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Carotid Body Tumor Resection

last modified on: Thu, 10/05/2023 - 14:57

see also: Carotid Body and Carotid Sinus - General Information; Carotid Body Paraganglioma; Carotid Body Tumor - Case Example; and Carotid body tumor resection and vasomotor instability (blood pressure problems)

GENERAL CONSIDERATIONS

  1. Indications
    1. Carotid body tumors
    2. Glomus vagale
  2. Contraindications
    1. Caution should be taken in the treatment of bilateral glomus tumor as blood pressure maintenance is compromised by bilateral carotid body denervation (Netterville et al. 1995).
    2. Patients at high risk of stroke with carotid resection or ligation should be observed or receive nonsurgical treatment.
  3. Pathogenesis
    1. The following 3 different types of carotid body tumors (CBTs) have been described in the literature: Familial, Sporadic, Hyperplastic. The sporadic form is the most common type, representing approximately 85% of carotid body tumors (CBTs). The familial type (10-50%) is more common in younger patients. The hyperplastic form is very common in patients with chronic hypoxia, which includes those patients living at a high altitude (Bryant et al. 2020).
    2. Defective succinate dehydrogenase has been postulated to cause an increase in the intracellular concentration of molecular hypoxia mediators and the vascular endothelial growth factor (VEGF) thus resulting in hyperplasia, angiogenesis, and neoplasia (Bryant et al. 2020).
  4. Relevant Anatomy
    1. Most literature states that the gland is located in the adventitia near the carotid artery bifurcation. However, many surgeons experienced with carotid body dissection maintain that it is more peripherally located, within periadventitial tissue. This distinction is critical, as dissections in the deeper planes of the carotid artery are associated with higher risk for complications from vessel injury.

PREOPERATIVE PREPARATION

  1. Additional Preoperative Evaluations
    1. MRI to evaluate location and extent of disease, as well as evaluate for additional lesions, ipsilateral and contralateral.
    2. Carotid body tumors are rarely associated with a clinical picture of pheochromocytoma, however, it is reasonable to test for urinary catecholamines, vanillylmandelic acid, and metanephrine. If the neck disease is associated with adrenal pheochromocytoma, the adrenal pheochromocytoma should be removed prior to any other surgery. Consider checking repetitive blood pressures as urinary studies are required in any patients with evidence of poorly controlled hypertension.
    3. Arteriogram and embolization
      1. Four-vessel head and neck arteriogram is done to evaluate the extent of tumor vascularity and to evaluate the contralateral side for possible bilateral carotid body tumors or small secondary glomus tumors.
      2. Embolize tumors greater than 4 cm in size with obvious large feeder vessels. This is usually done the day before surgery and requires observation for stroke symptoms after tumor embolization. Steroids should be started to decrease inflammation induced by the embolization.
      3. Consider carotid balloon test occlusion (see Carotid Artery Resection in Head and Neck Cancer Treatment protocol).
    4. Vascular surgery or neurosurgery consultation
      1. May require carotid artery by-pass
      2. May require carotid replacement
    5. Lower extremity ultrasound by vascular team to identify location and size of femoral veins that could be required for carotid replacement
    6. Neurology, electroencephalography (EEG) consultation
      1. Schedule the procedure in an operating room with EEG capabilities.
      2. Place EEG leads on the patient the night prior to surgery.
      3. Intraoperative monitoring of EEG will aid in the evaluation of cerebral blood flow should carotid occlusion, bypass, or replacement become necessary.
  2. Consent Inclusions
    1. Risk of stroke
    2. Death
    3. Injury to cranial nerves IX, X, XI, and XII
    4. Horner's syndrome
    5. Bleeding
    6. Infection
    7. Possible carotid bypass/replacement
    8. Possible harvest of vein grafts

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Basic Soft Tissue Room Setup
    2. Mayfield headrest
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
      4. Arterial Graft Instrument Tray
    2. Special
      1. Tracheotomy Tray
      2. Varidyne vacuum suction controller
      3. Nerve stimulator control unit and instrument
      4. Doppler unit and probe
      5. Vessel loops
      6. 9-0 nylon suture (for repair of torn vessels)
  3. Medications (specific to nursing)
    1. 1% lidocaine with 1:100,000 epinephrine
    2. 2% lidocaine
    3. Papaverine 30 mg/ml
    4. Antibiotic ointment
  4. Prep and Drape
    1. Standard
      1. 10% providone iodine
      2. Neck, pelvis, and upper thigh bilaterally
    2. Drape
      1. Head drape
      2. Towels around neck from lower mastoid to below clavicle
      3. Split sheet around head and neck
      4. Towel out pubic area with moisture-proof towels
      5. Square off upper thighs and pelvis
  5. Drains and Dressings
    1. Antibiotic ointment
    2. Varidyne vacuum suction drain: 7 mm or 10 mm
  6. Special Considerations
    1. Blood loss may be rapid; double suction may be needed immediately.
    2. Vascular instruments should be available.
    3. Carotid artery graft by peripheral vascular team may be necessary. In this case, vascular instrumentation and equipment will need to be available to harvest vein and perform carotid anastomosis.

ANESTHESIA CONSIDERATIONS

  1. General Anesthesia
    1. Tube position: transoral, taped to contralateral side
    2. Paralysis: maintain the patient in a nonparalyzed state to aid in the identification of cranial nerves
  2. Systemic Medication
    1. Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
    2. Steroids: 10 mg of Dexamethasone IV
  3. Positioning
    1. Supine
  4. Estimated Blood Loss
    1. 500 cc (300 to 2000) high-volume, rapid blood loss is possible.
    2. At least two large-caliber IV lines should be in place.
    3. Preop type and screen.

OPERATIVE PROCEDURE

  1. Surgical Approach (optional incisions)
    1. Perform wide exposure through horizontal incisions in a relaxed skin tension line (RSTL) extending up to mastoid tip.
    2. Long incision along anterior border of sternocleidomastoid (SCM) (carotid endarterectomy approach) could be used for small tumors.
  2. Identify and reflect the SCM and the jugular vein posteriorly to allow visualization of the tumor and adjacent cranial nerves.
  3. Expose and isolate the proximal (3 to 4 cm) and distal (2 cm) portions of the vessels (common carotid, internal carotid, and multiple branches of the external carotid). If vessel loops are retained around the common or internal carotid arteries, care must be taken to avoid unnecessary tension.
  4. Identify and preserve cranial nerves X, XI, XII, superior laryngeal nerve and sympathetic trunk.
  5. Begin slow and careful dissection using bipolar cautery, with gentle blunt and sharp dissection of the tumor off the internal carotid and carotid bifurcation using loupe or microscopic magnification.
    1. Irrigating bipolar forceps, or manual saline irrigation during bipolar activation, may be useful.
  6. Generally, the external carotid artery requires resection at or near the carotid bifurcation.
  7. Large tumors may require internal carotid resection and bypass (see Carotid Artery Resection in Head and Neck Cancer Treatment protocol).
  8. Drains
    1. 10 mm flat Jackson-Pratt drain
  9. Closure
    1. Two-layer closure: platysma layer and skin layer
  10. Dressings
    1. Antibiotic ointment

POSTOPERATIVE CARE

  1. Observation is on-ward unless carotid bypass/replacement performed.
  2. Close monitoring of blood pressure
  3. Watch for postoperative hemorrhage or late stroke.
  4. Bypass patients should be watched overnight in ICU and heparinized.
  5. Follow-Up
    1. Local recurrence is very rare.
    2. If additional tumors are identified during work-up or follow-up, these lesions will require treatment or close observation for growth or clinical symptoms.

REFERENCES

Eisele DE, Netterville JL, Hoffman HT, Gantz BJ. Parapharyngeal space masses. Head Neck J. 1999;21:154-159.

Lore JM, Anain J. Vascular procedures. In: Lore JM, ed. An Atlas of Head and Neck Surgery. 3rd ed., Philadelphia, Pa: WB Saunders Co. 1988:1032-1135.

Ikram A, Rehman A. Paraganglioma. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 5, 2022.

Netterville JL, Reilly KM, Robertson D, Reiber ME, Armstrong WB, Childs P. Carotid body tumors: a review of 30 patients with 46 tumors. Laryngoscope. 1995 Feb;105(2):115-26. doi: 10.1288/00005537-199502000-00002. PMID: 8544589.

Bryant JP, Wang S, Niazi T. Carotid Body Tumor Microenvironment. Adv Exp Med Biol. 2020;1296:151-162. doi: 10.1007/978-3-030-59038-3_9. PMID: 34185291.