Surgical outcomes for carotid body tumour resection without preoperative embolization: a 10-year experience.

Background: Carotid body tumours (CBTs) are neoplasms originating from the paraganglionic cells of the carotid body. Excision is the main route of treatment. This study sought to assess the surgical outcomes of post-carotid body tumour resection without preoperative embolization and discern any underlying relationships between modified Shamblin classes (MSC) and related complications. Methods: A retrospective medical record review of prospectively collected data is performed at Sulaymaniyah Teaching Hospital between 2008 and 2019, for 54 patients. Presurgical and postsurgical variables such as comorbidities and complications were noted, respectively. Results: Patient ages ranged between 26 and 60 years (x̄=40.06) with a minimal female predominance (57.4%). Complications included one minor stroke. MSC and postoperative complications were significantly related (P≤0.001). Our analyses also suggested a significant relationship between intraoperative blood loss and the incidence of postoperative complications (P=0.001, χ²=25). The MSC III subtype was significantly associated with intraoperative blood loss (P=0.000), length of stay (P=0.000), and operating time (P=0.001). Conclusions: Our study purports a strong relationship between greater MSC and complications of all types. As such, surgeons may benefit from preoperative strategies to minimize complications.

Traumatic cavernous sinus syndrome - A peculiar presentation of multiple cranial nerve neuropathies following a minor head injury: Case report and literature review.

BACKGROUND: In patients with traumatic head injuries, the percentage of cranial nerve injuries (CNI) range from4.3 to 17.6% in which majority are isolated CNI[1-5].In present literature, moderate to severe types of head injuries are often studied which may result in a lack of representation and description of CNI associated with minor head injuries (MHI). Alongside this peculiar case of a traumatic cavernous sinus syndrome (CSS) that is non-thrombotic and non-fistulous in nature, this paper aims to analyse traumatic CNI in non-severe head injuries and the surrounding literature. CASE REPORT: A 65-year-old man who had sustained a minor head injury was found to have CNI of III, IV and VI.Brain imaging showed scattered traumatic subarachnoid haemorrhage and a non-displaced right zygomatic arch fracture. Despite the short course of high dose dexamethasone, he showed only partial recovery of his CNI after one year. CONCLUSION: We present a case of traumatic CSS likely secondary to tractional injury from a MHI. Injury to the extraocular nerves wasfound to be one of the more commonly observed combination of CNI from the literature review conducted. In patients with MHI, multiple CNI is less common. Hence, consideration should be given to work upfor secondary causes such as tumours. There is presently no known clear identifiable pattern of CNI associated with MHI. CT brain findings of skull base fractures and early onset of cranial nerve palsies are generally associated with worse outcomes. More remains to be studied about tractional CNI in non-severe head injuries.

Association of Tumor Volumetry with Postoperative Outcomes for Cervical Paraganglioma.

Objectives: To analyze the association of tumor volume with outcome after surgery for cervical paraganglioma. Materials and Methods: This retrospective study included consecutive patients undergoing surgery for cervical paraganglioma from 2009-2020. Outcomes were 30-day morbidity, mortality, cranial nerve injury, and stroke. Preoperative CT/MRI was used for tumor volumetry. An association between the volume and the outcomes was explored in univariate and multivariable analyses. A receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated. The study was conducted and reported according to the STROBE statement. Results: Volumetry was successful in 37/47 (78.8%) of included patients. A 30-day morbidity occurred in 13/47 (27.6%) patients with no mortality. Fifteen cranial nerve lesions occurred in eleven patients. The mean tumor volume was 6.92 cm3 in patients without and 15.89 cm3 in patients with complications (p = 0.035) and 7.64 cm3 in patients without and 16.28 cm3 in patients with cranial nerve injury (p = 0.05). Neither the volume nor Shamblin grade was significantly associated with complications on multivariable analysis. The AUC was 0.691, indicating a poor to fair performance of volumetry in predicting postoperative complications. Conclusions: Surgery for cervical paraganglioma bears a relevant morbidity with a particular risk of cranial nerve lesions. Tumor volume is associated with morbidity, and MRI/CT volumetry can be used for risk stratification.

Comparing carotid endarterectomies with or without shunting in symptomatic and asymptomatic patients.

BACKGROUND: Recent research shows that placement of an intraluminal shunt during a carotid endarterectomy (CEA) can be associated with postoperative complications. Therefore, we compared CEA operations with or without shunting to further analyze their clinical outcomes. METHODS: From the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,736 cases between 2016 and 2019 were analyzed to compare adult symptomatic and asymptomatic carotid stenosis patients who underwent a CEA operation, with or without shunt placement. RESULTS: Rates of stroke with a neurological deficit (p = 0.012), myocardial infarction (p = 0.021), and urinary tract infection (p = 0.030) were higher among symptomatic patients with shunting. Multivariate logistic regression revealed that risk of CNI was higher among both symptomatic (93.63%, p < 0.001) and asymptomatic (69.58%, p = 0.001) patients with shunting, irrespective of confounding variables. CONCLUSION: Shunting was found to be associated with higher rates of postoperative complications in both symptomatic and asymptomatic patient populations.

A new potential risk factor for permanent cranial nerve injury following carotid body tumor resection.

Background: To quantify the association between the free distal segment length of the internal carotid artery (FDS-ICA) and permanent cranial nerve injury (p-CNI) following carotid body tumor (CBT) resection. Methods: This study is a case-control study. We surveyed 109 consecutive patients who underwent CBT resection between June 2015 and June 2020 at our single center. A total of 89 patients met the inclusion criteria and were selected for analysis. The FDS-ICA was measured by image post-processing software for computed tomography angiography (CTA). Postoperative p-CNI complications were evaluated using comprehensive statistical approaches. Results: The cohort was divided into 2 groups depending on the presence of p-CNI, namely the p-CNI group (n=17) and the non-CNI group (n=79). The average FDS-ICA of patients with p-CNI complications was shorter than that of those without p-CNI complications (P<0.001). For every 1 mm increase in FDS-ICA, there was an associated decrease of 8% in the risk of p-CNI (0.92, 95% CI: 0.85 to 0.98, P<0.05). Threshold effect analysis of the FDS-ICA on p-CNI identified that the FDS-ICA was 28.7 (95% CI: 23.8 to 30.9) mm. Conclusions: The results of this study revealed a significant independent association between FDS-ICA and permanent postoperative cranial nerve injury complications of CBTs. Further study is warranted to confirm these results in a larger patient cohort.

Effect of distance to the base of skull and tumor size characteristics on cranial nerve injuries in carotid body tumor resections.

OBJECTIVE: In the present study, we aimed to confirm the findings reported by Kim et al. They stated that the tumor's distance to the base of the skull was predictive of injury to the cranial nerves and their branches during carotid body tumor resection in an Austrian cohort. METHODS: In the present retrospective observational trial, we included all consecutive patients who had been discharged from our tertiary care teaching hospital with the diagnosis of a carotid body tumor (CBT) between January 2004 and December 2019. Tumor-specific parameters were measured from the preoperative contrast-enhanced computed tomography or magnetic resonance imaging studies. Patient-specific data were obtained from the patients' medical records. The effect of these parameters on the occurrence of cranial nerve injuries was calculated using univariate logistic regression analysis. Parameters significant on univariate analysis were included in a multivariate model. RESULTS: A total of 48 CBTs had been resected in 43 patients (29 women [67.4%] and 14 men [32.6%]), with a mean age of 55.6 years (95% confidence interval, 51.8-58.5). The mean distance to the base of the skull was 43.2 mm (95% confidence interval, 39.9-46.5). A total of 18 injuries to the cranial nerves and their branches in 10 CBTs were detected. The tumor-specific parameters that were significant on univariate analysis were the distance to the base of the skull (P = .009), craniocaudal tumor diameter (P = .027), and tumor volume (P = .036). Stepwise multivariate logistic regression analysis revealed that the distance to the base of the skull was the only parameter that remained statistically significant. CONCLUSIONS: We found that the distance to the base of the skull is a highly predictive parameter for injuries to the cranial nerves and their branches during CBT resection and should be included in the surgical risk assessment and patient information.

Carotid Body Tumor: Our Experience with 42 Patients and a Literature Review.

To review characteristics, signs, diagnostic methods, and surgical complications in patients with carotid body tumor, in addition to a literature review. This was a cross-sectional study carried out on 42 patients with carotid body tumors referred to Al-Zahra hospital of Isfahan from January 1, 2016, to December 31, 2019. The studied characteristics included age at the onset of symptoms, gender, symptoms, duration of symptomatic status before diagnosis, diagnostic methods, pathological outcome, tumor stage, and surgical complications. The collected data were analyzed using SPSS 21. In this study, 34 patients (80.96%) were female. The mean age at the onset of symptoms was 54.41 years. The mean duration of symptoms before diagnosis was 12.55 months. There was no significant difference between genders for the age and duration of symptoms before diagnosis (p > 0.05). Symptoms were mainly painless mass, hoarseness, coughing, earache, tinnitus, and headache. After surgery, two cases of permanent cranial nerve injuries were found. Thirty-nine patients (93%) were diagnosed by ultrasound imaging and CT scan. We had one case of arterial repair. There was one malignant and one functional tumor. According to the results, carotid body tumor is more common in females especially on the right side. Bilateral tumors are prevalent in females. This mass should be removed by surgery at the time of diagnosis in cases where the patient is not at high risk for surgery due to comorbidities, and the risk of complications following surgery is low. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-021-02453-8.

Unilateral lingual nerve and hypoglossal nerve injury caused by a novel laryngeal mask airway: a case report

Abstract Cranial nerve injury by a laryngeal mask airway is rare but a serious complication. The nerve injuries must be prevented during the intubation using a laryngeal mask airway. We report a female patient who complained of tongue numbness, slurred speech, and slight difficulty in swallowing solid food after a hand surgery. She was then diagnosed with unilateral lingual nerve and hypoglossal nerve injuries. Extreme head rotation, relatively small oral cavity, and wide rigid composition at the lower part of the novel laryngeal mask probably resulted in cranial nerve injury.

Orbital apex syndrome secondary to apical periodontitis of a tooth: a case report.

BACKGROUND: Orbital apex syndrome (OAS) is a rare disease with a noticeable mortality rate. Although its etiology has been repeatedly assessed, few reports have concentrated on odontogenic infection. We presented a rare case of OAS secondary to apical periodontitis. CASE PRESENTATION: A 61-year-old male was admitted to our hospital for a 3-day history of left orbital and head pain, along with diplopia for 1-day. He also had toothache symptoms before his admission. Due to the atypical early symptoms of orbital apex and cranial nerve injury, no timely and effective diagnosis and treatment were initially provided. However, as the disease progressed and complications occurred, we timely adjusted the diagnosis and successfully controlled the infection. During the one-year follow-up, no recurrence of inflammation was observed; nevertheless, the ptosis and ophthalmoplegia persisted. CONCLUSIONS: OAS is a rare, while severe complication of odontogenic infection. This case had various symptoms and nerve injury in the orbital apical area. When disease is atypical in its early stages, treatment is easily overlooked. Early detection and suspicion of orbital apex-related complications should be heightened.

Outcomes and role of shunting during carotid endarterectomy for symptomatic patients.

OBJECTIVE: Shunt placement during carotid endarterectomy (CEA) has often been advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. In the present study, we assessed the effect of shunt placement during CEA on postoperative stroke risk in symptomatic patients. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database (2016-2019) for CEA cases with complete CEA procedure-targeted data available. Symptomatic patients were identified as those with a preoperative diagnosis of stroke on presentation (DS), transient ischemic attack, amaurosis fugax, or temporary monocular blindness. The DS patients were further analyzed according to the severity of their stroke using the modified Rankin scale scores. To better assess the effect of shunt placement on the stroke rate, we compared cases of CEA with the patch angioplasty technique stratified by the use of an intraoperative shunt. Patients who had undergone carotid eversion or primary closure were excluded. The baseline demographics and perioperative outcomes were compared using the χ2 and Mann-Whitney U tests. Multivariate analysis was performed to identify the independent risk factors for postoperative stroke and cranial nerve injury. RESULTS: We identified 4652 cases of CEA with patch angioplasty in symptomatic patients, including 1889 with (40.6%) and 2763 without (59.4%) shunt placement. The distribution of age, race, and sex was similar for both procedures. Compared with patients without a shunt, those with a shunt had significantly higher rates of emergency surgery (9.1% vs 7.0%; P = .010), nonelective surgery (40.3% vs 37.2%; P = .035), general anesthesia (97.0% vs 86.3%; P < .001), and bleeding disorders (27.2% vs 22.7%; P < .001). The 30-day incidence of postoperative stroke was similar between the patients with (3.2%) and without (2.6%) shunt placement (P = .219). Additionally, a subgroup analysis failed to show any benefit from shunt placement on the incidence of postoperative stroke, regardless of the preoperative symptoms or neurologic disability. In contrast, shunt placement was associated with an increased rate of cranial nerve injury (4.1% vs 2.4%; P = .001). Multivariate analysis revealed that nonelective surgery (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.36-2.91; P < .001) and DS (vs transient ischemic attack, amaurosis fugax, or temporary monocular blindness; OR, 1.64; 95% CI, 1.12-2.41; P = .012) were predictive of 30-day postoperative stroke. After adjusting for confounders, shunt placement had no effect on stroke risk at 30 days but remained an independent risk factor for cranial nerve injury (adjusted OR, 1.87; 95% CI, 1.32-2.64; P < .001). CONCLUSIONS: For symptomatic patients undergoing CEA with patch angioplasty, shunt placement was associated with an increased risk of cranial nerve injury without a reduction in postoperative stroke risk.

Cranial nerve injury during transcarotid transcatheter aortic valve replacement.

BACKGROUND: No data exist about cranial nerve injury (CNI) as a potential complication of transcarotid (TC) transcatheter valve replacement (TAVR). METHODS: This monocentric study included 318 consecutive patients undergoing TC-TAVR from May 2015 to August 2021. RESULTS: CNI occurred in 7 (2.2%) TAVR-TC patients. Five out of the 7 patients (71.4%) had an injury of the laryngeal branch of the vagus nerve, and 2 patients (28.6%) had an injury of the facial nerve. The majority of patients were male (85.7%), with high body mass index (35.6 (IQR: 30.1-37.3) kg/m2). The induced disabilities were clinically important especially for patients with dysphonia. CONCLUSIONS: CNI is a potential complication of TC-TAVR likely avoidable by a meticulous surgical technique. Structural heart teams must be aware of this serious setback.

A new pattern of cranial nerve injuries caused by unfavorable fractures during Le Fort I osteotomy.

Cranial nerve injury is a described complication of Le Fort I osteotomy technique. The authors present the case of a 45-year-old patient that underwent bimaxillary orthognathic surgery and suffered unfavorable skull base fractures, which resulted in cranial nerve injury of the II, III, IV, V, and VI nerves on the left side and of the V nerve on the right side, through different mechanisms. One of the mechanisms was cavernous sinus thrombosis, which was never described following Le Fort I technique in a non-cleft patient. The fracture pattern involved the foramen ovale and Meckel's cave, which was also never described after this technique. The resolution of the deficits at the final follow-up at 14 months was incomplete. Le Fort I osteotomy technique is considered a safe technique to correct dentofacial deformities, but serious complications can occur. Pterygomaxillary disjunction and down-fracture must be performed with the utmost care to avoid it.

Unilateral lingual nerve and hypoglossal nerve injury caused by a novel laryngeal mask airway: a case report.

Cranial nerve injury by a laryngeal mask airway is rare but a serious complication. The nerve injuries must be prevented during the intubation using a laryngeal mask airway. We report a female patient who complained of tongue numbness, slurred speech, and slight difficulty in swallowing solid food after a hand surgery. She was then diagnosed with unilateral lingual nerve and hypoglossal nerve injuries. Extreme head rotation, relatively small oral cavity, and wide rigid composition at the lower part of the novel laryngeal mask probably resulted in cranial nerve injury.

Landmarks for the hypoglossal nerve within the anterior cervical triangle / Topografía del nervio hipogloso en el triángulo cervical anterior

SUMMARY: Cranial nerve injury is one of the neurologic complications following carotid endarterectomy. The hypoglossal nerve is one of the most frequently injured nerves during carotid endarterectomy. Guidelines suggest that proper anatomic knowledge is crucial to avoid cranial nerve injury. The aim of the present study is to provide landmarks for the localization of the hypoglossal nerve during carotid endarterectomy. 33 anterior cervical triangles of formalin-fixed adult cadavers were dissected. The "carotid axis" was defined and measured, the level of the carotid bifurcation within the carotid axis was registered. "High carotid bifurcation" was considered for those carotid bifurcation found in the upper 25 mm of the carotid axis. The distance between the hypoglossal nerve and the carotid bifurcation was measured (length 1). The relationship between the hypoglossal nerve and the posterior belly of the digastric muscle was registered. For caudal positions, the distance between hypoglossal nerve and posterior belly of the digastric muscle was determined (length 2). Carotid axis range 88.3 mm-155.4 mm, average 125.8 mm. Level of the carotid bifurcation within the carotid axis range 75.3 mm-126.5 mm, mean 102.5 mm. High carotid bifurcation was found in 19 cases (57 %). Length 1 ranged from 1.6 mm to 38.1, mean 17.5. Finally, in 29 specimens (87.8 %) the hypoglossal nerve was caudal to posterior belly of the digastric muscle, whereas in 4 cases (12.2 %) it was posterior. Length 2 ranged from 1 mm to 17.0 mm, mean 6.9 mm. Distances between the hypoglossal nerve and nearby structures were determined. These findings may aid the surgeon in identifying the hypoglossal nerve during carotid endarterectomy and thus prevent its injury.

RESUMEN: La lesión de pares craneales es una de las complicaciones neurológicas posteriores a la endarterectomía carotídea. El nervio hipogloso es uno de los nervios lesionados más frecuentemente durante la endarterectomía carotídea. Las guías de actuación clínica sugieren que el conocimiento anatómico adecuado es crucial para evitar lesiones de los nervios craneales. El objetivo del presente estudio fue proporcionar puntos de referencia para la ubicación del nervio hipogloso durante la endarterectomía carotídea. Se disecaron 33 triángulos cervicales anteriores de cadáveres adultos fijados en solución a base de formaldehído. Se definió y midió el "eje carotídeo", se registró el nivel de la bifurcación carotídea dentro del eje carotídeo. Se consideró una "bifurcación carotídea alta" para aquellas bifurcaciones carotídeas encontradas en los 25 mm superiores del eje carotídeo. Se midió la distancia entre el nervio hipogloso y la bifurcación carotídea (longitud 1). Se registró la relación entre el nervio hipogloso y el vientre posterior del músculo digástrico. Para las posiciones caudales, se determinó la distancia entre el nervio hipogloso y el vientre posterior del músculo digástrico (longitud 2). Rango del eje carotídeo 88,3 mm-155,4 mm, media 125,8 mm. Rango del nivel de la bifurcación carotídea dentro del eje carotídeo 75,3 mm-126,5 mm, media 102,5 mm. Se encontró una bifurcación carotídea alta en 19 casos (57 %). La longitud 1 osciló entre 1,6 mm y 38,1, con una media de 17,5. Finalmente, en 29 muestras (87,8 %) el nervio hipogloso fue caudal al vientre posterior del músculo digástrico, mientras que en 4 casos (12,2 %) fue posterior. La longitud 2 osciló entre 1 mm y 17,0 mm, con una media de 6,9 mm. Se determinaron las distancias entre el nervio hipogloso y las estructuras cercanas. Estos hallazgos pueden ayudar al cirujano a identificar el nervio hipogloso durante la endarterectomía carotídea y así prevenir su lesión.

Rehabilitation nursing of hoarseness and dysphagia after resection of schwannoma in jugular foramen: a case report / 中国实用护理杂志

Objective:To summarize the combined rehabilitation nursing process of a case of voice and deglutition disorders following surgical removal of intra-and extracranial schwannoma in the jugular foramen area.Methods:A case of hoarseness and dysphagia after surgery for intracranial and extracranial schwannomas in the left jugular foramen region in Xuanwu Hospital, Capital Medical University in October 2020 was collected. Early step-wise voice training assisted by respiratory muscles and tongue muscle exercises was carried out, electronic laryngoscope-based breathing and swallowing methods, assessment of food and bite-size, maintenance of food consistency with the assistance of chewing times, and swallowing and ingestion guidance for the update of dietary methods were performed. The continuous rehabilitation training was provided throughout the process.Results:The grade of GRBAS scale decreased from G3 to G2 after training from home for 3 months following discharge; the voice handicap index of Chinese version reduced from 75 points to 52 points, and the average pronunciation time extended from 2.45 s to 5.32 s. The frequency of choking with food optimized from 0.4 to 0.5 times/min to no choking.Conclusions:Early rehabilitation training of voice and, swallowing and ingestion is a boon for the recovery of hoarseness and dysphagia after resection of schwannomas in the jugular foramen region.

Management of Traumatic Trigeminal and Facial Nerve Injuries.

In the area of craniomaxillofacial trauma, neurosensory disturbances are encountered commonly, especially with regard to the trigeminal and facial nerve systems. This article reviews the specific microanatomy of both cranial nerves V and VII, and evaluates contemporary neurosensory testing, current imaging modalities, and available nerve injury classification systems. In addition, the article proposes treatment paradigms for management of trigeminal and facial nerve injuries, specifically with regard to the craniomaxillofacial trauma setting.

The effect of preoperative embolization on surgical outcomes for carotid body tumor resection.

OBJECTIVE: Compare the effects of preoperative embolization for carotid body tumor resection on surgical outcomes to carotid body tumor resections without preoperative embolization. METHODS: Single-center retrospective review of all consecutive patients who underwent carotid body tumor resection from 2001 to 2019. Surgical outcomes with emphasis on operative time (estimated blood loss and cranial nerve injury) of patients undergoing carotid body tumor resection following preoperative embolization were compared to those undergoing resection alone using unpaired Student's t-test and Fisher's exact test. RESULTS: Forty-six patients (15% male, mean age 50 ± 15 years) underwent resection of 49 carotid body tumors. Patients undergoing preoperative embolization (n = 20 (40%)) had larger mean tumor size (4.0 ± 0.7 vs 3.2 ± 1 cm, p = 0.006), increased Shamblin II/III tumor classification (18 (90%) vs 22 (76%), p < 0.001), operative time (337 ± 195 vs 199 ± 100 min, p = 0.004), and cranial nerve injuries overall (8 (40%) vs 2 (10%), p = 0.01) compared to patients undergoing resection without preoperative embolization (n = 29 (60%)). In subgroup analysis of Shamblin II/III classification tumors (n = 40), preoperative embolization (n = 18) was associated with increased tumor size (4.1 ± 0.6 vs 3.5 ± 0.9 cm, p = 0.01), operative time (351 ± 191 vs 244 ± 105 min, p = 0.02), and cranial nerve injury overall (8 (44%) vs 2 (9%), p = 0.03) compared to resections alone (n = 19). In further subgroup analysis of large (⩾ 3 cm) tumors (n = 37), preoperative embolization (n = 18) was associated with increased operative time (350 ± 191 vs 198 ± 99 min, p = 0.006) and cranial nerve injury overall (8 (44%) vs 2 (11%), p = 0.03) compared to resections alone (n = 19). There were no significant differences in estimated blood loss, transfusion requirement, or hematoma formation between any of the embolization and non-embolization subgroups. CONCLUSION: After controlling for tumor Shamblin classification and size, carotid body tumor resections following preoperative embolization were associated with increased operative time and inferior surgical outcomes compared to those tumors undergoing resection alone. Nonetheless, such results remain susceptible to the confounding effects of individual tumor characteristics often used in the decision to perform preoperative embolization, underscoring the need for prospective studies evaluating the utility of preoperative embolization for carotid body tumors.