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LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1863-1864

A Rare Case of Unsuspected Extra-Adrenal Pheochromocytoma in a Patient Undergoing Excision for Vagal Schwannoma


1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Ophthalmology, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission04-Sep-2019
Date of Decision24-Oct-2019
Date of Acceptance22-Jan-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Ankur Gupta
Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333509

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How to cite this article:
Singh S, Gupta A, Sarayu V, Taank P. A Rare Case of Unsuspected Extra-Adrenal Pheochromocytoma in a Patient Undergoing Excision for Vagal Schwannoma. Neurol India 2021;69:1863-4

How to cite this URL:
Singh S, Gupta A, Sarayu V, Taank P. A Rare Case of Unsuspected Extra-Adrenal Pheochromocytoma in a Patient Undergoing Excision for Vagal Schwannoma. Neurol India [serial online] 2021 [cited 2022 Jan 19];69:1863-4. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1863/333509




Dear Sir,

Paragangliomas are rare catecholamine producing tumours found anywhere along the sympathetic chain from the base of the skull to the pelvis. Paraganglioma of the head and neck is a rare tumour, andvagal schwannomais even rarer.[1]We had encountered an unexpected finding of paraganglioma in a case taken up for excision of vagal schwannoma.

A 36-year-old lady, weighing 62kg, height 160cm with no known co morbidities, reported to the hospital for evaluation of pain and swelling on the right side of the neck. Magnetic Resonance Imaging (MRI) identified a well-defined mass of 30 × 20 × 25mm in the right pre-styloid parapharyngeal region suggestive of a vagal schwannoma. The patient was induced with standard drugs as per the institutional protocol. She remained hemodynamically stable till the initiation of excision of mass, but during the procedure she developed sudden onset of hypertension (blood pressure 170–220/120–140mm of Hg) and tachycardia (heart rate 140–160/min). Additionally, there was profuse bleeding from the surgical site. This was managed by securing two large bore 16G IV lines and by administering ani-hypertensives esmolol and nitroglycerine. Despite these efforts, the patient continued to have hypertension and tachycardia which remained inconsistentthroughout the surgery. Patient was placed on nitroglycerine infusion to maintain Systolic Blood Pressure (SBP) of less than 160mmHg. Ultimately, her sympathetic response was controlled by deepening the plane of anesthesia and administration of calcium channel blockers and continuous nitroglycerine infusion. During the whole procedure two points of packed red blood cells were administered and there was an estimated blood loss of 800 ml and total urine output of200 ml. At the end of the surgery, the patient had a pulse of 158 beats per minute, and a blood pressure of 136/68 mmHg with vasopressor support. Taking into consideration the excessive bleeding, with sympathetic stimulation on surgical manipulation, a provisional diagnosis of catecholamine releasing extra adrenal pheochromocytoma/paraganglioma was made, and the same was later confirmed by histology. Postoperatively patient's relative gave no history of such disease or any sudden unusual death in the family and they were counselled and advised to undergo genetic testing. Keeping the possibility of adrenal pheochromocytomain mind, the patient wasadvised toundergo whole body screening and regularfollow up for next one year and then annual outpatient visit.[2],[3]

Considering the pre-operative diagnosis of vagal schwannoma, we expected intra-operative hypotension and bradycardia during the surgery.[4]However, sudden intraoperative adrenergic surge forced us to question our pre-operative diagnosis. To conclude, this is a reminder that, catecholamine producing paraganglioma must be considered in all incidentalomas, and that the operation theatre should be well prepared for handling all life-threatening emergencies that may arise as a result of the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mat Lazim N. Challenges in managing a vagal schwannomas: Lesson learnt. Int J Surg Case Rep2018;53:5-8.  Back to cited text no. 1
    
2.
Nambiar VK, Sajitha S, Viswanath N, Praveen VP, Bindhu MR. Cerebral venous thrombosis due to pheochromocytoma in a patient with Von Hippel Lindau mutation. Neurol India 2017;65:643-45.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Chen H, Sippel RS, O'Dorisio MS, Vinik AI, Lloyd RV, Pacak K, et al. The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer. Pancreas2010;39:775-83.  Back to cited text no. 3
    
4.
Saini S, Sabharwal N, Agrawal N, Singh B. Cervical vagal schwannoma: Anesthetic concerns. Anesth Essays Res2017;11:254-6.  Back to cited text no. 4
[PUBMED]  [Full text]  




 

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