Multidisciplinary Management of a Secretory Jugulo-Tympanic Paraganglioma: A Case Report

Rui Torres1 , Juliana Louro1 , Cristina Gomes 1

1-Hospital de Braga, Anaesthesiology, Braga, Portugal

 

Learning Objective: < 4% of head and neck paragangliomas are secretory tumors [1] Despite their rarity, surgical management imposes a multidisciplinary approach to minimize perioperative complications

53-year-old female ASA 3 by poorly controlled hypertension
Procedure: Excision of a norepinephrineproducing jugulo-tympanic paraganglioma
Total duration: 27 hours over two days

Preoperative;
Phenoxybenzamine 10 mg twice daily for 10 days High-salt diet and increased fluid intake Tumor embolization 72 hours before surgery

Intraoperative:
Total intravenous anesthesia
Monitoring: standard, invasive blood pressure, bispectral index, cerebral oximetry, stroke volume variation, and cranial nerve electromyography (VII, IX, X, XI, XII)
Airway management: hyperangulated video laryngoscopy
2g Tranexamic Acid for blood loss minimization
Sustained bradycardia managed with atropine during vagus nerve dissection

Postoperative:
ICU stay for 7 days Speech therapy rehabilitation

Discussion: ✓ Paragangliomas (PGL) are neuroendocrine tumors that originate in the sympathetic or parasympathetic ganglia of the autonomic nervous system ✓ Head and neck paragangliomas (HNPGL) constitute 65- 70% of all PGL. Despite their rarity, HNPGLs can be functional neuroendocrine tumors ✓ Initial biochemical testing should include plasma free metanephrines or urinary fractionated metanephrines for all patients ✓ Failure to recognize active PGLs increases the risk of severe intraoperative consequences ✓ Preoperative planning is crucial, focusing on controlling blood pressure and maintaining optimal blood volume status ✓ The case emphasizes the importance of a multidisciplinary approach in managing secretory jugulo-tympanic paragangliomas

References 1- Sandow, L., et al. (2023). Paraganglioma of the Head and Neck: A Review. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 29(2), 141–147. 2- Lin, E. P., et al. (2022). Head and Neck Paragangliomas: An Update on the Molecular Classification, State-of-the-Art Imaging, and Management Recommendations. Radiology. Imaging cancer, 4(3), e210088. 3- Lenders, J. W., et al. (2014). Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. The Journal of clinical endocrinology and metabolism, 99(6), 1915–1942.