Eur Arch Otorhinolaryngol (2010) 267:1483–1485

DOI 10.1007/s00405-010-1304-1

CASE REPORT

Cardiac tamponade: a rare presentation from a rare metastatic site in oral squamous cell carcinoma

Yao-Te Tsai · Shih-Wei Kuo · Sheng-Po Hao

Received: 10 March 2010 / Accepted: 2 June 2010 / Published online: 19 June 2010© Springer-Verlag 2010

Abstract Metastatic head and neck squamous cell carci-noma (HNSCC) is a rare cause of cardiac tamponade. Wereport on a 62-year-old male who presented with metastaticsquamous cell carcinoma (SCC) that caused cardiac tam-ponade secondary to a primary SCC originating from theretromolar trigone of the oral cavity. The clinical diagnosiswas conWrmed by physical examination, echocardiographyand complete resolution of symptoms after pericardial Xuiddrainage. Cytologic examination of the pericardial Xuidwas the only investigational tool able to render a deWnitiveevidence of malignant pericardial eVusion. However, evi-dence of a hemorrhagic pericardial eVusion must raise thesuspicion of a malignant etiology regardless of the result ofthe cytologic examination. Metastatic HNSCC may involvemultiple organ systems including the heart. We report thisrare clinical presentation of cardiac tamponade as the initiallocation of distant metastasis. Otolaryngologists shouldkeep a high index of suspicion and pay special attention tothe symptoms arising on the non-head and neck sites to

establish an early diagnosis and prompt management of thedisease process.

Keywords Cardiac tamponade · Head and neck cancer · Distant metastasis

Introduction

Metastatic head and neck squamous cell carcinoma(HNSCC) is a rare cause of cardiac tamponade. The primarysite most commonly responsible is the bronchus, followedby the uterine cervix. As a result, otolaryngologic literaturedescribing this unusual complication is relatively sparse.We report on a patient who presented with cardiactamponade secondary to metastatic SCC originating fromthe retromolar trigone of the oral cavity. This case wasapproved by the Institutional Review Board in Chang GungMemorial Hospital for publication.

Case report

A 62-year-old male was diagnosed with a left retromolarSCC, staged T4N1M0. He underwent wide local excisionincluding segmental mandibulectomy and ipsilateral modi-Wed radical neck dissection in January 2008. As a part ofthe treatment package, he received postoperative adjuvantradiotherapy with a total dose of 6,400 cGy over 33 frac-tions to the primary site and the whole neck. Regular peri-odic routine follow-up at the outpatient clinic wasorganized upon discharge.

In April 2009, approximately 1 year after the treatment,he presented acutely to our emergency room with a com-plaint of progressive dyspnea over the last 10 days. The

Approval of the case study was obtained from the Institutional Review Board of the Chang Gung Memorial Hospital.

Y.-T. Tsai · S.-W. KuoDepartment of Otolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, No. 5, Fu Shin Street, Kweishan, Taoyuan, Taiwan, R. O. Ce-mail: yaote1215@gmail.com

S.-P. Hao (&)Department of Otolaryngology, Head and Neck Surgery, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih Lin District, Taipei City, Taiwan, R. O. Ce-mail: shengpo747@gmail.com

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physical examination revealed tachycardia and pulsus para-doxus. An electrocardiogram showed low QRS voltage.Myocardial infarction was excluded by cardiac enzymetesting and electrocardiogram. Chest radiography revealeda markedly increased cardiothoracic ratio with blunting ofthe left costophrenic angle and clear lung Welds (Fig. 1).Investigation with a two-dimensional echocardiographydetected a coexisting massive pericardial eVusion with rightatrial and ventricular diastolic collapse. The diagnosis ofpleural eVusion and cardiac tamponade was established. Amultidisciplinary approach with the involvement of themedical and the cardiothoracic team was made. On chesttube insertion and drainage, 500 ml of serous pleural eVu-sion was drained. Due to the impending circulatory col-lapse, the patient consequently underwent an emergentthoracotomy with the creation of a pleuropericardial win-dow for decompression in an attempt to relieve the circula-tory collapse. A massive 1,300 ml of hemorrhagicpericardial eVusion was drained. A small piece of pericar-dium was obtained intraoperatively and sent for histologicexamination. The pericardial biopsy and cell cytology ofthe pericardial and pleural eVusions were negative forany evidence of malignancy. In the follow-up progresschest X-ray performed postoperatively, it was noted thatthere was persistent mediastinal widening with a markeddecrease of the cardiac silhouette.

A cervicothoracic CT conWrmed the presence of an inWl-trative mediastinal mass (Fig. 2). The patient underwentmultiple biopsies of the mediastinal mass through video-assisted thoracoscopic surgery. The pathological diagnosis

conWrmed moderately diVerentiated SCC matching the his-tology of the primary tumor excised from the retromolar tri-gone. In an extended PET scan, there was no evidence of asecond primary malignancy or recurrence of the primarysite, except for the mediastinal metastasis. The presence ofdistant metastasis contraindicated any further surgicaloptions and he underwent cisplatin-based palliative chemo-therapy plus cetuximab. The patient remained alive withoutany evidence of recurrent pericardial eVusion at the follow-upperiod of 10 months.

Discussion

The accurate diagnosis of cardiac tamponade relies on athorough clinical history and examination backed up byinvestigation including electrocardiogram, radiographs andechocardiography. The presence of pulsus paradoxus>10 mmHg in patients with pericardial eVusion also helpsto distinguish between those with and without cardiac tam-ponade [1]. The diVerential diagnosis of cardiac tamponadein the head and neck cancer patient includes malignantpericardial eVusion, myocardial rupture after myocardialinfarction, radiation pericarditis, infection, hypothyroidismand idiopathic pericarditis [2].

Only a cytologic examination of the pericardial Xuid canconWrm the diagnosis of a malignant pericardial eVusion.However, the positive rate in a patient with known cancerand a pericardial eVusion ranges from 57 to 100% [3].Mediastinal metastasis may cause cardiac tamponadethrough surrounding inXammation and blockage of lymph-atics or blood vessels from the heart and pericardium with-out direct invasion of the pericardium. All these couldpotentially yield a negative pericardial cytology.

Shaul et al. [4] reported that the most common causes ofcardiac tamponade were iatrogenic (31%), followed bymalignancy (26%) and acute myocardial infarction (11%),

Fig. 1 Initial chest radiograph demonstrated enlargement of thecardiac silhouette with left costophrenic angle blunting

Fig. 2 Contrast-enhanced cervicothoracic CT scans demonstrated aninWltrative mediastinal mass with foci, hypodense center and encase-ment of the adjacent great vessels

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whereas malignancy and tuberculosis predominate amongthe non-traumatic causes of hemorrhagic pericardial eVu-sions. For these reasons, the malignant etiology must behighly suspected in light of hemorrhagic pericardial eVu-sion. A negative cytology should not exclude the possiblediVerential diagnosis of malignancy.

The treatment strategy of malignant pericardial eVusionsmust be individualized in accordance with the underlyingmalignancy and the patient’s clinical condition. Pericardio-centesis alone relieves symptoms, but has recurrence ratesas high as 90% in 90 days [5]. Various surgical techniqueshave been described to alleviate cardiac tamponade. In ourcase, thoracotomy with creation of a pleuropericardial win-dow provides a wide communication between the pleuralspace and the pericardium. This allows the simultaneousdrainage of the co-existing pleural eVusion [5].

Conclusion

Patients with HNSCC may develop cardiac tamponade asthe initial presentation of distant metastasis. Malignant

causes rank high in the diVerential diagnosis in light ofhemorrhagic pericardial eVusion. Otolaryngologists shouldbe acquainted with the diagnosis and management of thedisease process.

References

1. Roy CL, Minor MA, Brookhart MA, Choudhry NK (2007) Doesthis patient with a pericardial eVusion have cardiac tamponade?JAMA 297:1810–1818

2. Posner MR, Cohen GI, Skarin AT (1981) Pericardial disease inpatients with cancer: the diVerentiation of malignant from idio-pathic and radiation-induced pericarditis. Am J Med 71:407–413

3. Wang P-C, Yang K-Y, Chao J-Y et al (2000) Prognostic role ofpericardial Xuid cytology in cardiac tamponade associated withnon-small cell lung cancer. Chest 118:744–749

4. Atar S, Chiu J, Forrester JS, Siegel RJ (1999) Bloody pericardialeVusion in patients with cardiac tamponade. Chest 116:1564–1569

5. DeCamp MM Jr, Mentzer SJ, Swanson SJ, Sugarbaker DJ (1997)Malignant eVusive disease of the pleura and pericardium. Chest112:291s–295s

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