called to try to bail them out, and you don't want to get in trouble on the front end if you understand the anatomy and recognize how the pathology can progress with these. This is an example, you know, this would, like, would this happen again at this point in time? No, probably, because this is a glomeruloneurotumor, although it was a tumor that was a very aggressive tumor. If you look at the pathology, it looked fairly benign, but this was a guy that I operated on back in, like, 1985. He was a young man, 26 years old. This is a glomeruloneurotumor, and this is what a glomeruloneurotumor can do to a carotid. It not only encases it, but you can actually have invasion pathologically of the abdentition, even the muscularis, of that, by that tumor, and so therefore you get in a situation you can't take the tumor completely out unless you take the carotid. In this individual, we operated on him, and within a year and a half after we operated on him, the guy had a big recurrence, and he was a young man, so what we did was that we had done a balloon occlusion. He cross-filled real well, and we selected in this particular case, because of the aggressiveness of the tumor, to go in and selectively ligate the internal carotid artery. We basically put a clip on the internal carotid artery above, below the ophthalmic, ligated the carotid, and then removed the tumor, resected this tumor, and the guy was cured, but again, that's, if you ask me how many times I did that, that's one. That's it, and today you wouldn't, I mean, you probably, you wouldn't, you know, but back then, we didn't, radiation wasn't, you know, these had to come out, and again, you'll get tumors like this that are very aggressive, and you'll be, you'll certainly be forced, even in this day and time, to consider having to do something like this. Obviously, malignancies are more common that you would do this, potentially, depending upon the type of tumor and the life expectancy, but non-tumors can sometimes get very aggressive, particularly these two tumors, the glomus jugulari tumors. They can become very aggressive, so just keep this in mind, and I show this for the residents simply because you've probably never seen this. I would expect you guys in your residency, most of you, has anybody, any of the residents in the room seen the glomus jugulari tumor surgery? Okay, we got two people, three, but it's important to understand that these are odd tumors. I mean, they, typically 50% of these things come from the glomus bodies in the dome of the jugular bulb, and they grow, but they grow intraluminally, they're inside the lumen as well as extraluminal, and they can invade in all different directions around the area of the bulb, into the temporal bone, posterior fossa, neck, et cetera, but these tumors are, again, very unusual tumors. Also in the tumors that you're dealing with, not only do you have to worry about the arterial blood supply, where the carotid's at, but you want to preoperatively evaluate them to know what the sigmoid sinus looks like. Is it occluded? Do I have good collateral, you know, venous outflow? By the way, is this side occluded, and the other side's atretic, and, you know, this guy's got all kinds of screwed up venous circulation, and when you did the venous phase of the arteriogram, you saw veins that's kind of like, what in the world am I looking at, because all these collaterals have developed around it. These are things you need to know before you get in there surgically and run into a mess that you could have avoided. Also remember that the glomus tumors in particular can be multiple. This is a case where you've got a glomus jugulari, a vagali, and a carotid body tumor, and this young lady who was 26 had two glomus tumors on the opposite side of the neck, one vagali, and also had a glomus jugulari on the opposite side. Remember, this is familial, so she came from a family, so if you find one like this, then you've probably got a career if you decide to operate on them, because they run in families, and you have to evaluate them and always be looking for things like this when you're dealing with this tumor. This is a case of bilateral situation like I was talking about, management for this. Back in the old days, these were surgically removed. Today, you know, you would certainly consider other options, radiosurgery, et cetera. And then this is just to show you that when you get into tumors, this can be a meningioma or it can be glomus jugulari tumors. I've seen this in both. You'll expose the nerves in the neck, lower cranial nerves. This is a case of a hypoglossal nerve that's invaded by the tumor. So these tumors are very large, and yet this hypoglossal nerve worked fine. So what do you do? Do you sacrifice that function to resect a benign tumor? You know, it's a whole issue of radical removal of tumor. Is that appropriate? Well, then again, I go back to the patient, the age of the patient, the aggressiveness of the tumor, you know, the length of time these people have had a deficit, either deficit or no deficit. And if you have to sacrifice a cranial nerve, have a game plan to manage and post-op. And of course, you know, you'll see calcification hypostosis, obviously, with meningiomas. So those are just some things for the residents in the audience who really have never seen the types of tumors that you're dealing with in the region of the jugular foramen or the carotid space. Typically benign, the swinomas, glomerular tubular tumors, obviously a very unusual tumor, the meningiomas. And then you can see other types of tumors, rare tumors. You may get a chondrosarcoma that starts off in the, you know, the pitreous area, pitreous apex, but the thing just takes off in a lateral direction and winds up presenting with a jugular foramen type syndrome. And you've got to, you know, got to deal with that. So there are other types of tumors that can invade, you know, the area of the jugular foramen. But the benign tumors that I mentioned, the three most common are the ones that I pointed out. I give this slide. This is a slide of Dr. Roten's. And I've ran across this. And after doing this type of surgery and talking about the anatomy for years, it was about, I don't know, it was about eight years ago, I was looking through his slides and I ran across this and it just, you know, it was like a big light came on, at least for me. The point being is that when you look at the jugular foramen area in the carotid space, have a broad picture of the anatomy. You can't just focus on that one area. If you're going to go in and surgically feel comfortable working in this region, then you really need to understand what's behind you and what's in front of you. So you really need to understand the infratemporal fossa anatomy and certainly the anatomy of the vertebral artery, the spine in relationship to the neurovascular anatomy anterior to the spine. And if you understand this whole region, then you'll feel very comfortable working in the infratemporal fossa, working in the region of the carotid space, the jugular foramen, and doing work through the far lateral exposure in regard to your vertebral artery and the anatomy that's around it. So why is this so important? Well, for instance, if you look at your jugular vein, most people, you don't think about this because you've never, you didn't have any surgical cases that were here. You had no reason to think about the anatomy. But look at the relationship of the jugular vein to the vertebral artery. When you're going down and exposing the vertebral artery as it comes out the frame of transverse ceremony, C1, the only thing that separates the vertebral artery from this jugular vein is this muscle mass here. And that's the rectus capillus lateralis muscle, which, you know, unless you have some crazy love for anatomy, I would bet a hundred bucks that most people resident wise in the audience, one, you've never seen it, you've never thought about it. It's kind of like it's there, but I never really knew it was there. And what does it do? Well, it sits between the vertebral artery and that jugular vein. And we're going to show that to you in the lab this morning. And the reason it's so important is because this muscle comes off the transverse process of C1 and it goes north and attaches to the posterior margin of the jugular frame. And if you're dissecting around the vertebral artery and you're down there and you're just dissecting and you put a hemostat and you're kind of pushing things around and you're bipolar in this and what have you, if you don't really know what you're doing, you might go through this muscle and wind up in the back of the jugular vein. Or you may bag the vagal nerve between the jugular vein and the carotid artery. I mean, all of this is sitting right anteriorly to you. Or if you get a bleeder down deep, you know, if you don't know the anatomy, you know, you don't know what to watch out for. And so this is a very, very important relationship, very close anatomy, as you'll see in the lab today. That's one take-home message for you to realize. The other take-home message is that you'll see at the transverse process of C1, you can use that as a landmark to identify where nine times out of ten you're going to find. That's going to be the level of where the accessory nerve either crosses over the anterior or posterior margin of the jugular vein to enter the sternocleidomastoid muscle. So that's a landmark to look for. So consider this anatomy, the carotid space anatomy, obviously we are going to get you up to the base of the skull today. I want everybody to go all the way to the base of the skull to where the carotid is going, the carotid canal, and expose, open your jugular vein, follow it up to the bulb, open the sigmoid sinus. You ought to have this entire area open now that you have done your mastoidectomy and you have exposed this. And actually look inside the bulb. You saw the beautiful anatomy pictures yesterday. You want to look at that. And if you get a chance, strip the medial wall away and look at the nerves. I mean really try to understand this anatomy. And also if you are going to be working in this area, if you understand the infratemporal fossa, where the carotid is, you know there is not a whole lot here that you can hurt if you understand the anatomy, but you would be surprised. A lot of the ENT folks, even some of the head and neck surgeons, they feel very comfortable working in here, but the closer they get to the carotid, they really want you to be around in the room near them in the event that you have trouble. So you need to know this anatomy well. And as I pointed out, there is one thing. You don't need stealth in the operating room if you follow your bony anatomy because it is always true in terms of leading you to specific anatomical landmarks. The facial nerve, if you want to know where the facial nerve is at, if you can identify the styloid process and the mastoid tip, it is going to be right between your thumb and the index finger. You run your index finger up the styloid process and put your thumb on the mastoid process, the facial nerve is going to be in between them. And I will show that to you in the lab this morning when we go down. I have done a dissection earlier. That is where you find that. So those are always bony landmarks you can depend upon. Again, that transverse process of C1, very important in terms of understanding the relationship of the rectuscapular lateralis muscle, the jugular vein, carotid artery, that is key not only for the anterior work but also if you are going to be doing your far lateral posteriorly. So simple things like that that you can depend upon. Know the infratemporal fossa anatomy. Have some kind of a concept of it from the standpoint if you are looking from below or if you are looking from above. Have a concept of that anatomy. Jeff showed you this anatomy yesterday. And this is just, I think everybody looks at this, the key things that when you look at it you can point out this anatomy but what is the functional significance of it? This is that rectuscapular lateralis muscle attaching along the posterior margin. That is that styloid process. So where is the facial nerve? You feel the styloid process, it is always going to be along the posterior lateral margin of the styloid process. So if you run your finger up to the base of the skull, you know, just lateral to that, lateral and posterior to that is always going to be the facial nerve. That is where you identify it. So, you know, just to understand this anatomy if you are going to do your dissections and it makes it so much easier. This is just to show you, this is another beautiful slide of Dr. Roden's but it shows you that relationship that again, if you had asked me this 15 years ago I didn't know this. You know, only with all these anatomical courses that we teach, most of the guys up here that are your faculty, we have learned the anatomy and appreciate relationships that we didn't really appreciate certainly when we started practice and even, you know, way into our practice. Constantly looking at the anatomy, try to understand relationships to help you in surgery. But this is the point I made about here is that vertebral artery, this is the rectuscapular lateralis muscle partially removed. Immediately in front of it is the jugular vein. It is just asking you to get into it. If you really take this anatomy apart, you can expose from a posterior approach, you know, you can mobilize that vertebral artery, drill your bone away at the base of the skull, open up the posterior margin of the jugular foramen, so you can absolutely get a good feel for all the anatomy that you see there. And then again, if you strip the vein and the medial wall completely away, you will see the relationships that you may have read about, thought about, but never have really seen. This was shown to you yesterday. Again, the importance of this and we will point that out in your dissections is the facial nerve, you know, the facial nerve you have to consider whether or not to transpose it anteriorly or posteriorly. Most people have done a lot of surgery. You get, you know, the more experience you get, you can most of the time skeletonize that nerve and just work in front or behind it. Why not to mobilize it? Because I don't know whether anybody mentioned it yesterday, but when they start talking about moving that nerve, if you move that nerve, you are never going to have a normal face again. I mean, it is just once you really mobilize it, you really hurt the blood supply to it and you wind up with probably a house grade three in the majority of patients. And this is just what was pointed out yesterday, the whole issue of if you expose the sigmoid sinus coming down to the bulb area and if you take all the lateral wall off, you are looking at the media wall of this bulb. If you take the media wall off, you are going to be looking at your lower cranial nerves. When you look inside in the vast majority, the inferior petrosus sinus is not typically one big channel that comes in. Most of the times there is a bunch of little small channels that you will run into, but if you are taking a tumor out, any tumor that you take out of the, if it is intraluminal within the jugular bulb region or for some reason you get into the jugular bulb region, if the patient is well oxygenated on the table, you think you got into the carotid artery because there is a bunch of bleeding. But somebody pointed this out already, all you have got to do is pack that with Surgicil and everything quietens down. So gentle pressure, Surgicil, give it a minute, it will do just fine. If Surgicil gets blown out of the operative field and it keeps bleeding, you are in the carotid, so it is too bad. Now this is just a point, I am going to just go through this real quick with you and again I am going to put some illustrations up here for the residents just to give you a concept if you are taking out a tumor around the area of the jugular frame or carotid space, intracranial, extracranial, just to kind of give you an idea because most of the time when you look at this anatomy, if you have never seen it, it doesn't make a whole lot of sense to you. So I am going to just try to be real simple with these illustrations and a couple of cases. So these are basically the surgical approaches to what I kind of lump all this together, you know, jugular frame and carotid space, upper temporal fossa. So you have got a small tumor, you know, it may just be in the carotid space or the jugular frame. You have got a big, big tumor, it may be everywhere. So you really need to understand the anatomy, but you have to plan your approach based upon the location, the pathology, etc. But it has been divided, the approach has been divided into a lateral group, posterior group, anterior group. You can read these. Essentially what you are really talking about doing is how to get around the anatomy and the pathology in such a way that you can remove the tumor, minimize injury to the lower cranial nerves, vessels and what have you. And everything is a little bit different, but over the years this has been the primary group that I have used and participated in with our head and neck ENT neurotology colleagues because the lateral approach, post-auricular approach, and I will show you in these slides, if you do this correctly, you can get 270-degree exposure of the jugular foramen area. You can get behind it, get along the lateral margin and get anterior to the pathology. And you get proximal and distal control. So this is just an illustration. This was back before you had videos that I had these put together. But it is easy to understand. If you have got a tumor that is involved in this area, what you want to do is get the anatomical exposure. And then once you get the anatomic exposure, you may or may not have to mobilize the facial nerve. That is what we are talking about, transposing the facial nerve, bringing it forward. And then the key is that you are going to ligate your jugular vein. And you do that because if you had a glomus tumor, that tumor is intraluminal and dissecting it, you may break tumors loose and it goes down to literally the atrium of the heart and then you have got a problem. So you want to ligate this first, get beyond the distal margin of this tumor. And then you come and you ligate your sigmoid sinus. And you can either ligate that with a single suture once you close it or you can individually sew it off in terms of the lumen. But bottom line, you ligate this. You are beginning to remove the tumor. You are essentially going to take the lateral wall of the sigmoid sinus, the bulb area, and the tumor, take it all out in one. And this is what you ought to have when you finish. So this is very simplified. But this is what you would love to have happen, taking the tumor out, packing off the inferior petrosus sinus area, leaving the medial wall of the jugular bulb and the distal sinus intact over the lower cranial nerves to protect them. And then finally, a closure can be a large adipose tissue, rotation of a vascularized flap. But that is the principles involved in removing a tumor, particularly a glomus tumor or some aggressive tumor, large meningioma, that would involve all of these structures. These were shown yesterday. Just to go through it real quick, this is a lateral approach. And the anatomy that I will point out to you in the lab when we go down this morning, again, these are things to emphasize to you. This represents the transverse process of one. You got your inferior oblique, superior oblique going on it. But if you watch this, the jugular vein is going to be right in front of it. Rectus capitis lateralis muscle is going to be going up from the transverse process up to the posterior margin of the jugular fragment. But if you watch your vein, you will find your accessory nerves going to be crossing that vein just about at the level of C1. The other anatomy, you can't really get up to the base of the skull with the carotid artery or the jugular vein unless you take the styloid process, the small muscles attached. You really got to do all of that to get up. Because to really see that internal carotid artery at the base, you got to get the styloid process out of your way. And so the dissection, you can see here that this is essentially what you should be looking at from what you did yesterday. The anatomy, as you see, will be several things. You got to run into a vessel, which is occipital artery. But you can't see a whole lot. Here is your facial nerve. But even with what you run into is once you take the posterior belly of the digastric down, you still got to run into the muscles attached to the styloid process. The styloid process has been removed along with those muscles that have been mobilized. Now you are beginning to see the internal carotid artery at the base of the skull. If you don't take that anatomy apart, you really have trouble getting up there. And ultimately, this is what you like to look at when you get through your dissection this morning. You are looking at the 9th nerve, the 12th nerve, the 10th nerve. And the accessory nerve is going to be coming back over the transverse process wrapping out going towards the sternocleidomastoid muscle. So let's just look at a couple of cases and we will stop. This is just an example. Again, for those in the audience who have never seen a glomus tumor, this is what it looks like. And it is a destructive invasive type tumor, but it has a distinct appearance on CT and MRI scan. And this is basically what you would be looking at once you have done a dissection. So here we have done this. Here is your facial nerve skeletonized, not mobilized. This is sigmoid sinus. This is the cavity, the mastoid cavity. Now the tumor is at the depth of this cavity in the jugular bulb region. Tumor is going to be growing through in the jugular bulb down into the jugular vein. This is tumor that is extended. You can actually see the difference. This is vein distal. This is tumor within it. But you can see how we are all the way up to the base of the skull at this level. And then, of course, what you are going to do is we are going to ligate this vein and this accessory nerve. So here you can see how the tumor is intraluminal and how we have opened up the vein just to demonstrate the tumor. And this looks like somebody dropped a bomb in it. And it is kind of like what the hell is that? So it is hard to recognize, but literally this is the sigmoid sinus that is ligated. This is your defect where the tumor was. Here is the ligated distal jugular vein. This is where the tumor is being literally pulled out of there. This is a cavity where the lateral wall of the sigmoid sinus, the bulb, and the proximal jugular vein below the skull base have been opened widely to remove that tumor. This is a meningioma. This is the case that I showed you initially where it is a dumbbell meningioma. You see this big thing here. The big problem with this is this is very vascular. The patient is a young person who has multiple cranial nerve deficits that are chronic. But you can see the vascularity is primarily supplied from the external. But you have got to understand your anatomy. And this lady presented with she was having trouble swallowing. She has got this big mass in her neck. She has got lower cranial nerves, multiple facial nerves intact. Hearing is intact. But if you look at those scans initially, this is, you know, the posterior fossa component of this meningioma not only involved the jugular foramen, but also was in the internal auditory canal. But when you open these cases, really it is a two-stage procedure. And what you are going to do is deal with the mass in the neck first. And whenever you open this, make your incision, this posterior belly of the digastric is usually spread out over that tumor. And so you have got to come down, isolate that, but come down proximal, identify the proximal bifurcation of the carotid, internal carotid, know where your internal carotid is, and protect it at all times as you do your dissection and expose this tumor. In this particular case, the cranial nerves, this was a, she had a hypoglossal deficit, 10th nerve deficit, 9th nerve deficit. I think her accessory nerve was, I think it was partially out too. So she had these multiple cranial nerve deficits for which she had compensated quite well. Her hearing and facial movement was fine. But again, when you are looking at this and doing a dissection, it is really kind of hard to separate exactly what is going on. That is why you have to go proximal, get the eyes, the internal carotid and follow it up. And as you get into this thing, we start debulking this. And essentially we remove everything. We mobilize the internal carotid so we have got it pulled out of the way. And we progressively remove this tumor and wind up with this big cavity. This is the neck mass that was removed. And in doing this, you wind up with all the lower cranial nerves involved out. They were removed along with the tumor. So then you come back for a second stage in this lady because you still got this posterior fossil mass. You got some internal auditory canal involvement. The plan here was to come in and remove this subtotally, not to go after the internal auditory canal portion because the lady has got good hearing and got a normal face. And anyway, this is what she turns out to be. So you have got this, this is a, she was, I think she was like 18 or 19 when we operated on her. This is six months post-op. I followed her for years. And this is, you can see where she got into, you know, she has a deficit of accessory nerve. She has got the hemiatrophy of the tongue. But face is good, hearing is good. And from a functional standpoint, this lady went on to nursing school, registered nurse. And I followed her. This is a five-year post-op follow-up. I never did anything to this residual stuff that was in the internal auditory canal, a little bit of stuff I left at the base. And over the last, she is now about eight years out, eight or nine, and she has done really quite well. So the point, I would make a simple point. If you are going to do this work, if you get a case that you want to do, first thing above all else, understand the anatomy, understand what you can get away with, what you can't. And if you anticipate any complications, you got to know how to take care of them. And if you don't do those things, then stay away from these tumors. Send them to some major center like Dr. Hallman's or send it to, if you are way, way up north, you can send it up to Dr. Link, way up north. But this anatomy can be very, very treacherous, and particularly the vascular aspect of this. If you get into a tumor that is bleeding and you don't have control, you didn't embolize the patient preoperatively, and, you know, you will just get in a mess. So anyway, caution dealing with these people, but have a game plan in terms of management of complications.

tumors

jugular foramen

carotid space

gamma knife radiosurgery

surgical management

cranial nerves

post-operative complications