Carotid sinus nerve cut in surgery
Regret for the inconvenience: we are taking measures to prevent fraudulent form submissions by extractors and page crawlers. Received: August 02, Published: December 8, DOI: Download PDF. Background: Injury to the cavernous portion of the Internal Carotid Artery ICA during nasal endoscopic sinus surgery is a rare complication, which is associated with high rates of morbidity and mortality.
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Carotid Artery Stenosis
Providing cutting-edge scholarly communications to worldwide, enabling them to utilize available resources effectively. We aim to bring about a change in modern scholarly communications through the effective use of editorial and publishing polices. Advanced knowledge sharing through global community…. Konstantinos Paraskevopoulos. Department of Oral and Maxillofacial Surgery, G. Papanikolaou General Hospital, Thessaloniki, Greece. E-mail : bhuvaneswari. Anna Patrikidou. Angelos Megalopoulos. Department of Vascular Surgery, G.
Panagiotis Palladas. Angeliki Cheva. Konstantinos Antoniades. Konstantinos Vahtsevanos. Background : Carotid body is a small mass of tissue in the carotid sinus containing chemoreceptors that monitor levels of oxygen, carbon dioxide, and hydrogen ions in the blood. Carotid body tumors CBTs are rare and found at carotid bifurcation. They are painless neck masses, which expand slowly and they could press the neighboring neurovascular tissues.
Because of their proximity to cranial nerves, neurological symptoms could present. The tumors are mostly benign. They can present at any age and appear at the same frequency in either sex. Papanikolaou General Hospital, Thessaloniki, Greece between and , aiming to highlight the multidisciplinary management of CBTs and highlight the role of head and neck surgeon. Results: Eight cases of CBT resection are reported. All tumors were excised by vascular and maxillofacial surgeons after preoperative embolization of the feeding vessels.
Double mandibular osteotomy DMO was the surgical approach of choice, as it enables ample access to the parapharyngeal space and facilitates safe excision. All patients are still in follow up. There were no postoperative cerebral strokes or mortality, but other post-operative complications occurred, notably cranial nerve palsies. No revealed recurrence of CBT was observed.
Conclusion : A collaborative, multidisciplinary approach is essential in the management of these highly vascular tumours with a reported high rate of neurological complications. Carotid body tumors CBTs , belonging to the extra-adrenal paragangliomas, arise from chomaffin-negative chemoreceptor cells found at the common carotid artery bifurcation.
First described by Von Haller in [1], they are extra-adrenal paragangliomas are neoplasms of the paraganglia located within the paravertebral sympathetic and parasympathetic chains. Paragangliomas may also occur in the context of Von Hippel Lindau syndrome, neurofibromatosis 1 or multiple endocrine neoplasia MEN syndromes type 2A or 2B. CBTs are painless neck masses with typical location, vessel displacement and specific blood supply.
They usually expand slowly and they could press the neighboring neurovascular tissues [7]. CBTs can present at any age and appear at the same frequency in either sex [8]. Functional, cathecholamine-secreting carotid body tumors are exceedingly rare [9,10]. It is crucial to make a correct preoperative diagnosis. Differential diagnosis includes a thyroid nodule, lymphadenopathy, brachial cyst, middle ear adenoma, meningioma and schwannoma [3,4].
In general, radiographic studies are pathognomonic, so fine needle biopsy is not indicated [12]. Ultrasound may be the first imaging procedure to determine the nature of a neck mass. Angiography can provide invaluable information on the lesion vascularisation, while CT and MRI offer more accurate locoregional assessment [13]. We performed a retrospective analysis of patients managed for a carotid body tumor at the G. Data collection was based on electronic and paper records. Informed consent for surgical procedures was obtained from all the patients.
Between and , eight patients with CBT were managed at G. Papanikolaou General Hospital 1 male, and 7 female patients, median age: 50 years, range: years Table 1. All patients presented with a slow-growing neck swelling, without any symptoms of cranial nerve involvement. No relevant family history was reported in any of these cases. Clinical examination did not identify signs or symptoms indicative of genetic syndromes such as Von Hippel-Lindau, neurofibromatosis 1 or MEN 2A or 2B.
Preoperative imaging evaluation did not identify other lesions, notably no lymph node involvement. Baseline endocrinology and cardiovascular assessment was normal, confirming an isolated non-secreting carotid body paraganglioma in all cases. Table 1. Patient cohort demographics, tumour description, post-operative functional outcome.
Preoperative imaging by CT scan of the head and neck and orthopantomogram was used to assess Shamblin type Table 1 and mandibular anatomy and position of the mental foramen so as to optimise surgical access. All patients underwent digital substraction angiography, typically showing intense tumor blush Figure 1 , followed by pre-operative particle embolization of the feeding vessels.
The efficacy of embolization was assessed via comparison of pre- and post-embolization angiographies Figure 1. Surgery of CBTs was performed at a hour interval post-embolization and involved a collaborative effort by a vascular and maxillofacial surgeons team.
Surgical access to the parapharyngeal space was performed by maxillofacial surgeons, followed by resection of CBTs by vascular surgeons. In all of these cases, double osteotomy of the mandible DMO was necessary in order to access the tumor Figure 2.
This surgical technique consists of two mandibular osteotomies, as previously described [14,15]. The first vertical subsigmoid one is positioned posterior to the lingula in order to avoid injury of the inferior alveolar nerve.
The second osteotomy is performed in front of the mental foramen protecting the mental nerve Figure 3. After the excision of the tumor, the mandible was reconstructed via mini-plate osteosynthesis. Figure 1. Digital substraction angiography, before left and after embolization right. Figure 2. Double osteotomy of the mandible via transcervical approach intra-operative picture. Figure 3. Diagram showing the design of the bone cuts for the type of double mandibular osteotomy anterior to the mental foramen combined with a vertical ramus osteotomy and coronoidectomy.
Osteotomy segments are retracted superiorly and laterally. After the tumor has been removed, the osteotomized mandibular segments are reapproximated and stabilized with the adapted bone plates Reprinted with permission from Lazaridis and Antoniades J Oral Maxillofac Surg Histological examination revealed highly vascular tumors composed of dual cell population arranged in clusters Zellballen pattern.
The chief cells type I were epithelioid, small- medium size, uniform cells, with granular, pink to clear cytoplasm. They were more numerous than type II cells and expressed CD56, synaptophysin and chromogranin but not cytokeratin.
No malignant component was identified in any specimen. Figure 4. There were no postoperative strokes or mortality. All patients are still in follow up, without recurrence of CBT. Post-operative complications were observed in five cases. Transient marginal mandibular nerve paresis was observed in one patient, resolving within the next four months after the surgery.
A second patient suffered transient hypoglossal nerve paresis and a third one suffered dysphonia due to left vocal fold paresis, also resolving. A fourth patient had inferior alveolar and lingual nerve paresis and lingual fibrillation. After a few months follow-up, the inferior alveolar nerve paresis had 3completely resolved, with persistence of the lingual nerve paresis. Another patient suffered marginal mandibular and hypoglossal nerve paresis with dysphonia and dysphagia.
In the next seven months, we observed improvement of these symptoms but accessory nerve paresis appeared. Carotid body is a small mass of tissue in the carotid sinus containing chemoreceptors that monitor levels of oxygen, carbon dioxide, and hydrogen ions in the blood [16].
CBTs expand slowly and are usually painless. The risk of intraoperative cranial nerves injuries depends on the location of CBTs, and it is higher in large tumors [19,20], rendering the assessment of preoperative status of cranial nerves crucial. Given these intricacies, a designed multidisciplinary approach optimizes management and aims to minimize peri-operative morbidity. Preoperative embolization of the feeding vessels is a valuable intervention for these vascular tumours [22], notably helping to reduce perioperative bleeding especially in cases of large CBTs, and thus reducing operative time.
It does not, however, decrease rates of cranial nerve injury []. Our approach of choice was double osteotomy of the mandible. This technique provides excellent access to the entire parapharyngeal space, in contrast to the difficulty encountered with non-DMO approaches [26,27]. This is necessary to enable complete removal of CBTs and vascular control, therefore obtaining radical excision and minimal functional or cosmetic effects after the surgery [14,15,26,28,29].
Indeed, even authors that advocate non-osteotomy approaches, they have opted for an osteotomy in cases of suspicion of malignant disease, hence required ample anatomical access to the parapharyngeal space.
Furthermore, the modification of the technique used, initially described by our team [14,15] and subsequently by others [28,29], avoids the necessity for a lip-incision approach. Finally, the the subsigmoid osteotomy provides larger bony surface for application of rigid fixation, as opposed to a subcondylar osteotomy [15,28].
In conclusion, our case series highlight the importance and value of multidisciplinarity in the management of CBTs, highlighting the valuable role of the head and neck surgeon in this demanding and functionally delicate anatomical region.
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Cavernous Sinus Syndrome
Skip to main content. Patients at high risk of stroke with carotid resection or ligation should be observed or receive nonsurgical treatment. Pathogenesis The following 3 different types of carotid body tumors CBTs have been described in the literature: Familial, Sporadic, Hyperplastic. The hyperplastic form is very common in patients with chronic hypoxia, which includes those patients living at a high altitude.
Endoscopic Repair of Carotid Artery Injury
Background: Injury to the internal carotid artery ICA during endoscopic transsphenoidal surgery ETSS is a serious complication with a risk of mortality. Several hemostatic procedures have been proposed for ICA injury in the intrasellar portion, whereas hemostatic methods for ICA injury in the extrasellar portion, where the ICA is surrounded by bone structures, are less well known. The petrous portion of the left ICA was injured during resection of the sphenoid septum connected with left carotid prominence using a cutting forceps. Bleeding was too heavy for simple hemostatic techniques. Hemostasis using a crushed muscle patch was tried unsuccessfully during controlling of the bleeding. Eventually, the injured site of the ICA was covered with cotton patties followed by closing with a vascularized pedicled nasoseptal flap. Cerebral angiography immediately after surgery showed no extravasation from the injured site of the left ICA petrous portion.
Carotid Body Tumors
Providing cutting-edge scholarly communications to worldwide, enabling them to utilize available resources effectively. We aim to bring about a change in modern scholarly communications through the effective use of editorial and publishing polices. Advanced knowledge sharing through global community…. Konstantinos Paraskevopoulos.
Glossary of Neurosurgical Terminology
This article is for educational purposes only. It should not be used as a template for consenting patients. The person obtaining consent should have clear knowledge of the procedure and the potential risks and complications. Always refer to your local or national guidelines, and the applicable and appropriate law in your jurisdiction governing patient consent. Carotid endarterectomy is undertaken to prevent ischaemic stroke.
Complications in Endoscopic Sinus Surgery
Neurosurg Cases Rev Transorbital penetrating injuries are particularly rare in the adult population. We present a case of TOPI sustained in an assault using a ballpoint pen-with concomitant transmaxillary injury due to a pencil stab wound-and a review of the literature. Transorbital penetrating injuries TOPI are particularly rare in the adult population, accounting for 0. In the setting of TOPI, there should be a high index of suspicion for damage to the intracranial vascular and neural structures. The conical orbital shape allows for penetrating objects to enter the intracranial space without fracture through three posterior apertures: The superior orbital fissure, optic canal, and the inferior orbital fissure [ 1 - 8 ].
Carotid sinus
Andrew W. Holt, David A. In cardiovascular research, translation of benchtop findings to the whole body environment is often critical in order to gain a more thorough and comprehensive clinical evaluation of the data with direct extrapolation to the human condition.
Health A to Z
RELATED VIDEO: Carotid Injury in Endonasal SurgeryA carotid endarterectomy is a surgical procedure to open or clean the carotid artery with the goal of stroke prevention. It is a durable procedure but not a cure; though rare, blockage can accumulate again. A carotid endarterectomy is performed in a sterile surgical suite or standard operating room. You may go home the same day or stay 1—2 nights after the procedure depending on your medical condition. Carotid Endarterectomy.
Surgery for Nasal Cavity and Paranasal Sinus Cancers
News Health News General health check. External carotid artery ligation surgery Share:. The external carotid artery is one of the two branches of the original carotid artery, which supplies blood to the facial neck region. Surgical ligation of the external carotid artery to stop bleeding in the ear, nose, throat, molars, skull. Surgical ligation of the external carotid artery is indicated when: Injury to the carotid artery in the head and neck area. Nose bleeding, bleeding after tonsillectomy persists after using conventional hemostatic measures to no avail, bleeding in oral cancer. Prophylactic ligation in major head and neck surgery: Surgery to remove maxilla, cut tongue cancer, parotid gland cancer, nasopharyngeal fibroma
The venous drainage system of the head and face have a unique anatomy. The dural sinuses and the cerebral and emissary veins have no valves, which allows blood to flow in either direction anterograde or retrograde according to venous pressure gradients in the vascular system. This fact and the extensive direct and indirect vascular connections of the centrally located cavernous sinuses make them vulnerable to pathology at many sites. The cavernous sinuses are dural venous sinuses that communicate with one another.
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