Delayed vagal nerve compressive neuropathy following placement of vagal nerve stimulator: case report.

Vagal neuropathy causing vocal fold palsy is an uncommon complication of vagal nerve stimulator (VNS) placement. It may be associated with intraoperative nerve injury or with device stimulation. Here we present the first case of delayed, compressive vagal neuropathy associated with VNS coil placement which presented with progressive hoarseness and vocal cord paralysis. Coil removal and vagal neurolysis was performed to relieve the compression. Larger 3 mm VNS coils were placed for continuation of therapy. Coils with a larger inner diameter should be employed where possible to prevent this complication. The frequency of VNS-associated vagal nerve compression may warrant further investigation.

Cervical vagal nerve schwannoma induced arrhythmia: a rare case report and literature review.

BACKGROUND: Schwannomas are benign tumors deriving from the sheath of cranial and peripheral nerves. The vagus nerve is comprised of a complex neuro-endocrine-immune network that maintains homeostasis, most tracts of it play a role in parasympathetic activity. We present an example of a rare cervical vagal schwannoma case accompanied by arrhythmia. CASE PRESENTATION: A 35-year-old female patient with a left cervical vagus schwannoma and ventricular arrhythmia underwent schwannoma resection in the operating room. The patient's suppressed heart rate increased after tumor removal, and the cardiac rhythm returned to normal postoperatively. Pathological examination demonstrated the diagnosis of schwannoma. CONCLUSIONS: This case explains the link between the vagus nerve and the cardiovascular system, proving that a damaged cervical vagus nerve can inhibit the heart rate and lead to arrhythmias, and eventually requiring surgical intervention.

Purely intracranial vagal schwannoma: A case report of a rare lesion.

We present a rare intracranial vagal schwannoma along with its preoperative, intraoperative, and postoperative course.

A literature review on surgery for cervical vagal schwannomas.

Cervical vagal schwannoma is a benign, slow-growing mass, often asymptomatic, with a very low lifetime risk of malignant transformation in general population, but diagnosis is still a challenge. Surgical resection is the treatment of choice even if its close relationship with nerve fibres, from which it arises, threats vagal nerve preservation. We present a case report and a systematic review of literature. All studies on surgical resection of cervical vagal schwannoma have been reviewed. Papers matching the inclusion criteria (topic on surgical removal of cervical vagal schwannoma, English language, full text available) were selected. Fifty-three patients with vagal neck schwannoma submitted to surgery were identified among 22 studies selected. Female/male ratio was 1.5 and median age 44 years. Median diameter was 5 cm (range 2 to 10). Most schwannoma were asymptomatic (68.2%) and received an intracapsular excision (64.9%). Postoperative symptoms were reported in 22.6% of patients. Cervical vagal schwannoma is a benign pathology requiring surgical excision, but frequently postoperative complications can affect patients lifelong, so, surgical indications should be based carefully on the balance between risks and benefits.

[Vagal Nerve Schwannoma Complicated with Bloody Pleural Effusion；Report of a Case].

A 51-year-old male who had received hemodialysis twice a week was referred to our hospital for a further examination of bloody pleural effusion in the right chest. He has been suffering from a fever and cough for 2 months. Chest computed tomography and magnetic resonance imaging revealed a pleural effusion in the right pleural cavity and posterior mediastinal tumor in paravertebral lesion. Chest drainage was performed, and cytological diagnosis did not show malignant findings. To make a definite diagnosis and treatment, surgical resection was carried out. During surgery, posterior mediastinal tumor originated from vagal nerve, and a schwannoma was diagnosed by frozen section. After resection, postoperative course was uneventful, and bloody pleural effusion disappeared.

[Surgical treatement by intracapsular enucleation of cervical peripheral neural sheath tumors]. / Traitement chirurgical des tumeurs nerveuses périphériques bénignes cervicales par exérèse intracapsulaire.

Schwannomas and neurofibromas are benign tumors of the peripheral neural sheath tumors (PNST), representing 5% of soft tissue tumors. Cervical PNST are mainly located on the vagus nerve or in the sympathetic nervous system. The treatment is based on a tumor resection with preservation of nerve function. Classical surgery consists in total tumor removal after dissection of the nerve and is frequently complicated by nerve paralysis. The authors describe a simpler surgical technique consisting in a resection of the intracapsular enucleation of PNST that can limit the risk of nerve injury without increasing recidivism. The description of this surgical technique is illustrated by its use in a type I neurofibromatosis patient with a large vagal nerve neurofibroma.

Treatment of cervical paragangliomas: is surgery the only way?

PURPOSE: To analyze the results after surgery or stereotactic radiotherapy (SRT) in the treatment of cervical paragangliomas. Against this background, the decision-making algorithm used in the treatment of carotid body tumors (CBTs) and vagal paragangliomas (VPs) was reevaluated relative to the existing literature on the topic. MATERIALS AND METHODS: Retrospective study between 2000 and 2012. A total of 27 CBTs and nine VPs in 32 patients were treated. Shamblin class I: 59.3% (n=16); class II: 29.6% (n=8); class III: 11.1% (n=3). Treatment modalities were surgery, radiotherapy, or observation. The end points for analysis were long-term tumor control and integrity of the cranial nerves. RESULTS: 21 CBTs and seven VPs underwent surgery; SRT was performed in three CBTs and two VPs. Three CBTs were clinically observed. Permanent nerve paresis followed after surgery for CBTs in five patients (20%) and in all patients with VPs. No impaired cranial nerve function resulted after SRT. The median follow-up period was 4.7 years. The tumor control rate after therapy for CBTs and VPs was 100%. One CBT that received clinical observation showed slow tumor progression. CONCLUSIONS: A surgical procedure should be regarded as the treatment of choice in patients with small CBTs. In larger CBTs, particularly in elderly patients with unimpaired cranial nerves, radical surgery should be regarded critically. As surgery for VPs caused regularly impairment of cranial nerves with functional disturbances of various degrees a comprehensive consultation with the patient is mandatory and nonsurgical strategies should be discussed.

Comparative results of infratemporal fossa approach with or without facial nerve rerouting in jugular fossa tumors.

Jugular fossa tumors are uncommon diseases. During the surgery and due to the interposition of the facial nerve in the tumor approach, the facial nerve must be elevated from the fallopian canal and placed permanently into an anterior position. Although this maneuver provides a wide exposure, most of the patients suffer a long-term total or partial facial palsy. The purpose of this article is to check whether the infratemporal fossa approach without transposition of the facial nerve is equivalent to the approach with rerouting of the facial nerve regarding postsurgical morbidity. The clinical records of 52 patients who underwent an infratemporal fossa approach were reviewed in which 34 patients were segregated into two comparable groups regarding the presence or absence of transposition of the facial nerve. There were 19 women and 15 males. The majority of the patients (73%) had jugular paragangliomas. The mean follow-up of the full series was 66 months. It was statistically significant that the worst facial nerve function at hospital discharge was in the patients who underwent facial nerve transposition (p = 0.001). Equally the facial nerve function in the no-rerouting group 1 year after the surgery was significantly much better than in the rerouting group (p = 0.003). Regarding to survival, recurrence or complications no significant differences were observed between both groups. Our study suggests that most of cases avoiding facial nerve transposition allow significant better functional results thereof without affecting other parameters such as recurrence, complications or survival.

Malignant vagal paraganglioma.

The purpose of this paper is to present and discuss a new case of malignant vagal paraganglioma. A 38-year-old woman was referred for the assessment of a bilateral firm cervical mass. CT scans revealed a left cervical ovoid mass; contralaterally, a mass with a similar enhancement could be observed too. The tumor was surgically removed via a transcervical surgical approach, together with levels I to III lymph nodes. Definitive histopathological examination proved the diagnosis of malignant vagal paraganglioma with contralateral cervical lymph node metastasis. One year after surgery, a PET-CT and a scintigraphy revealed the presence of a cervical recurrence and hepatic metastasis. Three months after a second surgical intervention, the patient died. Malignant vagal paraganglioma is a rare and challenging lesion that has to be carefully assessed to plan an appropriate treatment. A strict follow-up is fundamental for an early diagnosis of eventual recurrences.

Asymptomatic Purely Intracranial Vagal Schwannoma: Clinical Case Report and Literature Review.

Vagus nerve schwannoma is an infrequently occurring schwannoma, in which a distinct subtype exists wherein the tumor is confined to the cerebellomedullary cistern without invading the jugular foramen. This unique tumor is called purely intracranial vagal schwannoma. In this case report, we present a case of purely intracranial vagal schwannoma in its asymptomatic early phase, incidentally discovered during surgery performed on a patient with hemifacial spasm. Because of the small size of the tumor, we definitively recognized that it originated from the second rootlet on the caudal side. The tumor was totally resected uneventfully and a favorable prognosis was achieved. Furthermore, we conducted a comprehensive literature review to summarize the classification, origin, and surgical complications associated with this rare tumor type. Based on our literature review, we propose that: 1) the origin of tumor is related to the time of onset of symptoms, 2) nearly all purely intracranial vagal schwannomas can be entirely resected and favorable prognosis can be achieved, and 3) surgeons should be aware of potential cardiovascular complications during surgical procedures.

Functional vagal paraganglioma developing 15 years after resection of a retroperitoneal paraganglioma.

The patient, a 40-year-old woman, was diagnosed as having a functional right vagal paraganglioma (PGL) 15 years after undergoing resection for a retroperitoneal PGL. 123I-MIBG scintigraphy showed no accumulation, but as the blood noradrenaline and urinary normetanephrine concentrations were elevated, the tumor was judged as being functional, and surgery was scheduled. The patient was started on doxazosin infusion and embolization of the tumor feeding vessel was performed before the surgery. Intraoperative examination showed that the tumor was contiguous with the vagal nerve, necessitating combined resection of the vagal nerve with the tumor. Postoperatively, the catecholamine levels returned to normal range. Histopathologically, the tumor was diagnosed as a moderately differentiated, intermediate-malignant-grade PGL, with a GAPP score of 4 to 6. No non-chromaffin tissue was observed in the tumor background, so that the functional vagal PGL was considered as a sporadic metachronous tumor rather than as a metastasis from the retroperitoneal PGL. More than half of head and neck paragangliomas (HNPGLs) are reported to arise in the carotid body, and about 5% from the vagal nerve. In addition, HNPGLs rarely produce catecholamines. Herein, we consider the relationship with the previously resected retroperitoneal PGL based on a review of the literature.

[Synchronous schwannoma of the vagus nerve and the cervical sympathetic chain]. / Synchrones Schwannom des N. vagus und des zervikalen sympathischen Grenzstrangs.

Schwannomas are rare neural sheath tumors which are generally benign. Up to 45% of all schwannomas originate in the head and neck region. In the parapharyngeal space (PPS) they may arise from any of the lower cranial nerves IX, X, XI and XII or from the cervical sympathetic chain. We report a unique case of a synchronous schwannoma of the vagal nerve and the cervical sympathetic chain in a patient without neurofibromatosis.

Report of a vagal paraganglioma at the cervicothoracic junction.

BACKGROUND: Vagus nerve paragangliomas are rare tumors, comprising 0.03% of head and neck neoplasms. These tumors are usually located cephalad to the hyoid bone, and there is only one previously reported case that arose from the lower third of the neck. METHODS: We describe the second reported case of a lower neck vagus nerve paraganglioma that was managed with a limited sternotomy for access and surgical removal. RESULTS: A 66-year-old male presented with a long-standing lesion of the cervicothoracic junction. CT, MRI, and Ga-68 DOTATATE PET/CT showed an avidly enhancing 5.2 × 4.2 × 11.5 cm mass extending from C6 to approximately T4 level. FNA confirmed the diagnosis. The patient underwent catheter angiography and embolization via direct puncture technique followed by excision of the mass via a combined transcervical and limited sternotomy approach. CONCLUSION: We describe an unusual case of vagal paraganglioma at the cervicothoracic junction with retrosternal extension requiring a sternotomy for surgical excision.

Management of vagal paragangliomas including application of internal carotid artery stenting.

BACKGROUND: The primary treatment of vagal paraganglioma (VP) includes 'wait and scan', surgery and radiotherapy. OBJECTIVES: To present the clinical findings, surgical treatment including application of internal carotid artery (ICA) stenting to facilitate surgery, and complications, as well as to review the literature and to discuss the decision-making process in the management of VP cases based on our experience and the literature. DESIGN: A retrospective case review of 22 cases with VP. SETTING: Quaternary neurotologic and skull base referral center. MATERIAL AND METHODS: The retrospective chart review identified 22 patients presenting with VP. Our indication for surgery was VP in younger patients, irrespective of the existence of vocal cord paralysis. Preoperative endovascular management of the ICA included permanent balloon occlusion (PBO) and stenting. The transcervical approach and the infratemporal fossa approach type A (ITFA) were used. RESULTS: Fifteen cases had multicentric paragangliomas, 5 cases bilateral tumors, 3 cases a genetic mutation, and 2 cases a positive family history. The most common symptoms were hoarseness, tinnitus and hearing loss. The surgical approaches commonly employed for excision were the transcervical approach (9 cases) and the ITFA (12 cases), whereas 1 case did not have surgery. Three cases had PBO and 7 had intracarotid stent insertion. Gross total removal was achieved in 19 cases, and 1 case had a recurrence. Eighteen cases had no dysphagia or were well compensated after surgery. There were no significant complications noted in our series. CONCLUSIONS: In younger patients with VP, surgery should be recommended. The proper preoperative endovascular intervention and surgical approach facilitates gross total tumor removal. In the management of bilateral or familial paragangliomas, careful and appropriate decision making is essential.

Schwannoma originating from lower cranial nerves: report of 4 cases.

Four cases of schwannoma originating from the lower cranial nerves are presented. Case 1 is a schwannoma of the vagus nerve in the parapharyngeal space. The operation was performed by the transcervical approach. Although the tumor capsule was not dissected from the vagus nerve, hoarseness and dysphagia happened transiently after the operation. Case 2 is a schwannoma in the jugular foramen. The operation was performed by the infralabyrinthine approach. Although only the intracapsular tumor was enucleated, facial palsy, hoarseness, dysphagia and paresis of the deltoid muscle occurred transiently after the operation. The patient's hearing had also slightly deteriorated. Case 3 is a dumbbell-typed schwannoma originating from the hypoglossal nerve. The hypoglossal canal was markedly enlarged by the tumor. As the hypoglossal nerves were embedded in the tumor, the tumor around the hypoglossal nerves was not resected. The tumor was significantly enlarged for a while after stereotactic irradiation. Case 4 is an intracranial cystic schwannoma originating from the IXth or Xth cranial nerves. The tumor was resected through the cerebello-medullary fissure. The tumor capsule attached to the brain stem was not removed. Hoarseness and dysphagia happened transiently after the operation. Cranial nerve palsy readily occurs after the removal of the schwannoma originating from the lower cranial nerves. Mechanical injury caused by retraction, extension and compression of the nerve and heat injury during the drilling of the petrous bone should be cautiously avoided.

Pre-operative cerebellar mutism secondary to vagus nerve schwannoma.

Cerebellar mutism, also known as 'posterior fossa syndrome,' is an uncommon condition often reported after posterior fossa tumour resection in the paediatric population. It is infrequently associated with other intrinsic cerebellar pathologies. We hereby report a rare case of pre-operative cerebellar mutism associated with an extrinsic posterior fossa lesion - vagus nerve schwannoma.

[Neurogenic tumors originated from vagus nerve and intercostal nerve simultaneously; report of a case].

A 60-years-old man was presented with the posterior mediastinal tumor by chest computed tomography (CT) that had been taken for the examination of another disease. A well circumscribed mass of 9 x 6 x 5 cm in diameter between the body of the thoracic vertebra and pericardium and a well circumscribed mass of 2 x 2 x 0.8 cm in diameter in the 9th intercostal space were noted by chest CT. von Recklinghausen's disease was suspected by the presence of a lot of brown spots and subcutaneous small nodules in the whole body, and both was speculated as neurogenic tumors. Both tumors were removed by the operation, and the pathologic diagnosis of the neurofibroma was obtained.

Vocal cord paralysis after percutaneous embolization of a vagal paraganglioma--the role of intraoperative nerve monitoring.

The value of preoperative embolization is well established in the management of paragangliomas. Percutaneous direct intratumoral embolization has been described as a safe and effective technique to achieve devascularization of these tumors, thereby reducing intraoperative blood loss. However, the present article presents a case in which a patient developed vocal cord palsy after percutaneous embolization of a vagal paraganglioma. In view of the present findings, the possibility of intraoperative nerve monitoring needs to be explored to ensure safety of this procedure.

Vagus nerve schwannoma in the middle mediastinum.

Intrathoracic neurogenic tumors are generally located in the posterior mediastinum. They usually arise from an intercostal nerve or a sympathetic chain. Tumors originating from the vagus nerve in the middle mediastinum are extremely rare. This report describes a patient with a huge intrathoracic schwannoma of the vagus nerve in the middle mediastinum and reviews the literature.