Infratemporal Fossa Approach for Microsurgical Resection of a Giant Jugular Foramen Paraganglioma with Simultaneous Hypoglossal-Facial Anastomosis: Surgical Video.

Introduction: Jugular foramen paragangliomas (glomus jugulare tumors) are rare, highly vascular skull base neoplasms that frequently involve the temporal bone, jugular bulb, lower cranial nerves, facial nerve, and internal carotid artery. Their treatment remains challenging due to complex neurovascular relationships and significant vascularity. Preoperative embolization, skull base microsurgical techniques, and facial nerve reconstruction strategies are essential for achieving maximal safe resection while preserving neurological function. We present the microsurgical management of a giant jugular foramen paraganglioma through an infratemporal fossa approach with simultaneous hypoglossal–facial nerve anastomosis. Case Report: A 40-year-old Caucasian woman presented with a giant right jugular foramen paraganglioma associated with progressive hearing loss and facial paralysis, worsening over one year to House-Brackmann grade IV. She also presented lower cranial nerve dysfunction involving cranial nerves IX, X, and XI, with dysphagia, dysphonia, and ipsilateral shoulder weakness, while hypoglossal nerve function remained preserved. Magnetic resonance imaging demonstrated a large enhancing lesion centered on the jugular foramen, extending into the mastoid, hypotympanum, temporal bone, and upper cervical region, with the characteristic “salt-and-pepper” appearance caused by intratumoral vascular flow voids. Computed tomography revealed extensive erosion of the jugular foramen, jugular bulb, and adjacent temporal bone. Seventy-two hours before surgery, selective endovascular embolization was performed using calibrated microparticles. Feeding vessels from the ascending pharyngeal artery, occipital artery, posterior auricular artery, and stylomastoid branches were successfully occluded, significantly reducing tumor vascularity. Microsurgical resection was performed through a modified Fisch type A infratemporal fossa approach. Cervical exposure provided control of the carotid arteries, internal jugular vein, and lower cranial nerves. A canal wall-down mastoidectomy with skeletonization of the sigmoid sinus, jugular bulb, and mastoid segment of the facial nerve provided access to the jugular foramen. The facial nerve was preserved in situ until tumor infiltration was confirmed. Because the facial nerve was extensively infiltrated, anatomical preservation was not possible. Considering preserved hypoglossal nerve function, an end-to-end hypoglossal-facial nerve anastomosis was performed during the same procedure to optimize facial reinnervation. Intraoperative indocyanine green angiography assisted in identifying the petrous internal carotid artery and defining the medial limit of resection. Results: The postoperative course was uneventful. One-year follow-up demonstrated no radiological evidence of residual or recurrent tumor. Facial function progressively improved, reaching House-Brackmann grade II, while lower cranial nerve deficits remained stable without additional neurological deterioration. Conclusion: The infratemporal fossa approach provides excellent exposure for microsurgical management of giant jugular foramen paragangliomas. Preoperative embolization facilitates tumor removal by reducing vascularity, while simultaneous hypoglossal-facial nerve anastomosis offers an effective strategy for facial reanimation when the facial nerve is infiltrated.