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Case Report Head and Neck Schwannomas: a Surgical Challenge—A Series of 5 Cases

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Case Report Head and Neck Schwannomas: a Surgical Challenge—A Series of 5 Cases Hindawi Case Reports in Otolaryngology Volume 2018, Article ID 4074905, 10 pages https://doi.org/10.1155/2018/4074905 Case Report Head and Neck Schwannomas: A Surgical Challenge—A Series of 5 Cases Ishtyaque Ansari,1 Ashfaque Ansari,2 Arjun Antony Graison ,2 Anuradha J. Patil,3 and Hitendra Joshi2 1Department of Neurosurgery, MGM Medical College & Hospital, Aurangabad, India 2Department of ENT, MGM Medical College & Hospital, Aurangabad, India 3Department of Plastic Surgery, MGM Medical College & Hospital, Aurangabad, India Correspondence should be addressed to Arjun Antony Graison; [email protected] Received 25 September 2017; Accepted 29 January 2018; Published 4 March 2018 Academic Editor: Abrão Rapoport Copyright © 2018 Ishtyaque Ansari et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Schwannomas, also known as neurilemmomas, are benign peripheral nerve sheath tumors. +ey originate from any nerve covered with schwann cell sheath. Schwannomas constitute 25–45% of tumors of the head and neck. About 4% of head and neck schwannomas present as a sinonasal schwannoma. Brachial plexus schwannoma constitute only about 5% of schwannomas. Cervical vagal schwannomas constitute about 2–5% of neurogenic tumors. Methods. We present a case series of 5 patients of schwannomas, one arising from the maxillary branch of trigeminal nerve in the maxillary sinus, second arising from the brachial plexus, third arising from the cervical vagus, and two arising from cervical spinal nerves. Result. Complete extracapsular excision of the tumors was achieved by microneurosurgical technique with preservation of nerve of origin in all except one. Conclusion. Head and neck schwannoma though rare should be considered as a differential diagnosis of a unilateral slow growing mass in the head and neck region, particularly in an adult. Schwannomas are always a diagnostic dilemma as they are asymptomatic for long time, and histopathology is the gold standard for diagnosis. As a rule, treatment is surgical and dictated by the location of the tumor and nerve of origin. Due to its rarity, complex anatomical location and morbidity risk postexcision, they can pose a formidable challenge to surgeons. +is study aims to describe the presentation, workup, surgical technique, and outcome. 1. Introduction 2. Materials and Methods Neurilemmoma also known as schwannoma is a benign tumor of A retrospective analysis was done at MGM Medical College nerve sheath origin, arising from any nerve covered with a schwann and Hospital, Aurangabad, from January 2015 to December cell sheath, which includes the cranial nerves (except for optic and 2016. Of the five patients, two were female and three were olfactory), the spinal nerves, and autonomic nervous system [1, 2]. males, with a mean age of 33 years (ranging from 23 to 40 Schwannomas occurring in the head and neck region are years). Complete excision of the tumors was achieved by frequent, with 25–45% of all reported schwannomas being extracapsular excision using microneurosurgical technique found in this region [1]. with operating microscope. Preservation of nerve of origin We present our surgical experience with five such tumors, was achieved in all except one where conventional extrac- one arising from the maxillary branch of the trigeminal nerve in apsular excision technique was applied. Surgical observa- the maxillary sinus, second arising from the brachial plexus, third tion, histopathology, and immunochemistry confirmed the arising from the cervical vagus, and two arising from cervical tumors to be benign schwannomas in all five cases. +ere spinal nerves. +e clinical presentation, surgical treatment, and was no recurrence in any of the five patients (on clinical outcomes of patients with this pathology are described. examination) at one year follow-up. 2 Case Reports in Otolaryngology 2.1. Case 1. We describe a rare case of schwannoma arising Tinel sign was positive with the patient, and she reported primarily from the maxillary sinus extending into the orbit tingling sensation “pins and needles” along the shoulder tip. and intracranially. A 40-year-old female presented with Spurling’s test was negative in this patient. headache since 2 years, left nostril discharge since 1 year, and Pre- and postcontrast MRI neck screening revealed a well- left eye progressive vision loss since 1 year. defined, rounded space occupying lesion in the right side of Diagnostic nasal endoscopy (DNE) revealed left-sided the neck, that was found to be lateral to the neck vessels and nasal mass, pale, firm, pinkish in colour, not bleeding on superficial to the subclavian vessels. +e lesion was hyper- touch. Clinical examination revealed reduced vision in the intense on T2-weighted images and STIR (short T1 inversion left eye with finger counting less than five feet, with mild recovery) images and was found to be isointense on T1- proptosis of the left eye. +ere was no motor or sensory loss weighted images with heterogeneous contrast enhancement with no other cranial nerve dysfunction. in the lesion (Figure 4). +ese features were suggestive of Contrast-enhanced CT (CECT) scan with cisternog- a neurogenic tumor. raphy revealed a large lobulated mass of size 81 ×53 × 82 mm Under general anaesthesia, the tumor was approached in the left zygomatic and masseteric region with intracranial using a V-shaped incision. +e brachial plexus was explored. extension (Figure 1(a)). +e lesion was causing thinning and +e tumor was found arising from the upper trunk of the pressure erosion of the posterior wall of maxillary sinus, pter- brachial plexus and was found to be adherent to the middle and ygoid plate, posterior wall of orbit, medial wall of sphenoid on the lower trunk of the brachial plexus (Figure 5(a)). +e tumor left side, left lesser wing of sphenoid, and was causing thinning of appeared to be greyish white, firm, and globular (Figure 5(b)). left anterior clinoid process. +e tumor was carefully excised in toto after debulking by Superiorly, mass was extending to middle cranial fossa microneurosurgical technique. Intra-op nerve stimulator was and displacing left middle temporal lobe. Medially, it was used for localising the nerve fascicles around the tumor and extending to left nasal cavity causing complete blockage. during excision. After excision, the nerve fascicles were found to Posteriorly, it was extending to the posterior nasopharyngeal be intact. Postoperatively, the patient complained of paraes- region. Laterally, it was involving and abutting the masseter thesia of the right upper limb which recovered in two weeks. and pterygoid muscles and intraorbital muscles. Superiorly, it was extending to the infraorbital region and displacing and 2.3. Case 3. We describe a 23-year-old male patient who compressing the left optic nerve. Lamina papyracea and presented with right-sided painless neck swelling since one cribriform plate were intact. month. +ere was no history of trauma, fever, and systemic Clinical features and CECT were suggestive of malignant illness. +e patient had no complains of weakness, dys- tumor. +is divisive situation steered us to keep a possibility phagia, and hoarseness of voice. On local examination, of a malignant component in the tumor. a single ovoid swelling was present in the right carotid +e tumor was approached through Weber Furguson in- triangle, anterior to the sternocleidomastoid, measuring cision with subciliary extension. Left suprastructure maxillotomy 3 × 2 cms. Swelling did not move on deglutition or tongue was done. Tumor was firm, necrotic, moderately vascular, and protrusion. +ere was no loss of muscle power in all muscles, grayish white (Figure 2(a)) and found arising from the maxillary no signs of wasting, or neurological deficits. nerve. Tumour was found to be arising from the left maxilla, USG neck showed a hypoechoic lesion seen at bi- breaching it’s posterior wall and floor of orbit, extending into the furcation of the carotid artery. Moderate central and pe- retroorbital portion of orbit through the superior orbital fissure ripheral vascularity was seen within the lesion. Findings into the left temporal lobe. Total excision of the tumor was carried were suggestive of a carotid body tumor/nerve sheath tumor. out. Left temporal bone base was reached, and temporal lobe was CECT neck revealed a well-defined, well-encapsulated, identified. Total excision of intracranial portion of tumor was peripherally enhancing soft tissue mass lesion of size achieved. Bleeding from the left cavernous sinus was controlled 3.4 ×1.8 cm (Figure 6). +e mass lesion was noted in the with Abgel® and Surgicel®. Orbital floor reconstruction was done right carotid sheath between the right common carotid with titanium mesh. Maxilla reconstruction was done with ti- artery and internal jugular vein, posterolateral to the right tanium mesh and plate (Figure 2(b)). Postoperatively, patient had lobe of thyroid. +e lesion was seen below the carotid bi- an uneventful recovery, with minimal left eye vision improve- furcation. Features were suggestive of a vagal schwannoma. ment (Figure 1(b)). +e tumor was approached by an anterior approach along the medial border of sternocleidomastoid. Platysma and fascia were dissected to reach the tumor. +ere was a medium-sized 2.2. Case 2. We describe a 35-year-old female who presented globular smooth mass, well-encapsulated seen engulfing the with right-sided supraclavicular swelling since 3 years (Figure 3) vagus nerve (Figures 7(a)–7(c)). Extracapsular tumor excision and complained of paraesthesia over the right upper limb. was done in toto by conventional technique. Vagus was severed +ere was no history of trauma, fever, and systemic illness. in the process. Vagus was reanastomosed, using the sural nerve +e patient had evidence of right C5, C6 radicular pain, and graft (Figure 7(d)). hypoesthesia. +e patient had no complains of weakness, loss Postoperatively, the patient had mild dysphagia which of function of upper limb.
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