The presentation and management of multiple paraganglioma in head and neck

Carotid Body Tumors: Institutional Experience of 10 Cases and a Review of Literature

Carotid body tumors are slow growing neck masses that arise from the neural crest cells at the carotid bifurcation. Majority are asymptomatic and are diagnosed incidentally. Surgical excision is accepted as the treatment of choice to reduce complications. In the present series, we report 10 cases of carotid body tumors and our institutional experience. All patients underwent radiological evaluation with an ultrasonography with Doppler, contrast enhanced computed tomography and MR angiography. 6 cases were operated by a transcervical excision. The tumor was excised in tototranscervically. One of the cases required saphenous vein graft intraoperatively due to vascular injury and also had postoperative vocal cord palsy. The rest had an uneventful recovery. Carotid body tumors although rare and seemingly indolent can cause substantial symptoms if left untreated. A prompt multi modality approach is needed for both diagnosis and treatment to avoid major complications.

Outcomes of Carotid Body Tumor Management with Active Surveillance

OBJECTIVES

To assess outcomes of carotid body tumors (CBTs) managed with active surveillance.

METHODS

Retrospective chart review of CBTs managed with active surveillance from 2001 to 2019.

RESULTS

A total of 115 cases were identified during chart review. Sixty-five of these patients were managed with active surveillance, and 11 patients had bilateral tumors for a total of 76 tumors. Follow-up records with symptomatic outcomes were available for 51 patients, and 47 tumors had follow-up imaging. Thirty-one (66%) actively surveilled CBTs remained stable or decreased in size while 16 (34%) increased in size. Patients undergoing active surveillance developed symptoms in 12 cases, 6 of these patients underwent surgical intervention. Nine CBTs managed with active surveillance (18%) were ultimately resected. The majority of patients who did not undergo surgical intervention never developed symptoms (36/42, 86%).

CONCLUSIONS

Active surveillance may be a reasonable approach for a subset of CBTs.

Glomus jugulare in a pediatric patient: case report and literature review

PURPOSE

The jugular and tympanic glomus are rare neoplasms in the general population, being even more uncommon in the pediatric population. There is considerable morbidity associated with both disease and treatment. Treatment is essentially surgical, carried out in recent years in a multidisciplinary manner using preoperative embolization associated with microsurgery and eventually adjuvant radiotherapy. The outcome depends on the location of the lesion and its proximity to noble structures in addition to multidisciplinary monitoring in the postoperative period.

METHODS

In this article, a literature review was carried out in the PubMed database, finding reports from 17 patients diagnosed with the disease. Only articles in English were considered.

RESULTS

Moreover, we reported a case of a 14-year-old patient diagnosed with jugulotympanic glomus who underwent radical surgical treatment of the lesion.

CONCLUSION

This is a rare case of jugulotympanic glomus in a pediatric patient, who underwent surgical treatment associated with multidisciplinary therapy, with a favorable postoperative outcome.

The carotid body and associated tumors: updated review with clinical/surgical significance

Purpose: The carotid body functions as a chemoreceptor and receives richer blood supply, by weight, than any other organ in the body. We review the literature regarding the anatomy, histology, and function of the carotid body and the incidence, functionality, and clinical relevance of carotid body tumors and paragangliomas. These lesions are often nonfunctional but can be associated with catecholamine secretion. Most patients are asymptomatic or present initially with a cervical mass. As the tumors grow, they can impinge on nearby cranial nerves. Although there is some debate, the dominant clinical strategy is to surgically resect these tumors as early as possible. If they are resected early, the risk of postoperative neurovascular injury is minimized. Methods: Literature search was performed using the PubMed database with focus on articles including descriptions of the carotid body and associated tumors. Results: We reviewed recent literature that related to the anatomy of the carotid body while also including carotid pargangliomas and associated diagnosis with treatment interventions. Conclusion: As the carotid body serves as a vital modulator of cardiovascular and respiratory functions, illustrates the importance of identifying potential carotid paragangliomas due its ability to impede function of the carotid body. By understanding carotid paraganglioma's distinct etiologies while also understanding proper diagnosis of tumors allows for early detection and appropriate treatment options.

Multimodal management of pediatric carotid body tumors: a systematic review and case illustrations

OBJECTIVE Carotid body tumors (CBTs), extraadrenal paragangliomas, are extremely rare neoplasms in children that often require multimodal surgical treatment, including preoperative anesthesia workup, embolization, and resection. With only a few cases reported in the pediatric literature, treatment paradigms and surgical morbidity are loosely defined, especially when carotid artery infiltration is noted. Here, the authors report two cases of pediatric CBT and provide the results of a systematic review of the literature. METHODS The study was divided into two sections. First, the authors conducted a retrospective review of our series of pediatric CBT patients and screened for patients with evidence of a CBT over the last 10 years (2007–2017) at a single tertiary referral pediatric hospital. Second, they conducted a systematic review, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, of all reported cases of pediatric CBTs to determine the characteristics (tumor size, vascularity, symptomatology), treatment paradigms, and complications. RESULTS In the systematic review (n = 21 patients [includes 19 cases found in the literature and 2 from the authors’ series]), the mean age at diagnosis was 11.8 years. The most common presenting symptoms were palpable neck mass (62%), cranial nerve palsies (33%), cough or dysphagia (14%), and neck pain (19%). Metastasis occurred only in 5% of patients, and 19% of cases were recurrent lesions. Only 10% of patients presented with elevated catecholamines and associated sympathetic involvement. Preoperative embolization was utilized in 24% of patients (external carotid artery in 4 and external carotid artery and vertebral artery in 1). Cranial nerve palsies (cranial nerve VII [n = 1], IX [n = 1], X [n = 4], XI [n = 1], and XII [n = 3]) were the most common cause of surgical morbidity (33% of cases). The patients in the authors’ illustrative cases underwent preoperative embolization and balloon test occlusion followed by resection, and both patients suffered from transient Horner’s syndrome after embolization. CONCLUSIONS Surgical management of CBTs requires an extensive preoperative workup, anesthesia, and multimodal surgical management. Due to a potentially high rate of surgical morbidity and vascularity, balloon test occlusion with embolization may be necessary in select patients prior to resection. Careful thorough preoperative counseling is vital to preparing families for the intensive management of these children. ABBREVIATIONS BTO = balloon test occlusion; CBT = carotid body tumor; CN = cranial nerve; ECA = external carotid artery; ICA = internal carotid artery; MIBG = iodine-123-meta-iodobenzylguanidine; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Bilateral carotid body tumor resection in a female patient

INTRODUCTION

Carotid body tumors also called carotid paragangliomas are rare neuroendocrine neoplasms derived from neural crest cells, approximately 3% of all paragangliomas occur in the head and neck area (Xiao and She, 2015); although they represent 65% of the head and neck paragangliomas (Georgiadis et al., 2008).

PRESENTATION OF CASE

We present the therapeutic management of a 65-year-old woman with bilateral carotid body tumors. The patient presented to medical clinic for unrelated signs and symptoms of weight loss, dyspepsia, and epigastric pain. Physical examination showed bilateral non-tender neck masses for which imaging studies were ordered resulting in the diagnosis of bilateral carotid tumor. Surgical resection was staged with one week of distance between each tumor resection.

DISCUSSION

Carotid Body Tumors can arise from the paraganglia located within the adventitia of the medial aspect of the carotid bifurcation.Resection is the only curative treatment. Carotid body tumors resection represents a special challenge due to potential neurovascular complications.

CONCLUSIONS

Surgical resection of carotid body tumors represents a special challenge to the surgeon because of the complex anatomical location of the tumor, including close relationship with the cranial nerves, involvement of the carotid vessels and large vascularization of the tumor. With the advance of diagnosis and improvement in surgical techniques as well as the understanding of biological behavior of tumors, surgical treatment has become a safer alternative for treating these tumors.

Multiple paragangliomas of head and neck associated with hepatic paraganglioma: a case report

Background

Paragangliomas (PGs) are neuroendocrine tumors derived embryonically from the neural crest cells of the autonomic nervous system. Approximately 3 % of all paragangliomas occur in the head and neck area. Head and neck paragangliomas (HNPGs) are rare and highly vascularized tumors, the majority of which are benign. Multiple HNPGs with hepatic paraganglioma are exceedingly rare.

Case presentation

We report a 59-year-old male patient with a 40-year history of an enlarged mass at the right side of the neck and two months of epigastric discomfort. Neck physical examination revealed a 6 × 6 cm, ovoid, firm mass on the right side of the neck. A pre-contrast computed tomography (CT) scan of the head and neck revealed bilateral heterogeneous soft tissue masses at the bifurcation of the carotid artery with indistinct border, the size of which was 2.4 cm × 2.6 cm on the left and 5.4 cm × 4.3 cm on the right. The lesions were intensely and heterogeneously enhanced with the internal and external carotid arteries surrounded and pushed anteriorly after contrast administration. Magnetic resonance imaging (MRI) showed a hyperintense signal on T2 weighted images compared to the surrounding muscle tissue and an intense contrast enhancement on T1 weighted images. Digital subtraction angiography (DSA) exhibited a highly vascularized masses that occupied and deformed both sides of the carotid bifurcation. As for the hepatic mass, non-contrasted CT imaging of the upper abdomen showed a 6.1 cm × 5.5 cm × 5.8 cm low density mass in the liver with indistinct border. On late arterial phase, the mass showed slight enhancement with an enlarged hepatic artery pushed around the lesion. MR imaging of the lesion in the liver demonstrated low signal intensity on T1 weighted images but heterogeneous high signal intensity on T2 weighted images. On diffusion weighted images, the mass showed high signal intensity whereas low signal intensity was seen on the image of apparent diffusion coefficient (ADC). Moreover, the contrast-enhanced MRI showed that the lesion was intensely but heterogeneously enhanced.

Conclusion

Multiple HNPGs with hepatic paraganglioma are exceedingly rare. Advanced medical imaging modalities such as ultrasound (US), CT, MR, DSA and ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) are helpful in the evaluation of the patients with PGs. Increased awareness of their concomitant occurrence and familiarity with their characteristic features are critical for clinicians and radiologists to avoid diagnostic and therapeutic pitfalls and to facilitate the early diagnosis.

Five-year follow-up of a patient with bilateral carotid body tumors after unilateral surgical resection

Patient: Female, 34

Final Diagnosis: Carotid body tumor

Symptoms: Dysphagia • hoarseness • non-tender neck swelling

Medication: —

Clinical Procedure: —

Specialty: Surgery