What is the recommended treatment approach for glomus (glomus tumor) tympanicum tumors?

Treatment Approach for Glomus Tympanicum Tumors

Surgical excision is the recommended primary treatment for glomus tympanicum tumors, as it provides excellent tumor control with minimal morbidity and low recurrence rates. 1, 2, 3

Classification and Surgical Planning

Glomus tympanicum tumors are classified according to the Fisch and Mattox classification system, which guides the surgical approach:

• Type A: Tumors limited to the middle ear without extension
• Type B: Tumors extending into the mastoid

Surgical Approaches Based on Classification

1. For Type A tumors (64.7% of cases):

   • Transcanal approach (stapedectomy-type) or
   • Retroauricular-transcanal approach
   • These approaches provide complete access for small tumors confined to the middle ear

2. For Type B tumors (35.3% of cases):

   • Smaller Type B: Transmastoid approach
   • Larger Type B: Subtotal petrosectomy with blind sac closure of the external auditory canal and middle ear obliteration

Surgical Outcomes

The surgical approach to glomus tympanicum tumors has demonstrated excellent results:

• Gross total tumor removal achieved in nearly 100% of cases
• Very low recurrence rate (approximately 1.4%)
• Preservation of hearing function in most cases
• Minimal morbidity and complications 1, 2

Alternative Treatments

While radiation therapy has been advocated by some for glomus tumors, it is generally reserved for:

• Patients who are medically unfit for surgery
• Glomus jugulare tumors (which are different from glomus tympanicum)
• Cases where complete surgical excision is not possible 4

Technical Considerations

• Piezosurgery has been reported as an effective technique for excision of Type A glomus tympanicum tumors, allowing precise bone cutting without damage to soft tissues 5
• Preservation of the ossicular chain should be attempted when possible to maintain hearing function 3
• Long-term follow-up is important to monitor for recurrence, though this is rare after complete surgical excision 2

Practical Algorithm for Management

1. Diagnosis: Confirm diagnosis through clinical presentation (pulsatile tinnitus, retrotympanic mass) and imaging (CT scan as first choice, MRI for complex cases)

2. Tumor classification: Determine extent using Fisch and Mattox classification

3. Surgical planning: Select appropriate surgical approach based on tumor classification

   • Type A: Transcanal or retroauricular-transcanal approach
   • Type B: Transmastoid approach or subtotal petrosectomy

4. Surgical execution: Complete tumor removal with preservation of ossicular chain when possible

5. Follow-up: Regular monitoring to detect any recurrence, though this is uncommon after complete surgical excision

The surgical approach provides the best long-term tumor control with minimal morbidity and should be considered the gold standard for treatment of glomus tympanicum tumors.