paragangliomaCase presentation

Dr Eunice Rabiatu Abdulai05/12/16

STATISTICS KBTH 2012-2016year Age sex diagnosis Number of cases treatment

2014 38 F Bilateral 1 Excision of the left tumour (injury to CN X and XII)

and radiotherapy for the right tumour (yet to start)

2015 42 F Vagal schwanoma 1 Excision (injury to CNX)

2016 32 F Glomus jugularis +acoustic neuroma

1Radiotherapy (yet to start)

TOTAL NUMBER 3

• Name: J T• Age:38• Sex: F• Occupation: Teacher• NHIS: yes• Marital status: married

Presenting complainIntermittent Left ear pain: 10years

Intermittent dyspnoea: 2years

Bilateral neck swelling: 3 month

History of presenting complaint•Patient was well until 10yrs ago she started experiencing intermittent left ear arch which she sent to several hospital but it was not getting better. Few months prior to presentation, she notice she had bilateral neck mass and complained to her doctor at LA general hospital who referred her to ENT, KBTH.

• On Direct Questioning

She did not have

Dysphagia, odynophagia, easy fatigability,otorrhoea, aural fullness, tinnitus , hearing loss, vertigo ,

• nasal congestion, • rhinorrhea, • epistasis , • epiphora , • diplopia, • headache,• weight loss, • night sweats, • excessive sweating,• palpitations

Past Medical And Surgical History• She does not have• Hypertension• DM• TB• ASTHMA• Past surgeries • Past hemo transfusion

• But has• Allergies to dust

Family History• No family history of • Hypertension• Diabetes• cancers

Social history• Teacher ,• married with 2 children, • does not drink alcohol or smoke cigarate

Clinical examination• General: • Looks well, not pale or jaundice

• Ears:• Nose: NORMAL FINDINGS• Oropharynx:• IDL

• Head and neck• Bilateral Firm fixed swellings to the underlying tissues measuring about 3 by 4cm on

the right and 3 by 2cm on left• All cranial nerves were intact• Auscultation: carotid bruit

diagnosis• Bilateral Carotid body tumour•

OTHER Systemic Examination• CVS:

• CHEST: normal

• ABDOMEN:

• CNS:

INVESTIGATIONS (C T scan showed)

Angiogram

INVESTIGATIONS• 24 HR urine collection for catecholamine's: normal

• Histopathology after left carotid body excision: confirmed our diagnosis

Other investigations• FBC• Sickling and HB electrophoreses• Clotting profile• ESR• BUN Cr & Electrolytes• LFT• CHEST • ECG

• ANAESTHETIC ASSESSMENT

TREATMENT• Surgical resection was done

• COPLICATION • Injury to CN X, CNXII

procedure• Surgery ; left carotid body Excisional biopsy• Anaesthesia : GA • Position: supine with sand bag in between the shoulders and head turned to the opposite side of the lesion • Incision: left horizontal incision at the at the thyroid cartilage from midline to posterior border of SCM• Raised sub platysmal flap to above the hyoid superiorly and inferiorly• incision of the ipsilateral deep investing fascia to separate SCM muscle from strap muscles• SCM are retracted laterally to expose IJV & carotid sheet• Carotid sheath is entered• Proximal and distal control with vessel loops• Identification and preservation of neural structures if possible(Tumour was dissected out whiles trying to preserve CNX & CNXII

which were imbedded in tumour )• Prepare for vascular reconstruction if necessary(suture repair , patch grafting , interposition saphenous vein graft) :

• routine shunting not recommended and is used on when balloon occlusion fails(vascular complication 6.4%, mortality 1.6%)

• Haemostasis secured• Suction drain pass into the wound and secured• Skin closed in 2 layers

• Histopathology :left neck carotid tumour

2nd case • A. S is a 42year old who presented with a 3 years history of anterolateral mass which grew gradually in size to about 6 ₓ6ₓ 5cm at presentation. • she had FNAC at general surgery

which came as spindle cell tumour(most likely benign) b4 she was referred to ENT for further management.

CT- scan

CT- scan

treatment• Surgery ; Neck Exploration +Excisional biopsy• Anaesthesia : GA • Position: supine with sand bag in between the shoulders and head turned to the opposite side of

the lesion • Incision: 2cm above the sternal notch extending from one anterior border of one SCM to the other• Raised sub platysmal flap to above the hyoid superiorly and to sternal notch and clavicle inferiorly• incision of the ipsilateral strap muscles• Tumour was dissected out • Haemostasis secured• Suction drain pass into the wound and secured• Incised Strap muscles suture • Skin closed in 2 layers• COMPLICATION: CNX PALSY• Histopathology :right neck schwannoma

Intraoperative

Cystic elliptical

mass ≈ 9cm ₓ7cmₓ6cm

Attached to the vagus

nerve

3rd case• F.A is a 32years old F who presented with persistent unremitting hoarseness

and right otalgia for 8months, with right hearing loss for 3months duration .she also coughs when she eats dry food like yam and bread. • She had rising sun sign on otoscopy of right ear(reddening of lower part of

tympanic membrane) and severe to profound hearing loss on clinical voice test , right vocal cord palsy on flexible laryngoscopy and involvement right cranial nerve VI,VIII & X .• Pure tone audiometry confirmed the clinical voice test •

otoscopy of right ear(reddening of lower part of tympanic membrane)

right vocal cord palsy on flexible laryngoscopy

CT-Scan• ACOUSTIC NEUROMA• GLOMUS JUGULARE

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