view dr. orakzai's presentation here. new!
TRANSCRIPT
![Page 1: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/1.jpg)
Sarwar H. Orakzai MD, James T. Devries MD, Robert C. Griffin, Salvatore P. Costa MD, Robert Palac MD, Richard J. Powell MD.
From the vascular laboratory of Dartmouth-Hitchcock Medical Center, Dartmouth School of Medicine,
Lebanon, NH
Vascular Ultrasound Case Presentation
![Page 2: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/2.jpg)
• CC: Left sided neck mass
• HPI: 43 y female presented with enlarging left sided neck mass
• Left sided neck mass present for year but stable in size
• Overall the last few months, the mass slowly increased in size
• Continued growth despite course of antibiotics
Case
![Page 3: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/3.jpg)
• ROS: no dysphagia, odynophagia, flushing
• + intermittent dizziness and heart racing
• PMH: Nasal allergies
• SH: works in a neurology office in medical records, smokes ½ ppd, ocassional alcohol use
• FH: Father has premature CAD, Mother has DM , no malignancies
Case
![Page 4: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/4.jpg)
• Meds: zyrtec 10mg qd
zantac prn
MVI 1 tab qd
Case
![Page 5: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/5.jpg)
• Afebrile HR 95 BP 130/89 RR 18 sats 98% on RA
• HEENT: 4cm pulsatile left sided neck mass below the angle of the jaw, no movement on swallowing, + bruit
• On right side a smaller mass in upper neck was noted, no bruit
• CVS: S1,S2 audible, no m/r/g
• Resp: CTA bilaterally
• Neuro: CN II-XII intact
Examination
![Page 6: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/6.jpg)
Left CCA
![Page 7: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/7.jpg)
Left ECA and ICA
![Page 8: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/8.jpg)
Left ICA with mass
![Page 9: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/9.jpg)
Left ICA and ECA with mass
![Page 10: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/10.jpg)
Left ICA and ECA with mass
![Page 11: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/11.jpg)
Left ICA and ECA with mass
![Page 12: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/12.jpg)
Right sided tumor (mid neck)
![Page 13: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/13.jpg)
CT scan
![Page 14: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/14.jpg)
![Page 15: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/15.jpg)
Case
• Considering the vascularity of the mass, it was decided to perform preoperative embolization followed by surgical resection
• Successful embolization of left sided tumor by vascular surgery
• Followed by resection of left sided CBT by ENT within 48 hours
![Page 16: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/16.jpg)
Angiogram
![Page 17: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/17.jpg)
• Post op course uncomplicated except for mild hoarseness and dysphagia
• Both hoarseness and dysphagia resolved soon
• Plan to resect right sided CBT in the future
Case Managment
![Page 18: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/18.jpg)
• Paragangliomas are rare tumors that arise from neural crest cells associated with autonomic ganglia
• Can secrete neuropeptides and catecholamines
• Carotid body (CB) is the largest paraganglion in the head and neck and is located at the carotid artery bifurcation
Carotid Body Tumor
![Page 19: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/19.jpg)
• Upon stimulation, the CB releases neurotransmitters that activate the sensory fibers to increase ventilation rate
• CB thus protects the rest of the internal organs from hypoxic damage
• Carotid body tumors (CBT) are the most frequent type of head and neck paragangliomas, accounting for 65% of these tumors
Carotid Body Tumor
![Page 20: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/20.jpg)
• Typically presents in the 4th or 5th decades of life
• Painless, gradually enlarging neck mass at the level of the carotid bifurcation
• Limited mobility in the vertical direction but mobile in the lateral plane (Fontaine sign)
Carotid Body Tumor
![Page 21: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/21.jpg)
• CBT can cause compression of carotid arteries, cranial nerves, sympathetic chain and other neighboring structures
• Leading to pain, hoarseness, dysphagia, Horner's syndrome, and other neurological symptoms
• Functional hormone secretion is less common with head and neck paragangliomas
Carotid Body Tumor
![Page 22: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/22.jpg)
• CBTs may be familial
• Familial CBT are associated with mutations in the succinate dehydrogenase complex.
• Chronic hypoxia in patients with emphysema or in patients living at high altitudes can also lead to hyperplasia/neoplasia of the chief cells
Carotid Body Tumor
![Page 23: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/23.jpg)
• Bilateral CBT may be seen in 30% of familial cases but are rare in sporadic cases
• CBT may be malignant in 5-10% of cases
• Histologically, chief cells are arranged in a characteristic pseudoalveolar pattern referred to as “cell balls” (zellballen)
Carotid Body Tumor
![Page 24: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/24.jpg)
• Evaluation of CBT usually includes ultrasound, CT, MRI/MRA and angiography
• Ultrasound is usually the first diagnostic modality
• Solid, slightly heterogenous mass is detected at the level of carotid bifurcation
• Broadening of the bifurcation with shifting of ICA posteriorly and laterally and the ECA anteriorly and medially
Diagnosis
![Page 25: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/25.jpg)
• Color and power doppler demosntrate the characteristic increased vascularity of the tumor
• Ultrasound also excludes the presence of lymph nodes, thyroid or brachial cysts
• Also useful for follow up of CBT and screening of familial cases
Cerebrovascular US
![Page 26: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/26.jpg)
• CT usually shows a homogeneous mass with intense contrast enhancement and displacement of the carotid bifurcation by the mass
• MRI/MRA provides superior definition of the relationship of CBT to adjacent vascular and skull base structures
• MR/MRA shows intense homogeneous contrast enhancement and the classic “salt and pepper" appearance reflecting signal voids intermixed with regions of focally intense signal intensity
CT and MR/MRA
![Page 27: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/27.jpg)
• Angiography is used for better evaluation of tumor vascularity, tumor invasion of blood vessels and adequacy of the intracranial circulation if internal carotid artery sacrifice is necessary
• It also serves to preoperatively embolize the dominant blood supply to the tumor, thus reducing intraoperative profuse bleeding.
Angiography
![Page 28: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/28.jpg)
• For large tumors with symptoms, surgical resection is usually the treatment of choice
• CBTs have a rich blood supply, and preoperative embolization of the main arterial supply helps to reduce bleeding and other complications
• Surgery may be complicated by postoperative cranial nerve dysfunction and other neurological complications
Management
![Page 29: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/29.jpg)
• Bilateral excision of CB tumors may cause the baroreflex failure syndrome
• Characterized by hypertension in the first 24-72 h after surgery followed by labile hypertension/hypotension, headaches, emotional instability, and palpitations
• Long term follow-up is important following resection to evaluate for recurrence
Management
![Page 30: VIEW DR. ORAKZAI'S PRESENTATION HERE. NEW!](https://reader036.vdocuments.site/reader036/viewer/2022062319/555dbf42d8b42a63328b590e/html5/thumbnails/30.jpg)
Thank You