Neurilemmoma of the vagus nerve: a case report

Cervical vagal nerve schwannoma induced arrhythmia: a rare case report and literature review

Background

Schwannomas are benign tumors deriving from the sheath of cranial and peripheral nerves. The vagus nerve is comprised of a complex neuro-endocrine-immune network that maintains homeostasis, most tracts of it play a role in parasympathetic activity. We present an example of a rare cervical vagal schwannoma case accompanied by arrhythmia.

Case presentation

A 35-year-old female patient with a left cervical vagus schwannoma and ventricular arrhythmia underwent schwannoma resection in the operating room. The patient’s suppressed heart rate increased after tumor removal, and the cardiac rhythm returned to normal postoperatively. Pathological examination demonstrated the diagnosis of schwannoma.

Conclusions

This case explains the link between the vagus nerve and the cardiovascular system, proving that a damaged cervical vagus nerve can inhibit the heart rate and lead to arrhythmias, and eventually requiring surgical intervention.

Cervical Vagal Schwannoma: Anesthetic Concerns

Schwannomas arising from cervical vagus nerve is an extremely rare benign neoplasm. The majority of patients present with insidiously growing lateral neck mass without neurological deficit. We report a case of symptomatic cervical vagal nerve schwannoma in a 32-year-old female. Complete surgical resection is the treatment of choice. However, anesthetic management of these tumors can be challenging. We describe here the complications experienced during the management of the patient.

Superiority of resection over enucleation for schwannomas of the cervical vagus nerve: A retrospective cohort study of 22 consecutive patients

INTRODUCTION

Schwannoma of the cervical vagus nerve is rare. Treatment options include intracapsular enucleation and en bloc resection. The purpose of this study was to compare the outcomes of enucleation and resection in terms of postoperative mortality and morbidity, freedom from vocal cord palsy, freedom from local recurrence, quality-adjusted life-year (QALY) and vocal handicap index (VHI).

METHODS

Twentytwo consecutive patients were divided into two groups. Patients in group A (n = 9) underwent intracapsular enucleation, whereas patients in Group B (n = 13) underwent en bloc resection. Main endpoints of the study were postoperative mortality and morbidity, freedom from vocal cord palsy, freedom from local recurrence and quality of life. The quality of life after surgery was assessed according to the quality-adjusted life-year (QALY) EQ-5D-5L methodology, and calculation of the voice handicap index (VHI).

RESULTS

Postoperative mortality was nil. Morbidity included 1 wound dehiscence in group A and 2 transitory dysphagias in group B. Freedom from vocal cord palsy was 22% in group A and zero in group B (p = 0.15). Operation-specific local recurrence rate was 33% (3/9 patients) in group A and nil in group B (0/23 patients) (p = 0.05). QALYs was 0.55 in group A and 0.54 in group B (p = 1.0). VHI was 23.77 in group A and 26.15 in group B (p = 1.00).

CONCLUSION

Resection is superior to enucleation in terms of freedom from local recurrence. Functional results are comparable for both techniques.

Carotid Space Mass Proximal to Vagus Nerve Causing Asystole and Syncope

Manipulation of vagal nerve rootlets, whether surgical or through mass effect of a neoplasm, can result in asystole and hypotension, accompanied by ST depression and right bundle branch block. There are few case reports of a neoplasm causing these effects, and this case describes a patient with such a mass presenting with syncopal episodes. A 43-year-old man with a past medical history of HIV, bipolar disorder, and epilepsy was admitted to the neurology service for a video electroencephalogram (vEEG) to characterize syncopal episodes that were felt to be epileptic in origin. During the study, he experienced symptoms of his typical aura, which correlated with a transient symptomatic high degree AV block on telemetry, and an absence of epileptic findings on vEEG. Magnetic Resonance Imaging (MRI) of the brain showed a mass in the left posterior carotid space at the skull base. The patient underwent permanent dual chamber MRI-compatible pacemaker placement for his heart block. His syncopal episodes resolved, but presyncopal symptoms persisted. We discuss the presentation and treatment of vagal neoplasms.

Thoracoscopic resection of a vagal schwannoma in the superior mediastinum: A case report

Neurogenic tumors are the most common type of mediastinal tumor and constitute the majority of neoplasms of the posterior mediastinum. Schwannomas originating from the intrathoracic vagus nerve are extremely rare. The present study describes the case of a 58-year-old man with a large vagal schwannoma in the left superior mediastinum. A large tumor with a round shape was identified in the left superior mediastinum. The tumor originated from and encased the vagus nerve. Using video-assisted thoracoscopic surgery, the tumor was completely excised with amputation of the vagus nerve encased within in the tumor. One year post-surgery, the patient was free of recurrence with no symptoms other than hoarseness.

Two cases of schwannoma with marked cystic changes

We report two cases of schwannoma displaying marked cystic changes; one in the temporalis muscle and one in the submandibular space. The first patient, a 44-year-old male, presented after complaining of a swelling rapidly increasing in size in the left temporal region. Computed tomography (CT) indicated a low-density area surrounded by soft tissue. Magnetic resonance imaging (MRI) revealed signal hypointensity on T1 weighted imaging and strong signal hyperintensity on T2 weighted imaging. The extirpated tumour specimen measured 58 mm x 58 mm x 30 mm. Histopathological examination identified schwannoma, comprising spindle cell proliferation in a palisading pattern with obvious cystic changes. The second case involved a 46-year-old female who presented with swelling of the right submandibular region. Panoramic radiography and lateral oblique mandible projection, which were used together with conventional sialography of the submandibular gland, revealed the so-called "ball in hand" appearance of the submandibular gland, and contrast-enhanced CT identified a lesion of 30 mm diameter with a well-defined annular margin and homogeneous low-density near the tumour centre. Benign pleomorphic adenoma was suspected, but histopathological examination identified schwannoma, predominantly comprising Antoni B type tissue.

An unusual cause of reflex cardiovascular syncope: vagal paraganglioma

Vagal paraganglioma is one of the rare tumors of the neuroendocrine system. We are reporting a vagal paraganglioma case presented with uncommon features of the disease: asystole and syncope. Syncope episodes occurred 3 years before the major symptoms of the disease. Dual chamber pacemaker failed to prevent syncope attacks because of the vasodepressor component. The patient was treated successfully with en bloc removal of tumor and vagal nerve. Syncope episodes disappeared after operation.

Neurogenic tumors of the cervical vagus nerve: report of four cases and review of the literature

OBJECTIVE AND IMPORTANCE

Nerve sheath tumors arising from the cervical vagus nerve are extremely rare. These tumors most often present as asymptomatic, slowly enlarging, lateral neck masses and therefore often come initially to the attention of otolaryngologists and general surgeons. Because they are nerve tumors, however, neurosurgeons must be able to recognize and treat these rare entities. We report three cases of schwannoma and one case of neurofibroma of the cervical vagus nerve that were encountered at our center (Louisiana State University Medical Center) during a 31-year period.

CLINICAL PRESENTATION

The patients ranged from 31 to 61 years of age at the time of presentation to Louisiana State University Medical Center. Presenting complaints included hoarseness, Horner's syndrome, and palpation of an enlarging, asymptomatic, cervical mass. Reviews of systems revealed episodes of aspiration for one patient and frequent respiratory illnesses for two patients. These episodes were possibly related to their tumors. Imaging studies demonstrated well-circumscribed masses in the region of the carotid sheath.

INTERVENTION

Using microsurgical techniques, gross total resection of all four tumors was accomplished. For one patient, the vagus nerve needed to be divided and an end-to-end anastomosis was performed. For the other three patients, resection of the tumor was achieved with the vagus nerve in continuity.

CONCLUSION

Vagal nerve schwannomas and neurofibromas in the neck are rare neoplasms. We present four cases of these benign tumors. The pathological features, epidemiological characteristics, presentation, differential diagnosis, and management are discussed. Gross total resection with preservation of the vagus nerve remains the treatment of choice.

Cervicothoracic vagal neurilemoma: report of a case

We report herein the rare case of a 45-year-old man with a cervicomediastinal neurilemoma of the vagus nerve. The tumor was 160 x 40 x 35 mm in size and extended from the angle of the right mandible to the aortic arch. Despite this being the largest such tumor ever reported, the patient presented without any symptoms. Thus, although vagal neurilemoma is uncommon, it should nevertheless be included in the differential diagnosis of any asymptomatic mass along the vagus nerve. In the evaluation of such masses, magnetic resonance imaging can provide useful information regarding not only the location, but also the nature of the lesion.

Neurofibroma of the vagus nerve in the head and neck: a case report

A case of a tumor of the vagus nerve, showing typical features of a neurofibroma, is presented. The natural history is reviewed, and several technical investigations, with particular reference to the contributions of magnetic resonance imaging and immunohistochemical techniques in the differential diagnosis, are discussed.

Vagal nerve schwannoma--a new diagnostic sign

A case of vagal nerve schwannoma with a new physical sign is presented. The tumour was largely cystic and aspiration, performed twice, immediately elicited a cough reflex from the patient. Treatment was by total excision and the patient made a good recovery. Complete cystic degeneration of a vagal nerve schwannoma is uncommon. A search of the literature has failed to find any previous reports of fine needle aspiration causing a cough reflex in these tumours.

Intrathoracic tumors arising from the vagus nerve. Review of resected tumors in Japan

Nineteen surgically treated intrathoracic vagus nerve tumors (16 neurilemmomas, 3 neurofibromas), including three treated by the authors, were reviewed. Tumor resection with vagus nerve amputation was performed in 14 and intracapsular excision without nerve amputation in 3 of the 17 adequately recorded cases. The location of vagus nerve tumor was the left upper mediastinum in 11 patients, almost all of whom were hoarse postoperatively due to sacrifice of the recurrent laryngeal nerve.

Schwannoma of the vagus nerve

A case is described in which severe bradycardia complicated removal of a Schwannoma of the vagus nerve in the parapharyngeal space. The presentation of this rare tumour is discussed.

Malignant schwannoma of the cervical vagus nerve in a patient with neurofibromatosis (von Recklinghausen's disease)

A patient with malignant schwannoma arising from the cervical vagus nerve has been described. Treatment consisted of wide en bloc resection of the tumor and adjacent carotid artery. A subclavian-middle cerebral arterial bypass procedure, using a saphenous vein graft, was performed. A course of postoperative radiotherapy was administered. The patient remains without evidence of disease 11 months following therapy.

Malignant schwannoma of the vagus nerve: a case report and review of the literature

A case of neuroectodermal tumor, a malignant schwannoma, of the cervical vagus nerve is presented. It had been previously misdiagnosed and was a recurrence. A review of the literature reveals this to be the sixth such case reported. The difficulties in establishing a diagnosis and the principals of adequate therapy are discussed; these include wide surgical resection and postoperative radiotherapy to the tumor bed. The correct recognition of their malignant potential is essential for long-term disease-free survival.