Preoperative diagnosis of vagal and sympathetic cervical schwannomas based on radiographic findings

Intracapsular Enucleation of Cervical Sympathetic Chain Schwannoma

OBJECTIVES

Schwannoma arising from cervical sympathetic chain (CSC) is a rare clinical entity. CSC is hard to preserve in CSC schwannoma (CSCS) surgeries, resulting in Horner's syndrome (HS) and first bite syndrome (FBS). This article aims to explore our experience in successful preservation of CSC in CSCS surgeries.

METHODS

This is a retrospective review of CSCS cases treated at our tertiary medical institution between Apr 2018 and March 2022. Only cases with successful intraoperative preservation of CSC were included.

RESULTS

In total, 3 cases were included. There were 2 male patients and 1 female patient. Their age was between 38 years old and 66 years old (average and median age was 52 and 51 years old, respectively). Presenting symptom was neck mass for all them, 2 of which were on the left side, while 1 was on the right. Intracapsular enucleation of the CSCS was attempted and achieved in all 3 cases. Hemorrhage from the inner surface of capsules was diffuse and heavy. Constant saline irrigation, suction, and bipolar coagulation were needed to achieve hemostasis. Postoperative HS presented between 4 hours and 14 hours after surgery for all 3 patients, which took 1 month to 3 months to recover, whereas FBS did not occur in any patient. Median duration of follow-up was 6 months. No recurrence was observed.

CONCLUSIONS

Intracapsular enucleation should be attempted in CSCS surgeries, although hemorrhage might be diffuse and hard to control. When intracapsular enucleation was achieved, postoperative FBS can be avoided, while postoperative HS could occur, but its recovery was satisfactory.

Quantification of vessel separation using the carotid-jugular angle to predict the nerve origin of neck peripheral nerve sheath tumours: a pooled analysis of cases from the literature and a single-center cohort

BACKGROUND

Postoperative nerve palsy is a major complication following resection of neck peripheral nerve sheath tumours (PNSTs). Accurate preoperative identification of the nerve origin (NO) can improve surgical outcomes and patient counselling.

MATERIAL AND METHODS

This study was a retrospective cohort and quantitative analysis of the literature. The authors introduced a parameter, the carotid-jugular angle (CJA), to differentiate the NO. A literature review of neck PNST cases from 2010 to 2022 was conducted. The CJA was measured from eligible imaging data, and quantitative analysis was performed to evaluate the ability of the CJA to predict the NO. External validation was performed using a single-centre cohort from 2008 to 2021.

RESULTS

In total, 17 patients from our single-centre cohort and 88 patients from the literature were analyzed. Among them, 53, 45, and 7 patients had sympathetic, vagus, and cervical nerve PNSTs, respectively. Vagus nerve tumours had the largest CJA, followed by sympathetic tumours, whereas cervical nerve tumours had the smallest CJA ( P <0.001). Multivariate logistic regression identified a larger CJA as a predictor of vagus NO ( P <0.001), and receiver operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.907 (0.831-0.951) for the CJA to predict vagus NO ( P <0.001). External validation showed an AUC of 0.928 (0.727-0.988) ( P <0.001). Compared with the AUC of the previously proposed qualitative method (AUC=0.764, 0.673-0.839), that of the CJA was greater ( P =0.011). The cut-off value identified to predict vagus NO was greater than or equal to 100°. Receiver operating characteristic analysis showed an AUC of 0.909 (0.837-0.956) for the CJA to predict cervical NO ( P <0.001), with a cut-off value less than 38.5°.

CONCLUSIONS

A CJA greater than or equal to 100° predicted a vagus NO and a CJA less than 100° predicted a non-vagus NO. Moreover, a CJA less than 38.5 was associated with an increased likelihood of cervical NO.

Interest in the Endoscopic Endonasal Route as Access to the Parapharyngeal Space for Cervical Sympathetic Chain Schwannoma Resection: A Case Report

Schwannomas are tumors originating from Schwann cells, about 45% of them are located in the head and neck region, including the parapharyngeal space (PFS). Vagus nerve schwannomas (VS) and cervical sympathetic chain schwannomas (CSCS) are most commonly found in this region. We present a case of CSCS located in the PFS of a middle-aged female patient who had surgery with the endoscopic endonasal approach (EEA). There have been no earlier reports of CSCS resection utilizing EEA, according to our literature search. To our knowledge, there is no scientific record of CSCS resection using EEA.

Evaluation of Carotid Space Schwannoma Using Ultrasonography: Characteristics and Role in Defining the Nerve of Origin

OBJECTIVES

We aimed to evaluate the ultrasonography (US) characteristics of carotid space schwannoma and their role in identifying the nerve of origin.

METHODS

This prospective study enrolled patients with cervical carotid space schwannoma accessible by US. The US characteristics of vagus nerve schwannomas (VNSs) and sympathetic nerve schwannomas (SNSs) were assessed; a carotid space schwannoma was defined as a VNS if the tumor originated in the mid-vagal region and an SNS if it arose posterior to the intact vagus nerve, displacing the vagus nerve anteriorly.

RESULTS

Twenty patients with carotid space schwannoma were enrolled. The vagus and sympathetic nerves were identified as the nerve of origin in 12 and 8 patients, respectively. VNSs were centered at levels II, III, and IV in 5, 3, and 4 patients, respectively, while SNSs were centered at levels II (7 patients) and IV (1 patient) (P = .105). The maximal diameters were 3.2 and 4.8 cm for VNSs and SNSs, respectively (P = .011). Internal vascularity was absent and low in 9 and 3 VNSs, respectively, and low and intermediate in 4 SNSs each (P = .002). Twelve patients with VNSs underwent active surveillance without immediate surgery; no adverse events occurred during the 55.2-month follow-up period. Eight patients with potential SNSs underwent surgery, confirming the sympathetic nerve as the nerve of origin.

CONCLUSIONS

US facilitates identification of the nerve of origin in cervical carotid space schwannoma. VNSs are more frequent in infrahyoid locations and tend to be smaller in size with lower vascularity compared with SNSs on US.

Cervical Sympathetic Chain Schwannoma-Our Experience

Tumours arising from the parapharyngeal space are uncommon. The most common tumour arising primarily from this region is a neurogenic tumour, especially Schwannoma. The most common site of origin of a Schwannoma in parapharyngeal space is Vagus nerve. Cervical sympathetic chain (CSC) schwannomas are extremely rare. Here, we discuss a case of a 30-year old female with cervical sympathetic chain schwannoma, the clinical presentation, diagnosis and management.

Skull Base Vagal Schwannoma

ABSTRACT

Skull base vagal nerve schwannoma (VNS) is relatively uncommon and poses a challenge to surgeons. Although schwannomas are benign and slowly growing neoplasms arising from Schwann cells, they may cause significant dysfunction by causing the surrounding structures compression or infiltrating vital structures such as the skull base, the orbit, and the cranial nerves. These tumors are resistant to radiotherapy and chemotherapy. Complete surgical removal is the optimal treatment modality, with recurrence being rare. The authors report a case of a 58-year-old man with an extensive VNS involving the left jugular foramen and parapharyngeal space. The clinical presentation, surgical management, and outcomes of VNS are discussed.

Castleman Disease Presenting as a Parapharyngeal Mass: A Case Report and Review of the Literature

Objectives:

Masses in the parapharyngeal space often pose a diagnostic and therapeutic challenge due to an inaccessible location for biopsy and proximity to critical neurovascular structures of the neck. The aims of this study are to describe a rare case of Castleman disease (CD) presenting in the parapharyngeal space.

Methods:

Case report of a 38-year-old male presenting to a tertiary care center and literature review.

Results & conclusions:

The parapharyngeal space is an unusual location for CD. Surgeons, radiologists, and pathologists must be aware of this disease entity within the differential diagnosis to provide appropriate perioperative counseling for patients.

Cervical Sympathetic Chain Schwannoma Masquerading as a Vagus Nerve Schwannoma Complicated by Postoperative Horner's Syndrome and Facial Pain: A Case Report

INTRODUCTION

Cervical Sympathetic Chain Schwannomas (CSCS) of the carotid sheath are rare neoplasms that can be misdiagnosed on imaging. The following case documents a rare incident of a misdiagnosed CSCS with unusual outcomes of permanent Horner's syndrome and facial pain.

PRESENTATION OF CASE

A 36-year-old female presented with a slow-growing neck mass. CT and MRI led to a preoperative diagnosis of vagus nerve schwannoma (VNS). However, surgical treatment revealed the mass to be involved with the cervical sympathetic chain rather than the vagus nerve. The diagnosis was corrected to CSCS and the nerve was resected with the mass. The patient presented postoperatively with Horner's syndrome and severe facial pain. These symptoms persisted despite two years of medical management.

DISCUSSION

Studies indicate that imaging trends used for distinction between VNS and CSCS show inconsistencies in making preoperative diagnoses. Recent literature reveals helpful criteria for improving diagnostic standards that assist with preoperative patient counseling. In addition, postoperative outcomes, such as temporary, asymptomatic Horner's syndrome are common in CSCS. The following case report exemplifies the difficulties in diagnosis and addresses the unique complications of facial pain and permanent Horner's syndrome.

CONCLUSION

This case report examines postoperative outcomes and improves clinician awareness of the potential for misdiagnosis of a rare neoplasm and the recently improved diagnostic measures, providing for higher quality preoperative counseling. Future research is recommended to confirm and improve diagnostic guidelines and accuracy. Additional studies may focus on evaluating the effects of incorrect preoperative diagnosis on postoperative complication rates.

A rare case of bilateral cervical vagal neurofibromas: role of high-resolution ultrasound

Background

Neurofibromas originating from vagus nerves are rarely reported in the literature. In particular, plexiform neurofibromas of the bilateral cervical vagus nerve are extremely rare.

Case presentation

A 21-year-old female presented with a 2-year history of swelling on the right side of her neck. Physical examination revealed a soft-tissue mass on the right side of her neck. Ultrasonography (US) and magnetic resonance (MR) imaging showed a tumor centered in the right carotid sheath between the internal jugular vein and the common carotid artery. In addition, a similar nodular mass in the left carotid sheath was detected on US. The right mass was surgically resected; histopathological examination revealed a neurofibroma.

Conclusions

US can be a valuable method for preoperative evaluation of cervical mass, as it is capable of displaying the vagus nerve and provides sufficient diagnostic information. The cervical vagal neurofibroma can manifest as solitary or multifocal lesion. Bilateral neurofibromas are usually associated with neurofibromatosis type 1 (NF1). Early diagnosis and prompt surgical treatment should be considered.