Dealing with a challenging carotid body tumor

Abstract

A 30-year-old woman presented with a painless swelling in her right neck for 1 year. On physical examination, a large pulsatile and nontender mass (w15 10 cm in size) was present in the right anterolateral neck region. Selective carotid arteriography and computed tomography angiography confirmed an intensely enhancing mass at the bifurcation of the internal (ICA) and external carotid arteries (ECA), extending from the base of the skull and almost reaching the clavicle bone (A). The lesion encased the ICA, ECA, common carotid artery (CCA), and the regional nerves, although no symptoms of cranial neuropathy were detected. A temporary balloon occlusion test showed open collateral vessels through the anterior communicans artery. The operation was undertaken by a team of vascular surgeons and otolaryngologists. A 25-cm-long, S-shaped incision was made along the posterior border of the sternocleidomastoid muscle. We removed the mastoid and styloid processes to facilitate adequate skull base exposure. A large, hypervascular tumor (15 10 cm) was visualized extending from the level of the sternoclavicular joint to the base of the skull. As expected, the ICA and CCA were wholly enclosed in the tumor. The vascular walls were infiltrated without a dissection plane between the tumor and the vessel adventitia (white line of Gordon-Taylor). An autologous saphenous vein graft was indicated. After we obtained control of the petrous carotid artery and proximal CCA with vessel loops, the saphenous vein was anastomosed in an end-toside fashion into the CCA in 8 minutes, followed by the end-to-end anastomosis to the petrous portion of the ICA in 11 minutes (B). Finally, the tumor was removed, together with the ICA, after artery reconstruction. The ECA was ligated. The VII and XI cranial nerves were identified and well protected. The X and XII nerves were resected due to direct tumor involvement. Operative blood loss was 600 mL. Histologic analysis showed findings typical of a carotid body paraganglioma. The patient’s postoperative course was uneventful, with a slight XII cranial nerve deficit and temporary hoarseness. No recurrence or any further complications were noted at the 10-month follow-up.