Abordaje quirúrgico en el tumor del glomus carotídeo: caso clínico.

Abstract

Introduction and objective: Paragangliomas of the head and neck are rare tumours that arise from paraganglionic tissue originating from the ectodermal cells of the neural crest. The most frequent in this area is the one originating from the carotid bifurcation. These are generally benign, slow-growing tumours, but in the long term they can generate symptoms that greatly affect patients' quality of life. For this reason, the possibility of a wait-and-see approach, radiotherapy or surgical treatment must be considered in the treatment, with the consequent risk of morbidity and mortality that this entails. Presentation of the case: we present the case of an 83-year-old woman who came to the otorhinolaryngology department for a right laterocervical tumour that had been present for 20 years and which caused her significant dysphagia, requiring a nasogastric tube, and a deep voice that had been present for two months. On examination she presented with a high cervical tumour that spreads to the tonsillar cell and the right latero-pharyngeal region. Ultrasound revealed a highly vascularised mass in the carotid bifurcation, so a scan was requested which confirmed that it expressed somatostatin receptors and, therefore, that it was a carotid paraganglioma. Given this diagnosis, two therapeutic options were offered: surgical excision of the tumour, assuming a high surgical risk, or symptomatic treatment when required (percutaneous endoscopic gastrostomy and tracheotomy). She assesses it and the patient prefers excision of the tumour. For this, an infratemporal - cervicotransoral Biller approach is performed, after embolisation of the mass. A paramedial mandibulotomy is required for parapharyngeal extension.  It also requires ligation of the external carotid artery and the internal jugular vein for removal, and repair of the kinking of the internal carotid artery triggered by compression of the mass on the internal carotid artery. Postoperatively, she developed a salivary fistula in the right parotid area, which eventually led to carotid bleeding, for which an internal carotid ligation was performed. However, the patient died a month and a half after the operation. Discussion: Carotid glomus tumour is a rare pathology that requires a high degree of suspicion for diagnosis. Treatment consists of surgical resection, which must be performed by an expert surgeon who has mastered the techniques of vascular reconstruction in the carotid territory. In this case, the fatal outcome was due to the salivary fistula that occurred as a complication in the postoperative period and which generated carotid bleeding that, in the long term, led to this outcome. In this case, having assessed the risk of morbidity and mortality and given her personal situation, the patient decided to have the lesion surgically excised. This is a highly complex surgery with a mortality risk of 1-2% and a morbidity risk of 40% (cranial nerve damage, stroke, haemorrhage, etc.). Conclusions: the Biller infratemporal - cervicotransoral approach is an appropriate approach for this type of intervention. It involves a high surgical risk, so a correct preoperative assessment and doctor-patient communication is essential.