Case Presentation. Jayer Chung, MD University of Colorado August 6, 2007

Transcription

1 Case Presentation Jayer Chung, MD University of Colorado August 6, 2007

2 J.E.S Cc: Neck mass HPI: The pt is a 68 y.o.. male with neck mass on the left neck. The patient began noticing the mass several months ago. No problems with speech, swallowing, or breathing. No changes with his voice, or hoarseness. The mass is slowly enlarging PMH: DVT complicated by PE, chronic venous insufficiency, hyperlipidemia,, GERD

3 PSH: CTR, hernioplasty,, R varicose vein stripping Meds: Prilosec 20 mg po qd, Lipitor 40 mg po qd,, ASA 81 mg po qd All: NKA SH: former smoker- quit > 20yrs ago. Lives in Aspen, works as a bookkeeper ROS: No TIA s,, stroke, or seizures. No headaches, chest pain, sob, palpitations, coughing, wheezing. No abdominal pain, constipation, melena.

4 PE: /79 18 wt: 156lbs Gen: Thin male, AAOx3, NAD Neuro: : CN II-XII intact HEENT: L neck mass, midway along the ant SCM, soft, compressible, non-pulsatile pulsatile,, immobile. (+) carotid pulses B, no bruits. Oral & nasal mucosa intact. No other masses. No tenderness to palpation, no floctuance.. No movement of the mass with swallowing. Pulm: : CTAB CV: RRR, no m/g/r Abd: s/ntnd No organomegaly Ext: warm, no edema, chronic venous stasis changes to RLE

5 Labs: WBC=6.9, hct=38.0, Plt=136 Na=139, K=3.9, Cl=109, HCO3=24, Cr=1.1

6 DDx?

7 Inflammatory & Infectious Congenital & Cystic Lesions Benign Neoplasms Malignant Neoplasms Acute lymphadenitis (bacterial, viral, fungal), abscess, EBV, cat-scratch fever, HIV, Scrofula, sarcoidosis thyroglossal duct cyst, branchial cleft cyst, cystic hygroma (lymphangioma), vascular malformation (hemangioma), laryngocele salivary gland tumor, thyroid nodules or goiter, soft tissue tumor (lipoma( lipoma,, sebaceous cyst), chemodectoma (carotid body tumor), neurogenic tumor (neurofibroma( neurofibroma, neurilemoma) ) laryngeal tumor (chondroma( chondroma) Primary: : salivary gland tumor, thyroid cancer, upper aerodigestive tract cancer, sarcoma, skin cancer (melanoma, SCC, BCC), lymphoma Metastatic: upper aerodigestive tract cancer, skin cancer (melanoma, SCC), salivary gland tumor, thyroid cancer, adenocarcinoma (breast, GI/GU tract, lung), unknown primary

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9 Carotid Body Tumors Nomenclature: paraganglioma, chemodectoma, glomus caroticum < 0.5% of all tumors Neural crest in origin 5% malignant, 5% bilateral, 5% neuro-secretory activity 75% present with an asymptomatic neck mass. Others present with headache, neck pain, hoarseness, dysphagia,, and syncope Imaging: Ultrasound CTA Angiography

10 Shamblin classification

11 Operative technique

12 Operative Technique

13 Operative Technique

14 Outcomes Hallet et al. Retrospective review of 153 carotid body tumors excised from the Mayo Clinic experience from Mortality- 6% to 2% Peri-operative stroke- 20 to 2.7% Cranial nerve injury- unchanged over time, 40% of patients XII, XII, superior laryngeal, X

15 Zones of Injury

16 Pre-operative embolization Litle et al. Retrospective review 22 carotid body tumors excised over 10 years Longer pre-operative LOS in the embolization group No pre-operative embolization for tumors < 5cm

17 OR & Hospital Course Oblique incision along SCM with superior extension ant to the L ear Shamblin II tumor, beginning just distal to the CCA, and ending at the mandible. No involvement of vagus,, and easily dissected from s laryngeal. Carefully dissected free from hypoglossal. Glossopharyngeal also completely free of tumor. Began dissection off of external carotid, then proceed caudad to cephalad on the ICA until the tumor was freed. Closed in standard fashion Postoperatively, the patient had respiratory distress, and oxygen requirment.. CT chest revealed no PE, but some pulmonary nodules, and effusions. The pt ultimately was weaned from O2, and went home, with outpatient follow up with the Pulmonary service scheduled Pathology= Shamblin II carotid body tumor, completely excised.

18 References 1. Whitehill, TA, Chung J. Carotid Body Tumors and Cervical Schwannoma Tumors. In WH Pearce, JS Matsumura and JST Yao Eds. Operative Vascular Surgery in the Endovascular Era. Evanston, IL: Greenwood Academic. In Press. 2. Roseman,, BJ, Clark, OH. Assessment of a Neck Mass. In WW Souba ed. ACS Surgery: Principles & Practice. New York, NY: WebMD Reference Kafie,, FE et al. Carotid Body Tumors: Role for Preoperative Embolization. Annals of Vascular Surgery. 2001; 15: Hallett,, JW et al. Trends in neurovascular complications of surgical management m for carotid body and cervical paragangliomas: : A fifty-year year experience with 153 tumors. Journal of Vascular Surgery. 1988; 7: Litle,, VR et al. Preoperative Embolization of Carotid Body Tumors: When Is it Appropriate? Annals of Vascular Surgery. 1996; 10: