Carotid Space Research Articles

Penetrating neck trauma” - Enigma to surgeons: A case report with review of literature

: We report for the first time a case of penetrating injury to carotid artery by a stone piece during welding using hammer.: A 26, year old male labourer presented with a penetrating neck injury by a stone piece. As the patient was stable, NCCT neck was done which revealed a metallic foreign body obliterating the right carotid space. CT Angiography was also done to rule out any vascular injury. The patient underwent neck exploration during which foreign body was removed and right carotid artery repair was done with 4-0 prolene. : The patient had no complications and showed no sequalae from this injury during follow up.: CT angiography should be done in all patients who are stable to rule out injury to great vessels before neck exploration .

6645 Paraganglioma or Benign Ectopic Thyroid Tissue?

Abstract Disclosure: J.A. Dower: None. R. MacLeod: None. B. Cardoso: None. C. Matouk: None. S. Mehra: None. G. Riccio: None. L. Williams: None. S.K. Majumdar: None. Introduction: During gestation, cells destined to form the thyroid descend through the thyroglossal duct; ectopic thyroid tissue may deposit anywhere along this route from tongue base to mediastinum (1). Less commonly, thyroid tissue can be found lateral to the duct, either alone or in association with a lymph node (2). We present a case of lateral ectopic thyroid tissue mimicking paraganglioma. Clinical Case: A healthy 32-year-old woman presented to ENT with cervical adenopathy persisting for several months after a flulike illness. FNA showed no evidence of malignancy. A neck CT with contrast ordered for further evaluation revealed a 3.2 x 2.3 x 1.5 cm enhancing mass within the right carotid space, splaying the external and internal carotid artery branches, most concerning for paraganglioma. A second, smaller lesion was noted inferiorly. Neck MRI confirmed these findings and revealed a subcentimeter T2 lesion within the right thyroid lobe. The patient was referred to endocrine for further workup. She had no symptoms of sympathetic hyperactivity and no family history suggestive of pheochromocytoma or paraganglioma. Biochemical workup was largely within normal limits: plasma metanephrines 53 pg/mL (57), normetanephrines 94 pg/mL (148), calcitonin <2 pg/mL, TSH 1.210 uIU/mL (0.27-4.2), FT4 1.52 ng/dL (0.8-1.7). Follow-up 24-h urine studies were also unremarkable: metanephrines 166 mcg (36-190), normetanephrines 159 mcg (35-482). Brain MRI, chest CT, and abdomen/pelvis MRI were negative for additional masses. DOTATATE PET/CT was completed to determine if the thyroid lesion was another potential paraganglioma requiring resection versus a nodule amenable to biopsy; uptake was confined to the carotid space lesions, so FNA of the thyroid nodule was considered safe. Thyroid FNA revealed FLUS with genetic testing indicating low likelihood of malignancy. The patient underwent tumor embolization followed by neck dissection with successful removal of both the larger and smaller masses identified on imaging. Frozen and permanent tissue section revealed that both masses consisted of benign thyroid tissue without associated lymphoid tissue. The patient experienced jaw pain with eating after surgery and is under consideration for Botox injection. Conclusion: Benign thyroid tissue can deposit in unexpected places, mimicking malignancy and paraganglioma, alike. Even a very thorough workup can mistake the identity of a mysterious mass; only the tissue itself can make the diagnosis.

Anatomy, Diagnosis, and Clinical Management of Deep Neck Space Infections

Any surgeon providing care to patients with congenital, oncologic, infectious, or traumatic processes impacting the head and neck should have an intimate knowledge of the local anatomy. The complex fascial system in this region results in a series of loosely and tightly bound spaces that can both harbor and/or facilitate the rapid spread of infections through these fascial planes and potential spaces. Deep neck space infections may occur spontaneously from cutaneous, lymphatic, odontogenic, otologic, salivary gland, sinus, and hematogenous sources or develop as the result of surgical/iatrogenic manipulation. These infections are typically polymicrobial, involving a mixture of Gram-positive cocci, Gram-negative rods, and beta-lactam-resistant anaerobes commonly found in the oropharyngeal flora. Other populations, such as immunocompromised or hospitalized patients, are particularly vulnerable to infection by certain opportunistic and antibiotic-resistant pathogens. Understanding the deep neck anatomy is crucial for predicting the spread of infection and guiding treatment strategies. The superficial and deep cervical fascial planes form a series of compartments and spaces including the retropharyngeal, danger, prevertebral, carotid, parapharyngeal, submandibular, sublingual, parotid, masticator, temporal, and infrahyoid spaces. Despite their rarity in the post-antibiotic era, deep neck space infections pose a significant threat as they progress rapidly and can quickly lead to life-threatening complications. Delayed clinical presentation is common due to the compartmentalization by fascial planes, therefore early recognition requires a high index of suspicion, thorough clinical examination, and diagnostic imaging studies, typically contrast-enhanced computed tomography (CECT). Treatment requires a multidisciplinary approach, including advanced airway management, administration of empirical broad-spectrum antibiotics, and surgical drainage when indicated. This review provides a comprehensive overview of deep neck space anatomy and its defining fascial planes, as well as discussions on epidemiology, specific microbiology, clinical presentation, diagnosis, antibiotic selection, and surgical treatment options.

How to do it: excision of carotid space tumours in proximity to skull base.

This article along with the descriptive video demonstrates the step-by-step surgical approach for excision of tumours located in carotid space in proximity to skull base. We have described the surgical steps without mandibular osteotomy and also demonstrated the technique to safeguard all neuro-vascular anatomy in the vicinity of the carotid space and skull base.

Deep Neck Infection: A Case Series

Background: Deep neck abscess is a collection of pus (pus) in the potential space between the fascia of the deep neck due to spread from various sources of infection, such as teeth, mouth, throat, paranasal sinuses, ears and neck. Various spaces can be a place for deep neck abscesses including the submandibular, peritonsillar, parapharyngeal, retropharyngeal, submental, parotid, anterior visceral, carotid, and masseter spaces. Inflammation or damage to chronic problem teeth can lead to complications of deep neck abscesses. The main complaint that causes sufferers to come to the hospital is dysphagia, which is difficulty swallowing due to the pain felt by the patient. These complaints can also be accompanied by trismus, stridor caused by tracheal compression, to airway obstruction. Purpose: To determine the progressivity of deep neck abscess so that it can provide medical management until operative incision and drainage. Case report: We report 5 cases of deep neck abscess with management according to the progress of each case. Conclusion: The most common cause or etiology that can lead to deep neck abscess is toothache. Management of deep neck abscess, starting with the administration of empirical antibiotics which is the first step to reduce the infection of bacteria that produce beta lactamase. In deep neck abscess, medical therapy can be given in the form of an antibiotic combination of ceftriaxone with metronidazole, or meropenem with metronidazole as well as surgery in the form of incision and drainage. Treatment can be chosen based on the presence or absence of warning signs and signs of complications. Incision and drainage is performed when complaints do not improve after administration of antibiotics, multiple abscesses and airway obstruction that threatens the patient's life.

Beyond the Crib: Unraveling the Enigma of Neonatal Nasopharyngeal Mass

Germ cell tumours that develop at birth are rare, with teratomas most frequently occurring in the sacrococcygeal area. Nasopharyngeal teratomas are also rare, occurring in less than 10% of head and neck teratomas. Immature Nasopharyngeal Teratoma (INT) in neonates presents a rare yet challenging clinical scenario. It can manifest with significant respiratory distress and airway compromise, necessitating prompt recognition and intervention. Diagnostic modalities such as imaging studies and biopsy aid in accurate diagnosis and treatment planning. Surgical resection remains the cornerstone of management, with complete excision being essential to optimise outcomes. The present case report highlights the importance of multidisciplinary collaboration and continued research efforts to refine therapeutic approaches and improve patient outcomes. Here, the authors present a rare case of INT in a 51-day-old male child. A 51-day-old male child, normal vaginal delivery and cried immediately after birth with complaints of respiratory distress from 8th day of life, for which he was treated with antibiotics and started on mechanical ventilation. In view of failure of extubation, bronchoscopy was done which revealed a nasopharyngeal mass. Magnetic Resonance Imaging (MRI) showed a heterogeneous mass measuring 2.3×3.9×3.1 cm (anteroposterior x transverse x craniocaudal) involving the parapharyngeal space and carotid space, extending into the retropharyngeal space, with no evidence of intracranial extension. Histopathology showed features of an immature solid teratoma. Nasopharyngeal teratomas are extremely rare congenital tumours, with only a few cases reported in the medical literature. INT in neonates represents a rare yet clinically significant entity that requires prompt recognition and intervention. Multidisciplinary collaboration and comprehensive management strategies are essential to optimise outcomes for affected neonates.

A Case of Impalement Injury from the Pharynx into the Carotid Artery Space

A Case of Impalement Injury from the Pharynx into the Carotid Artery Space

The Lateral Supraorbital Approach: 2-Dimensional Operative Video.

The lateral supraorbital approach (LSO), a minimally invasive alternative to the pterional approach, can be used for anterior circulation aneurysms (except distal anterior cerebral artery), some posterior circulation aneurysms, and tumors located around the sellar and suprasellar regions. Performing one-layer myocutaneous flap that is retracted anteriorly, exposure of the superior temporal line, and zygomatic process of the frontal bone and the inferior limit of the craniotomy represent the upper edge of the Sylvian fissure, exposing the anterolateral skull base. Skin incision behind the hairline, one-layer myocutaneous flap retracted anteriorly, minimal detachment of the temporalis muscle, burr hole over the superior temporal line, and craniotomy of 4 cm in diameter (inferior limit of the craniotomy represents the Sylvian fissure). Potential risks include opening of the frontal sinus, entering the orbit and exposure of the orbital fat, wrong craniotomy location, and limited exposure. Inadequate craniotomy size limits instruments maneuverability. To avoid complication, identification of anatomic landmarks, sinus closure, preoperative evaluation of computed tomography scans, and use of neuronavigation are necessary. This requires surgical expertise and familiarity of minimal invasive craniotomies. Anatomic limitations of the LSO include temporomesial region, distal Sylvian +/-, posterior communicating artery aneurysms medial projection, retro carotid space, and carotid cave. For pathologies requiring an additional lateral trajectory, we use an extended LSO, drilling the sphenoid wing through the fronto-pterio-orbital window without drilling of the temporal bone. Additional variations include performing an intradural or extradural clinoidectomy. The patient consented to the procedure and to the publication of their image.

Central Nonenhancement Sign in Carotid Body Tumor on CT Angiography

AbstractCarotid body tumors are rare benign tumors that arise in the carotid space of neck typically presenting as soft to firm, painless swelling in the neck. While specific imaging characteristics have been previously described for carotid body tumors, we report a new imaging sign in three cases of carotid body tumors on computed tomography angiography.

Delayed Surgical Intervention in Cranio-Maxillofacial Splinter Injury: Report of a Case and A Literature Review.

In the context of Indian combat scenario, maxillofacial injuries from gunshots are uncommon. The first section of this study is a case report of a rare instance of metal foreign bodies that were lodged in the parapharyngeal space, deeper to the deep lobe of the parotid right next to the carotid space in the neck. The second section focusses on the unique treatment for blast injuries as well as the variety of imaging procedures that are readily available to assist with surgery, such as plain film, CT, angiography, and occasionally MR imaging. According to the study, understanding the pertinent anatomy, precise imaging of the penetrating object in relation to vital structures, meticulously planned and conducted surgical removal of the foreign body, and repair of damaged structures are the key elements of a successful treatment.

Hypoglossal nerve delineation in nasopharyngeal carcinoma patients may reduce the radiation dose and damage to the nerve

This study aims to establish a delineation guideline for the contouring of the hypoglossal nerve by dividing the nerve into different segments, and to test the possibility of a radiation dose reduction to the hypoglossal nerve in NPC patients receiving radiotherapy. Twenty NPC patients were selected arbitrarily. The hypoglossal nerves were delineated using anatomic landmarks and divided into the cisternal, intracanalicular, carotid, and transverse segments. The tumor coverage by radiation and dose-volume parameters of the nerve with and without various dose constraints to the hypoglossal nerve were compared. The hypoglossal nerve, which is invisible on CT images, can be delineated accurately with the assistance of several anatomic landmarks. Without a dose constraint to the hypoglossal nerve, the carotid space, intracanalicular, and transverse segments had high radiation dose-volumes. The dose-volume to the nerve, however, can be reduced when the nerve was defined and a dose constraint was given. The delineation of the hypoglossal nerve with its different segments is feasible. The carotid space, intracanalicular, and transverse segments received the highest dose, where the nerve damage was most likely located. The dose to the nerve can be reduced to less than 70 Gy using the intensity-modulated radiotherapy technique.

THU523 A Rare Case Of Functional Cervical Paraganglioma: Case Report

Abstract Disclosure: V.D. Oliveira: None. G.C. Vaccarezza: None. A.E. Vieira: None. N.M. Scalissi: None. A.R. dos Santos: None. P.R. Lazarini: None. A.B. Suehara: None. C. Olivati: None. J.V. Lima: None. INTRODUCTION: Head and neck paragangliomas (HNPGL) are rare tumors arising from cells associated with parasympathetic ganglia. Catecholamine hypersecretion is founded in less than 5% of the patients. Evidence is growing that about 50% of the HNPGL are associated with hereditary syndromes. CASE REPORT: Male patient, 34 years old, previously healthy, presented with a 1-year history of jaw pain and hypoacusis, associated with progressive symptoms of dysphagia, facial paralysis, dysphonia and hoarseness. He also had a 2-month history of hypertension and palpitations. On physical examination, the patient had deficits in cranial nerves (CN) VII, VIII, IX, X, XI and XII and blood pressure of 150x90mmHg. Head and neck MRI showed an expansive lesion occupying the right jugular foramen extending above the cistern at the cerebellopontine angle and below the carotid space in the ipsilateral infratemporal fossa, reaching 50% of the internal carotid artery and extending into the right internal auditory canal, suggestive of glomus jugulare paraganglioma. Laboratory examination showed normetanephrines 9.1 mmol/L (VR < 0.9), confirming catecholamine-secreting paraganglioma. Next Generation Sequence (NGS) genetic testing evaluating 24 genes (ATM, DLST, EGLN1, EGLN2, FH, EPAS1 (HIF2A), HRAS, KIF1B , MAX, MDH2, MEN1 , MERTK , MET, NF1, RET, SLC25A11, SDHA, SDHAF2, SDHB, SDHC, SDHD, TMEM127, TP53 and VHL) was positive for the pathogenic variant c.166_170del:p.(Pro56Tyfs*5) of the SHDB gene. Patient with no family history of paraganglioma. Alpha-adrenergic blockade was started with doxazosin and, after two weeks, beta-adrenergic blockade with propranolol. After 3 months, he underwent preoperative embolization 48 hours before surgery with total tumor resection. Patient did not require antihypertensive drugs after surgery. CONCLUSIONS: We reported a case of a young patient diagnosed with catecholamine secreting HNPGL that carries pathogenic variant of SHDB. Presentation: Thursday, June 15, 2023

Abstract #1400148: Anterior Cervical Liposarcoma Masquerading as a Thyroid Nodule

Primary sarcomas of the head and neck account for < 1% of tumors in this anatomic region. We present a case of a large anterior neck mass initially thought to originate from the thyroid gland but diagnosed as a cervical liposarcoma closely adjacent to the thyroid. A 64-year-old woman was referred for a right anterior neck mass that she first noticed about 6 weeks prior to evaluation. The patient reported mild degrees of dysphagia and dyspnea. Examination was notable for a large, painless, right anterolateral neck mass that was mobile on deglutition. Serum TSH level was unremarkable. Neck ultrasound revealed a well circumscribed 6.0 x 3.7 x 5.4 cm isoechoic mass that appeared to largely replace the right thyroid lobe. Fine needle biopsy yielded a specimen composed only of peripheral blood elements. Computed tomography of the neck revealed a 9.1 x 6.2 x 6.0 cm hypodense (- 4 Hounsfield units) mass originating in the right carotid space and displacing the trachea, larynx, and esophagus to the left of midline, the right sternocleidomastoid muscle anteriorly, and the right carotid artery and jugular vein laterally. Cytology on a core biopsy was notable for a pleomorphic spindle cell neoplasm with lipoid differentiation and positive staining for CD34 and vimentin felt to be consistent with a liposarcoma. The mass was removed during a right modified radical neck dissection, and postsurgical histopathology revealed an encapsulated tumor with negative surgical margins and MDM2 amplification by fluorescent in situ hybridization (FISH), making the final diagnosis a well-differentiated liposarcoma. Neck masses adjacent to the thyroid may appear to arise from thyroid parenchyma. Several tumors, including paragangliomas, very large parathyroid tumors, lipomas, and a case of low-grade fibromyxoid sarcoma are reported as mimicking thyroid nodules on initial evaluation. There is limited literature on liposarcomas of the head and neck, with 30 patients seen at M.D. Anderson from 1945-2005 the largest published case series. Well-differentiated liposarcomas accounted for approximately 25% (7/30) of cases, and painless neck mass as in this case was the most common presenting symptom. No patients with well-differentiated extrathyroidal liposarcomas died of their tumors in the M.D. Anderson series, in contrast to a tumor-related mortality rate of approximately 30% in the rare (N=13) cases of liposarcoma arising from the thyroid. A PubMed search failed to reveal any cases of liposarcoma mimicking a thyroid nodule. This case illustrates that large anterior neck masses require careful imaging evaluation to confirm apparent origin from the thyroid gland.

CAROTID SPACE TUMOUR – SCHWANNOMA

The cervical schwannoma is very rare but benign mass lesion. It often results in nonspecic clinical presentations requiring surgical ablation. Surgical indications should be based carefully on the balance between risks and benets. Intracapsular enucleation seems to give good results without much complications and recurrence is rare. Reporting case of schwannoma which at rst stance seems to be having features of typical carotid body tumour but on histopathology it is seen as Schwann cell tumour arising in left carotid space

Transoral Approach to Parapharyngeal Space Tumours: Preliminary Reports from a Single-Centre Retrospective Analysis

The aim of this study is to identify certain parapharyngeal space tumours with specific characteristics that can be treated successfully through an endoscopically assisted transoral approach (EATA). Nine patients with PPS tumours underwent surgery through an EATA between 2003 and 2021. All patients underwent clinical examination and fibrolaryngoscopy. Preoperative CT and/or MRI was performed on all patients. All the patients were successfully treated through an endoscopically assisted transoral approach. Histological examination revealed five pleomorphic adenomas, two schwannomas, one ectopic thyroid gland and one lipoma. The only long-term sequelae observed was Horner syndrome in the two schwannomas arising from the carotid space. The mean hospitalisation time was 2.6 days, while the mean follow-up time was of 9.7 years. An endoscopically assisted transoral approach (EATA) is a valid technique for treating benign capsulated tumours of the true PPS and some benign capsulated tumours of the superomedial aspect of the carotid space.

A case report of a carotid space abscess due to extraluminal migration of a fishbone into the deep cervical space

Laryngopharyngeal foreign bodies are among the cases most frequently encountered by otolaryngologists. Most foreign bodies can be easily removed without any complications. However, surgical removal is required in some cases. Therefore, a delayed diagnosis or misdiagnosis could cause fatal complications for patients who need a surgical approach. We report a rare case of extraluminal migration of a foreign body to the deep cervical space. The foreign body (a fishbone) was removed by a surgical approach. With a literature review, we also propose an algorithm for the management of suspicious foreign bodies in the neck.

Imaging of the Infrahyoid Neck: Systematic Approach

In this presentation a systemic approach to infrahyoid neck imaging analysis is presented based on five individual spaces: the visceral, carotid, retropharyngeal, posterior cervical and perivertebral space. These spaces are defined by the three layers of the Deep Cervical Fascia (DCF). Each space has its own specific anatomical ‘contents’. Therefore, once a disease process is assigned to one space, it is usually possible to formulate a short differential diagnosis based on the anatomy present in that space.

Carotid space involvement is a prognostic factor and marker for induction chemotherapy in patients with nasopharyngeal carcinoma

ObjectivesThe carotid space is an integral part of the parapharyngeal space, with ambiguous prognostic value for patients with nasopharyngeal carcinoma (NPC). This study aimed to investigate the prognostic significance of carotid space involvement (CSI) and propose a treatment strategy. Materials and methodsThis retrospective study enrolled 792 patients with biopsy-confirmed, non-distant metastatic NPC staged by magnetic resonance imaging before treatment. We used multivariable Cox regression models and Kaplan–Meier methods to assess the association between the variables and survival outcomes. A matched-pair method (1:1) was used to compare the survival differences between the patients with CSI treated with induction chemotherapy (ICT)and that of those who were not. ResultsThe incidence rate of CSI was 21.7 % (172/792). Multivariate analysis revealed that CSI was not an independent prognostic factor for survival outcomes in the 792 patients with NPC; however, the Chi-square test showed a different distribution of treatment strategies with ICT for patients with and without CSI. After stratification by ICT, CSI was an independent prognostic factor for overall survival (OS) (p = 0.049) in patients without ICT, but not for distant metastasis-free, local recurrence-free, or progression-free survival (p˃0.05). Additionally, ICT improved OS in patients with CSI (hazard ratio, 0.42; p = 0.019). Matched pair analysis showed that patients with CSI gained prolonged OS from ICT compared with the non-ICT group (88.4 % vs 69.4 %, p = 0.028). ConclusionCSI was an independent negative prognostic factor for OS in patients with NPC without ICT and might be an imaging marker for identifying eligible candidates for ICT.

Accuracy of point‑of‑care ultrasonography in the diagnosis of necrotizing fasciitis: A case report

Necrotizing fasciitis is a serious infectious condition that may compromise the patient's life. In the present case study, a 42-year-old male patient was reported. The condition manifested as the presence of subjective fever, general malaise, myalgia, non-productive cough, dysphagia and neck pain ~1 week prior to hospital admission. Vascular dissection was considered as the initial diagnostic suspicion, and thus, angiotomography of neck vessels was performed, ruling out aortic and neck vessel dissection. Radiology indicated negativity for aortic syndrome and cervical vascular disease, but the presence of cervical-mediastinal edema, lamellar fluid between muscular and fatty planes and posterior pulmonary atelectasis, absence of pleural fluid or consolidations, and tonsillar hypertrophy without abscesses. Due to the rapid evolution of the condition, the presence of dyspnea with the need for supplemental oxygen, and the disproportion between the intensity of the pain described by the patient and the external findings observed, the presence of necrotizing fasciitis was considered. Point-of-care ultrasonography was performed, indicating a cobblestone pattern of the subcutaneous cellular tissue, with diffuse thickening of the anterior cervical fascia and increased echogenicity with soft tissue edema posterior to the fascia. Magnetic resonance imaging confirmed the inflammatory findings in the fascia and other cervical soft tissues, without exhibiting any signs of necrosis, but with the presence of abscesses in the visceral and carotid space.

Suprahyoid Neck: Anatomy and Principle of Pathology

The suprahyoid neck extends from the hyoid bone inferiorly to the skull base, excluding the orbit, sinonasal and oral cavity. The suprahyoid neck is anatomically complex but can be organized into different spaces based on the fascial planes. Multiple systems with slightly different namings are adapted. As a consensus, 5 principal spaces and 2 posterior midline spaces can be recognized. Each space contains unique contents which are subject to a predictable set of disease processes. Localization of lesions to a particular space allows the generation of a limited radiologic differential diagnosis. This is termed a “space-specific diagnosis”. The anatomy and related pathology of the pharyngeal mucosal, the parapharyngeal, the carotid space, the masticator space, the parotid space, the retropharyngeal space, and the perivertebral space will be discussed. After the presentation, participants will be able to comprehend the anatomy of the suprahyoid neck, understand the concept of a space- specific diagnosis and formulate a (differential) diagnosis when encountering pathology in the suprahyoid neck region.