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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 2  |  Page : 32-34

An aneurysm-like entity inside a giant carotid body tumor reaching lateral skull base


1 Department of Vascular Surgery, Peking Union Medical College Hospital; School of Medicine, Tsinghua University, Beijing, China
2 Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China

Date of Submission11-Jul-2019
Date of Decision31-Aug-2019
Date of Acceptance02-Sep-2019
Date of Web Publication27-Nov-2019

Correspondence Address:
Yuehong Zheng
Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan #1, Dongcheng, Beijing 100730
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_10_19

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  Abstract 


The successful resection of giant carotid body tumors (CBTs) with full protection of cranial nerve is challenging. Meanwhile, entities with fresh blood inside a CBT were commonly considered liquefactive necrosis preoperatively. However, we reported a case with an aneurysm-like entity inside the CBT instead. A patient with lump on the right neck complained of feeling dizzy. She was then reported with a giant CBT reaching lateral skull base. Preoperative imaging revealed a low-density entity inside the tumor, which was considered as liquefaction necrosis. However, during surgery, the low-density area was observed pulsing with fresh blood. Under the collaboration of vascular surgeons and otolaryngologists, the tumor was resected uneventfully. We reported a case of giant CBT over 10 cm and successful resection with no major facial nerve deficit. Moreover, an aneurysm-like entity inside the tumor was observed during the surgery, which was not reported before.

Keywords: Aneurysm-like entity, carotid body tumor, internal carotid artery, lateral skull base


How to cite this article:
Zhang H, Li F, Zheng Y. An aneurysm-like entity inside a giant carotid body tumor reaching lateral skull base. Transl Surg 2019;4:32-4

How to cite this URL:
Zhang H, Li F, Zheng Y. An aneurysm-like entity inside a giant carotid body tumor reaching lateral skull base. Transl Surg [serial online] 2019 [cited 2019 Dec 10];4:32-4. Available from: http://www.translsurg.com/text.asp?2019/4/2/32/271819




  Introduction Top


Carotid body tumor (CBT) is a very rare hypervascular tumor in the head-and-neck region, with an incidence lower than 0.03%. Although with relatively high risk, surgical removal is considered the main treatment of CBT. Common complications include hemorrhage, cranial nerves deficit, and risk of stroke with an overall mortality rate of 17.85%.[1] Tumors over 4 cm that needs a vascular reconstruction incurred a higher risk of cranial nerve injury.[1],[2] Here, we reported a case of giant CBT over 10 cm and successful resection with no major facial nerve deficit. Meanwhile, a very rare aneurysm-like entity inside the tumor was observed during the surgery, which was not reported in any previous publications.


  Case Report Top


A 49-year-old female found her right neck swelling 5 years ago. The lump grew to egg size within 3 years. During the past 5 years, she complained of feeling dizzy occasionally, with no further complaints as nausea, vomiting, or blurred vision. Digital subtraction angiography at local hospital revealed a tumor invading the right carotid body. Guglielmi detachable coils were implanted into her right carotid artery to reduce the size of the tumor [Figure 1]c. She was then admitted to our hospital for further treatment. Computed tomography (CT) revealed a mass of 8.6 cm × 5.6 cm × 8.8 cm [Figure 1]a and [Figure 1]b, and an entity appeared as nonenhancing soft-tissue opacity with heterogeneous density [[Figure 1]a and [Figure 1]b, red arrow] was observed inside the mass. The position of the tumor was relatively high and invaded lateral skull base [Figure 1]d. The carotid bifuracation and the platysma myoide were all invaded. The patient was diagnosed with right CBT, which could only be treated by surgical resection.
Figure 1: Preoperative imaging revealed a giant carotid body tumor invading cranial base with low-density entity inside. (a) The whole cervical segment (C1) of ICA was invaded, petrous segment (C2, circled) of internal carotid artery need to be exposed to reconstruct cervical-to-petrous internal carotid artery. Computed tomography revealed a nonenhancing soft-tissue opacity with heterogeneous density, demonstrated by the red arrows in (a and b). (c) Digital subtraction angiography was performed showing the Guglielmi detachable coils implanted into patient's right carotid artery. (d) Computed tomography angiography confirmed a mass at the bifurcation of the internal carotid artery and external carotid artery, extending from the skull base to the clavicle bone

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The surgery was conducted by a team of vascular surgeons and otolaryngologists. After general anesthesia and incision, the internal jugular vein and the internal carotid artery (ICA) distal to the tumor were separated. External auditory canal was cut [Figure 2]d, white arrow] and put back at the end of the surgery. Mastoid and styloid were then partially removed with driller under the microscope to expose ICA at superior border of the tumor body. After removal of mastoid and styloid, facial canal was opened and cranial nerve VII (facial nerve) was well protected afterward [Figure 2]a and [Figure 2]c. The trunk of facial nerve and its cervicofacial branch were isolated with a resection of the posterior part of the parotid gland, and the segment of the VII cranial nerve [arrow in [Figure 2]c crossing the operating field was not mobilized to avoid permanent postoperative paralysis. A hard, hypervascular tumor (10 cm × 15 cm) was visualized extending from under the carotid bifuracation to the base of skull [Figure 2]b. A 15-cm long autologous right saphenous vein graft was obtained and anastomosed to the carotid artery through “prereconstruction” approach [Figure 2]d.[3] It is worth mentioning that the low-density area previously showed on computed tomography angiography (CTA) was observed pulsing during removal. The entity was occasionally cut and instead of necrosis expected, fresh blood squirted out. Vascular shunt was immediately used to reduce blood loss. Operative blood loss was <3000 mL and mainly from the aneurysm-like entity.
Figure 2: (a) Intraoperative image of facial nerve under the microscope. (b) Bony structure of cranial base was removed to expose C2 segment of internal carotid artery at superior border of the tumor body. (c) Anatomic relationship between C2 and adjacent facial nerve (white arrow) after removal of mastoid and styloid. (d) Prereconstruction cervical-to-petrous internal carotid artery in situ bypass surrounding the lesion. The external auditory canal (white arrow) was cut and put back at the end of the operation

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Histologic analysis showed findings typical of a carotid body paraganglioma. The patient was in good condition postoperatively, with a slight XII cranial nerve deficit and temporary hoarseness, which both remitted after 3 months. No recurrence or any complications were noted at the 12-month follow-up.


  Discussion Top


As a very rare kind of tumor with high operative risk, the surgical resection of CBT remains a big challenge to vascular surgeons.[4],[5] This case brought us several questions that worth further studying.

First, we found that the low-density entity on CTA was not liquefactive necrosis of tumor as expected, but an aneurysm-like entity with fresh blood and pulsing like artery. To the best of our knowledge, this phenomenon was not reported in previous publications. It may indicate that the blood flow inside the tumor body distributed unevenly. Mutlu and Ogul reported a rare case of external carotid artery and coexisting CBT.[6] Further study is needed to explore the mechanism of CBT and possible connection between CBT and aneurysms. To safely remove a giant CBT with less blood loss is both meaningful and challenging. To achieve this goal, it is particularly important to precisely evaluate the condition of tumor as well as blood supply inside and around the tumor. To achieve a better preoperative evaluation of tumors, imaging techniques in addition to CT may be applicable.[7],[8]

Second, the tumor body was not only huge but also reached the skull base, making it hard to separate the ICA and protect cranial nerves, as well as anastomose ICA afterward. The standard procedure for resection of large Shamblin III CBTs is to reconstruct the ICA with autologous or artificial saphenous vein after total removal of tumor body.[9] In this case, we conducted the surgery with “prereconstruction” technique.[3] The ICA was reconstructed in advance of excising the tumors; to farthest maintain intraoperative cerebral flow by reducing clamping time. One of the most delicate parts of this surgery was to expose ICA at superior border of the tumor body. In this case, the tumor body reached the lateral skull base, which made it impractical to separate and reconstruct the artery due to the hard bone structure and the large amount of blood vessels and nerves it involved. With the help of otolaryngologist, we were able to expose the distal ICA inside the skull completely with full protection of nerves and blood vessels.

In conclusion, we reported an aneurysm-like entity with fresh blood inside a CBT, which was considered liquefactive necrosis preoperatively. To the best of our knowledge, this is the first reported of aneurysm-like entity inside a CBT.

Ethics approval and consent to participate

This study was approved by the Peking Union Medical Hospital Ethical Committee. Written informed consent was provided by the patient for patient information and images to be published.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gad A, Sayed A, Elwan H, Fouad FM, Kamal EH, Khairy H, Elhindawy K, Taha A, Hefnawy E. Carotid body tumors: A review of 25 years experience in diagnosis and management of 56 tumors. Ann Vasc Dis 2014;7 (3):292.  Back to cited text no. 1
    
2.
Metheetrairut C, Chotikavanich C, Keskool P, Suphaphongs N. Carotid body tumor: A 25-year experience. Eur Arch Otorhinolaryngol 2016;273 (8):2171-9.  Back to cited text no. 2
    
3.
Li FD, Gao ZQ, Ren HL, Liu CW, Song XJ, Li YF, Zheng YH. Pre-reconstruction of cervical-to-petrous internal carotid artery: An improved technique for treatment of vascular lesions involving internal carotid artery at the lateral skull base. Head Neck 2016; 38 (S1): E1562-7.  Back to cited text no. 3
    
4.
Ke VD, Vrancken Peeters MP, van Baalen JM, Hamming JF. Resection of carotid body tumors: results of an evolving surgical technique. Ann Surg 2008;247 (5):877.  Back to cited text no. 4
    
5.
Patetsios P, Gable DR, Garrett WV, Lamont JP, Kuhn JA, Shutze WP, Kourlis H, Grimsley B, Pearl GJ, Smith BL. Management of carotid body paragangliomas and review of a 30-year experience. Ann Vasc Surg 2002;16 (3):331-8.  Back to cited text no. 5
    
6.
Mutlu V, Ogul H. Magnetic resonance imaging and magnetic resonance angiography findings of external carotid artery aneurysm and coexisting carotid body tumor. J Craniofac Surg 2016;27 (8):e772-3.  Back to cited text no. 6
    
7.
Cui L, Gu G, Ye L, Liu B, Shao J, Liu C, Zheng Y. An evaluation on novel application of cone-beam CT imaging with multi-volume technique in carotid body tumor. Eur Arch Otorhinolaryngol 2017;274 (3):1713-20.  Back to cited text no. 7
    
8.
Taieb D, Varoquaux A, Chen CC, Pacak K. Current and future trends in the anatomical and functional imaging of head and neck paragangliomas. Semin Nucl Med 2013;43 (6):462-73.  Back to cited text no. 8
    
9.
Salvador JT, Tarnoff J, Feinhandler E. Difficult lesions of the carotid arteries and their surgical management. Angiology 1977;28 (8):500-14.  Back to cited text no. 9
    


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