Intracapsular Enucleation
Here is an amazing technique that removes the tumour as well as preserving the nerves. Extracranial non-vestibular head and neck schwannomas: a ten-year experience.
Kang GC<http://www.ncbi.nlm.nih.gov/pubmed?term=Kang+GC%5BAuthor%5D&cauthor=true&cauthor_uid=17483850>, Soo KC<http://www.ncbi.nlm.nih.gov/pubmed?term=Soo+KC%5BAuthor%5D&cauthor=true&cauthor_uid=17483850>, Lim DT<http://www.ncbi.nlm.nih.gov/pubmed?term=Lim+DT%5BAuthor%5D&cauthor=true&cauthor_uid=17483850>.
Source
Department of General Surgery, Singapore General Hospital, Singapore.
Abstract
INTRODUCTION:
We present a series of head and neck extracranial non-vestibular schwannomas treated during a ten-year period, assessing epidemiology, presenting signs and symptoms, location, nerve of origin, diagnostic modalities, treatment and clinical outcome.
MATERIALS AND METHODS:
Clinical records of all patients with head and neck schwannomas treated at our department from April 1995 to July 2005 were retrospectively reviewed.
RESULTS:
There was female predominance (67%). The mean age at diagnosis was 48 years. Sixteen (76%) presented with a unilateral neck mass. Eleven schwannomas (52%) were in the parapharyngeal space. The most common nerves of origin were the vagus and the cervical sympathetic chain. The tumour may masquerade as a cervical lymph node and other myriad conditions. Treatment for all but 2 cases was complete excision with nerve preservation. Two cases of facial schwannoma required sacrifice of the affected nerve portion with nerve reconstruction. All facial schwannoma patients suffered postoperative facial palsy with only partial resolution (mean final House-Brackman grade, 3.25/6). Among non-facial schwannoma patients, postoperative neural deficit occurred in 12 with partial to complete resolution in 7. The median follow-up period was 24 months. No schwannoma was malignant and none recurred.
CONCLUSION:
Non-vestibular extracranial head and neck schwannomas most frequently present as an innocuous longstanding unilateral parapharyngeal neck mass. Preoperative diagnosis may be aided by fine-needle cytology and magnetic resonance imaging or computed tomographic imaging. The mainstay of treatment is complete intracapsular excision preserving the nerve of origin, but for extensive tumour or facial schwannomas, subtotal resection or nerve sacrifice with reconstruction and rehabilitation are considerations. Surgery on intraparotid facial schwannomas carries considerable morbidity and conservative management has a place in treatment. Early recognition of facial schwannomas is key to optimal treatment.
Neck nerve trunks schwannomas: clinical features and postoperative neurologic outcome.
de Araujo CE<http://www.ncbi.nlm.nih.gov/pubmed?term=de+Araujo+CE%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Ramos DM<http://www.ncbi.nlm.nih.gov/pubmed?term=Ramos+DM%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Moyses RA<http://www.ncbi.nlm.nih.gov/pubmed?term=Moyses+RA%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Durazzo MD<http://www.ncbi.nlm.nih.gov/pubmed?term=Durazzo+MD%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Cernea CR<http://www.ncbi.nlm.nih.gov/pubmed?term=Cernea+CR%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Ferraz AR<http://www.ncbi.nlm.nih.gov/pubmed?term=Ferraz+AR%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>.
Source
Department of Head and Neck Surgery, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil. [email protected]
Abstract
OBJECTIVES/HYPOTHESIS:
To analyze clinical and epidemiological features of neck nerve schwannomas, with emphasis on the neurologic outcome after surgical excision sparing as much of nerve fibers as possible with enucleation technique.
STUDY DESIGN:
Retrospective study.
METHODS:
Review of medical records from 1987 to 2006 of patients with neck nerve schwannomas, treated in a single institution.
RESULTS:
Twenty-two patients were identified. Gender distribution was equal and age ranged from 15 to 61 years (mean: 38.6 years). Seven vagal, four brachial plexus, four sympathetic trunk, three cervical plexus, and two lesions on other sites could be identified. Most common symptom was neck mass. Local or irradiated pain also occurred in five cases. Median growing rate of tumors was 3 mm per year. Nerve paralysis was noted twice (a vagal schwannoma and a hypoglossal paralysis compressed by a vagal schwannoma). Different techniques were employed, and seven out of nine patients kept their nerve function (78%) after enucleation. No recurrence was observed in follow-up.
CONCLUSIONS:
Schwannomas should be treated surgically because of its growing potential, leading to local and neural compression symptoms. When possible, enucleation, which was employed in 10 patients of this series, is the recommended surgical option, allowing neural function preservation or restoration in most instances. This is especially important in the head and neck, where denervation may have a significant impact on the quality of life.
Yonsei Med J.<http://www.ncbi.nlm.nih.gov/pubmed/20879063#> 2010 Nov;51(6):938-42.
Schwannoma in head and neck: preoperative imaging study and intracapsular enucleation for functional nerve preservation.
Kim SH<http://www.ncbi.nlm.nih.gov/pubmed?term=Kim+SH%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Kim NH<http://www.ncbi.nlm.nih.gov/pubmed?term=Kim+NH%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Kim KR<http://www.ncbi.nlm.nih.gov/pubmed?term=Kim+KR%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Lee JH<http://www.ncbi.nlm.nih.gov/pubmed?term=Lee+JH%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Choi HS<http://www.ncbi.nlm.nih.gov/pubmed?term=Choi+HS%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>.
Source
Department of Otorhinolaryngology, Yonsei University College of Medicine, Gangnam Severance Hospital, Gangnam-gu, Seoul, Korea.
Abstract
PURPOSE:
In treating schwannoma patients, it is critical to determine the origin of the tumor to preserve nerve function. We evaluated the validity of preoperative imaging studies in distinguishing the neurological origin of the schwannomas of the head and neck, and the efficacy of intracapsular enucleation in preserving nerve function.
MATERIALS AND METHODS:
In 7 cases of schwannomas in the head and neck region, we predicted whether the tumor originated from the vagus nerve or the cervical sympathetic chain through imaging studies including computed tomography (CT) and magnetic resonance imaging (MRI). All patients were performed intracapsular enucleation, and the function of the vagus nerve and the sympathetic nerve was evaluated preoperatively and postoperatively.
RESULTS:
Preoperative imaging studies showed 6 cases where the tumor was located between the carotid artery and the internal jugular vein, and 1 case where the tumor was located posteriorly, displacing the carotid artery and the internal jugular vein anteriorly. At the time of operation, we confirmed schwannoma originating from the vagus nerve on the first 6 cases, and schwannoma originating from the sympathetic nervous system on the last case. All patients went through successful intracapsular enucleation, and of the seven schwannoma cases, 6 patients maintained normal postoperative neurological function (85.7%).
CONCLUSION:
Preoperative imaging studies offer valuable information regarding the location and origination of the tumor, and intracapsular enucleation helped us to preserve the nerve function.
James L. Netterville M.D.
Mark C. Smith Professor
Director, Head & Neck Surgery
Dept. of Oto. Head & Neck Surgery
Bill Wilkerson Center
Vanderbilt Medical Center
Nashville, Tennessee 37232
Admin. Assistant - Joanne Merriam
Phone - 615-322-9598
Fax - 615-343-9725
Kang GC<http://www.ncbi.nlm.nih.gov/pubmed?term=Kang+GC%5BAuthor%5D&cauthor=true&cauthor_uid=17483850>, Soo KC<http://www.ncbi.nlm.nih.gov/pubmed?term=Soo+KC%5BAuthor%5D&cauthor=true&cauthor_uid=17483850>, Lim DT<http://www.ncbi.nlm.nih.gov/pubmed?term=Lim+DT%5BAuthor%5D&cauthor=true&cauthor_uid=17483850>.
Source
Department of General Surgery, Singapore General Hospital, Singapore.
Abstract
INTRODUCTION:
We present a series of head and neck extracranial non-vestibular schwannomas treated during a ten-year period, assessing epidemiology, presenting signs and symptoms, location, nerve of origin, diagnostic modalities, treatment and clinical outcome.
MATERIALS AND METHODS:
Clinical records of all patients with head and neck schwannomas treated at our department from April 1995 to July 2005 were retrospectively reviewed.
RESULTS:
There was female predominance (67%). The mean age at diagnosis was 48 years. Sixteen (76%) presented with a unilateral neck mass. Eleven schwannomas (52%) were in the parapharyngeal space. The most common nerves of origin were the vagus and the cervical sympathetic chain. The tumour may masquerade as a cervical lymph node and other myriad conditions. Treatment for all but 2 cases was complete excision with nerve preservation. Two cases of facial schwannoma required sacrifice of the affected nerve portion with nerve reconstruction. All facial schwannoma patients suffered postoperative facial palsy with only partial resolution (mean final House-Brackman grade, 3.25/6). Among non-facial schwannoma patients, postoperative neural deficit occurred in 12 with partial to complete resolution in 7. The median follow-up period was 24 months. No schwannoma was malignant and none recurred.
CONCLUSION:
Non-vestibular extracranial head and neck schwannomas most frequently present as an innocuous longstanding unilateral parapharyngeal neck mass. Preoperative diagnosis may be aided by fine-needle cytology and magnetic resonance imaging or computed tomographic imaging. The mainstay of treatment is complete intracapsular excision preserving the nerve of origin, but for extensive tumour or facial schwannomas, subtotal resection or nerve sacrifice with reconstruction and rehabilitation are considerations. Surgery on intraparotid facial schwannomas carries considerable morbidity and conservative management has a place in treatment. Early recognition of facial schwannomas is key to optimal treatment.
Neck nerve trunks schwannomas: clinical features and postoperative neurologic outcome.
de Araujo CE<http://www.ncbi.nlm.nih.gov/pubmed?term=de+Araujo+CE%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Ramos DM<http://www.ncbi.nlm.nih.gov/pubmed?term=Ramos+DM%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Moyses RA<http://www.ncbi.nlm.nih.gov/pubmed?term=Moyses+RA%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Durazzo MD<http://www.ncbi.nlm.nih.gov/pubmed?term=Durazzo+MD%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Cernea CR<http://www.ncbi.nlm.nih.gov/pubmed?term=Cernea+CR%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>, Ferraz AR<http://www.ncbi.nlm.nih.gov/pubmed?term=Ferraz+AR%5BAuthor%5D&cauthor=true&cauthor_uid=18596560>.
Source
Department of Head and Neck Surgery, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil. [email protected]
Abstract
OBJECTIVES/HYPOTHESIS:
To analyze clinical and epidemiological features of neck nerve schwannomas, with emphasis on the neurologic outcome after surgical excision sparing as much of nerve fibers as possible with enucleation technique.
STUDY DESIGN:
Retrospective study.
METHODS:
Review of medical records from 1987 to 2006 of patients with neck nerve schwannomas, treated in a single institution.
RESULTS:
Twenty-two patients were identified. Gender distribution was equal and age ranged from 15 to 61 years (mean: 38.6 years). Seven vagal, four brachial plexus, four sympathetic trunk, three cervical plexus, and two lesions on other sites could be identified. Most common symptom was neck mass. Local or irradiated pain also occurred in five cases. Median growing rate of tumors was 3 mm per year. Nerve paralysis was noted twice (a vagal schwannoma and a hypoglossal paralysis compressed by a vagal schwannoma). Different techniques were employed, and seven out of nine patients kept their nerve function (78%) after enucleation. No recurrence was observed in follow-up.
CONCLUSIONS:
Schwannomas should be treated surgically because of its growing potential, leading to local and neural compression symptoms. When possible, enucleation, which was employed in 10 patients of this series, is the recommended surgical option, allowing neural function preservation or restoration in most instances. This is especially important in the head and neck, where denervation may have a significant impact on the quality of life.
Yonsei Med J.<http://www.ncbi.nlm.nih.gov/pubmed/20879063#> 2010 Nov;51(6):938-42.
Schwannoma in head and neck: preoperative imaging study and intracapsular enucleation for functional nerve preservation.
Kim SH<http://www.ncbi.nlm.nih.gov/pubmed?term=Kim+SH%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Kim NH<http://www.ncbi.nlm.nih.gov/pubmed?term=Kim+NH%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Kim KR<http://www.ncbi.nlm.nih.gov/pubmed?term=Kim+KR%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Lee JH<http://www.ncbi.nlm.nih.gov/pubmed?term=Lee+JH%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>, Choi HS<http://www.ncbi.nlm.nih.gov/pubmed?term=Choi+HS%5BAuthor%5D&cauthor=true&cauthor_uid=20879063>.
Source
Department of Otorhinolaryngology, Yonsei University College of Medicine, Gangnam Severance Hospital, Gangnam-gu, Seoul, Korea.
Abstract
PURPOSE:
In treating schwannoma patients, it is critical to determine the origin of the tumor to preserve nerve function. We evaluated the validity of preoperative imaging studies in distinguishing the neurological origin of the schwannomas of the head and neck, and the efficacy of intracapsular enucleation in preserving nerve function.
MATERIALS AND METHODS:
In 7 cases of schwannomas in the head and neck region, we predicted whether the tumor originated from the vagus nerve or the cervical sympathetic chain through imaging studies including computed tomography (CT) and magnetic resonance imaging (MRI). All patients were performed intracapsular enucleation, and the function of the vagus nerve and the sympathetic nerve was evaluated preoperatively and postoperatively.
RESULTS:
Preoperative imaging studies showed 6 cases where the tumor was located between the carotid artery and the internal jugular vein, and 1 case where the tumor was located posteriorly, displacing the carotid artery and the internal jugular vein anteriorly. At the time of operation, we confirmed schwannoma originating from the vagus nerve on the first 6 cases, and schwannoma originating from the sympathetic nervous system on the last case. All patients went through successful intracapsular enucleation, and of the seven schwannoma cases, 6 patients maintained normal postoperative neurological function (85.7%).
CONCLUSION:
Preoperative imaging studies offer valuable information regarding the location and origination of the tumor, and intracapsular enucleation helped us to preserve the nerve function.
James L. Netterville M.D.
Mark C. Smith Professor
Director, Head & Neck Surgery
Dept. of Oto. Head & Neck Surgery
Bill Wilkerson Center
Vanderbilt Medical Center
Nashville, Tennessee 37232
Admin. Assistant - Joanne Merriam
Phone - 615-322-9598
Fax - 615-343-9725
Rick's question to Dr. Steven Chang (Professor of Neurosurgery) from Stanford University School of Medicine in California regarding Cyberknife and age limit.
Good evening, Dr. Chang, I am a post 6 year CK'er for a Vagus Nerve Schwannoma (Dr. Nate Kaufman - Riverview Medical - Red Bank, NJ). I am a regular on the Accuray patient forum and am very active on the Face Book site for Schwannomas. Since there has been considerable discussion by lay people regarding the use of CK on childen and younger adults, the consensus by some of these forum members is that CK is to be avoided. They have no sources or documentation, but say that there is a likelihood for the treated areas to become cancerous due to CK's radiation. Have any studies been conducted supporting their claims? And what is your take on their position? The Face Book page is administered by a fellow CK'er, Rhonda Edwards, Ontario Canada. She actually has two sites: [email protected] and http://www.vagalschwannoma.com/index.html Thanks for your time. Sincerely, Rick Hageman
Response from Dr. Steven Chang
(with permission from Dr. Chang to post here, he responded in his own opinion)
Rick, There exists a small risk of radiosurgery for any patient, regardless of age. In a younger patient, there is a concern that the many more years that they will live compared to an older patient creates that much longer a period of time in which they might develop some malignancy from radiation. This risk of a maligant tumor developing after radiosurgery is quite low, with estimates of 1 in 20,000 to 1 in 100,000 over the lifetime of the patient. While this appears concerning at first, it needs to be put into perspective. Conventional surgery for these types of tumors has about a 1in 500 chance of the patient dying during the surgery or hospital period. Furthermore, a person who drives has a 1 in 7000 chance of dying EACH year as a result of car accident. Men have a 1 in 10 chance of prostate cancer in their life. Women have a 1 in 8 chance of breast cancer in their life. Thus, as you can see, the relative risk of malignancy after radiosurgery is much smaller that all these other more common risks. Therefore, I think that patients should not really worry about the relatively small risk of radiosurgery, since the surgical risk and the risk of doing nothing are higher, in my opinion. Steven Chang, MD
Response from Dr. Steven Chang
(with permission from Dr. Chang to post here, he responded in his own opinion)
Rick, There exists a small risk of radiosurgery for any patient, regardless of age. In a younger patient, there is a concern that the many more years that they will live compared to an older patient creates that much longer a period of time in which they might develop some malignancy from radiation. This risk of a maligant tumor developing after radiosurgery is quite low, with estimates of 1 in 20,000 to 1 in 100,000 over the lifetime of the patient. While this appears concerning at first, it needs to be put into perspective. Conventional surgery for these types of tumors has about a 1in 500 chance of the patient dying during the surgery or hospital period. Furthermore, a person who drives has a 1 in 7000 chance of dying EACH year as a result of car accident. Men have a 1 in 10 chance of prostate cancer in their life. Women have a 1 in 8 chance of breast cancer in their life. Thus, as you can see, the relative risk of malignancy after radiosurgery is much smaller that all these other more common risks. Therefore, I think that patients should not really worry about the relatively small risk of radiosurgery, since the surgical risk and the risk of doing nothing are higher, in my opinion. Steven Chang, MD
I have taken reasonable care to ensure that the information contained on these pages is accurate. I cannot accept liability for any errors or omissions or for information becoming out of date. The information given is not a substitute for getting medical advice from your own GP or other healthcare professional.