Anaesthetic management in the excision of large carotid body tumours: Surgeons perspectives
Abstract
Objective(s): Carotid body tumours (CBT) are considered rare. Surgical excision is the treatment of choice and poses many anaesthetic challenges especially in large tumours. In this paper we present our experience of anaesthetic management of CBT which is one of the largest series on management of large (Shamblin II, III) tumours in the world.
Design: Retrospective cohort, Instituitional Review Board (IRB) Approved.
Setting: Single-Centre Tertiary care institute in South India.
Participants: Patients undergoing operative intervention for carotid body tumours.
Interventions: nil, observational.
Results: 66 tumours were excised in 62 patients (27 female, 39 male). The average age was 37.5. All tumours presented with a slow growing neck mass.7 patients complained of pain,as the presenting symptom. 2 were malignant, all were non-functional. 4 presented with preoperative neurological dysfunction- 2 with cranial nerve palsy following excision of contralateral CBT and 2 with resolved stroke following preoperative embolization. Nasotracheal intubation with mandibular subluxation was performed in 5. The average operating time was 2.5 hours. Average blood loss was 900 ml (200- 5000ml). Perioperative blood or product requirement varied from no transfusion to one patient with a very large (20cm tumour) requiring transfusion of a total of 20 products. Clamping of the carotid was necessary in 22 patients. 3 patients received heparin prior to clamp. There were 4 perioperative strokes, none of whom had any precipitous intraoperative hypotension. Transient postoperative cranial nerve palsy/paresis occurred in 50% with permanent cranial nerve deficits in 5%. There was no perioperative mortality. Tracheostomy was required in one patient for bilateral vocal cord palsy.
Conclusions: Several preoperative, intraoperative and postoperative management points (airway, intraoperative blood loss, stroke, cranial nerve dysfunction ,blood pressure control), are specific to the management of carotid body F tumours.Increased awareness of these specific scenarios and appropriate management ensures minimal perioperative morbidity and mortality.
Downloads
References
2. Luna-Ortiz K, Rascon-Ortiz M, Villavicencio-Valencia V, Granados-Garcia M, Herrera-Gomez A. Carotid body tumours: review of a 20-year experience. Oral Oncol. 2005 Jan; 41(1):56-61. PMID: 15598586 doi:10.1016/j.oraloncology.2004.06.006.
3. Sajid MS, Hamilton G, Baker DM. Joint Vascular Research Group:A multicenter review of carotid body tumour management. Eur J Vasc Endovasc Surg. 2007 Aug;34(2):127-30. Epub 2007 Apr 2. PMID: 17400487 doi: 10.1016/j.ejvs.2007.01.015.
4. Hallett JW Jr, Nora JD, Hollier LH, Cherry KJ Jr, Pairolero PC. Trends in neurovascular complications of surgical management for carotid body and cervical paragangliomas: a fifty-year experience with 153 tumors. J Vasc Surg. 1988 Feb 7;284-91. PMID: 2828696.
5. Moore JP, Claydon VE, Norcliff LJ, Rivera-Ch MC, Leon-Velarde F, Appenzeller O, et. al.Carotid baroreflex regulation of vascular resistance in high-altitude Andean natives with and without chronic mountain sickness. Exp Physiol. 2006 Sep; 91(5):907-913. Epub 2006 Jun 8. PMID: 16763007 doi: 10.1113/expphysiol.2005.033084.
6. Pacheco-Ojeda L, Durango E, Rodriquez C, Vivar N. Carotid body tumors at high altitude: Quito, Ecuador, 1987. World J. Surg. 1988 Dec; 12(6):856- 860. PMID:3250136. [PubMed]
7. Lim JY, Kim J, Kim SH, Lee S, Lim YC, Kim JW et al. Surgical treatment of carotid body paragangliomas: outcomes and complications according to the shamblin classification.Clin Exp Otorhinolaryngol. 2010 Jun;3(2):91-5. Epub 2010 Jun 30. PMID: 20607078 PMCID: PMC2896739 doi: 10.3342/ceo.2010.3.2.91.
8. Hinojosa CA, Ortiz-Lopez LJ, Anaya-Ayala JE, Orozco-Sevilla V, Nunez-Salgado AE. Comparison of retrocarotid and caudocranial dissection techniques for the surgical treatment of carotid body tumors .J Vasc Surg. 2015 Oct;62(4):958-64. Epub 2015 Aug 4 PMID: 26254456 doi: 10.1016/j.jvs.2015.05.001.
9. Amsalu A; Anderson B; Tesfaye W. Giant malignant carotid body tumor in a 40 years old woman: a case report from Gondar University Hospital. Ethiop Med J. 2013 Oct;51(4): 285-91. PMID:24696980.
10. Puggioni A, Delis KT, Fields CE, Viozzi CF, Kallmes DF, Gloviczki P. Large symptomatic carotid body tumor resection aided by preoperative embolization and mandibular subluxation.Perspect Vasc Surg Endovasc Ther. 2005Mar;17(1):21-8. PMID: 15952693. [PubMed]
11. Dossa C, Shepard AD, Wolford DG, Reddy DJ, Ernst CB.Distal internal carotid exposure: a simplified technique for temporary mandibular subluxation.J Vasc Surg. 1990 Sep;12(3):319-25. PMID: 2398590. [PubMed]
12. Fisher DF Jr, Clagett GP, Parker JI, Fry RE, Poor MR, Finn RA, Brink BE, Fry WJ. Mandibular subluxation for high carotid exposure. J Vasc Surg. 1984 Nov;1(6):727-33. PMID: 6492304. [PubMed]
13. Bercin S, Muderris T, Sevil E, Gul F, Kılıcarslan A, Kiris M. Efficiency of preoperative embolization of carotid body tumor. Auris Nasus Larynx. 2015 Jun;42(3):226-30. Epub 2014 Dec 1. PMID: 25476121 doi: 10.1016/j.anl.2014.10.013.
14. Piazza P, Di Lella F, Bacciu A, Di Trapani G, Ait Mimoune H, Sanna M. Preoperative protective stenting of the internal carotid artery in the management of complex head and neck paragangliomas: long-term results. Audiol Neurootol. 2013;18(6):345-52. Epub 2013 Oct 4. PMID: 24107406 doi: 10.1159/000354158.
15. Gwon JG, Kwon TW, Kim H, Cho YP. Risk factors for stroke during surgery for carotid body tumors. World J Surg. 2011 Sep;35(9):2154-8. PMID: 21717241 doi: 10.1007/s00268-011-1167-7. [PubMed]
16. Pasternak JJ, Lanier WL. J Neuroanesthesiology update. Neurosurg Anesthesiol. 2014 Apr;26(2):109-54. PMID: 24594653 doi: 10.1097/ANA.0000000000000048. [PubMed]
17. Schifilliti D, Grasso G, Conti A, Fodale V. Anaesthetic-related neuroprotection: intravenous or inhalational agents? CNS Drugs. 2010 Nov;24(11):893-907. PMID: 20932063 doi: 10.2165/11584760-000000000-00000.
18. Murkin JM, Arango M. Near-infrared spectroscopy as an index of brain and tissue oxygenation. Br. J. Anaesth. 2009 Dec;103 Suppl 1:i3-13. 103 (suppl 1): i3-i13. PMID: 20007987 doi:10.1093/bja/aep 299. [PubMed]
19. Stabile E, Sannino A, Schiattarella GG, Gargiulo G, Toscano E, Brevetti L, et al. Cerebral embolic lesions detected with diffusion-weighted magnetic resonance imaging following carotid artery stenting: a meta-analysis of 8 studies comparing filter cerebral protection and proximal balloon occlusion. JACC Cardiovasc Interv. 2014 Oct;7(10):1177-83. Epub 2014 Sep 17. PMID: 25240544 doi: 10.1016/j.jcin.2014.05.019.
20. Bauer AM, Smith RB, Thorell WE. Implications of carotid sinus hypersensitivity following preoperative embolization of a carotid body tumour. An indication for prophylactic intraoperative cardiac pacing. Bauer AM, JAMA Otolaryngol Head Neck Surg. 2014 May;140(5):459-63. PMID: 24651937 doi: 10.1001/jamaoto.2014.144.
21. Gur I, Katz S. Baroreceptor failure syndrome after bilateral carotid body tumorsurgery. Ann Vasc Surg. 2010 Nov;24(8):1138.e1-3. PMID: 21035715 doi: 10.1016/j.avsg.2010.05.022. [PubMed]
22. Onan B, Oz K, Onan IS. Baroreflex failure syndrome: a rare complication of bilateral carotid body tumour excision. Turk Kardiyol Dern Ars. 2010 Jun;38(4):267-70. PMID: 20935434. [PubMed]
23. Marcus NJ, Del Rio R, Schultz HD. Central role of carotid body chemoreceptors in disordered breathing and cardiorenal dysfunction in chronic heart failure. Front Physiol. 2014 Nov 24;5:438. PMID: 25505417 PMCID: PMC4241833 doi:10.3389/fphys.2014.00438. eCollection 2014.
24. Holmes AP, Turner PJ, Buckler KJ, Kumar P. Moderate inhibition of mitochondrial function augments carotid body hypoxic sensitivity. Pflugers Arch. 2016 Jan;468(1):143-55. PMID: 26490460 doi:10.1007/s00424-015-1745-x.
25. López-Barneo J, Ortega-Sáenz P, Pardal R, Pascual A, Piruat JI, Durán R, et al. Oxygen sensing in the carotid body. Ann N Y Acad Sci. 2009 Oct;1177:119-31. PMID: 19845614 doi:10.1111/j.1749-6632.2009.05033.x. [PubMed]
26. Niemeijer ND, Corssmit EP, Reijntjes RH, Lammers GJ, van Dijk JG, Thijs RD. Sleep-mediated heart rate variability after bilateral carotid body tumour resection. Sleep. 2015 Apr 1;38(4):633-9. PMID: 25325476 PMCID: PMC4355903 DOI: 10.5665/sleep.4586. [PubMed]
27. O'Neill S, O'Donnell M, Harkin D, Loughrey M, Lee B, Blair P. A 22-year Northern Irish experience of carotid body tumours. Ulster Med J. 2011 Sep;80(3):133-40. PMID: 23526121 PMCID: PMC3605524.
OAI - Open Archives Initiative
