SciELO - Scientific Electronic Library Online

 
vol.12 número4Tratamento de aneurisma da aorta abdominal com implante de endoprotese e embolizacao de saco aneurismatico justacoloAneurisma verdadeiro roto de arteria femoral superficial índice de autoresíndice de assuntospesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados

Journal

Artigo

Indicadores

Links relacionados

Compartilhar


Jornal Vascular Brasileiro

versão impressa ISSN 1677-5449

J. vasc. bras. vol.12 no.4 Porto Alegre out./dez. 2013  Epub 11-Nov-2013

http://dx.doi.org/10.1590/jvb.2013.052 

Case Reports

Emergency embolization after resection of a laryngeal Schwannoma

Fábio Augusto Cypreste Oliveira1  ,2  ,3 

Carlos Eduardo de Sousa Amorelli1  ,2  ,3 

Fábio Lemos Campedelli1  ,2  ,3 

Werther Sales4 

Maria Cunha Ribeiro Amorelli4 

Juliana Caetano Barreto5 

Mariana Caetano Barreto5 

Philippe Moreira da Silva4 

1Sociedade Brasileira de Angiologia e Cirurgia Vascular - SBACV, São Paulo, SP, Brazil

2Colégio Brasileiro de Radiologia e Diagnóstico por Imagem - CBR, São Paulo, SP, Brazil

3Associação Médica Brasileira - AMB, São Paulo, SP, Brazil

4Angiogyn, Goiânia, GO, Brazil

5Hospital das Clínicas - HC, Universidade Federal de Goiás - UFG, Goiânia, GO, Brazil

ABSTRACT

Schwannoma is a rare cause of benign tumors of the larynx. The first-choice treatment is surgical resection. The objective of this paper is to report on a rare case of a young female patient who suffered severe intraoperative hemorrhaging during surgical resection of a laryngeal Schwannoma and needed emergency embolization.

Key words: therapeutic embolization; schwannoma; larynx

INTRODUCTION

Schwannomas are benign tumors that typically grow slowly, are encapsulated and have extensive vascularization. They get their name from the fact that they originate in the Schwann cells of motor, sensory or cranial nerves, but do not contain nervous elements. The most common site is the side of the neck, originating in the cervical nerve roots and the cervical sympathetic trunk1. They are rarely found in the larynx and there are only sporadic reports of this presentation in the literature. Laryngeal Schwannomas account for less than 0.5% benign tumors of the larynx and the first choice treatment is surgery, despite the fact that degeneration to malignancy is extremely rare2 - 7.

CASE DESCRIPTION

The patient was a 29-year-old female (S.R.X.) with a history of progressive solids dysphagia and a sensation of pharyngeal bolus. After initial evaluation by the otorhinolaryngology team, videolaryngoscopy and computed tomography of the neck identified an encapsulated solid tumor of the larynx with an intimate relationship with the right external and internal carotid arteries (Figure 1).

Figure 1 Computed tomography with venous contrast and axial cross-section, showing laryngeal tumor with an intimate relationship with the right-side carotid arteries. 

The patient was operated on by the otorhinolaryngology team under general anesthetic. A transoral approach was used to achieve total resection of the tumor. However, after removal of the tumor, the patient exhibited massive and persistent bleeding via the oral cavity, presenting hemodynamic instability, even after careful review of hemostasis and tests for intraoperative coagulation disorder. The vascular surgery team were called and requested to make an emergency assessment.

After hemodynamic stabilization, selective arteriography of the right carotid arteries was conducted, showing injury to branches of the right external carotid artery, with considerable contrast leakage (Figure 2).

Figure 2 Selective arteriography with digital subtraction, showing contrast leaking via branches of the right external carotid artery. 

Superselective catheterization was performed using an Echelon 14(r) microcatheter (eV3 Neurovascular, Inc.) in a coaxial system, and embolization was achieved using controlled release 2 mm × 2 mm and 2.5 mm × 2 mm Micrus(r) microcoils (Micrus Endovascular Corporation. CA/USA), with immediate control of bleeding (Figure 3).

Figure 3 Control arteriography after selective embolization. No sign of contrast leakage. 

The patient recovered in the intensive care unit for 24 hours without further intercurrent conditions and without requiring blood transfusion, with hemodynamic stability maintained and no further bleeding. She was discharged from hospital 48 hours after embolization. The material removed was sent for pathoanatomical assessment and histological analysis confirmed a laryngeal Schwannoma. The patient attended outpatients follow-up for 30 days with the vascular surgery team and showed no sign of relapse of bleeding, laryngeal symptoms exhibited improvement and there was no evidence of neurological damage.

DISCUSSION

Schwannomas of the larynx present as tumors with extensive vascularization and slow growth and symptomology is caused by their growth and mass effects. The treatment of choice is surgical resection and access can be intraoral, by direct laryngoscopy, or via an external approach (lateral pharyngotomy or laryngofissure)8 , 9, depending on the tumor's anatomic characteristics. The transoral approach is associated with a lower incidence of recurrent paralysis of the laryngeal nerve during the postoperative period, but complete resection of the tumor can prove difficult using this approach4.

Arteriographic assessment and preoperative embolization are described for management of head and neck Schwannomas10, but no cases of embolization of a laryngeal Schwannoma, whether preoperative or postoperative, were found in the literature, probably because of the rarity of the presentation.

This paper described a rare case of a patient with a Schwannoma of the larynx who required immediate emergency embolization to control severe hemorrhage.

Acknowledgements

We are grateful to Dr. Gustavo Jorge of the otorhinolaryngology team at the Hospital São Francisco de Assis for the referral and for following the case in conjunction.

REFERENCES

1. Fini-Storchi I, Frosini P. Laryngeal neurinomas (a case report and review). ORL. 1997;59:182-5. PMid:9186976. http://dx.doi.org/10.1159/000276935Links ]

2. Palva T, Jokinem K, Karja J. Neurilemmoma (schwannoma) of the larynx. J Laryngol Otol. 1975;89:203-7. PMid:1123570. http://dx.doi.org/10.1017/S0022215100080270Links ]

3. Phang WK, Raman R, Jayalaksmi E. Neurogenous tumour of the larynx (a case report). J Laryngol Otol. 1987;101:1209-10. PMid:3694036. http://dx.doi.org/10.1017/S0022215100103512Links ]

4. Takumida M, Taira T, Suzuki M, Yajin K, Harada Y. Neurilemmoma of the larynx (a case report). J Laryngol Otol. 1986;100:847-50. PMid:3734607. http://dx.doi.org/10.1017/S0022215100100180Links ]

5. Barnes L, Ferlito A. Soft tissue neoplasms. In: Ferlito A. Neoplasms of the larynx. Edinburgh: Churchill Livingstone; 1993. p. 277-9. [ Links ]

6. Supance JS, Quenelle DJ, Crissman J. Endolaryngeal neurofibromas. Otolaryngol Head Neck Surg. 1980;88:74-8. PMid:7393604. [ Links ]

7. Delozier HL. Intrinsic malignant schwannoma of the larynx: a case report. Ann Otol Rhinol Laryngol. 1982;91:336-8. PMid:7092059. [ Links ]

8. Schaeffer BT, Som PM, Biller HF, Som ML, Arnold LM. Schwannoma of the larynx: review and computed tomographic scan analysis. Head Neck Surg. 1986;8:469-72. PMid:3721890. http://dx.doi.org/10.1002/hed.2890080613Links ]

9. Whittam DE, Morris TMO. Neurilemmoma of the larynx. J Laryngol Otol. 1970;84:747-50. http://dx.doi.org/10.1017/S0022215100072480Links ]

10. Abramowitz J, Dion JE, Jensen ME, et al. Angiographic diagnosis and management of head and neck schwannomas. AJNR. 1991;12:977-984. PMid:1950934. [ Links ]

*All authors should have read and approved of the final version of the article submitted to J Vasc Bras.

The study was carried out at Angiogyn – Service of Vascular and Endovascular Surgery, Hospital São Francisco de Assis, Goiânia-GO, Brazil.

Received: May 11, 2013; Accepted: May 19, 2013

Correspondence Fabio Augusto Cypreste Oliveira Av. Alphaville Flamboyant, 3900, casa 283 CEP 74884527 - Goiânia (GO), Brasil Fone: +55 (62) 81475111 E-mail: fabioacoliveira@gmail.com

Author information

FACO, CESA and FLC are physicians with a Lato Sensu degree in Vascular Surgery - Angioradiology and Endovascular Surgery from Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV), Colégio Brasileiro de Radiologia (CBR), and Associação Médica Brasileira (AMB).

WS is vascular surgeon at Angiogyn.

MCRA is hematologist at Angiogyn.

JCB is resident physician of infectology at Hospital das Clínicas da Universidade Federal de Goiás.

MCB is resident physician of intensive care at Hospital das Clínicas da Universidade Federal de Goiás.

PMS is nurse technician and surgical technician at Angiogyn.

Author's contributions

Conception and design: FACO

Analysis and interpretation: FACO, CESA, FLC, WS

Data collection: FACO, MCRA, JCB, MCB, PMS

Writing the article: FACO, MCRA, JCB, MCB,WS

Critical revision of the article: FACO, CESA, FLC

Final approval of the article*: FACO, CESA, FLC

Statistical analysis: FACO, CESA, FLC

Overall responsibility: FACO, CESA, FLC

Obtained funding: None.

Financial support: None.

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.