Surgical management of high jugular bulb in acoustic neurinoma via retrosigmoid approach.

Of 200 patients with acoustic neurinoma undergoing an operation via the retrosigmoid transmeatal approach in the semisitting position, 18 patients had a high jugular bulb on the tumor side. The frequency was 9%. From a neurosurgical point of view, a jugular fossa above the low border of the internal auditory canal (IAC) is classified as a high one. All 200 patients were evaluated by computed tomography with bone window reconstruction of high-resolution thin axial slices (1.5 mm). High jugular bulbs were classified into three grades as follows: Grade I, jugular bulb situated less than 1.5 mm above the low border of IAC; Grade II, jugular bulb between 1.5 and 3.0 mm above the low border of the IAC; Grade III, jugular bulb > 3 mm above the low border of IAC. There were eight patients with Grade I, six patients with Grade II, and four patients with Grade III. In these patients, in order to open the IAC without concomitant injury of the jugular bulb, the superior posterior portion of the porus was drilled away. Opening the jugular fossa was unavoidable in Grade III cases. No difference was noted in functional preservation of facial or cochlear nerve between HJB cases and normal jugular bulb cases, but HJB cases had a higher frequency of air embolism during tumor removal than did normal cases (16 versus 5%), especially Grade III cases (two of four). There was no mortality or morbidity in the cases of air embolism. Details of the surgical procedure in such cases are discussed.