Cervical Sympathetic Chain Schwannoma Masquerading as a Vagus Nerve Schwannoma Complicated by Postoperative Horner's Syndrome and Facial Pain: A Case Report

Intracapsular Enucleation of Cervical Sympathetic Chain Schwannoma

OBJECTIVES

Schwannoma arising from cervical sympathetic chain (CSC) is a rare clinical entity. CSC is hard to preserve in CSC schwannoma (CSCS) surgeries, resulting in Horner's syndrome (HS) and first bite syndrome (FBS). This article aims to explore our experience in successful preservation of CSC in CSCS surgeries.

METHODS

This is a retrospective review of CSCS cases treated at our tertiary medical institution between Apr 2018 and March 2022. Only cases with successful intraoperative preservation of CSC were included.

RESULTS

In total, 3 cases were included. There were 2 male patients and 1 female patient. Their age was between 38 years old and 66 years old (average and median age was 52 and 51 years old, respectively). Presenting symptom was neck mass for all them, 2 of which were on the left side, while 1 was on the right. Intracapsular enucleation of the CSCS was attempted and achieved in all 3 cases. Hemorrhage from the inner surface of capsules was diffuse and heavy. Constant saline irrigation, suction, and bipolar coagulation were needed to achieve hemostasis. Postoperative HS presented between 4 hours and 14 hours after surgery for all 3 patients, which took 1 month to 3 months to recover, whereas FBS did not occur in any patient. Median duration of follow-up was 6 months. No recurrence was observed.

CONCLUSIONS

Intracapsular enucleation should be attempted in CSCS surgeries, although hemorrhage might be diffuse and hard to control. When intracapsular enucleation was achieved, postoperative FBS can be avoided, while postoperative HS could occur, but its recovery was satisfactory.

Quantification of vessel separation using the carotid-jugular angle to predict the nerve origin of neck peripheral nerve sheath tumours: a pooled analysis of cases from the literature and a single-center cohort

BACKGROUND

Postoperative nerve palsy is a major complication following resection of neck peripheral nerve sheath tumours (PNSTs). Accurate preoperative identification of the nerve origin (NO) can improve surgical outcomes and patient counselling.

MATERIAL AND METHODS

This study was a retrospective cohort and quantitative analysis of the literature. The authors introduced a parameter, the carotid-jugular angle (CJA), to differentiate the NO. A literature review of neck PNST cases from 2010 to 2022 was conducted. The CJA was measured from eligible imaging data, and quantitative analysis was performed to evaluate the ability of the CJA to predict the NO. External validation was performed using a single-centre cohort from 2008 to 2021.

RESULTS

In total, 17 patients from our single-centre cohort and 88 patients from the literature were analyzed. Among them, 53, 45, and 7 patients had sympathetic, vagus, and cervical nerve PNSTs, respectively. Vagus nerve tumours had the largest CJA, followed by sympathetic tumours, whereas cervical nerve tumours had the smallest CJA ( P <0.001). Multivariate logistic regression identified a larger CJA as a predictor of vagus NO ( P <0.001), and receiver operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.907 (0.831-0.951) for the CJA to predict vagus NO ( P <0.001). External validation showed an AUC of 0.928 (0.727-0.988) ( P <0.001). Compared with the AUC of the previously proposed qualitative method (AUC=0.764, 0.673-0.839), that of the CJA was greater ( P =0.011). The cut-off value identified to predict vagus NO was greater than or equal to 100°. Receiver operating characteristic analysis showed an AUC of 0.909 (0.837-0.956) for the CJA to predict cervical NO ( P <0.001), with a cut-off value less than 38.5°.

CONCLUSIONS

A CJA greater than or equal to 100° predicted a vagus NO and a CJA less than 100° predicted a non-vagus NO. Moreover, a CJA less than 38.5 was associated with an increased likelihood of cervical NO.