Shamblin Classification Research Articles

Carotid Body Tumor Resection: Long-Term Outcome of 67 Cases without Preoperative Embolization

Carotid body tumors (CBTs) are rare tumors in the neck. Surgical resection is the gold standard of treatment. Surgical resection may be complicated by bleeding. Preoperative embolization has recently been introduced for the treatment to reduce the quantity of blood loss; however, the outcomes of this procedure are still under debate. In this article, we have presented the outcomes of patients who underwent surgical resection for CBT without undergoing preoperative embolization in our institution. This retrospective study reviewed 67 tumor resection cases who underwent surgical resection for CBTs without undergoing preoperative embolization. Tumor classification was performed as per the Shamblin classification. The demographic, clinical characteristics, and the operative information about the patients were retrieved from the patient records. The obtained data were analyzed with descriptive statistics. The study included 12 male and 55 female patients. The mean age was 51.95±16.59years. Of the surgically resected tumors; 11 (16.4%) were Shamblin type I, 30 (44.8%) were Shamblin type II, and 26 (38.8%) were Shamblin type III. The mean duration of operation was 109.10±32.36min. The volume of intraoperative blood loss in the Shamblin type I, type II, and type III groups were 98.64±23.46cc, 215.33±75.74cc, and 351.73±62.51cc, respectively, and they were significantly different among the groups (P<0.001). The volume of postoperative blood loss in the Shamblin type I, type II, and type III groups were 34.09±10.44cc, 53.00±20.02cc, and 62.50±25.11cc, respectively, and they were significantly different among the groups (P=0.003). Cranial nerve injury developed in 10 (15.0%) patients. Postoperative stroke developed in 2 (3%) patients. No mortality or persistent nerve injury was observed in association with the injury in the patients during the 1-year follow-up period. CBTs can be surgically resected safely and effectively without a need for preoperative embolization.

Distinct features of malignant carotid body tumors and surgical techniques for challengeable lesions: a case series of 11 patients.

Malignant carotid body tumor (CBT) is a rare disorder with poor prognosis. In this article, we presented the clinical features and surgical management of malignant CBTs at our department, aiming to improve the outcome for treating such lesions. A retrospective analysis (2005-2018) of CBT excisions at our institution was performed. About 195 patients with CBTs were identified, among which 11 patients with eleven malignant CBTs were identified and carefully reviewed. Data obtained included demographics, radiological details, intra-operative details, post-operative morbidity, and long-term outcomes. Compared with benign CBTs, malignant CBTs have more advanced Shamblin classification (p < 0.001) and larger tumor size (4.5 ± 2.1cm vs. 6.7 ± 2.6cm, p = 0.003). Among the 11 malignant cases, 9 patients underwent surgical resection and 8 cases (8/9, 89%) underwent internal carotid artery (ICA) reconstruction. Intra-operative findings showed that malignant CBTs revealed more severe arterial and nerve adhesions. With the use of specific techniques including pre-reconstruction technique and carotid shunt, all surgeries were successful and no deaths or major complications including stroke or hemiplegia occurred perioperatively and during the follow-up. During the follow-up period (41.6 ± 44.5months), two patients developed distant metastasis at 7 and 11 years post-operatively. The 5-year and 10-year distant metastasis-free survival rates were 72.7% and 36.4%, respectively. With more advanced Shamblin classification and larger tumor size, malignant CBTs remain challengeable for surgery due to severe intra-operative hemorrhage, need of vascular reconstruction and cervical nerve injury. Specific surgical techniques including pre-reconstruction technique and carotid shunt are safe and effective to improve the outcome.

Assessment of health-related quality of life in patients prior to carotid body tumor resection.

Background Carotid body tumors represent approximately 0.5% of the total head and neck tumors, and the most common presentation form is an asymptomatic cervical mass. Despite of being most of them asymptomatic the quality of life could be impacted; however, the literature remains silent about this matter. The Short Form 36 (SF-36) is a health-related quality of life (HRQoL) instrument that includes eight domains to assess physical and emotional function in different diseases. The aim of this study was to compare HRQoL in preoperative patients with carotid body tumor and a control paired group. The secondary objective was to compare HRQoL between carotid body tumor patients according to the volume tumor and Shamblin classification. Methods A cross-sectional study that included 23 patients diagnosed with carotid body tumor prior to resection and 23 control patients paired by age and gender was conducted from January 2017 to December 2018. The SF-36 questionnaire was applied in 46 patients. Three-dimensional volume reconstruction and estimation (3DVR) was obtained from a preoperative computed tomography angiography (CTA). Descriptive statistical analysis was performed for demographics and categorical variables were reported by frequencies and percentages. Continuous variables were summarized using median with interquartile ranges (IQR) with 95% confidence interval (CI) and were compared. Differences between medians were analyzed with the Mann–Whitney U test and all statistical tests were two-sided. Results In the carotid body tumor group, the mean age was 55 years, females were more frequently affected 19 (83%). Shamblin I was identified in 9% of patients, Shamblin II in 52% and Shamblin III in 39%. Carotid body tumor laterality were 57% right, 34% left and 9% bilateral tumors. The eight domains that comprise the SF-36 questionnaire were statistically significant when compared to the control group. Conclusion Significant differences were found in all SF-36 domains in carotid body tumor patients in comparison to control subjects, confirming that this neoplasm has negative impact in the general HRQoL.

Role of Preoperative Embolization in Surgical Treatment of the Carotid Body Paragangliomas.

In this study, we aimed to show the benefits of preoperative embolization on surgery of carotid body tumors.This is a retrospective study of the medical records of 20 patients who were operated for carotid body paragangliomas during 2011-2017. Computed tomography angiography (BTA) and/or magnetic resonance angiography (MRA) were performed for the entire patients. Patients were assessed according to the Shamblin classification. All patients were subjected to direct cerebral angiography by the femoral route 24 to 48 hours before the surgery and tumor embolization was performed in the appropriate cases (19 patients). The amount of hemorrhage and transfusion need during surgery has been reported. The ages of the patients ranged from 21 to 66, with an average of 45.65. In 20 patients ascendan pharyngeal artery was found as the main artery of tumor. No complications were seen after the embolization procedure. Tumor sizes ranged from 12 mm to 95 mm diameter (mean: 45, 5 mm). 10 patients (50%) were Shamblin type 1, 6 patients (30%) were Shamblin type 2, 4 patients (20%) were Shamblin type 3. In 5 patients (25%), the nerve (N. vagus or hypoglossus) was sacrificed due to cranial nerve involvement. Vagal and hypoglossal nerve sacrificed together in 4 patients.These patients' tumor sizes were bigger than 70 mm. Only in 1 patient, internal carotid artery injured and reconstructed with saphenous vein graft. Neurological deficit did not develop postoperatively. Bleeding was mean 275 mL (125 mL-700 mL). In conclusion, we believe that preoperative embolization of carotid paraganglioma is an effective procedure that helps surgeon during dissection with minimal blood loss. The embolization is relatively easy procedure without no additional complications.

Update in the classification and the role of intra‐arterial stenting in the management of carotid body paragangliomas

To review the Shamblin classification of carotid body paragangliomas (CBPs) and the role of intra-arterial stenting in their surgical management. Retrospective case series of 20 patients with 28 CBPs that were surgically resected at our center. Intra-arterial stenting was performed in Shamblin II and II classes. The mean follow-up was 47.8 months. Five (17.9%) tumors were Shamblin class I, 15 (53.6%) were class II, and 8 (28.6%) were class III. Thirteen (68.4%) CBPs were associated with other paragangliomas. The internal carotid artery (ICA) was stented preoperatively in eight (28.6%) cases and occluded in four (14.3%) cases. The tumor extended to the jugular foramen in six cases (21.4%). Intraoperatively, there was an ICA injury in one case of Shamblin II CBP in the present era. The proposed classification enables the clinician to plan the management of the ICA and the right approach. Stenting of the ICA gives a chance for complete tumor removal with arterial preservation.

Usefulness of preoperative three-dimensional volumetric analysis of carotid body tumors.

The Shamblin classification is the commonest method to predict complications and outcomes during carotid body tumor (CBT) resection. The aim of this study is to describe the utility of the three-dimensional volumetric reconstruction (3DVR) analysis of the CBT and its relationship with postoperative outcomes. Preoperative computed tomography angiography (CTA) was obtained to perform 3DVR of the CBT. Imaging data were analyzed and correlated with surgical outcomes: estimated blood loss (EBL), surgical time (ST), and hospital length of stay (HLOS). The Pearson test was used to determine the correlation between volume and postoperative outcomes. Fifty-seven patients were studied, 13 had Shamblin type I tumors with a mean 3DVR of 7.69cm3 (standard deviation [SD 8.27]), 21 were type II with a mean 3DVR of 15.57cm3 (SD 8.40), and 23 were type III with a mean 3DVR of 30.58cm3 (SD 20.16). EBL mean was 559milliliters (mL) (standard error [SE] 80.44), the mean ST of resection was 202min (SD 67), and the mean HLOS was 5.8days (SD 3.23). The Pearson test showed a correlation of r = 0.69 (p < 0.0001) between 3DVR and EBL, a r = 0.4 (p = 0.05) was obtained between 3DVR and ST, and finally, a r = 0.3 (p = 0.05) between 3DVR and HLOS was obtained. The preoperative 3DVR determination of CBTs allows to analyze possible predictors of surgical outcomes. We found a positive correlation between the 3DVR volume and EBL. Further research is necessary to validate this method in the evaluation of these rare neoplasms.

Cervical paragangliomas: experience of 114 cases in 14 years

Introduction and objectiveTo report a single center experience with carotid body paraganglioma cases that were treated by the same surgeon in a city with high prevalence of paragangliomas due to high altitude. MethodsWe retrospectively investigated the demographic, clinicopathological and radiological data of 104 patients diagnosed with cervical paragangliomas between 2003 and 2017. The patients were classified according to the Shamblin classification. ResultsIn this study a total of 104 patients (33 male and 71 female, with a mean age of 54.6±13 years) diagnosed with cervical paragangliomas located on carotid bifurcation between 2003 and 2017 were included. Among those patients, 10 presented with bilateral tumors and in total, 114 paragangliomas were managed in this period. The mean diameter of the tumors was 5.12±1.45cm. Malignant tumor was determined in only one (0.9%) patient. All patients were operated. In 12 patients with the tumor diameter larger than 5cm, preoperative coil embolization was achieved. In 14 patients, preoperative angiographic embolization was employed and in 4 patients intraoperative sclerosing agent injections were performed. Facial paralysis was observed in 2 patients and dysphagia was present in 1 patient, Horner syndrome was seen in 1 patient and hoarseness was reported in 7 patients after operation. All those complications improved during follow-up. Mortality was not reported in any cases. ConclusionSurgery is the definitive treatment for patients with cervical paragangliomas. Although, it may be difficult in patients with the advanced Shamblin types, in experienced hands, complication rates are very low.

Complications associated with carotid body tumor excision.

This study aims to evaluate associated complications of carotid tumor excisions and outcomes. Between January 2013 and April 2016, a total of 29 patients (2 males, 27 females; mean age 55.2±4.4 years; range, 17 to 76 years) were operated with the preliminary diagnosis of a carotid body tumor. According to the Shamblin classification of carotid body tumors, 12 patients were type 1, 13 patients were type 2, and four patients were type 3. Main symptoms were dizziness, pain in the neck area, tinnitus, and headache. Headache was the most common symptom among them. Neurological and surgical complications developed in 10 patients (34.4%). Of operated patients, dysphagia developed in three (8.7%), facial hemiparesis in two (6.8%), hemorrhage in two (6.8%), hematoma-related respiratory distress in one (3.4%), left hemiparesis in one (3.4%), and transient bradycardia in one (3.4%). The patient who had respiratory distress associated with bleeding following extubation was reoperated. In the patients with facial and left hemiparesis, paresis was transient. Dysphagia also resolved in the subsequent follow-up outpatient visits. None of the patients experienced a permanent complication. Surgical excision is the most appropriate choice of treatment in carotid body tumors, and postoperative complications can be minimized through careful dissections and retractions. A special attention should be paid to nerve-preserving surgery.

Carotid body tumors – diagnostis and treatment. Case report

Introduction: Glomus tumors are tumors of the paraganglia in the skull base and neck. These paraganglia are named according to their specific location – glomus caroticum, glomus jugular, tympanicum or vagal, thus the tumors are referred to as tumor of glomus caroticum of glomus jugular etc. Carotid body tumors are rare, benign neoplasms, originating from chemoreceptor cells located in the vessel adventitium of the carotid bifurcation. Considering the high risk during the surgical procedure, accurate preoperative diagnosis is of a great importance. Materials and Methods: We present a clinical case of a 54 y.o. patient Y. G. The patient is diagnosed with a glomus caroticum tumor in the left, found intraoperatively, followed by multidisciplinary treatment approach. Results: The patient Y. G. 54 y.o. is hospitalized in Ear, Nose and Throat department, St. George University Hospital – Plovdiv. With complaints as follows: painless swelling in the left region of the neck, with soft-elastic consistency. After a CT examination, the patient undergoes a surgical procedure, during which, together with a team of vascular surgeons, a glomus caroticus tumor is found. Tumor resection is not done. MRT-angiography is made and a decision for placing a coil implant is taken. After placing the coil implant in the region of the internal carotid artery, the patient is followed; for a period of 6 months the tumor is with reduced size, no postoperative complications are observed. Conclusion: Diagnostic and treatment a of carotid body tumors acquires multidisciplinary approach and assessment of the risks and benefits of surgical intervention. The use of Shamblin classification has its important clinical meaning regarding the decision for undeertaking surgical intervention. There are contradictory opinions regarding the embolization of glomus caroticus tumor, never the less in Shamblin III the risk of resectiong and reconstructing the carotid artery is much more considerable.

CAROTID BODY TUMOR MASQUERADING AS AN ISOLATED SUBMANDIBULAR LYMPH NODE- A CASE REPORT AND LITERATURE REVIEW

Carotid body tumors (CBT) are very rare tumors and CBT masquerading as a submandibular lymph node are even rarer. The authors report a case of a middle aged male who was referred to the Otolaryngology department for investigation of a suspected/ apparent left submandibular lymph node. It was slow growing in nature, painless and firm to the touch but was otherwise asymptomatic. Given this presentation and his history of smoking two (2) packs of cigarettes a day for fifty-three (53) years a malignancy of the head and neck area was suspected. A Fine Needle Aspiration Cytology (FNAC) was done at his first visit and this was negative for malignancy. A Computed Tomography (CT) scan of the neck revealed a mass within the carotid sheath with the characteristic Lyre sign: the splaying of the internal and external carotid arteries typical of a paraganglioma or chemodectoma. Based on the recommendations of Shamblin, this case was classified as a Shamblin I, i.e. a perfect candidate for surgical resection. After adequate preparation, informed consent and further imaging, the tumor was resected an uneventful recovery was to be in keeping with the dictum of the Shamblin classification. The histology was reported as a Paraganglioma with no atypical features. We think this is the first reported case of CBT from the Caribbean countries.

Surgical management of carotid body tumor - Is Shamblin classification sufficient to predict surgical outcome?

Background The study aims to conduct a review of the surgical management of carotid body tumor. Methods Consecutive patients with CBT who received surgical interventions from January 1994 to January 2014 at our institution were reviewed. Clinical, operative, pathological and follow up information were reported. Results Twenty patients (four males; median age was 36) with 21 CBT operations were recorded during the period. One patient undertook sequential operations for bilateral CBTs. Patients had 19 neck mass, 1 incidental finding and 1 facial nerve palsy. Six CBTs (28.6%) were Shamblin class I, ten (47.6%) were class II and five (23.8%) were class III. Nine CBTs had preoperative conjunctive embolization. Two operations required internal carotid artery resection and reconstruction. Four patients received subtotal resections, while 17 achieved complete resection. Complications included two major strokes, three hoarse voice and two Horner's syndrome. Shamblin class was significant predictor of operative time, blood loss, and whether complete resection accomplished, but could not predict postoperative complication. With median follow up period of 94 months, there was no tumor recurrence found in those had complete resection. Conclusions This small cohort showed that Shamblin class was significant in predicting technical difficulties but could not predict occurrence of complications.

Neurovascular complications following carotid body paraganglioma resection

ObjectiveThe present consecutive case series reports our experience in the management of carotid body paraganglioma and aims to assess whether the Shamblin classification or tumor size are predictive of early and late postoperative neurovascular complications. Material and methodsA retrospective study included 54 carotid body tumor resections in 49 patients, between 1980 and 2011. Data comprised early (<1month) and late (18 months) postoperative neurovascular complications. ResultsEarly postoperative complications occurred in 31 cases, including 30 cases of cranial nerve deficit (56%). Cranial nerve deficit occurred in 83% of Shamblin III carotid body paragangliomas and was associated with significantly larger mean tumor size (4±1.4cm versus 2.9±1.3cm; P<0.01). Shamblin III tumor and tumor size>3.2cm emerged as predictive factors for early postoperative peripheral neurological complications. Eight patients (17%) showed no cranial nerve deficit recovery, even after 18 months’ follow-up; no predictive factors could be identified for this. ConclusionSurgical resection remains the only curative treatment in carotid body paraganglioma, with low vascular morbidity. However, early postoperative nerve deficit remains frequent (56%), although mostly temporary, with 17% definitive sequelae at 18 months. Tumor size and Shamblin classification are predictive of early neurovascular complications.

Carotid Body Tumors: Surgical Management and Review of Patients Over 10 Years

Background: Carotid body tumours (CBTs) are rare but highly vascular neoplasms originating in the paraganglionic cells of the carotid bifurcation. Exact etiology of these tumors is not known. Male and female distributions are equal except at high altitude where females appear to predominate. Diagnosis of a chemodectoma usually begins with a color flow duplex scan. Magnetic resonance angiography are also useful, especially to evaluate bilateral disease. Conventional Arteriography with CT Angiography are valuable, especially in larger tumours, and are regarded as the best tools for diagnosis. The treatment of choice for carotid body tumours is surgical removal. Shamblin's classification system is used to categorize carotid body tumours based on their size and the difficulty of surgical resection. Results: It was observed that majority of the patients in this study were females numbering 35(79.45%) whereas there were 9 (20.43%) males. commonest age group involved was of patients 50 to 59 years of age. Surgery was done in all 44 (100%) patients with complete resection in 41 (93.07%) and incomplete in 3 (6.81%) patients. 10 (23%) were Shamblin grade 1, 29 (66%) grade 2 and 5 (11%) grade 3. ECA repair was done in 4 (9.08%) of patients, ICA repair in 2 (4.54%), ECA ligation in 2 (4.54%) and vascular graft was used in 1 (2.27%) of patients. 7 (15.89%) had transient cranial nerve palsy most commonly involving hypoglossal nerve. 3 (6.81%) had permanent cranial nerve palsy. In 6 (13.62%) patients there was local wound infection .There was post op stroke in 2 (4.54%) of patients. No operative mortality was seen.43 (97.61%) patients were proved to be paraganglionomas on HPE while 1 (2.27%) patients had inconclusive biopsy on Histopathological examination. Conclusion: Although rare, Carotid body tumor is still a pathology that we encounter in our experience and it should be kept in mind as a differential diagnosis for painless lateral neck masses.

Anesthetic approaches in carotid body tumor surgery.

OBJECTIVE:Carotid body tumors (CBT) are benign tumors that originate from neural non-chromaffin cells that are typically localized near carotid bifurcation. Surgical removal of the tumor is the most appropriate treatment. General anesthesia is preferred anesthetic technique for CBT surgery. Basic elements of anesthetic management are protection of hemodynamic stability and maintaining cerebral perfusion pressure (CPP). The aim of this study was to evaluate anesthetic management of CBT surgery and present the literature knowledge.METHODS:The study included 10 consecutive patients with diagnosis of CBT who underwent surgery at Antalya Training and Research Hospital, in Antalya, Turkey, between 2013 and 2016. Preoperative demographic details; comorbidities; side of surgical site; duration of operation; length of intensive care unit (ICU) and hospital stay; change of intraoperative blood pressure; use of inotropic drugs, blood products, and analgesics; postoperative visual analogue scale (VAS) pain score; and complications were recorded.RESULTS:According to Shamblin classification, 3 tumors were type I and the remaining 7 were type II. Tumors were located on right side in 6 patients, and on left in 4. Blood loss sufficient to require transfusion was observed in 1 patient. Average intraoperative blood loss was 287±68 mL. Tachycardia and hypertension were observed in 1 patient; bradycardia and hypotension were seen in 4 patients. Infusion for inotropic support was administered to 1 patient. Mean duration of operation was 109±20 minutes. Mean VAS score was 4±1, mean ICU tramadol consumption was 80±25 mg. Duration of stay in ICU and hospital were 2.4±1.1 hours and 3.8±0.7 days, respectively. Mortality and neurological complications were not seen in postoperative period.CONCLUSION:CBT surgery requires close and complex anesthesia management. Protection of hemodynamic stability against sudden hemodynamic changes, monitoring, and maintaining CPP are the most important aspects of anesthetic management.

Carotid Body Tumor: Clinical Features.

Although carotid body tumor (CBT) is a rare neoplasm, it should always be considered in differential diagnosis of lateral neck masses. We shared the 10 years of CBT experience in our clinic and started a discussion on CBT with literature support. A total of 21 patients with CBT diagnosis in Fırat University Hospital, Otorhinolaryngology Clinic, participated in the study. Patients were evaluated based on demographical data and particularities of the tumor. Participant patients were 19 women and 2 men, and their ages were between 21 and 79 (mean age 54.06 ± 12.48). The most frequent reason for the patients to apply to the hospital was painless swelling in the neck (76.2%). Tumor was located in the right side of the neck in 10 patients (47.6%), and in the left side of the neck in 11 (52.4%). Twenty patients (95.2%) had undergone computerized tomography angiography. Surgical treatment was applied to 19 patients (90.5%) and the tumor was totally excised. According to Shamblin classification, 15 of the tumors of these patients were class II (78.9%) and 4 were class III (21.1%). In 1 patient (5.3%), postoperative contusion infection that recovered after medical treatment was observed; in 2 patients (10.5%), n. vagus injury was observed because of tumor's pervasion of n. vagus; and in 1 of these patients vocal cord paralysis was developed and this patient was later taken into thyroplasty surgery. Two patients (10.5%) suffered n. hypoglossus injury, 1 of these recovered within 3 months postoperative and the other developed n. hypoglossus palsy. The size and extension of the tumor should be determined by preoperative imaging for the correct planning of surgical procedure. It should be taken into consideration that despite advanced surgical techniques, the rate of postoperative cranial nerve damage is still high.

Comparison of retrocarotid and caudocranial dissection techniques for the surgical treatment of carotid body tumors

Carotid body tumors (CBTs) are rare neoplasms. Complete surgical resection is the curative therapy and is considered the therapeutic gold standard. This study compared the retrocarotid dissection (RCD) technique with the standard caudocranial dissection (SCCD) technique in operative time, blood loss, vascular or nerve injuries, and hospital stay. A retrospective review was conducted of patients with CBTs who underwent surgical treatment with the RCD technique at the National Institute of Medical Sciences and Nutrition "Salvador Zubirán" in Mexico City from July 2007 to January 2013. This cohort was compared with an historical cohort treated with standard SCCD from 1995 to 2007 at the same institution. A total of 68 procedures (41 SCCD, 27 RCD) were performed in 68 patients (91% women) with a mean age of 54 years (standard deviation [SD], 15 years). According to the Shamblin classification, 6 CBTs were type I (9%), 35 were type II (51%), and 27 were type III (40%). Comparative analysis identified mean blood loss of 480 mL (SD, 380 mL) in the RCD group and 690 mL (SD, 680 mL) for the SCCD cohort (P < .31). The mean procedural time was 172 minutes (SD, 60 minutes) for the RCD group and 260 minutes (SD, 100 minutes) for the SCCD group (P < .001). Hospital stay was significantly shorter for the RCD group with an average of 5 days (SD, 2 days) compared with 9 days (SD, 6 days) for the SCCD cohort (P < .0001). Cranial nerve deficit occurred in 17 patients, consisting of six transient nerve palsies in the RCD cohort and 11 in the SCCD group. Postoperative cerebrovascular accidents occurred in three patients in the SCCD cohort, with none observed in the RCD group. This translates into a rate of 22% of postoperative neurologic complications for the RCD cohort and 34% in the SCCD group (P < .08). Significant differences in intraoperative vascular injuries were not observed. The RCD technique is a safe and viable option for the surgical resection of CBTs. In our experience, this approach was associated with a significant decrease in procedural time and hospital stay.

Renal Function Changes Following Fenestrated EVAR

Conclusions: This large study of CBTs demonstrates the importance of determining the CBT’s distance to the BOS as well as the Shamblin classification. Shamblin classification predicts the need for vascular reconstruction and the risk of bleeding and temporary nerve injury, and distance to BOS predicts bleeding risk and permanent nerve injury. Preoperative EMB is more often performed for CBTs located higher in the neck but may not reduce bleeding in CBTs that are located lower in the neck. Distance to BOS should be calculated in all patients with CBTs to provide precise preoperative counseling of risks.

Mid and Long Term Results of Carotid Body Tumors Radioguided Surgical Resection

Aim: We present our experience about surgical resection of Carotid body tumor (CBT) and to define the role of colour coded ultrasound (CCU) and of somatostatin receptor scintigraphy (SRS) with Indium-111-DTPA-pentreotide (Octreoscan) using both planar and single photon emission tomography (SPECT) technique. Methods: Twenty-three patients suffering from 27 CBTs were treated from 1997 to 2014. Preoperative investigations included CCU and SRS-SPECT. All tumours were grouped according to Shamblin's classification. Intraoperative radiocaptation by Octreoscan was also carried out in all cases to evaluate the radicality of surgery. Results: Preoperatively CCU showed CBTs with sensitivity 100%. Radioisotope imaging identified the CBTs as carotid body tumors in 25 cases while no radio isotopic uptake was detected in 2 cervical vagal schwannoma. Combined data from CCU and SPECT allowed determining tumour size in order to select 12 larger tumours. Intraoperative Octreoscan demonstrated microscopic tumour leftovers promptly removed in 2 cases and an unrespectable remnant at the base of skull in another case. During follow-up (6 months-10 years, mean 3.9 years) CCU and radioisotope scans showed no recurrence in 25 cases, a slightly enlargement of that intracranial residual as detected during surgery in 1 patients and a little recurrence in another one case. Conclusion: CCU may allow an early and noninvasive detection of CBTs and hence safer operations. The combined use of CCU and SPECT provide useful data to identify that tumour and to evaluate their extent and carotid arteries infiltration. Radioisotope imaging is a sensitive modality to detect metastases and lymph node involvement that are markers of CBT malignancy. Mid and long terms results in terms of recurrence and carotid repairs patency seems very encouraging with this approach. After surgery CCU and SPECT seem to be accurate modalities for surveillance for an early detection of CBTs recurrence.

Carotid Body Tumour: The Second Case Series from Baghdad, Iraq

Background: Carotid body tumour (CBT) is a rare neoplasm, yet it is the commonest head and neck paraganglioma. In Iraq, relevant literature is sparse. Herein, we present our second case series. Methodology: Patients with CBTs that were operated upon in the Department of Thoracic and Vascular Surgery, Baghdad Medical City from 2010 to 2014 were enrolled. History and examination were followed by a workup of duplex ultrasonography, CT scan, magnetic resonance imaging, CT or conventional carotid angiography. Surgical exploration via a standard anterolateral cervical incision and subadventitial dissection was used to resect the tumours with preservation of carotid arteries. Intra-luminal carotid shunts and vein grafts were prepared to be used if necessary. Results: There were 5 males and 2 females aging 17 - 46 with a mean of 32.9 ± 9.8 year. All patients had slowly growing painless pulsatile swelling below mandiblular angle for long durations (1 - 25 years) and a positive Fontaine’s sign. All tumours were benign, unilateral (right n = 4, left n = 3) and ranging in size from 3 × 3 cm to 6.4 × 3.2 cm. Beside US neck exam, carotid angiography was done in 5 patients. According to Shamblin classification, 4 were class II, 2 class I and 1 class III. All tumours were successfully resected with preservation of ICA. However, the ECA was safely ligated twice due to severe involvement. Tongue deviation occurred once (14.3%) but no patient died and none had stroke or recurrence. Conclusions: Our results of surgery for CBT compare very well with the international standards.

Paradigm Shift of Carotid Body Paraganglioma Surgical Technique from Caudocranial to Craniocaudal Dissection: Analysis of Recent Literature

ABSTRACT Background The classical Shamblin's classification predicts only vascular morbidity without remarking on the neurological morbidity, while the neurological damage increase with vessel ligation and reconstruction. A modified Shamblin's classification described by Luna-ortiz with incorporation of the Hallett's zones of injury has been studied here. Materials and methods We present a case series analysis of carotid body paraganglioma managed in our institute. The study included 17 patients, 14 females and three males with a mean duration of presentation of 6.82 months. All were imaged with multislicer computed tomography angiography (CTA) and magnetic resonance angiography (MRA) for preoperative assessment and operated in the craniocaudal technique. The tumors were graded according to the modified Shamblin's criteria: grades I (2), II (13), IIIa (2), IIIb (0). Results All the preoperative assessment of grading matched with the intraoperative findings. External carotid artery (ECA) ligation was done in two cases, no internal carotid artery (ICA) ligation and reconstruction were done. Two cases of permanent damage to the 12th nerve, two vagal nerve weakness was seen. No stroke or mortality recorded. The tumor was confirmed on immunohistochemistry. The patients were followed up for 6 months to 5 years with a mean follow-up of 2.5 years. Conclusion Preoperative imaging assessment using multislicer computed tomography angiography (MSCTA) and MRA helps to measuring the circumferential vessel involvement in grade III tumors. So, a craniocaudal dissection with assessment of all the zones of injury reduced blood loss and minimized neurovascular complications. How to cite this article Halkud R, Shenoy AM, Nanjundappa A, Chavan P, Sidappa KT, Madhu SD, Biswas S, Naik SM. Paradigm Shift of Carotid Body Paraganglioma Surgical Technique from Caudocranial to Craniocaudal Dissection: Analysis of Recent Literature. Int J Head Neck Surg 2014;5(3):119-125.