Neurogenic tumors of the neck

Comprehensive analysis of radiological and surgical predictors in cervical sympathetic schwannomas: a novel staging approach and its implications

BACKGROUND

Vagal schwannomas are well-documented, but cervical sympathetic chain schwannomas (CSCS) are rare, with most knowledge from case reports. This study aims to identify radiological predictors of misdiagnosis and factors guiding surgical approaches based on tumor size and extent.

METHODS

An ambispective analysis was conducted on 21 cases of CSCS, examining preoperative data, intraoperative findings and the questionnaire to identify the potential predictors. Tumors were classified into three types based on their relationship with the carotid sheath, and this classification was correlated with vessel ligation and postoperative neural outcomes.

RESULTS

An excellent agreement was found between radiologist on new classification system(Kappa:0.89). Tumor classification revealed a diverse distribution, with 6 cases identified as Type 1, 6 as Type 2, 5 as Type 3, and 4 as Type 3S. The necessity of external carotid artery (ECA) ligation correlated with the tumor type. Type 3 tumors required ECA ligation in 50% of cases, while Type 1 and Type 2 tumors predominantly involved vascular preservation. Postoperative complications included vagal palsy in 28.5% of cases and first bite syndrome in 71.4%.

CONCLUSION

Accurate preoperative planning and a novel staging system can enhance surgical outcomes and reduce postoperative complications as validated by our study.

Low back pain with axillary mass in a perimenopausal woman: A case of schwannomatosis mimicking metastasis

Schwannomatosis is a rare neurocutaneous syndrome characterized by the presence of multiple schwannomas along the peripheral nerves, distinctly excluding the vestibular nerves. It is recognized as the third principal form of neurofibromatosis, alongside neurofibromatosis types 1 and 2. In this report, we discuss the case of a 45-year-old woman who initially sought medical attention for low back pain and swelling in her left axilla. Her magnetic resonance imaging revealed multiple enhancing intradural extramedullary lesions, along with a mass in the right upper thoracic region and another in the left axilla, raising suspicions of metastasis. However, a comprehensive analysis that aligned imaging results with histopathological findings confirmed the diagnosis of schwannomatosis. This case highlights the importance of differentiating between various conditions that can cause multiple intradural extramedullary masses, such as nerve sheath tumors, meningiomas, and metastasis. The presence of multiple schwannomas suggests a diagnosis of either neurofibromatosis type 2 or schwannomatosis, making the distinction between these two conditions critical for appropriate management.

Solitary neurofibroma in the external auditory canal

Significance Statement: Neurofibromas, derived from perineural cells, are usually benign in the nervous system. Although neurofibromas are common in the head and neck, they rarely affect the external auditory canal (EAC), and few cases have been reported. We describe a case of a solitary EAC neurofibroma with otoscopy, radiological imaging, a surgical approach, and an uneventful outcome.

Pseudo-Lyre Sign

To study the causes of the Pseudo- Lyre sign which is radiologically demonstrated in tumours other than the carotid body tumour. The study is based on an unusual case of neurofibroma of the cervical sympathetic chain presenting as a pulsatile mass in the carotid triangle in a 34 years female. Radiological investigation pointed to a diagnosis of a carotid body tumour because of typical splaying of the internal and external arteries causing the Lyre sign. At surgery, the tumour which was arising from the cervical sympathetic chain (CSC) was excised with minimum blood loss and histopathology confirmed it to be neurofibroma. This, we presume is the first ever report of a neurofibroma of the cervical sympathetic chain causing Lyre sign which we have referred to as Pseudo-Lyre sign. The various investigations which help in diagnosing the cause of Pseudo-Lyre sign have been discussed. All tumours causing Lyre sign on radio-imaging are not carotid body tumours. Other masses mostly neurogenic can demonstrate this sign and an attempt should be made preoperatively to confirm the diagnosis.

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.

Small biopsies in the head and neck: Bone and soft tissue

Bone and soft tissue lesions in the head and neck encompass not only a broad morphologic spectrum but also significant inherent clinicopathologic overlap. Epidemiology, radiology, and location - similar to the diagnostic assessment in other sites - are especially important considerations in the context of an established mesenchymal proliferation. Herein, the approach towards diagnosis is stratified by morphology (spindle, sarcomatoid, epithelioid, round cell), cellular lineage (fibroblastic, nerve sheath, rhabdomyogenic), and tumor grade (benign, low- to high-grade malignant) as the basis of further immunohistochemical or molecular investigation.

A Rare Case of Extralaryngeal Schwannoma Arising from the Superior Laryngeal Nerve

Schwannomas are the most common neurogenic tumours arising in the parapharyngeal space. Usually they arise from the vagus nerve but rarely have an extralaryngeal presentation arising from the superior laryngeal nerve. In the case reported here, cytology could not confirm the diagnosis and imaging could not identify the nerve of origin.

A Rare Cause of Dysphagia: A Giant Ganglioneuroma in Parapharyngeal Space

Parafarengeal ganglioneuroma is a very rare benign tumor originating from the sympathetic nervous system that produces mass and functional effects. Ganglioneuroma is most commonly caused by the posterior mediastinal, retroperitoneal area and adrenal glands. Generally, they do not present any additional signs or symptoms other than mass. Horner's syndrome may sometimes occur due to the compression of the sympathetic chain. A 41-year-old male patient with a long-standing mass in the lateral compartment of the left neck was admitted to our clinic. The patient was operated, and the pathological result of the mass was reported as ganglioneuroma. We present a rare case of ganglioneuroma in paraphryngeal space by reviewing the current literature.

Mimics of perineural tumor spread in the head and neck

Perineural spread (PNS) is an important potential complication of head and neck malignancy, as it is associated with decreased survival and a higher risk of local recurrence and metastasis. There are many review articles focused on the imaging findings of PNS. However, a false-positive diagnosis of PNS can be just as harmful to the patient as an overlooked case. In this manuscript, we delineate and classify various imaging mimics of PNS. Mimics can be divided into the following categories: normal variants (including vascular structures and failed fat suppression), infections, inflammatory disease (including granulomatous disease and demyelination), neoplasms, and post-traumatic/surgical changes. Knowledge of potential mimics of PNS will prevent false-positive imaging interpretation, and enable appropriate oncologic management.

A population-based analysis of clinical features and lymph node dissection in head and neck malignant neurogenic tumors

Background

The influence of lymph node dissection (LND) on survival in patients with head and neck neurogenic tumors remains unclear. We aimed to determine the effect of LND on the outcomes of patients with head and neck neurogenic tumors.

Methods

Data of patients with surgically treated head and neck neurogenic tumors were identified from the Surveillance, Epidemiology, and End Results (SEER) database (1975–2016) to investigate the relationship between LND and clinical outcomes by survival analysis. Subgroup analysis was performed in IVa and IVb group.

Results

In total, 662 head and neck neurogenic tumor patients (median age: 49.0 [0–91.0] years) met the inclusion criteria, of whom 13.1% were in the IVa group and 86.9% were in the IVb group. The median follow-up time was 76.0 months (range: 6.0–336.0 months), and the 5-year and 10-year overall survival was 82.4% (95% CI, 0.79–0.85) and 69.0% (95% CI, 0.64–0.73). Cox regression analysis revealed older age (P < .001), advanced stage (P = .037), African American race (P = .002), diagnosis before 2004 (P < .001), and chemotherapy administration (P < .001) to be independent negative predictors of overall survival. Kaplan-Meier analysis demonstrated that LND was not a predictor of clinical nodal negativity (cN0) in either IVa or IVb patients.

Conclusions

In head and neck neurogenic patients, LND may not impact the outcome of cN0 in either IVa or IVb group. These data can be recommended in guiding surgical plan and future studies.

Mapping the rest of the human connectome: Atlasing the spinal cord and peripheral nervous system

The emergence of diffusion, structural, and functional neuroimaging methods has enabled major multi-site efforts to map the human connectome, which has heretofore been defined as containing all neural connections in the central nervous system (CNS). However, these efforts are not structured to examine the richness and complexity of the peripheral nervous system (PNS), which arguably forms the (neglected) rest of the connectome. Despite increasing interest in an atlas of the spinal cord (SC) and PNS which is simultaneously stereotactic, interactive, electronically dissectible, scalable, population-based and deformable, little attention has thus far been devoted to this task of critical importance. Nevertheless, the atlasing of these complete neural structures is essential for neurosurgical planning, neurological localization, and for mapping those components of the human connectome located outside of the CNS. Here we recommend a modification to the definition of the human connectome to include the SC and PNS, and argue for the creation of an inclusive atlas to complement current efforts to map the brain's human connectome, to enhance clinical education, and to assist progress in neuroscience research. In addition to providing a critical overview of existing neuroimaging techniques, image processing methodologies and algorithmic advances which can be combined for the creation of a full connectome atlas, we outline a blueprint for ultimately mapping the entire human nervous system and, thereby, for filling a critical gap in our scientific knowledge of neural connectivity.

Differential Diagnosis and Treatment Outcomes of Tumors at the Carotid Bifurcation

Purpose

Primary tumor at the carotid bifurcation is uncommon, which includes paraganglioma, schwannoma, and lymphoma. Due to their rarity, characteristics of these tumors and problems related to their surgical treatment have not been well known. We tried to elucidate different clinical characteristics and surgical complications of these tumors.

Materials and Methods

We retrospectively reviewed 21 patients with carotid bifurcation tumor from the Vascular Surgery division of a Korean tertiary institution from 1995 to 2018. We investigated patients' demographics and clinical features, image characteristics, treatment details, and surgical outcomes.

Results

During the period from January 1995 to January 2018, we experienced surgical resections of 21 carotid bifurcation tumors which included 16 (76.2%) paragangliomas and 5 (23.8%) schwannomas. The most common clinical feature was a non-tender cervical mass. According to Shamblin classification, paragangliomas were classified into class II in 68.8% and class III in 25.0%. On the preoperative computed tomography images, all the paragangliomas showed characteristic splaying of the carotid bifurcation and hypervascularity of the tumors. On the contrary, all the schwannomas showed hypovascularity and splaying sign in 60%. Surgical complications related to cervical nerve injury developed in 50% and 60% of patients with Shamblin class III paraganglioma and schwannoma, respectively. During the mean follow-up period of 25 months (range, 1 to 163 months), distant metastases developed in 2 (12.5%) of paraganglioma patients.

Conclusion

Neurologic complications were more common after surgical resection of Shamblin class III paraganglioma and schwannoma. For patients with paraganglioma, postoperative periodic follow-up examination is advised to detect distant metastasis.

Supraclavicular Cervical Schwannoma: A Case Report

Schwannoma generally occurs in the vestibular nerve. Cervical schwannomas are quite rare. Herein, we present a case of slow-growing asymptomatic supraclavicular schwannoma in an elderly woman of 74 years. The patient was managed conservatively with regular follow-up as the tumor showed slow progressive growth (presented after seven years) and asymptomatic.

Schwannoma in the Supraclavicular Region: Case Report

Schwannomas are benign tumors arising from schwann cells in peripheral, cranial, and autonomic nerve sheaths. Approximately half of all cases of schwannomas are observed in the head and neck region. In this study, a 71-year-old male patient presenting with a stiff mobile mass in the left supraclavicular region and diagnosed as a schwannoma after total excision was presented.

Diagnostic, Surgical, and Postoperative Challenges of Neuroendocrine Tumors of the Neck: Clinical Experience and Literature Review

BACKGROUND

Neuroendocrine tumors of the neck are rare swellings, which constitute about 0.03% of all tumors. Most are sporadically arising paragangliomas. Over 50% arise from the carotid bodies and pose difficulties in diagnosis and surgical management, which may result in disabling complications.

OBJECTIVE

To determine the diagnostic, surgical, and postoperative challenges, and how to overcome them, in the management of neuroendocrine tumors of the neck.

STUDY DESIGN

Descriptive case series.

METHODS

A retrospective analysis of 19 patients who presented to our surgery clinics between 2010 and 2015 with neck swelling and suspicion of neurogenic tumors were included in the study. All patients received preoperative evaluation with Doppler studies and neck computed tomography scan, with the finding of suspicion of neurogenic tumor. Preoperative tissue diagnosis was not attempted as this usually required excisional biopsy. All tumors were surgically excised. Data regarding mean tumor size, neurovascular invasion, postoperative complications, and histopathological findings were recorded and statistically analyzed.

RESULTS

Nineteen patients (7 male) with median age of 45 years were included. Mean size of the tumor was 7.5 cm (range: 4.0-11.8 cm). Six of the tumors were right sided and 13 left sided. Clinical findings often were nonspecific and mimicked other conditions. Operative challenges were encountered in 11 (57.9%) patients, who had tumors of more than 5 cm. Vascular invasion was found in 2 (10.5%) patients, but bleeding requiring preoperative transfusion was not required in any patient. Neurological complications occurred in 11 (57.8%) patients; 3 had transit hypoglossal nerve palsy, with full recovery; 2 had complete nerve palsy, with reasonable rehabilitation without further surgical intervention; and 5 developed neurological deficits (hoarseness, dysphagia, or Horner's syndrome) but recovered and compensated well without further operation. Two patients who had vascular invasion required vascular reconstruction. Histopathology in 14 (73.7%) cases was carotid body tumor and 5 were Schwannomas (1 vagal and 4 sympathetic chain). All 4 patients with Schwannomas of cervical sympathetic chain developed Horner's syndrome; 2 of them have compensated well with reasonable recovery; 2 have had tarsorrhaphy for cosmetic reasons. The patient with vagal Schwannoma developed hoarseness and swallowing difficulties, which resolved without intervention. No malignancy was encountered in this series, and there was no mortality.

CONCLUSIONS

Neuroendocrine tumors of the neck present diagnostic challenges because of nonspecific clinical findings mimicking other conditions. Preoperative tissue diagnosis is mostly unsuccessful, and exact diagnosis requires excisional biopsy. Surgical excision, which is the main treatment, often has associated technical difficulties and unavoidable complications requiring further intervention.

Neurofibroma of the Cheek and Nasal Dorsum: A Case Report and a Mini Review

Neurofibroma is a benign neoplasm derived from peripheral nerves. Most of these are associated with neurofibromatosis but may also occur as solitary lesions. When found in the neck, they are often located in the soft tissues. They are slow-growing masses, often asymptomatic and have been found most commonly in the oral cavity. We report a case of neurofibroma involving two separate and unusual sites of face, which are subcutaneous tissues of the cheek and dorsum of nose, and present a brief review of literature.

How to cite this article

Gupta N, Kaur R, Rai A, Wadhwa N, Singh PP. Neurofibroma of the Cheek and Nasal Dorsum: A Case Report and a Mini Review. Int J Otorhinolaryngol Clin 2016;8(2):62-64.

Is surgery for brachial plexus schwannomas safe and effective?

BACKGROUND

Schwannomas rarely are found in the brachial plexus, and although they are benign, they present significant challenges to surgical treatment. To our knowledge, there are few studies investigating the surgical outcomes of patients with brachial plexus tumors.

QUESTIONS/PURPOSES

We analyzed the outcomes of 19 patients with brachial plexus schwannomas and asked: (1) How do these patients present? (2) Where are the tumors located in the brachial plexus? (3) What are the complications and neurologic results of patients after excision of the tumor?

METHODS

From February 2002 to August 2012, one orthopaedic hand surgeon treated 19 patients with schwannomas of the brachial plexus. We retrospectively reviewed the medical records and MRI data of all patients. There were 11 women and eight men, with a mean age of 50.2 years (range, 32-63 years). The tumor was located on the right side in eight patients and on the left in 11 patients. We evaluated neurologic deficits preoperatively and neurologic deficits and local recurrence of tumors postoperatively. Minimum followup was 12 months (mean, 37.2 months; range, 12-90 months).

RESULTS

The most common initial presentation was a palpable mass. The masses were located at all levels along the brachial plexus, including the root, trunk, cord, and terminal branches. The smallest mass was 1.5 × 1.5 × 0.5 cm and the largest was 11 × 10 × 6 cm. Fourteen of the 19 patients did not have any postoperative neurologic deficits. All the removed masses were proven histologically to be schwannomas. Of the five patients who had postoperative neurologic deficits, three had transient sensory deficits, one had weakness of the flexor pollicis longus and second flexor digitorum profundus, and another had weakness of the extensor pollicis longus. No recurrence was observed during the followup period.

CONCLUSIONS

Schwannomas of the brachial plexus are a potentially curable lesion with an acceptable surgical risk of injury to neurovascular structures. With precise surgical techniques, these tumors can be removed to improve symptoms with minimal morbidity.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Intrapharyngeal schwannoma in a pediatric patient

Schwannomas are benign peripheral nerve neoplasms that arise from Schwann cells. They usually occur in the adult population. The most common site in the head and neck region is the parapharyngeal space. Intrapharyngeal schwannomas are extremely rare, and those that have been reported all occurred in adults. We report what to the best of our knowledge is the first case of an intrapharyngeal schwannoma in a pediatric patient. The patient, a 15-year-old boy, was treated successfully with surgical excision.

Management of an incidental malignant peripheral nerve sheath tumour in the parapharyngeal space

Background:

Parapharyngeal space tumours are uncommon and represent 0.5–1 per cent of all head and neck neoplasms; 20–30 per cent of these are malignant. Malignant peripheral nerve sheath tumours are rare and mostly encountered in patients with neurofibromatosis type 1. Only four cases of parapharyngeal space tumours have been reported in the English language in patients without neurofibromatosis type 1.

Case report:

We report the case of a 64-year-old man with no stigmata of neurofibromatosis type 1, in whom a mass in the left pre-styloid region of the parapharyngeal space was an incidental finding following magnetic resonance imaging for investigation of cervical spine problems. The mass was consequently removed using a transcervical approach. A histological review revealed a low-grade malignant peripheral nerve sheath tumour.

Discussion:

We consider the pathophysiology of this highly malignant tumour as well as the challenging anatomy of the parapharyngeal space and the surgical and other therapeutic modalities utilised to treat this condition.

Magnetic resonance imaging of the pediatric neck: an overview

Evaluation of neck lesions in the pediatric population can be a diagnostic challenge, for which magnetic resonance (MR) imaging is extremely valuable. This article provides an overview of the value and utility of MR imaging in the evaluation of pediatric neck lesions, addressing what the referring clinician requires from the radiologist. Concise descriptions and illustrations of MR imaging findings of commonly encountered pathologic entities in the pediatric neck, including abnormalities of the branchial apparatus, thyroglossal duct anomalies, and neoplastic processes, are given. An approach to establishing a differential diagnosis is provided, and critical points of information are summarized.

Novel use of a Weerda laryngoscope for transoral excision of a cervical ganglioneuroma: a case report

INTRODUCTION

A ganglioneuroma is a benign neoplasm arising from neural crest cells of the sympathetic nerve fibers and is most commonly seen in the posterior mediastinum or retroperitoneum. Although very uncommon, ganglioneuromas must be included in the differential diagnosis of neck masses. In young adult women, neck incisions made for excision of these benign tumors should be avoided whenever possible.

CASE PRESENTATION

We herein describe the case of a 19-year-old Japanese woman with a ganglioneuroma. The tumor was found in the parapharyngeal space, an unusual location. A fine-needle aspiration biopsy was performed but was considered inadequate to make a definitive diagnosis, so the asymptomatic lesion was surgically excised using a Weerda laryngoscope. The lesion measured 4 × 3 cm in size and was encapsulated. A pathological analysis showed the presence of two distinct cell types, ganglion cells and Schwann cells, embedded in a loose myxoid stroma. The final diagnosis was a ganglioneuroma.

CONCLUSION

A complete excision was made possible by using a transoral approach with a novel use of the Weerda laryngoscope. Although its applicability to specific cases depends on the location, size and nature of the tumor, we believe that the Weerda laryngoscope will continue to be useful for performing transoral surgery for cervical tumors.

Imaging of pediatric neck masses

Palpable neck masses are a common indication for pediatric imaging. Such lesions may be caused by infectious, inflammatory, tumoral, traumatic, lymphovascular, immunologic, or congenital etiologies. Radiological assessment of neck masses in young children should be tailored based on patient presentation and physical examination, as well as clinical suspicion. The goal of imaging should be to help arrive at a diagnosis or limited differential in an efficient manner while minimizing radiation exposure.

CT and MRI evaluation of nerve sheath tumors of the cervical vagus nerve

OBJECTIVE

Nerve sheath tumors arising from the cervical vagus are rare. The purpose of this study was to evaluate the role of CT and MRI in the diagnosis of these uncommon neoplasms.

MATERIALS AND METHODS

The CT and MR studies and clinical data of 11 patients with surgicopathologic evidence of a nerve sheath tumor of the cervical vagus (nine schwannomas [including two ancient schwannomas] and two neurofibromas) who had been referred to our institute from January 1999 through 2009 were retrospectively reviewed. The tumors were evaluated with respect to their location, number, morphology, attenuation and/or signal intensity, enhancement characteristics, and patterns of mass effect.

RESULTS

The tumors were solitary and well circumscribed. On CT, eight tumors were hypodense with poor enhancement, two were predominantly isodense, and a single lesion had multiple cystic areas with enhancing solid components. On MRI, they were heterogeneously bright on T2-weighted images with intense, inhomogeneous postgadolinium enhancement. The "split fat" sign, "entering and exiting nerve" sign, "fascicular" sign, and "hyperintense rim" sign were seen in some patients. The internal or common carotid artery was displaced anteriorly in eight patients, maintained a neutral position in two patients, and was displaced posterolaterally in another patient. In all patients except two, the tumor separated the carotid artery from the internal jugular vein. Vagal schwannomas splayed the carotid bifurcation in three patients.

CONCLUSION

In conclusion, we present the patterns of mass effect and a spectrum of CT and MRI characteristics of nerve sheath tumor of the cervical vagus including observations that are sparingly described in the published literature.

Retropharyngeal ganglioneuroma presenting with neck stiffness: report of a case and review of literature

Ganglioneuromas rarely occur in the retropharynx with only three cases reported in the current literature. The most common symptom associated with retropharyngeal ganglioneuromas is dysphagia. We report a retropharyngeal ganglioneuroma with an unusual clinical presentation of neck stiffness and pain. A 42-year-old woman presented with incapacitating neck pain, neck stiffness, right upper extremity weakness, as well as dysphagia. Neurological workup was normal. Imaging revealed a hyperdense, ill-defined, diffuse right retropharyngeal mass suggestive of a possible nerve sheath tumor with no communication with the cervical spine. Surgical removal was uneventful and associated with a postoperative Horner's syndrome. In follow-up, dysphagia and neck symptoms improved. Retropharyngeal ganglioneuromas can occur in a wide age range of patients. Surgical excision via a cervical approach offers definitive therapy but may be associated with an iatrogenic Horner's syndrome for which the patients should be counseled prior to operative intervention. Neck pain is an atypical symptom that needs to be worked up to rule out a communication with the spinal column prior to surgical removal. Patients must be counseled that atypical symptoms may not completely resolve with surgical treatment.

Hypoglossal schwannoma presenting only with headache

Hypoglossal schwannoma is a rarely encountered skull base lesion that has generally both intracranial and extracranial parts. This article reports a case of hypoglossal schwannoma that is purely extracranial and presents itself only with persistent headache. Magnetic resonance imaging delineated a mass at the skull base that consisted of both cystic and solid components, consistent with a nerve sheath tumor. Cervical approach was chosen, and the mass was completely removed. Postoperatively, the patient developed hypoglossal nerve palsy because the hypoglossal nerve was sacrificed. Hypoglossal schwannomas are briefly discussed with a literature review.

Schwannoma of the vagus nerve masquerading as a carotid body tumor

A 45-year-old male presented with increasing hoarseness and swelling of his right neck over 5 months. He was noted to have right vocal cord paralysis and hemiatrophy of his tongue. He was found to have a schwannoma of the vagus nerve with compression of the right hypoglossal nerve. One month after his surgery, the patient's tongue mobility was improving, he was not aspirating, his voice was better and his right vocal cord remained abducted. A discussion of this case is followed by a review of the literature surrounding this rare disease and this unique presentation.

Imaging lesions of the cavernous sinus

Our aim was to review the imaging findings of relatively common lesions involving the cavernous sinus (CS), such as neoplastic, inflammatory, and vascular ones. The most common are neurogenic tumors and cavernoma. Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the CS as can perineural and hematogenous metastases. Inflammatory, infective, and granulomatous lesions show linear or nodular enhancement of the meninges of the CS but often have nonspecific MR imaging features. In many of these cases, involvement elsewhere suggests the diagnosis. MR imaging is sensitive for detecting vascular lesions such as carotid cavernous fistulas, aneurysms, and thromboses.

Cystic schwannoma of the cervical plexus masquerading as a type II second branchial cleft cyst

This case illustrates the rare occurrence of a cystic schwannoma of the neck, presenting clinically and ultrasonographically as a type II second branchial cleft cyst. Histology demonstrated that it was in fact a rare cystic schwannoma, most likely arising from the cervical plexus. This is the first documented case of a cystic schwannoma of the neck being mistaken for a type II second branchial cleft cyst based on clinical and ultrasound findings alone. It suggests that more sophisticated radiological investigations, such as magnetic resonance imaging, may enable accurate diagnosis of a cystic schwannoma of the neck pre-operatively.

Extracranial head and neck schwannomas—A 10-year review

OBJECTIVES

To present our experience in managing a large case series of extracranial schwannomas highlighting presenting features, diagnostic difficulties, and outcomes associated with surgical treatment of these tumours.

METHOD

A retrospective case note study of 31 patients with a diagnosis of extracranial schwannoma seen in the Department of Otolaryngology, Head and Neck Surgery at Southmead Hospital, a tertiary referral centre and University hospital between 1 June 1993 and 30 May 2003.

RESULTS

The commonest anatomical location was in the neck (42%) and an isolated neck lump was the commonest presentation (77%). Pressure symptoms were the next most common mode of presentation, and were often a helpful indicator of the nerve of origin. The nerve of origin was identified in 47% of patients who underwent surgery. Immunohistochemistry was a useful tool in the diagnosis of these tumours and magnetic resonance imaging was the preferred imaging technique to delineate their extent. The most significant postoperative morbidity was associated with the schwannomas of the vagus nerve, sympathetic chain, hypoglossal nerve, glossopharyngeal nerve and the facial nerve.

CONCLUSION

Schwannomas can present in a wide variety of sites within the head and neck region and therefore it is important that otolaryngologists and head-neck surgeons are familiar with the more common sites of presentation and the potential difficulties associated with the diagnosis and management of these tumours. Adequate imaging should be carried out preoperatively to gain as much information as possible about the individual tumour and allow informed patient counseling regarding to potential risks and morbidity of surgical intervention.

Sporadic and multiple neurofibromas in the head and neck region: a retrospective study of 33 years

The neurofibroma occurs as isolated or multiple lesions frequently associated with neurofibromatosis type 1 (NF-1). The aim of this study was to analyze the clinical and histopathological features of neurofibromas, particularly the plexiform variant, in the skin and oral mucosa, discussing their pathogenesis as well as clinical management of isolated lesion unassociated with NF1. The clinicopathologic features of 66 neurofibromas in the head and neck region diagnosed at the pathology laboratories of the Bauru Dentistry School and Lauro de Souza Lima Research Institute from 1970 to 2003 were reviewed. The clinical data, therapy, and follow-up information were obtained from the medical records. The results showed a high frequency of cutaneous lesions (81.8%) occurring mainly in females older than 40 years. Isolated neurofibromas were found in 51.2% of patients, and multiple lesions were often associated with the NF-1. The histopathological analysis demonstrated that diffused neurofibromas occur more frequently than the plexiform type. However, one case of plexiform neurofibroma was detected in the oral mucosa as an isolated lesion non-associated with the NF-1. The indolent clinical behavior of isolated neurofibromas in the head and neck region and the absence of NF-1 association reinforce that sporadic lesion could be hyperplastic or hamartomatous rather than neoplastic in nature.

Schwannoma of the Retropharyngeal Space

We report a rare case of schwannoma arising from the retropharyngeal space. A 24-year-old man presented a 2-month-history of a foreign body sensation in the throat and gradually progressing dysphagia when he swallowed solids and liquids. The patient had no odynophagia, fever, or blood in his saliva. Computed tomographic scans and magnetic resonance images revealed a well-defined and oval mass, measuring about 40 mm x 20 mm in size, in the retropharyngeal space. Because the tumor existed in the retropharyngeal space and was the adequate size, the patient underwent trans-oral resection under the direct laryngoscope without the need for skin incision. On the basis of the histological findings, the tumor was diagnosed as a schwannoma. It was mostly composed of spindle cells arranged in short bundles and fascicles, with focal palisading of the nuclei. The neoplasm arising from the retropharyngeal space is quite rare, because of few anatomical structures in the space. The post-operative course was uneventful, and the patient is currently free from disease 30 months after surgery. Diagnosis, clinical behavior, and treatment of retropharyngeal schwannoma are reviewed from perusal of the literature. When schwannomas are located in the pharynx, they may cause foreign body sensation or dysphagia. Therefore, when a foreign body sensation in the larynx is present, a thorough diagnostic procedure should be performed to evaluate the morphology of the upper aerodigestive tract.

A schwannoma mimicing hypopharyngeal carcinoma

Hypopharyngeal schwannoma is quite rare, with only nine cases presented in the literature to our knowledge. The presentation itself requires a distinction from malignant hypopharyngeal disease, which is usually the initial diagnosis. A transcervical approach and laryngomicrosurgery are two possible operating methods for the treatment of hypopharyngeal schwannoma. The selection of the surgical method depends on the size of the tumor. For this case, we preferred the transcervical approach without tracheotomy. In contrast to previous case reports, we were unable to trace the original nerve.

Neck masses in children

Infants and children with neck masses frequently present to the radiologist for further evaluation. The role of the radiologist is to differentiate between conditions using imaging modalities such as ultrasound with colour Doppler, CT and MRI. Where appropriate, the radiologist will also stage lesions for management purposes and aid in guiding aspiration or biopsy. This paper presents a pictorial review of paediatric neck masses and their imaging features. Particular emphasis is applied to the anatomical site of the mass to aid in differential diagnosis. It must be emphasised that the radiological findings should always be interpreted in conjunction with the patient's age, the clinical history and the findings on physical examination.

Extracranial head and neck schwannomas: a review of 8 years experience

Schwannomas of the head and neck are uncommon tumors that arise from cranial, peripheral or autonomic nerves. In this study we review a series of 52 cases of schwannoma originating in the head and neck region over an 8-year period. All the tumors were benign, with the exception of one malignant schwannoma. The age range of the patients studied was 13-76 years and there was a predilection for males. Twenty-five schwannomas occurred in the scalp, face and external ear canal, 9 in the oral or nasal cavity and 18 in the neck. Seven cases of neck schwannoma originating from the major nerve system were found in the parapharyngeal space, all of which were located in the post-styloid compartment. Cervical plexus schwannomas originated either in the peripheral nerves or in an unidentified area of the nervous system; seven tumors were found in the posterior triangle of the neck and two in the anterior triangle. Two of the tumors originating in the brachial plexus were located in the posterior neck and one in the anterior neck. Tumors originating in the vagus nerve or sympathetic chain were all located in the anterior triangle of the neck.