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OBJECTIVES:
Paragangliomas of the neck are rare tumors. The most common paragangliomas of the neck are located in the carotid bifurcation. These tumors are generally supplied by the external carotid artery. We present a case of a large right lower neck paraganglioma with atypical blood supply from the right thyrocervical trunk.
METHODS:
RESULTS:
A 47 year old female presented with a right neck mass. Diagnostic workup included a computer tomography (CT) and ultrasound of head and neck which revealed a 4.5 cm in diameter hypervascular mass in the right lower neck lateral to the internal jugular vein. On the left side a smaller hypervascular lesion was discovered in the carotid bifurcation. We first addressed the large right sided neck mass.
The patient was taken to the angiosuite for embolization of the right sided neck mass prior to excision. Selective angiogram of the right thyrocervical trunk visualized two main branches feeding the highly vascularized mass. Using a microcatheter system all branches were selectively cannulated and embolized with ethylene vinyl alcohol (Onyx Liquid Embolic System). A completion angiogram showed embolization of the entire mass.
The next day, the patient was taken to the operating room for excision of the mass. The mass was located postero-lateral to the internal jugular vein abutting but not adhered the common carotid artery. The embolized vessels were clearly visible which facilitated excision and minimized blood loss. The patient tolerated the procedure well and was discharged home on post-operative day 2. Histologic workup revealed a 4.5 x 3.4 x 2.2 cm paraganglioma.
CONCLUSIONS:
Due to the size and vascular structure we decided to embolize the mass prior to resection. We chose the Onyx Liquid Embolization System which consists of ethylene vinyl alcohol copolymer dissolved in DMSO (dimethyl sulfoxide) and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy that precipitates in situ into a black, spongy embolus which makes it easy to visualize vessels intra operatively. As we could readily identify feeding vessels resection of the tumor was facilitated with minimal blood loss. We believe that preoperative embolization can be useful in selected cases, especially verifying the blood supply and assessing the risk of cerebral embolization to minimize the risk of stroke.