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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.