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Temporal Paragangliomas. A 12-Year Experience
Paragangliomas temporales. Experiencia de 12 años
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A 12-year experience" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 710 "Ancho" => 950 "Tamanyo" => 209841 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Durante un abordaje infratemporal en paciente con paraganglioma yugulotimpánico derecho tipo C2 de Fisch.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ángel Ramos Macías, Jorge Bueno Yanes, Pilar Bolaños Hernández, Isidoro Lisner Contreras, Ángel Osorio Acosta, Mario Vicente Barrero, María Luisa Zaballos González" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Ángel" "apellidos" => "Ramos Macías" ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "Bueno Yanes" ] 2 => array:2 [ "nombre" => "Pilar" "apellidos" => "Bolaños Hernández" ] 3 => array:2 [ "nombre" => "Isidoro" "apellidos" => "Lisner Contreras" ] 4 => array:2 [ "nombre" => "Ángel" "apellidos" => "Osorio Acosta" ] 5 => array:2 [ "nombre" => "Mario" "apellidos" => "Vicente Barrero" ] 6 => array:2 [ "nombre" => "María Luisa" "apellidos" => "Zaballos González" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173573511000706" "doi" => "10.1016/j.otoeng.2011.05.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173573511000706?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000165191100121X?idApp=UINPBA00004N" "url" => "/00016519/0000006200000005/v1_201304231437/S000165191100121X/v1_201304231437/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173573511000548" "issn" => "21735735" "doi" => "10.1016/j.otoeng.2011.01.005" "estado" => "S300" "fechaPublicacion" => "2011-09-01" "aid" => "275" "copyright" => "Elsevier España, S.L." 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A 12-Year Experience" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "375" "paginaFinal" => "380" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ángel Ramos Macías, Jorge Bueno Yanes, Pilar Bolaños Hernández, Isidoro Lisner Contreras, Ángel Osorio Acosta, Mario Vicente Barrero, María Luisa Zaballos González" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Ángel" "apellidos" => "Ramos Macías" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Jorge" "apellidos" => "Bueno Yanes" "email" => array:1 [ 0 => "fambuya@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Pilar" "apellidos" => "Bolaños Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Isidoro" "apellidos" => "Lisner Contreras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Ángel" "apellidos" => "Osorio Acosta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Mario" "apellidos" => "Vicente Barrero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "María Luisa" "apellidos" => "Zaballos González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Maxilofacial, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paragangliomas temporales. Experiencia de 12 años" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 710 "Ancho" => 950 "Tamanyo" => 209841 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">During an infratemporal approach in a patient with Fisch type C2 right jugulotympanic paraganglioma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Paragangliomas are structures formed by paraganglionic cells derived from the neural crest and from autonomic ganglion cells that relate to the neuroendocrine system.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The term paraganglioma is the most appropriate to refer to the extra-adrenal paraganglionic tumours, although they have also been called glomus tumours or chemodectomas.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the cervicocephalic region, paragangliomas are related to the embryonic development of the branchial or pharyngeal arches, so they are known as branchiomeric paragangliomas.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The classification of paragangliomas varies depending on the parameter selected: patient age, secretory capacity, whether tumours are sporadic or familial syndromes, isolated or multifocal, benign or malignant, etc. In addition, there are classifications based on aspects such as location, extension, surgical approaches, immunohistochemical characteristics, and so on. No classification has been universally accepted so far. As for location, cervicocephalic paragangliomas are divided into 2 groups: temporal (which in turn are subdivided into jugular and tympanic, orbital, carotid, subclavian, and laryngeal) and vagal paragangliomas. With respect to extension of temporal paragangliomas, the most commonly used classifications are those by Fisch–Valavanis (a review of Fisch–Jenkins, from 1981) and by Glassock–Jackson.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Paragangliomas are highly vascularised but usually benign tumours (although there are malignant cases, especially in the functioning and familial<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>). Their growth, albeit slow, can cause compression, displacement, and invasion of adjacent structures such as bone, blood vessels, dura mater, and cranial nerves.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is the most common benign neoplasm of the middle ear and the second most common in the temporal bone.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> These tumours are more common in women, with a ratio of 1:3.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Up to 10% of paragangliomas originating in the head and neck are familial and are transmitted in a modified autosomal dominant pattern.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> They may appear as bilateral tumours in 1%–2% of cases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In rare cases, they may metastasize (1%–3%).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> If we observe their secretory capacity or biochemical functionality, we note that less than 4% of cervicocephalic paragangliomas are active enough to be considered functional.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This article presents a retrospective and descriptive study of patients with a diagnosis of temporal paraganglioma, and discusses the general characteristics and results obtained after treatment of a total of 21 patients in our service.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We carried out a review of 21 patients who were diagnosed with temporal paraganglioma at our department between January 1999 and April 2011.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The main reason for consultation was pulsatile tinnitus, which appeared in 17 patients (81%). Other symptoms leading to consultation were transmission hearing loss (which occurred in 15 patients), otalgia (8), and otorrhea (5).</p><p id="par0040" class="elsevierStylePara elsevierViewall">All patients underwent a complete ENT examination including an otomicroscopy and audiological studies, a high-resolution computed tomography (HRCT), and magnetic resonance imaging (MRI) and a detailed history was taken. In addition we also carried out an angiography at the interventional vascular radiology department for all cases diagnosed as Fisch types B and C<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) to evaluate collateral circulation and study afferent and efferent tumour vessels. In the case of 1 patient with a Fisch–Valavanis type C2 secreting jugulotympanic paraganglioma (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A–F) along with two retroperitoneal paragangliomas, we also performed a whole body scan with I-<span class="elsevierStyleSup">31</span> and I-<span class="elsevierStyleSup">123</span> meta-iodobenzylguanidine (MIBG) on several occasions, as well as I-<span class="elsevierStyleSup">123</span> MIBG single photon emission computed tomography (SPECT). In all cases, we determined 24-h urine fractionated catecholamines and metanephrines, 24-h urine vanillylmandelic acid levels and plasma free levels of catecholamines and metanephrines.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">We used the Fisch–Valavanis classification for jugulotympanic paragangliomas in the staging of tumours.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The surgical approaches used were the endaural approach for 1 case of Fisch type A temporal paraganglioma (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A–F), the transcanal retroauricular approach for Fisch type A tumours, radical tympanomastoidectomy for type B, and type A infratemporal approach for Fisch type C tumours (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">In our series, the age interval was 29–77 years, with a mean of 39.6 years. We also found a female predominance (13/21).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Upon otoscopic examination, 16 patients (76.2%) showed a purplish tympanic membrane; a polypoid inflammatory formation in the external auditory canal was also observed in 4 (19%) and only 1 patient (4.8%) presented otorrhea associated with a purplish mass.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The plasma concentrations of free catecholamines and metanephrines, as well as 24-h urine determinations of catecholamines, fractionated metanephrines and vanillylmandelic acid were all within the normal limits, except in 1 case of Fisch–Valavanis type C2 jugulotympanic paraganglioma, which turned out to be secreting paraganglioma (this patient also presented two retroperitoneal paragangliomas of 3.3×2.8<span class="elsevierStyleHsp" style=""></span>cm and 1×1.1<span class="elsevierStyleHsp" style=""></span>cm, which were intervened by the Urology Department during a first surgery; she is currently awaiting the results of genetic studies to rule out multiple paraganglioma syndrome).</p><p id="par0070" class="elsevierStylePara elsevierViewall">According to the Fisch–Valavanis classification, 43% (<span class="elsevierStyleItalic">n</span>=9) of patients presented type A tumour, 24% (<span class="elsevierStyleItalic">n</span>=5) type B, and 33% (<span class="elsevierStyleItalic">n</span>=7) type C2–C3.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We carried out an arteriographic study of the supra-aortic trunks in all cases and 12 patients (57.1%) underwent tumour embolisation 72<span class="elsevierStyleHsp" style=""></span>h before surgery. In 1 case of advanced age and poor general condition, we decided to perform stereotactic radiosurgery.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The distribution of the surgical approaches carried out is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">According to the Makek<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> classification, there was infiltration of the facial nerve in 3 cases: in 1 (4.8%) patient in grade II and in 2 (9.5%) patients in grade III.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The diagnosis of paraganglioma was confirmed in all cases by anatomopathological examination of the surgical specimen.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The postoperative complications for each type of approach employed are summarised in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Surgery achieved control of tumours, and no recurrence was observed in any patient after a follow-up period between 1 and 12 years. In the patient who received radiosurgery, we observed tumour persistence without growth, with areas of tumoral necrosis and with no increase in size.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Paraganglioma of the jugular bulb is the most common benign tumour of the middle ear. It is a slow-growing, highly vascular tumour, but with potential for extension and involvement of structures of the skull base, nerves and blood vessels.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Most series report a predominance of females.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Pulsatile tinnitus coincident with the pulse and hearing loss are the most frequent forms of clinical presentation of jugulotympanic paragangliomas.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Hearing loss is generally conductive, although a sensorineural component can also be found, in which case the possibility of labyrinthine invasion should be kept in mind.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Other symptoms include occasional otorrhea, otalgia, and vertigo. Up to 15% of these tumours are asymptomatic. Physical examination generally reveals a hypotympanic or mesotympanic mass, which is characteristic but not pathognomonic. It is also possible to observe a formation with polypoid or inflammatory appearance in the external auditory canal.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The existence of symptoms of involvement of low cranial nerves indicates extensive injury by the temporary paraganglioma.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Facial paralysis by involvement of the 7th cranial nerve is the most common form of presentation of neural disease, with this invasion being most frequently located in the mastoid portion of the nerve. Next in order of frequency are involvement of the 10th, 9th, 11th, and 12th cranial nerves, although the degree of nerve dysfunction observed in the preoperative period is not an indicator of neural condition.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,12</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Although histochemical and ultrastructural studies have proved that all paragangliomas produce catecholamines, less than 4% of cervicocephalic paragangliomas are active enough to be considered as functional.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In those cases where they are functional, preoperative treatment should include alpha and beta blockers.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Preoperative evaluation includes HRCT to obtain a good analysis of the bony structures of the skull base, tumour size, and areas of bone erosion. Gadolinium-enhanced MRI and angiography allow the study of tumour vascularisation, extension and its relationship to surrounding structures. Digital subtraction angiography (this was not used in our cases) enables a diagnosis and acts as a guide for embolisation.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The treatment of glomus includes different therapeutic modalities, such as surgical resection, stereotactic radiosurgery, radiotherapy, chemotherapy, use of intratumoral sclerosing agents (with the aim of necrotizing and reducing the tumour), metabolic therapy with I-<span class="elsevierStyleSup">131</span> MIBG, treatment with somatostatin analogues (octreotide), and expectant attitude with regular controls.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Once a surgical attitude has been adopted, preoperative embolisation of these lesions reduces intraoperative bleeding and surgical time and results in complete tumour resection in all cases.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Complications observed in the postoperative period include CSF leak, imbalance, and tissue ischemia, as well as those resulting from damage to the cranial nerves and major cardiovascular, pulmonary, and cerebral complications.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Glomus is considered as a relatively non-radiosensitive tumour.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,13–16</span></a> Fractionated radiotherapy reports 7% of minor complications and 2%–3% of major complications.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Benign tumours in patients undergoing radiation therapy may develop secondary tumours; there is an estimated 2.7% chance of developing secondary malignancy within 10 years.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Stereotactic radiosurgery with gamma-knife appears to enable a local control associated with low morbidity and essentially no mortality. It is thus recommended in patients with advanced age, poor general condition, advanced tumour, rejection of surgery, or unresectable tumour.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres94841" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec81992" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres94840" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec81993" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-11-15" "fechaAceptado" => "2011-05-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec81992" "palabras" => array:4 [ 0 => "Head and neck paragangliomas" 1 => "Temporal paragangliomas" 2 => "Tympanic paragangliomas" 3 => "Jugular paragangliomas" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec81993" "palabras" => array:4 [ 0 => "Paragangliomas cervicocefálicos" 1 => "Paragangliomas temporales" 2 => "Paraganglioma timpánico" 3 => "Paraganglioma yugular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Our objective was to perform a retrospective analysis of patients with jugulotympanic paragangliomas. We present the results according to the surgical approach applied in each case.</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This retrospective study presents the findings in 21 patients with jugulotympanic paragangliomas who were observed and treated in our department over a 12-year period (1999–2011). We performed a general otolaryngology exam, systemic evaluation, and radiological exam. Surgical treatment was performed in 20 cases out of 21. In 1 case, treatment with stereotactic radiosurgery was carried out.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The surgical approaches were: endaural, retroauricular transcanal, radical or modified mastoidectomy through facial recess, and infratemporal fossa approach. Preoperative embolisation was used in 12 cases. In all cases the diagnosis of paraganglioma was confirmed. The most frequent postoperative complications found were transitory palsy of the facial nerve, sensorineural hearing loss, imbalance, paralysis of the cranial nerves IX and XI, and salivary fistula. No recurrences were found after 12 years of follow-up. One case of persistence was found in the case treated with radiosurgery.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our series surgery was found to be the elective therapy for patients with paraganglioma, with no recurrences after 12 years of follow-up. Preoperative embolisation decreases surgery time and intraoperative bleeding. Stereotactic radiotherapy cannot eliminate the tumour.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este trabajo es realizar un estudio retrospectivo en pacientes con diagnóstico de paraganglioma temporal, analizando los resultados según la conducta terapéutica aplicada para cada caso.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyó a 21 pacientes con diagnóstico de paraganglioma temporal tratados en nuestro servicio entre enero de 1999 y abril de 2011. A todos se les realizó un examen otorrinolaringológico, sistémico y de imagen. En 20 casos se realizó cirugía para su exéresis y en un caso se realizó tratamiento con cirugía estereotáxica.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se realizó embolización preoperatoria en 12 casos. Los abordajes quirúrgicos fueron: extirpación endaural, resección transcanal tras abordaje retroauricular, mastoidectomía radical ampliada con abordaje de receso facial y abordaje infratemporal. El diagnóstico de paraganglioma fue confirmado en todos los casos. Las complicaciones postoperatorias más frecuentes fueron: paresia transitoria del <span class="elsevierStyleSmallCaps">VII</span> par, hipoacusia neurosensorial, desequilibrio, parálisis del VII, parálisis del <span class="elsevierStyleSmallCaps">IX</span> y el <span class="elsevierStyleSmallCaps">XI</span> par y fístula salival. No se observó recidiva de enfermedad con seguimiento entre 1 y 12 años. En un caso tratado con radiocirugía persiste el tumor, estabilizado.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestra serie la cirugía constituye la terapia con la que se logró la resección tumoral total en todos los casos. El uso de embolización preoperatoria reduce el tiempo quirúrgico y el sangrado intraoperatorio. La radiocirugía estereotáxica no permite la desaparición tumoral y persiste la enfermedad.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Ramos Macías Á, et al. Paragangliomas temporales. Experiencia de 12 años. Acta Otorrinolaringol Esp. 2011;62:375–80.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 920 "Ancho" => 950 "Tamanyo" => 125117 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Angiography of a Fisch type C2 right jugulotympanic paraganglioma.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1339 "Ancho" => 1740 "Tamanyo" => 261501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A and B) Coronal CT images of a Fisch type C2 right jugulotympanic paraganglioma. (C–E) Axial CT images of Fisch C2 right jugulotympanic paraganglioma.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 695 "Ancho" => 1683 "Tamanyo" => 213672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">(A–C) Axial CT images of a Fisch type A right tympanic paraganglioma. (D–F) Coronal CT images of a Fisch type A right tympanic paraganglioma.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 710 "Ancho" => 950 "Tamanyo" => 209841 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">During an infratemporal approach in a patient with Fisch type C2 right jugulotympanic paraganglioma.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Approach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Endaural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retroauricular Transcanal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mastoidectomy Through Facial Recess \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infratemporal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not Intervened \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179667.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Surgical Approaches Used.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Approach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Endaural (<span class="elsevierStyleItalic">n</span>=1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Retroauricular Transcanal (<span class="elsevierStyleItalic">n</span>=7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mastoidectomy Through Facial Recess (<span class="elsevierStyleItalic">n</span>=5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Infratemporal (<span class="elsevierStyleItalic">n</span>=7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No IQ (<span class="elsevierStyleItalic">n</span>=1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sensorineural hypoacusis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Instability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VII temporal paresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VII paralysis (House–Brackmann Grade III–IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IX–XI paralysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">XI paresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Salivary fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 2 | 0 | 2 |
| 2021 March | 0 | 3 | 3 |
| 2021 February | 0 | 6 | 6 |
| 2021 January | 0 | 4 | 4 |
| 2020 December | 0 | 1 | 1 |
| 2020 September | 0 | 1 | 1 |
| 2020 June | 0 | 1 | 1 |
| 2020 March | 22 | 0 | 22 |
| 2020 February | 28 | 6 | 34 |
| 2020 January | 28 | 15 | 43 |
| 2019 December | 25 | 10 | 35 |
| 2019 November | 30 | 5 | 35 |
| 2019 October | 30 | 9 | 39 |
| 2019 September | 20 | 3 | 23 |
| 2019 August | 21 | 6 | 27 |
| 2019 July | 21 | 5 | 26 |
| 2019 June | 72 | 23 | 95 |
| 2019 May | 165 | 72 | 237 |
| 2019 April | 52 | 44 | 96 |
| 2019 March | 15 | 5 | 20 |
| 2019 February | 25 | 13 | 38 |
| 2019 January | 18 | 9 | 27 |
| 2018 December | 16 | 7 | 23 |
| 2018 November | 23 | 6 | 29 |
| 2018 October | 16 | 10 | 26 |
| 2018 May | 1 | 0 | 1 |
| 2018 April | 7 | 2 | 9 |
| 2018 March | 22 | 0 | 22 |
| 2018 February | 27 | 1 | 28 |
| 2018 January | 10 | 3 | 13 |
| 2017 December | 17 | 0 | 17 |
| 2017 November | 17 | 6 | 23 |
| 2017 October | 17 | 5 | 22 |
| 2017 September | 7 | 2 | 9 |
| 2017 August | 25 | 6 | 31 |
| 2017 July | 28 | 3 | 31 |
| 2017 June | 26 | 21 | 47 |
| 2017 May | 32 | 10 | 42 |
| 2017 April | 31 | 6 | 37 |
| 2017 March | 20 | 4 | 24 |
| 2017 February | 30 | 13 | 43 |
| 2017 January | 41 | 5 | 46 |
| 2016 December | 30 | 8 | 38 |
| 2016 November | 43 | 16 | 59 |
| 2016 October | 52 | 11 | 63 |
| 2016 September | 36 | 9 | 45 |
| 2016 August | 40 | 10 | 50 |
| 2016 July | 38 | 1 | 39 |
| 2016 June | 37 | 12 | 49 |
| 2016 May | 42 | 16 | 58 |
| 2016 April | 35 | 18 | 53 |
| 2016 March | 43 | 19 | 62 |
| 2016 February | 52 | 22 | 74 |
| 2016 January | 48 | 18 | 66 |
| 2015 December | 36 | 16 | 52 |
| 2015 November | 34 | 13 | 47 |
| 2015 October | 30 | 12 | 42 |
| 2015 September | 24 | 14 | 38 |
| 2015 August | 63 | 4 | 67 |
| 2015 July | 47 | 3 | 50 |
| 2015 June | 33 | 1 | 34 |
| 2015 May | 40 | 7 | 47 |
| 2015 April | 37 | 13 | 50 |
| 2015 March | 37 | 11 | 48 |
| 2015 February | 15 | 6 | 21 |
| 2015 January | 36 | 7 | 43 |
| 2014 December | 51 | 7 | 58 |
| 2014 November | 20 | 4 | 24 |
| 2014 October | 53 | 12 | 65 |
| 2014 September | 44 | 6 | 50 |
| 2014 August | 29 | 13 | 42 |
| 2014 July | 39 | 5 | 44 |
| 2014 June | 28 | 2 | 30 |
| 2014 May | 24 | 5 | 29 |
| 2014 April | 25 | 6 | 31 |
| 2014 March | 38 | 5 | 43 |
| 2014 February | 18 | 9 | 27 |
| 2014 January | 26 | 1 | 27 |
| 2013 December | 24 | 2 | 26 |
| 2013 November | 30 | 0 | 30 |
| 2013 October | 64 | 8 | 72 |
| 2013 September | 47 | 5 | 52 |
| 2013 August | 17 | 2 | 19 |
| 2013 July | 1 | 0 | 1 |
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