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Poster Design & Printing by Genigraphics ® - 800.790.4001 Surgical Resection of Cervical Surgical Resection of Cervical Schwannoma Schwannoma or or Paraganglioma Paraganglioma at a Single at a Single Institution: Speech and Swallow Outcomes Institution: Speech and Swallow Outcomes Noah P Parker MD, Noel Jabbour MD, Amy Ann Lassig MD, Bevan Yueh MD, and Samir S Khariwala MD Department of Otolaryngology-Head and Neck Surgery, University of Minnesota RESULTS METHODS AND MATERIALS Institutional review board approval was obtained. Pathological diagnoses of cervical schwannoma or paraganglioma between 2003 and 2009 at a tertiary care academic institution were identified through a pathology database. Patient charts were reviewed for demographics, presenting signs and symptoms, radiologic evaluations, surgical approaches and intra-operative findings, postoperative functional outcomes, and management of postoperative sequelae. Table 1: Cervical Schwannoma Functional Outcomes Pt: Age/Sex Location Approach Involved Nerve(s) (condition)* Primary Treatment Initial Outcome Subsequent Treatment (timing- outcome) A. Speech and Swallow Deficits 1: 62/F PPS (skull base) TC IX, X , XI, XII (X & XII dissected extensively) Ansa cervicalis interposition graft Dysphonia and aspiration (VF paralysis); hemiglossal paresis VF injection x 1 (7 months- resolved) 2: 42/F Carotid bifurcation TC X (sacrificed) Ansa cervicalis interposition graft Mild dysphonia and dysphagia only (VF paralysis) Speech and swallow therapy (persistent dysphonia) 3: 56/M PPS (skull base) TC + mandible split IX, X , XI, XII (X & XII sacrificed) None Dysphonia and aspiration (VF paralysis); hemi-glossal paralysis VF injection x 2; thyroplasty (1, 3, and 9 months-resolved) 4: 28/F PPS (skull base) TC X (sacrificed) None Dysphonia and aspiration Speech and swallow therapy (resolved) 5: 37/M PPS; extension to jugular foramen TC + retro-sigmoid IX and rootlets of X (IX sacrificed) None Dysphonia and aspiration (VF paralysis) VF injection x 2; thyroplasty (1, 3, and 6 months-resolved) B. Other Deficits 6: 29/F Carotid bifurcation TC Sympathetic chain (sacrificed) None Horner’s and first bite syndrome Declined botulinum toxin injection *Underlined nerve defines diagnosis; TC=transcervical approach; PPS=parapharyngeal space; VF=vocal fold Table 2: Cervical Paraganglioma Functional Outcomes Pt: Age/Sex Location Embolized Involved Nerve(s) (condition) Diagnosis Initial Outcome Subsequent Treatment (timing- outcomes) A. Speech and Swallow Deficits 1: 61/F PPS to skull base Yes IX, X, XI, XII (X sacrificed) Glomus vagale Dysphonia and aspiration (VF paralysis) VF injection x 2, then thyroplasty (1, 4, and 10 months-PEG required) 2: 62/F PPS to skull base No IX, X, XI, XII (X sacrificed) Glomus vagale Dysphonia and aspiration (preoperative VF paralysis) VF injection x 2, then thyroplasty (1, 4, and 16 months-resolved) 3: 56/M Carotid bifurcation to skull base No X & XII (intact) Glomus vagale Dysphonia and dysphagia (VF paralysis) VF injections x 2 (1 and 6 months- resolved) 4: 43/F Carotid bifurcation Yes X (intact) Carotid body tumor Dysphonia and dysphagia (VF paralysis) VF injection x 1 (2 months- resolved) 4: 26/F Carotid bifurcation and separate PPS to skull base No PPS to skull base tumor intimately involved with X (intact) Glomus vagale and carotid body tumor Dysphonia and dysphagia (VF paralysis) Speech and swallow therapy (resolved) 6: 44/M Carotid bifurcation Yes Pharyngeal plexus (intact) Carotid body tumor Mild dysphonia and pooling of secretions resolved spontaneously Speech and swallow therapy (resolved) B. No Deficits 7: 76/F Carotid bifurcation No None Carotid body tumor No issues None 8: 73/F Carotid bifurcation No None Carotid body tumor No issues None 9: 52/F Carotid bifurcation No None Carotid body tumor No issues None 10: 75/M Carotid bifurcation; hypotympanum No None Carotid body tumor and glomus tympanicum No issues None PPS=parapharyngeal space, VF=vocal fold INTRODUCTION Extracranial neurogenic tumors of the head and neck are rare and are frequently intimately involved with critical neurovascular structures, especially when located within the parapharyngeal space. Cervical schwannoma and paraganglioma are two such tumors. While there are multiple management options for each, surgical resection remains the treatment of choice in most cases. Unfortunately, operative dissection of associated nerves, especially cranial nerves (CN) IX and X, may result in speech and swallow deficits. The resulting postoperative dysphonia and dysphagia require speech and swallow therapy and, in select patients, subsequent procedure to minimize aspiration and to improve quality of life. While cervical schwannoma and paraganglioma have similar potential for morbidity after treatment, no study has focused on outcomes following resection of both tumors. We sought to review our experience with cervical schwannoma and paraganglioma by evaluating speech and swallow outcomes and the extent of subsequent management for postoperative sequelae. Six patients aged 26 to 68 years underwent resection of cervical schwannoma. Patient operative and outcome data for the schwannoma group are shown in Table 1, which is organized by postoperative deficit. Five patients (83.3%) had initial dysphonia and dysphagia with or without aspiration postoperatively. Ten patients aged 26 to 76 years underwent resection of cervical paraganglioma. Tumors most commonly arose from the carotid bifurcation. No primary reinnervation was performed. Patient operative and outcome data for the paraganglioma patients are shown in Table 2, which is also organized by postoperative deficit. Six patients (60.0%) had initial dysphonia and dysphagia with or without aspiration postoperatively. DISCUSSION Our series showed cervical schwannoma along multiple CNs. Assuming surgical candidacy, we typically treat such tumors with resection. Dysphonia and dysphagia complicated initial patient recovery in 5 of 6 patients (83.3%). At 6 months postoperatively, 4 patients (66.6%) had dysphonia and 3 (50.0%) had dysphagia. At final follow up, the only residual symptom was persistent dysphonia in a single patient (16.7%) who suffered CNX sacrifice treated with primary reinnervation followed by speech and swallow therapy. All other patients ultimately recovered speech and swallow function with vocal fold augmentation alone (n=2), reinnervation followed by vocal fold augmentation (n=1), or therapy alone (n=1). Our series showed cervical paraganglioma tumors confined to the neck that did not involve extension into the temporal bone. Tumors were primarily located at the carotid bifurcation (n=8). Assuming surgical candidacy, we typically treat such tumors with resection. In our series, no patient underwent primary nerve repair. Dysphonia and dysphagia complicated initial patient recovery in 6 of 10 patients (60.0%). At 6 months postoperatively, 3 patients (30%) had residual dysphonia and dysphagia. At final follow up, only 1 patient (10.0%) with CNX sacrifice had persistent feeding tube dependence after subsequent treatments. The other 5 patients with initial dysfunction recovered speech and swallow function with vocal fold augmentation (n=3) or therapy alone (n=2). Four patients (40%) had normal speech and swallow outcomes following resection. CONCLUSIONS Cervical schwannoma and paraganglioma are intimately involved with neurovascular structures. Both tumors can be treated in a variety of ways; however, both are typically treated with surgical excision. Consistent with previous reports, speech and swallow deficits are common following complete excision. CN X trauma carries the greatest risk. Primary reinnervation may improve outcomes when CNs are sacrificed, while speech and swallow therapy with or without VF augmentation allows for functional improvement in a majority of patients.

Surgical Resection of Cervical Schwannoma or Paraganglioma at a Single Institution: Speech and Swallow Outcomes

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Poster Design & Printing by Genigraphics® - 800.790.4001

Surgical Resection of Cervical Surgical Resection of Cervical SchwannomaSchwannoma oror ParagangliomaParaganglioma at a Single at a Single Institution: Speech and Swallow OutcomesInstitution: Speech and Swallow Outcomes

Noah P Parker MD, Noel Jabbour MD, Amy Ann Lassig MD, Bevan Yueh MD, and Samir S Khariwala MDDepartment of Otolaryngology-Head and Neck Surgery, University of Minnesota

RESULTS

METHODS AND MATERIALSInstitutional review board approval was obtained. Pathological diagnoses of cervical schwannoma or paragangliomabetween 2003 and 2009 at a tertiary care academic institution were identified through a pathology database. Patient charts were reviewed for demographics, presenting signs and symptoms, radiologic evaluations, surgical approaches and intra-operative findings, postoperative functional outcomes, and management of postoperative sequelae.

Table 1: Cervical Schwannoma Functional OutcomesPt:

Age/Sex Location Approach Involved Nerve(s) (condition)* Primary Treatment Initial Outcome Subsequent Treatment (timing-outcome)

A. Speech and Swallow Deficits

1:62/F PPS (skull base) TC IX, X, XI, XII

(X & XII dissected extensively)Ansa cervicalis

interposition graft

Dysphonia and aspiration (VF paralysis);

hemiglossal paresis

VF injection x 1 (7 months-resolved)

2:42/F

Carotid bifurcation TC X (sacrificed) Ansa cervicalisinterposition graft

Mild dysphonia and dysphagia only (VF

paralysis)

Speech and swallow therapy (persistent dysphonia)

3:56/M PPS (skull base) TC + mandible

splitIX, X, XI, XII

(X & XII sacrificed) NoneDysphonia and

aspiration (VF paralysis); hemi-glossal paralysis

VF injection x 2; thyroplasty (1, 3, and 9 months-resolved)

4:28/F PPS (skull base) TC X (sacrificed) None Dysphonia and

aspiration Speech and swallow therapy

(resolved)5:

37/MPPS; extension to jugular

foramen TC + retro-sigmoid IX and rootlets of X (IX sacrificed) None Dysphonia and aspiration (VF paralysis)

VF injection x 2; thyroplasty (1, 3, and 6 months-resolved)

B. Other Deficits6:

29/F Carotid bifurcation TC Sympathetic chain (sacrificed) None Horner’s and first bite syndrome Declined botulinum toxin injection

*Underlined nerve defines diagnosis; TC=transcervical approach; PPS=parapharyngeal space; VF=vocal fold

Table 2: Cervical Paraganglioma Functional OutcomesPt:

Age/Sex Location Embolized Involved Nerve(s) (condition) Diagnosis Initial Outcome Subsequent Treatment (timing-outcomes)

A. Speech and Swallow Deficits

1:61/F PPS to skull base Yes IX, X, XI, XII (X sacrificed) Glomus vagale Dysphonia and aspiration

(VF paralysis)

VF injection x 2, then thyroplasty(1, 4, and 10 months-PEG

required)2:

62/F PPS to skull base No IX, X, XI, XII (X sacrificed) Glomus vagale Dysphonia and aspiration (preoperative VF paralysis)

VF injection x 2, then thyroplasty(1, 4, and 16 months-resolved)

3:56/M

Carotid bifurcation to skull base No X & XII (intact) Glomus vagale Dysphonia and dysphagia

(VF paralysis)VF injections x 2 (1 and 6 months-

resolved)4:

43/F Carotid bifurcation Yes X (intact) Carotid body tumor Dysphonia and dysphagia(VF paralysis)

VF injection x 1 (2 months-resolved)

4:26/F

Carotid bifurcation and separate PPS to skull

base No

PPS to skull base tumor intimately involved with X

(intact)

Glomus vagale and carotid body tumor

Dysphonia and dysphagia(VF paralysis)

Speech and swallow therapy (resolved)

6:44/M Carotid bifurcation Yes Pharyngeal plexus (intact) Carotid body tumor

Mild dysphonia and pooling of secretions resolved

spontaneously

Speech and swallow therapy (resolved)

B. No Deficits7:

76/F Carotid bifurcation No None Carotid body tumor No issues None

8:73/F Carotid bifurcation No None Carotid body tumor No issues None

9:52/F Carotid bifurcation No None Carotid body tumor No issues None

10:75/M

Carotid bifurcation; hypotympanum No None Carotid body tumor and

glomus tympanicum No issues None

PPS=parapharyngeal space, VF=vocal fold

INTRODUCTIONExtracranial neurogenic tumors of the head and neck are rare and are frequently intimately involved with critical neurovascular structures, especially when located within the parapharyngeal space. Cervical schwannoma and paragangliomaare two such tumors. While there are multiple management options for each, surgical resection remains the treatment of choice in most cases. Unfortunately, operative dissection of associated nerves, especially cranial nerves (CN) IX and X, may result in speech and swallow deficits. The resulting postoperative dysphonia and dysphagia require speech and swallow therapy and, in select patients, subsequent procedure to minimize aspiration and to improve quality of life. While cervical schwannoma and paragangliomahave similar potential for morbidity after treatment, no study has focused on outcomes following resection of both tumors. We sought to review our experience with cervical schwannoma and paraganglioma by evaluating speech and swallow outcomes and the extent of subsequent management for postoperative sequelae.

Six patients aged 26 to 68 years underwent resection of cervical schwannoma. Patient operative and outcome data for the schwannoma group are shown in Table 1,which is organized by postoperative deficit. Five patients (83.3%) had initial dysphonia and dysphagia with or without aspiration postoperatively.

Ten patients aged 26 to 76 years underwent resection of cervical paraganglioma. Tumors most commonly arose from the carotid bifurcation. No primary reinnervationwas performed. Patient operative and outcome data for the paraganglioma patients are shown in Table 2, which is also organized by postoperative deficit. Six patients (60.0%) had initial dysphonia and dysphagia with or without aspiration postoperatively.

DISCUSSIONOur series showed cervical schwannoma along multiple CNs. Assuming surgical candidacy, we typically treat such tumors with resection. Dysphonia and dysphagia complicated initial patient recovery in 5 of 6 patients(83.3%). At 6 months postoperatively, 4 patients (66.6%) had dysphonia and 3 (50.0%) had dysphagia. At final follow up, the only residual symptom was persistent dysphonia in a single patient (16.7%) who suffered CNXsacrifice treated with primary reinnervation followed by speech and swallow therapy. All other patients ultimately recovered speech and swallow function with vocal fold augmentation alone (n=2), reinnervation followed byvocal fold augmentation (n=1), or therapy alone (n=1). Our series showed cervical paraganglioma tumors confined to the neck that did not involve extension into the temporal bone. Tumors were primarily located at the carotid bifurcation (n=8). Assuming surgical candidacy,we typically treat such tumors with resection. In our series, no patient underwent primary nerve repair. Dysphonia and dysphagia complicated initial patient recovery in 6 of 10 patients (60.0%). At 6 monthspostoperatively, 3 patients (30%) had residual dysphonia and dysphagia. At final follow up, only 1 patient (10.0%) with CNX sacrifice had persistent feeding tube dependence after subsequent treatments. The other 5patients with initial dysfunction recovered speech and swallow function with vocal fold augmentation (n=3) or therapy alone (n=2). Four patients (40%) had normal speech and swallow outcomes following resection. CONCLUSIONSCervical schwannoma and paraganglioma are intimately involved with neurovascular structures. Both tumors can be treated in a variety of ways; however, both are typically treated with surgical excision. Consistentwith previous reports, speech and swallow deficits are common following complete excision. CN X trauma carries the greatest risk. Primary reinnervation may improve outcomes when CNs are sacrificed, whilespeech and swallow therapy with or without VF augmentation allows for functional improvement in a majority of patients.