 HELLO EVERYONE This is Dr. Mahavir Yadav PG Residence in the Department of Radio Diagnosis of Kalinga Institute of Medical Science, Bhuvaneshwar I am here to present my paper on the topic GLOMAS JUGULARE Paraganglianumas the case series in the imaging review To start with, the Paraganglianumas are rare neuroendocrine tumors that arise from paraganglion or chromathing cells originating from the neural phase also called as GLOMAS TUMAS Paraganglianumas of the head and neck represent less than 1% of the head and neck tumors generally benign locally in aggressive tumors malignancy with my thinning 2-3% of the cases now this paraganglianumas generates from sympathetic chain or parasympathetic the sympathetic paraganglianumas usually secrete the cat colamine and are located in the sympathetic sympathetic paravertical or ganglion of the thorax abdomen and the pelvis the sympathetic can be adenal or extra-adenal extra-adenal, like from the thorax abdomen and the pelvis can be 15-35% malignancy adenal may need to go from cytoma to 10% malignancy parasympathetic more than 90% of all the paraganglianumas are characteristic and primarily from the head and neck that is the cat body and mostly they are benign in each the tumors arise from any 3 gromas bodies that is jugglerberg thinpanic branch of the 9th paraganglianum that is the jackopson nerve auricular branch of the 10th paraganglianum that is the anulose nerve the main arterial supply is the ascending pharyngeal artery has supralateral growth and can spread into middle ear, mastoid ASLs and the stage injury now coming to the cases case 1 a 37-year-old male came with a complaint of fulness of right ear on otoscopy a small radius mask was seen behind the intact fast tensor no critical deficits were noted the excel city that is the figure A demonstrated the erosion of the right juggler bulb with the more hidden appearance of the valves of the right juggler for a man there is no invasion or extension into the middle ear as the cochlear promontory that we can see is intact now the figure B and C are the axiac and the coronal T2-weighted MR images which demonstrate a well-defined predominantly T2-hyper intense expansile lesion centred in the right juggler for a man there is no extension into the middle ear as seen characteristic salt and paper apparently is present in the punctate regions of hyper intensity representing the salt while the small flow voids represent the paper now the case 2 a 55-year-old female came with a complaint of frightful pain and discharge in the ear associated with tinnitus she mentioned the beginning of the syndrome 6 years ago for 2 months she complained of dginase, nausea, vomiting and headache radiating to the whole cranium upon right otoscopy, oturia and the presence of achuma in the external auditory mediators the neurological examination of the patient was normal the audiometric salt right mixed hearing loss now here we can see the figure A and B which is both the axial and the coronal CT images which demonstrate the erosion of the right juggler bulge with a more intense appearance of the walls of the right juggler for a man expansion into the middle ear cavity is seen with innovation of the cochlear pommetry now the figure C and D represent the axial and coronal T1 weighted post contrast MR images which demonstrate the avit enhancement of the mask which arises between the juggler for a man and the cochlear pommetry the mask fills the juggler for a man in extension of the middle ear and to electrical now the case 3 in the case 3 we have a 60 year old woman presented with same terms of hearing loss pulsatile ringing sound in the left ear for the last 4 years the patient also had difficulties swallowing for the last 9 months on examination there was also left palatal parisies and the abs and gag reflex on the left posterior pharyngeal one on otoscopy a pulsatile radius mask was seen behind the intact past now we can see the left side clomus jugglery paragonal remorse skull base the figure A is the axial and the figure B is the coronal image of the city that demonstrated a permeative destruction and enlargement of the juggler for a man with extension into the posterior cranial fossa so what do you mean by the permeative permeative is the destruction of the bone with complete loss of the normal cortex and the loss of the normal architecture of the bone here we can easily see in these images now the figure A, B and C are the A is the T1 axial image MR image T1 axial MR image which shows the hyper intense tumor T2 weighted axial image the figure B shows the hyper intense tumor and the T1 weighted post contrast conal image that is T it shows the intense tumor enhancement tumor A is seen expanding the juggler for a man and the extending posterior now here we can see the images 1A, 1B and 2 the 1A, 1B are the DSA image that is 1A is before embolization which is demonstrating the characteristic intense tumor blast the 1B is after selective embolization that is the significant reduction in the vascular blast indicative now here we can see the history image in the figure 2 which is the epitheloid chief that is arranged in the distinctive clusters which is known as the gel-belan nis-pattern which is separated by the permanent fibrovescose tumor now coming to the discussion part juggler for a man is the bony canal located in the skull base between the patrus portion of the temporal and the occipital bone from the skull base to the ferriti disk base so this for a man is divided into two parts entromidally and the posterior the entromidal part is known as the past navosa and the posterior lateral part is known as the past vascularis which is divided by the juggler spine of the patrus bone the past navosa contains the inferior patrus of sinus and the ninth canal the juggler bul 10th canal and 11th canal now coming to the epidemology it is a rare with an estimated annual incidence of one case for 1.3 million people but clomus tumors are common tumors of the medial cavity and the temporal bone occurs in 40 to 60 years of age with a female predominance and more common in the left side can be bilateral or multi-centric especially in the familial course the radiological features pulsatile t-niters levels of fearing retro-tympanic mass crinial neuropathy involvement in the 19th and 11th nerve presentation depends on the degree of the medial involvement the radiological features on CT we will see the mass in the juggler for a man with the permeative destruction changes of the adjacent bone that is the typical moth on T2 weighted images mixed hyper intense mass on contrast every intense homogenous enhancement perfusion elevated perfusion values with rapid dynamic enhancement on angiography enlarged feeding arteries intense tumoural bloods early draining on indium 111 level octriotrite intense uptake will be there due to the presence of tomato stain receptor now Glasgow Jackson classification is there it is one in a type 1 type 2 type 3 type 2 in type 1 there is a small tumour involving only the juggler above middle ear or the mastoid in type 2 extension will be under the internal auditory canal with or without the intracranial extension type 3 extension will be in a petrus epic with or without the intracranial extension in type 4 extension will be on the petrus apex into the clivers or infratemporal fossa with or without the intracranial extension the surgical approach may change depending on the extent of tumour invention in type 1 and type 2 will be limited to the skull based approach and in type 3 and type 4 the surgical approach will be more extensive and it will be limited to the infratemporal approach in treatment observation will be done it is not monitoring for tumours less than 2 cm radiotherapy will be done if the goal is not the tumour level it is the tumour stability sarjali will you prefer treatment when the tumour high bulk tumour will be there secondly resection would not sacrifice adjacent structure preoperative arterial embolisation can be done before sarjali or non fulsening paraglomer to reduce the bleeding complication what are the differential juggla sarama juggla sarama is one of the differential innate no internal flow words will be there saple demarcated smooth bony margins will be there not very vascular on engeography indium 111 level octotide will be negative supramedial growth will be there meningoma meningoma is the T1 hyperintensity to hyperintensilism with avid enhancement formative discretive bone changes encasement of ossicles will be there centrifugal growth will be there in case of meningoma metastasis juggla sarama marks with irregular and destictive margins will be there T1, T2, isointensilism no diffusion restriction increased perfusion in the hypervexibular metastasis condro sarcoma usually marks will be seen medial to the juggla sarama in condro sarcoma T1 isointens and T2 hyperintens rings and arcs calcification will be present so finally come to the conclusion the conclusion around that paragon lumas are very rare often asymptomatic tumors characterization of the tumor extent is necessary as they have an intimate association with knobs and vessels specific therapeutic approach may vary depending on tumor location and extent is defined by imaging the presence of concomitant tumors should be verified as paragon lumas are multifocalism in 30% of the patients thank you very much