Left Carotid Sheath Research Articles

Cervical schwannoma: diagnosis and treatment

Schwannomas are benign, encapsulated, slow-growing, tumours deriving from the peri neural cells located in the nerve sheath. They can arise from any cranial, peripheral or autonomic nerves, and show a predilection for the head and neck region. They may produce secondary symptoms like nasal obstruction, dysphagia, and hoarseness of voice depending upon the location of the tumour. Preoperative diagnosis is difficult, relying on clinical suspicion, and confirmed by surgical pathology. Preoperative imaging or fine needle aspiration cytology may help to reveal diagnosis. The definitive diagnosis is made by histopathological examinations. A 28 years old female patient presented to the OPD with painless swelling on the left lateral side of the neck since 1 year. The swelling was mobile, non-tender, non-pulsatile firm in consistency measuring 4×3 cm with no bruit. MRI neck with contrast was done which revealed a moderately enhancing lesion of size 7×4×3 cm in the left carotid sheath. The tumour was approached by an anterior approach along the medial border of the sternocleidomastoid. Platysma and fascia were dissected followed by carotid sheath to reach the tumour. As the mass was seen arising from a branch of the ansa cervicalis, it had to be sacrificed.

Intraoperative video captured with Stryker SPY-PHI system in white light, green overlay, and greyscale fluorescence modes. Procedure performed: resection of parathyroid adenoma from left carotid sheath.

Intraoperative video captured with Stryker SPY-PHI system in white light, green overlay, and greyscale fluorescence modes. Procedure performed: resection of parathyroid adenoma from left carotid sheath.

Supernumerary ectopic parathyroid located in the left carotid sheath

Supernumerary ectopic parathyroid located in the left carotid sheath

A rare case of bilateral cervical vagal neurofibromas: role of high-resolution ultrasound

BackgroundNeurofibromas originating from vagus nerves are rarely reported in the literature. In particular, plexiform neurofibromas of the bilateral cervical vagus nerve are extremely rare.Case presentationA 21-year-old female presented with a 2-year history of swelling on the right side of her neck. Physical examination revealed a soft-tissue mass on the right side of her neck. Ultrasonography (US) and magnetic resonance (MR) imaging showed a tumor centered in the right carotid sheath between the internal jugular vein and the common carotid artery. In addition, a similar nodular mass in the left carotid sheath was detected on US. The right mass was surgically resected; histopathological examination revealed a neurofibroma.ConclusionsUS can be a valuable method for preoperative evaluation of cervical mass, as it is capable of displaying the vagus nerve and provides sufficient diagnostic information. The cervical vagal neurofibroma can manifest as solitary or multifocal lesion. Bilateral neurofibromas are usually associated with neurofibromatosis type 1 (NF1). Early diagnosis and prompt surgical treatment should be considered.

A Case of Idiopathic Carotidynia Diagnosed by Non-contrast CT

Idiopathic carotidynia is a rare disease of unknown origin characterized by unilateral cervical pain of carotid-sheath origin and soft-tissue infiltration surrounding the carotid sheath on imaging examination. Herein, we report the case of a 65-year-old male who presented with the chief complaint of left cervical pain. Otorhinolaryngological examination showed mild swelling and tenderness of the left carotid sheath. A plain CT showed soft-tissue infiltration surrounding the left carotid sheath at the level of the left hyoid bone. Laboratory test results were normal. These clinical manifestations and the findings of CT were consistent with a diagnosis of idiopathic carotidynia. The above symptoms were relieved by one-day treatment with an anti-inflammatory drug. Although soft-tissue infiltration of the carotid sheath of in cases of carotidynia on contrast-enhanced CT has been described in previous reports, it was observed on plain, non-contrast CT images in this patient, which allowed avoidance of any anxiety from the point of view of potential contrast medium allergy in our case. From the reports in the literature and data from our own case, we propose a revised classification of carotidynia, dividing it into five categories (i.e. idiopathic, migrainous, arteriosclerotic, drug-induced, and others).

Carotid sheath abscess caused by a tooth decay infection on the opposite side.

Deep neck infections are mortal diseases that need emergency treatment. It can occur at any age but usually in pediatric ages. In this report, a left cervical carotid space abscess of a pediatric patient was discussed. It was interesting that the only origin of the left carotid sheath abscess was right inferior first molar tooth decay. Right neck spaces were all clean. Patient had no immunosupression and also there were no congenital masses such as branchial cleft cysts, foreign bodies, or masses suspicious for malignancies in cervical ultrasound and MRI. We discussed this rare condition under the light of the literature.

Vagal nerve stimulator infection: a lead-salvage protocol

Vagal nerve stimulator (VNS) hardware infections are fraught with difficult management decisions. As with most implanted medical device-related infections, standard practice traditionally involves complete hardware removal, systemic antibiotic therapy, and subsequent reimplantation of the device. To avoid the potential morbidity of 2 repeat left carotid sheath surgical dissections, the authors have implemented a clinical protocol for managing VNS infections that involves generator removal and antibiotic therapy without lead removal. A prospective, single-surgeon database was compared with hospital billing records to identify patients who underwent primary implantation or reimplantation of a VNS lead, generator, or both, from January 2001 to May 2010, at Oregon Health & Science University. From these records, the authors identified patients with VNS hardware infections and characterized their management, using a lead salvage protocol. In their review, the authors found a matching cohort of 206 children (age 3 months-17 years) who met the inclusion criteria. These children underwent 258 operations (including, in some children, multiple operations for generator end of life and/or lead malfunction). Six children experienced a single postimplantation infection (2.3% of the 258 operative cases), and no child experienced repeated infection. A lead-salvage protocol was used in 4 of 6 infected patients and was successful in 3 (75%), with clinical follow-up ranging from 10 months to 7.5 years. The fourth patient subsequently underwent lead removal and later reimplantation in standard fashion, with no adverse sequelae. Vagal nerve stimulator lead salvage is a safe and potentially advantageous strategy in the management of VNS-related infection. Further study is necessary to validate appropriate patient selection, success rates, and risks of this approach.

Langerhans Cell Histiocytosis of the Thyroid is a Rare Entity, but an Association with a Papillary Thyroid Carcinoma is Often Described

Comments on “Langerhans cell histiocytosis of the lung and thyroid, co-existing with papillary thyroid cancer” Jamaati HR, Shadmehr MB, Saidi B, Khosravi A, Arab M, Mohammadi F. Endocr Pathol 20:133–136, 2009 and “Incidental langerhans cell histiocytosis of thyroid: case report and review of the literature” Foulet-Roge A, Josselin N, Guyetant S, Gardet JJ, Besancon A, Saint-Andre JP, Fabiani B. Endocr Pathol 13:227–233, 2002. We read with great interest the contributions of Jamaati et al. and Foulet-Roge et al. respectively entitled “Langerhans cell histiocytosis of the lung and thyroid, co-existing with papillary thyroid cancer” and “Incidental langerhans cell histiocytosis of thyroid: case report and review of the literature” [1, 2]. We have had a similar case of coexistent thyroid Langerhans cell histiocytosis (LCH) and papillary thyroid carcinoma (PTC). A 29-year-old male patient presented with a huge neck mass, immobile, and compressive, involving the trachea, the pharynx, the left jugular vein and the left carotid sheath. Bone (mandible), lung, skin and hypothalamo-pituitary LCH lesions had been documented for 6 years, and clinical stability had been obtained with corticosteroids. The transpharyngeal biopsies performed during a panendoscopy revealed a PTC with positive immunostaining for TTF1, HBME1 and CK19. Associated LCH involvement was diagnosed by the presence of Langerhans cells reactive to CD1a and S100 protein (Fig. 1). The cytological examination of a blind transcutaneous thyroid fine needle aspiration biopsy and other surgical biopsies isolated only the LCH section and a lymphocytic thyroiditis. A surgical resection of this advanced disease could not be considered and a multidisciplinary panel proposed a medical treatment (Prednisone 40 mg/day). Given that there was no response 6 months later, chemotherapy with Vinblastine (Velbe® 6 mg/m every 2 weeks) produced a stabilization over 14 months. Then, due to a severe increase in size and the extension from the oropharynx to the mediastinum in a vertical axis and from the cervical rachis to the subcutaneous tissues in a horizontal axis, a treatment with Cladribine was initiated (Leustatin® 0.1 mg/kg/day over 5 days every 2 months). After 7 months without a response, the treatment was stopped and changed to Imatinib (Gleevec® 100 mg/day for 1 month and then 400 mg/day). Three months after the beginning of this targeted therapy and 3 years after the appearance of the cervical mass, a dramatic dyspnea caused by the compression and the infiltration of the trachea occurred. A tracheostomy under local anaesthesia was carried out in difficult technical conditions. Despite this attempt, acute pulmonary distress resulted in the death of the patient. The family refused an autopsy. S. Vergez (*) Department of Head and Neck Surgery, University-Hospital Rangueil-Larrey, 24 chemin de Pouvourville, 31059 Toulouse Cedex 9, France e-mail: vergez.s@chu-toulouse.fr

Crossbow injury in a developed country

Crossbow injuries are not common in developed countries such as Australia and New Zealand. Despite this, there have been a number of crossbow injuries in New Zealand mainly related to hunting exercises. When such incidents occur, it is important for the surgeons involved in the emergency care of the patient to have some background in the management of these injuries. A 24-year-oldmanpresented to the emergency department (ED) with a crossbow bolt penetrating his left supraclavicular fossa. A broad head arrow was accidentally fired with a high powered crossbow during a hunting exercise and travelled approximately 30 m before striking the jaw (resulting in a superficial laceration) and the left supraclavicular fossa (Fig. 1a). Theaccident occurred in a rugged terrain resulting in 4-h delay in transfer to ED. Vital signs on arrival were: pulse 88 beats/min, systolic blood pressure 140mmHg (after 1 l of normal saline), oxygen saturation 100% (trauma mask) and respiratory rate 32 breaths/min. Chest X-ray (CXR) showeda left haemothoraxwith the arrow traversing through the left supraclavicular fossa into the thoracic cavity (Fig. 1b). Insertionofan intercostal chestdrain immediatelydrained600 mlof bloodwith resolution of the haemothorax on repeat CXR. Therewas minimal chest drain output with no air leak and the patient remained haemodynamically stable. He was then transferred for a computerised tomography (CT) scan. The shaft of the bolt had to be carefully shortened in order for the patient to fit into the scanner. The CT scan (Fig. 2) showed that the bolt lodged posterior to the left carotid sheath, trackingmedially across the left first intercostal space, directing downwards and posterior across the vertebral processes with its tip at the right erector spinae muscle. There was no obvious vital vascular injury or residual pneumothorax. In the operating theatre, an incision was made in the back where the tip of the bolt was expected to be located based on the CT scan and approximation by gentle manipulation of the bolt (Fig. 3). After the identification of the tip, the bolt was carefully advanced forward

Carotid sheath meningioma: Case presentation

Meningiomas are common intracranial tumours that can extend extracranially. Primary extracranial meningioma, however is a rare condition occuring about less than 1% of all meningiomas. We present a rare case of primary extracranial meningioma occuring in the left carotid sheath that was initially diagnosed as schwannoma. The case highlights the use of MR spectroscopy in the evaluation of extracranial meningioma.

Jugular foramen fibromatosis in a 3-month-old male

A 3-month-old male with a chief complaint of episodic choking with feeds and a hoarse cry is presented. Left eye ptosis and asymmetric soft palate elevation were detected on physical examination. Fiberoptic examination showed a left vocal fold paresis and pooling of secretions in the pyriform sinuses. MRI demonstrated an ill-defined lesion at the left jugular foramen extending into the left carotid sheath. A fine needle biopsy revealed spindle shaped cells consistent with fibromatosis. The histopathology of fibromatosis and the differential diagnosis of jugular foramen masses in children will be described. To our knowledge, this represents the earliest reported case of fibromatosis in the jugular foramen.

Twice-Recurrent Primary Hyperparathyroidism Due to Parathyroid Hyperplasia in an Ectopic Supernumerary Gland

To describe a patient with multiple recurrences of primary hyperparathyroidism during a 24-year period. We present the long-term history, including clinical and laboratory evaluations as well as findings on surgical interventions, in a 42-year-old man with recurrent hyperparathyroidism. In addition, the relevant literature is briefly reviewed. At initial surgical exploration when the patient was 18 years old, a single enlarged parathyroid gland and a normal-appearing ipsilateral gland were found. After more than a decade without symptoms, the patient experienced recurrent symptomatic hypercalcemia. Surgical exploration revealed symmetric multiglandular disease that was treated by resection of 3 enlarged parathyroid glands and implantation of a portion of 1 gland in the forearm. After another 6-year asymptomatic period, the patient had recurrent symptoms and was found to have recurrent hypercalcemia. Surgical intervention revealed an enlarged supernumerary gland in an ectopic location. A preoperative technetium Tc 99m sestamibi scan and intravenous administration of methylene blue were helpful in identifying the ectopic parathyroid gland in the left carotid sheath. This case illustrates the difficulty of determining which of a patient's parathyroid glands may become hyperfunctioning and the importance of considering whether supernumerary glands may be present. The case also demonstrates the need for long-term follow-up before a patient is considered "cured" of hyperparathyroidism.

Localisation atypique d’un adénome parathyroïdien: la gaine carotidienne

We report the imaging features of an occult parathyroid adenoma with unusual location in the carotid sheath. Our patient presented with primary hyperparathyroidism. Following negative neck ultrasound and scintigraphy, exploratory neck dissection with partial thyroidectomy was performed twice over a 2 day period without biological response. Cervical and mediastinal CT and MRI were performed with no result. Digital angiography showed a tumoral blush supplied by the left inferior thyroid artery and located in close contact with the carotid artery. Venous sampling of the neck confirmed the left location of the adenoma and a third surgical intervention found the adenoma embedded in the left carotid sheath. This is an unusual case of parathyroid adenoma that necessitated the use of several imaging techniques.

Supernumerary intravagal parathyroid hyperplasia

Surgery 2002;131:359-61.

Radiographic assessment of the infiltrating retropharyngeal lipoma

658 Neoplasms of the retropharyngeal space (RPS) are uncommon tumors that frequently remain asymptomatic until they reach a critical size that induces a mass effect on surrounding structures. Consequently, these neoplasms often remain undiagnosed until they are quite large, resulting in dysphagia or airway obstruction. The retropharyngeal lipoma is an extremely rare neoplasm. Although 31 cases of retropharyngeal lipoma have been described in the literature since the late 1800s, only 1 case of an infiltrating retropharyngeal lipoma has previously been documented.1 Because the recurrence rate of the infiltrating lipoma has been reported to be as high as 62.5%, preoperative determination of infiltration would allow the surgeon to widely resect the neoplasm in order to minimize the chance for recurrence.2 We present a patient in which preoperative diagnostic imaging was predictive of an infiltrating retropharyngeal lipoma and detail the patient’s management and follow-up. CASE REPORT A 49-year-old African American female presented to the Medical College of Ohio with a history of progressive dysphagia, increased upper airway resistance, loud snoring, and frequent nighttime awakening, as well as daytime somnolence. The patient had undergone polysomnography that demonstrated an apnea-hypopnea index of 14 events per hour of sleep, consistent with mild obstructive sleep apnea. On physical examination, the patient demonstrated no evidence of airway restriction or alteration in vocal quality. Inspection of the oropharynx demonstrated a submucosal prominence of the posterior pharyngeal wall that on palpation was homogeneous and doughy. The overlying mucosa was normal. Laryngoscopy documented the posterior pharyngeal prominence with extension caudally behind the larynx, compressing the laryngeal inlet anteroposteriorly. The larynx and hypopharyngeal region were otherwise normal and no masses were appreciated on palpation of the neck. A CT scan was performed on the basis of the patient’s examination findings that demonstrated a radiolucent mass involving the retropharyngeal space that compressed and displaced the larynx, trachea, and esophagus anteriorly and the left carotid sheath laterally (Fig 1A). There was also radiographically evident destruction of the prevertebral musculature posteriorly and the irregular interface between the mass and the prevertebral muscles suggested infiltration of the mass into the prevertebral musculature. To better define the radiographic extent and quality of