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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 1  |  Issue : 2  |  Page : 37-39

Giant schwannoma arising from cervical nerve root with intra-thoracic extension


1 Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Department of ENT, MM Institute of Medical Sciences and Research, Mullana (Ambala), Haryana, India

Date of Web Publication15-Jan-2014

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore 524 003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-2585.125044

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  Abstract 

Schwannomas are well-encapsulated benign neurogenic tumors that arise from the nerve sheaths of peripheral nerves. Schwannomas may occur nearly anywhere in the body, but have a predilection for the head and the neck, with an incidence of 40-50%. Rarely, the cervical nerve root can be the site of a large dumbbell neurogenic tumor in the neck. In the present article, we describe the case of a 40-year-old male with a large schwannoma arising from the cervical nerve root with intrathoracic extension. Surgical excision is the treatment of choice for neurogenic tumors, and it has been described that if the lesion is known to be a schwannoma, it is possible to open the capsule and shell out the tumor from the nerve, possibly avoiding functional deficits. However, as in the present case, it may not be possible to resect the tumor safely from the involved nerve root and it may be necessary to sacrifice the nerve involved in the tumor to achieve complete resection.

Keywords: Brachial plexus, cervical nerve root, neck tumor, neurogenic tumor, schwannoma


How to cite this article:
Agrawal A, Baisakhiya N. Giant schwannoma arising from cervical nerve root with intra-thoracic extension. J Orthop Allied Sci 2013;1:37-9

How to cite this URL:
Agrawal A, Baisakhiya N. Giant schwannoma arising from cervical nerve root with intra-thoracic extension. J Orthop Allied Sci [serial online] 2013 [cited 2019 Oct 21];1:37-9. Available from: http://www.joas.in/text.asp?2013/1/2/37/125044


  Introduction Top


Schwannomas are well-encapsulated benign neurogenic tumors that arise from the nerve sheaths of peripheral nerves. Schwannomas may occur nearly anywhere in the body, but have a predilection for the head and the neck, with an incidence of 40-50%. [1],[2],[3],[4],[5],[6],[7] Rarely, the cervical nerve root can be the site of a large dumbbell neurogenic tumor in the neck. [8] In the present article, we describe the case of a large schwannoma arising from the cervical nerve root with intrathoracic extension.


  Case Report Top


A 40-year-old male presented with progressively increasing swelling on the lower part of the right side of the neck of 1 year duration. This was associated with radicular pain, paresthesia and weakness of the right upper limb and with wasting of the hand muscles. There was a history of hoarseness and dry cough but there were no associated symptoms of dysphagia or odynophagia. On neurological examination, he had grade 3/5 weakness of foreman flexion and 50% grip weakness. There were no other deficits. Local examination revealed a firm, nontender, fixed and nonpulsatile mass on the right side of the neck [Figure 1]. The skin over the mass was freely mobile and there was no ulceration. There was no bruit or any cranial nerve palsies. Carotid pulse was not palpable. Other examinations were unremarkable. Thin sliced computed tomography (CT) scan and magnetic resonance (MR) imaging showed a well-defined dumbbell-shaped mass located in the right neuronal foramina causing foraminal widening with extension into the thoracic cavity and patchy enhancement after contrast administration. The mass was pushing the trachea and esophagus medially. The carotid artery was displaced anteromedially [Figure 2], [Figure 3], [Figure 4], [Figure 5]. All these imaging findings, including configuration, were suggestive of peripheral schwannoma with intrathoracic extension. Fine needle aspiration cytology of the tumor was suggestive of schwannoma. Intraoperatively, the mass was exposed through a cervical incision and could be removed completely [Figure 6]. The mass was seen clearly arising from the cervical nerve root and was going into the neural foramina. During the procedure, the nerve root could not be saved. Histological examination confirmed the diagnosis of schwannoma. The patient did well postoperatively and the drain was removed on the second postoperative day.
Figure 1: Clinical photograph showing the fullness in the lower part of the neck on the right side

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Figure 2: Axial computed tomography scan showing a tumor arising from the nerve root on the right side with mainly extraspinal growth and patchy enhancement. Note the widening of the nerve root exit foramina

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Figure 3: Multislice spiral computed tomography image with coronal and sagittal reconstruction showing the cervicomediastinal extent of the tumor

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Figure 4: Multislice spiral computed tomography angiography images showing the position of the carotid artery and parapharyngeal mass. Note the anteromedial displacement of the internal carotid artery and displacement and compression of the trachea

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Figure 5: Magnetic resonance image showing the details of neck mass with thoracic extension

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Figure 6: Specimen of the totally resected mass

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  Discussion Top


As in the present case, schwannomas in the head and neck region are mostly located in the parapharyngeal space; the vagus nerve is the most commonly involved nerve, followed by the cervical symphathetic nerve. [1],[2],[3],[4],[5],[6],[7] Rarely, cervical schwannoma may originate from the brachial plexus [9],[10],[11],[12],[13],[14],[15] or cervical root, [8] with associated intrathoracic extension posing a difficult management challenge. [1],[2],[3],[4],[5],[6],[7] Rarely, cervical schwannoma may originate from the brachial plexus. [9],[10],[11],[12],[13],[14],[15] These lesions can present either as asymptomatic solitary mass in the parapharyngeal space or neck [9],[10],[11],[12],[13],[14] or, as in the present case, with neurological signs related to the involved nerve/nerves. [8],[14] On clinical examination, the displaced carotid artery can be palpated in an anteromedial direction [9],[10],[11],[12],[13],[14] ; however, in the present case, it could be felt probably because of the tumor size. A contrast-enhancing CT and particularly MR image is the cornerstone of preoperative planning as other tumors that can present in a similar manner (a vagal or cervical symphathetic chain tumor) can be ruled out. Apart from this, imaging will help to determine the relation of the tumor mass to the carotid artery system. [9],[10],[11],[12],[13],[14] As in the present case, a CT scan can reveal a displaced carotid artery in the anteromedial direction. [9],[10],[11],[12],[13],[14] Surgical excision is the treatment of choice for neurogenic tumors [8],[15],[16],[17] and it has been described that if the lesion is known to be a schwannoma, it is possible to open the capsule and shell out the tumor from the nerve, possibly avoiding functional deficits. [15],[17] However, as in the present case, it may not be possible to resect the tumor safely from the involved nerve root and it may be necessary to sacrifice the nerve involved in the tumor to achieve complete resection. [8],[18]

 
  References Top

1.Myssiorek DJ, Silver CE, Valdes ME. Schwannoma of the cervical sympathetic chain. J Laryngol Otol 1988;102:962-5.  Back to cited text no. 1
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2.Zbären P, Markwalder R. Schwannoma of the true vocal cord. Otolaryngol Head Neck Surg 1999;121:837-9.  Back to cited text no. 2
    
3.Rosner M, Fisher W, Mulligan L. Cervical sympathetic schwannoma: Case report. Neurosurgery 2001;49:1452-4.  Back to cited text no. 3
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4.Uzun L, Ugur MB, Ozdemir H. Cervical sympathetic chain schwannoma mimicking a carotid body tumor: A case report. Tumori 2005;91:84-6.  Back to cited text no. 4
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5.Kahraman A, Yildirim I, Kiliç MA, Okur E, Demirpolat G. Horner's syndrome from giant schwannoma of the cervical sympathetic chain: Case report. B-ENT 2009;5:111-4.  Back to cited text no. 5
    
6.Sanghvi V, Lala M, Borges A, Rodrigues G, Pathak KA, Parikh D. Lateral thyrotomy for neurilemmoma of the larynx. J Laryngol Otol 1999;113:346-8.  Back to cited text no. 6
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7.Enzinger FM, Weiss SW. Soft tissue tumors. 2 nd ed. St. Louis: Mosby; 1988.  Back to cited text no. 7
    
8.Agrawal A, Singh GK, Rauniyar RK, Singh I, Shrestha S, Agrawal R. CT Characteristics of dumbbell schwannomma arising from the fifth cervical nerve root. Eur J Gen Med 2009;6:123-6.  Back to cited text no. 8
    
9.Noda M, Minowa M, Hosaka T, Takahashi S, Handa M, Kondo T. Schwannoma arising from brachial plexus with intrathoracic extension; report of a case. Article in Japanese. Kyobu Geka 2005;58:78-81.  Back to cited text no. 9
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10.Kanzaki M, Ohtsuka T, Obara T, Yamamoto H, Onuki T. Surgically treated dumbbell schwannoma arising in the brachial plexus with intrathoracic extension. Jpn J Thorac Cardiovasc Surg 2003;51:62-4.  Back to cited text no. 10
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11.Umemori Y, Makihara S, Kotani K, Miyahara N. A case of schwannoma arising in brachial plexus with intrathoracic extension. [Article in Japanese]. Kyobu Geka 2001;54:599-602.  Back to cited text no. 11
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12.Tanimura S, Ishikawa K, Mun M, Tomoyasu H, Kohno T, Matsushita H. A case of benign schwannoma arising in the brachial plexus with intrathoracic extension. [Article in Japanese]. Kyobu Geka 2001;54:493-6.  Back to cited text no. 12
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13.Tokitsu K, Tachibana S, Kawakami M, Orino T, Nakao K, Morita T, et al. A case of schwannoma arising in the brachial plexus with intrathoracic extension. [Article in Japanese]. Kyobu Geka 1997;50:598-601.  Back to cited text no. 13
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14.Gyhra A, Israel J, Santander C, Acuña D. Schwannoma of the brachial plexus with intrathoracic extension. Thorax 1980;35:703-4.  Back to cited text no. 14
    
15.Leal Filho MB, Aguiar Ade A, de Almeida BR, Dantas Kda S, Vieira MA, de Morais RK, et al. Schwannoma of brachial plexus: Report of two cases. [Article in Portuguese]. Arq Neuropsiquiatr 2004;62:162-6.  Back to cited text no. 15
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16.Ku HC, Yeh CW. Cervical schwannoma: A case report and eight years review. J Laryngol Otol 2000;114:414-7.  Back to cited text no. 16
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17.Sheridan MF, Yim DW. Cervical sympathetic schwannoma: A case report and review of the English literature. Otolaryngol Head Neck Surg 1997;117:S206-10.  Back to cited text no. 17
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18.Kwok K, Davis B, Kliot M. Resection of a benign brachial plexus nerve sheath tumor using intraoperative electrophysiological monitoring. Neurosurgery 2007;60(Suppl 4):316-20.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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