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CAROTID BODY TUMOUR
Rajeev M Joshi*, Ashfaq A Tapia**, Prasad K Wagle***,Sm Navadgi**, Taranpreet Bainz****
*Associate Professor; **Registrar; ***Lecturer; ****Resident, Department of Surgery, TN Medical College and BYL Nair Charitable Hospital, Mumbai 400 008.
A carotid body tumour though not an uncommon entity, is seldom put forth as the likely diagnosis in the case of upper neck swelling. An attempted biopsy of the tumour may lead to bleeding with disastrous consequences. We present here the case of a young male who was suspected of having a carotid body tumour only after an attempted biopsy was followed by torrential haemorrhage.CASE REPORT
A 22 year old male patient presented with an asymptomatic painless slowly growing swelling since 3 years in the right upper neck. There was no history of swellings elsewhere over the body, nor was there a past history of tuberculosis.
There was no dysphagia or dyspnoea.
A biopsy which had been attempted earlier under the impression that it was a lymph node swelling, had met with torrential bleeding. Haemostasis had been achieved with difficulty.
Examination revealed an oval 4 x 4 cm swelling in the right upper neck partially extending below the right sternocleidomastoid muscle. The skin over the swelling revealed the scar of previous biopsy. Pulsations were seen over the swelling. On palpation, the lump had a smooth surface, firm consistency and showed transmitted pulsations. On turning the face to the opposite side, the swelling became less prominent. No bruit was heard. There was no lymphadenopathy localisd or generalised.
CT scan picked up a highly vascular lesion in the right upper neck encasing the right external carotid artery (Fig. 1).
Colour doppler showed a mass between the two carotid vessels compressing the internal carotid and the internal jugular vein medially. Blood flow through the vessels was normal.
A four vessel angiography showed a highly vascular lesion in the neck with feeding vessels from the external carotid artery. The intra-cerebral circulation was normal (Fig. 2).
Fig 1 : CT scan showing the highly vascular lesion in the right upper neck encasing the external carotid artery.
At surgery the mass was approached through an incision anterior and parallel to the right sternocleidomastoid muscle. The internal jugujar vein and the common carotid artery were identified below the mass and the external and internal carotids were identified above the tumour. The middle thyroid vein and the vessels feeding the tumour were ligated. The external carotid was divided and the tumour was entirely separated from the internal carotid, maintaining the intra-cerebral circulation. The patient recovered uneventfully and was discharged.
Histopathology demonstrated the mass to be a paraganglioma.
DISCUSSION
Carotid body tumours[1] are derived from both, the mesoderm of the second branchial arch and the ectoderm of the neural crest. They are also called paragangliomas because they arise from the paraganglionic cells. They may have malignant potential in 2.6 - 50% of the cases and lymphatics are the most favoured route of spread.
On the basis of incidence, they may be divided into two types :
1) Sporadic type - more common2) Familial type - autosomal dominant pattern with a 32% incidence of bilaterality
Carotid body tumours usually present as a painless palpable mass over the region of carotid bifurcation. Large tumours may produce hoarseness of voice, dysphagia, stridor and even tongue weakness. Some tumours may secrete catecholamines leading to hypertension.The investigation of choice is a bilateral cerebral angiography[2] were the tumour appears as a hypervascular oval mass. Furthermore angiography also helps to identify the sources of blood supply.
The treatment is essentially operative, consisting of excision of the tumour and maintenance of blood supply to the brain.[3]. The dissection generally proceeds along the subadventitial plane but when deeper involvement of the wall is present, full thickness excision of the base of the tumour is done with the application of a vein patch. When the carotid artery requires clamping, the cerebral function is monitored and an indwelling carotid shunt (Javed Shunt) is used to maintain cerebral perfusion.
When the tumour is very large, the carotid artery may have to be sacrificed and the circulation is restored with an arterial graft. If the pressure in the carotid stump is more than 65 mm of Hg, then the carotid artery may be ligated without reconstruction, the complication of this procedure is contralateral hemiplegia.
When the tumour is unresectable, radiotherapy may be tried. Carotial body tumours should be kept in mind whenever upper neck swellings are encountered to avoid the pitfalls of unexpected severe bleeding during biopsy.
REFERENCES1.Connel J. Carotid tumours Aust NZ J Surg 1977; 47 : 495.
2.Rush BF Jr. Current concepts in treatment of carotid body tumours. Surg 1962; 52 : 692.
3.Westbrook KC, Guillamondegui OM, Mendellium H, Jess RH. Chemodectomas of the neck selective management. Am J Surg 1972; 124 : 760.
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