|Year : 2019 | Volume
| Issue : 4 | Page : 298-301
Extending the boundaries of carotid body tumor excision with a maxillofacial surgeon
SS Daniel Sathiya1, Edwin Stephen2, Albert Abhinay Kota2, Vimalin Samuel2, Prabhu Premkumar2, Dheepak Selvaraj2, Sunil Agarwal2
1 Department of Dental Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
2 Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
|Date of Submission||23-Feb-2019|
|Date of Acceptance||17-Apr-2019|
|Date of Web Publication||20-Dec-2019|
Dr. Dheepak Selvaraj
Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Carotid body tumor (CBT) excision at times requires a multidisciplinary approach. Requests for mandibular swing or mandibular subluxation were received by the department of dental and oral surgery to aid in CBT excision. Methods: Patients who were referred between March 2013 and April 2018 were retrospectively reviewed. Criteria for deciding between mandibular swing and mandibular subluxation for each patient were identified and outcome of the decision was analyzed. Follow-up period was 6 months to 5 years. Results: Of 53 patients operated during the study, 16 patients were referred for intraoperative assistance. Of the 16 patients, 10 were Shamblin 3 with 2 of these being redo cases and others were Shamblin 2. In all cases, the length of internal carotid artery (ICA) from the base of the skull was 1.5 cm or less. Mandibular swing was performed in three patients, all for Shamblin 3 with two of them being the redo cases, and mandibular subluxation was done for 13 patients. One patient who underwent mandibular swing and two patients who had mandibular subluxation had transient hypoglossal nerve palsy and all of them recovered. None of the patients for whom a mandibular swing was done had marginal mandibular nerve weakness. One patient lost a tooth at the mandibular osteotomy site. All patients had an acceptable scar. Among the patients who underwent mandibular subluxation, one patient had postoperative temporomandibular joint pain, which gradually subsided over 3 weeks. Conclusions: Mandibular swing and mandibular subluxation help provide the vascular surgeon with the additional space needed when excising CBTs, which extend close to the base of the skull with 1.5 cm or less of ICA from the base of the skull. The maneuvers help easier dissection and reconstruction of the ICA, reduce nerve injury and operating time, and reduce hospital stay and therefore cost to the patient.
Keywords: Carotid body tumor, mandibular subluxation, mandibular swing, maxillofacial surgeon, Shamblin 2, Shamblin 3
|How to cite this article:|
Daniel Sathiya S S, Stephen E, Kota AA, Samuel V, Premkumar P, Selvaraj D, Agarwal S. Extending the boundaries of carotid body tumor excision with a maxillofacial surgeon. Indian J Vasc Endovasc Surg 2019;6:298-301
|How to cite this URL:|
Daniel Sathiya S S, Stephen E, Kota AA, Samuel V, Premkumar P, Selvaraj D, Agarwal S. Extending the boundaries of carotid body tumor excision with a maxillofacial surgeon. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Feb 20];6:298-301. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/298/273586
| Introduction|| |
Carotid body tumors (CBTs) are one of the common paragangliomas occurring in the head and neck region. Surgical excision is the treatment of choice and at times necessitates a multidisciplinary team approach to increase access to the tumor intraoperatively and reduce postoperative complications.,,
| Methods|| |
Patients who were diagnosed with a CBT were evaluated by the vascular surgeons at our institute. While planning the surgery, they took into consideration the distance from the base of the skull, Shamblin score, and whether the planned surgery was the first attempt or a redo. Based on these factors, decision was taken to do mandibular swing or mandibular subluxation., After deciding between the two options, the decision was conveyed to the maxillofacial surgeon and patients were referred to the dental department to be evaluated for the feasibility of performing the additional procedure.
The maxillofacial surgeon then evaluated the existing status of dentition, temporomandibular joint (TMJ) disorders, and medical history to determine if a mandibular swing or mandibular subluxation was possible intraoperatively.
Based on this assessment, the best possible procedure was decided between the two teams and informed consent was obtained from the patient.
| Results|| |
Fifty-three patients underwent CBT excision during the study. Of these, 16 patients were referred to the maxillofacial surgeon for assistance with mandibular subluxation or swing.
Of the 16 patients, 10 were Shamblin 3 with 2 of these being redo cases and the others were Shamblin 2. In all cases, the length of internal carotid artery (ICA) from the base of the skull was 1.5 cm or less. Mandibular swing was performed in three patients [Figure 1], all for Shamblin 3 with two of them being the redo cases, and mandibular subluxation was done for 13 patients [Figure 2]. Preoperatively, 1 of the 16 patients had a fixed partial denture in the canine and premolar region of the maxilla, which made a mandibular subluxation impossible or difficult. This was discussed with the primary surgeons who also decided that a mandibular swing would be the better option. None of the patients preoperatively had TMJ disorders or any other medical conditions previously discussed.
|Figure 1: (a) Exposure for mandibular swing (b) mandibulotomy (c) closure of mandibular swing exposure (d) postoperative picture after suture removal|
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|Figure 2: (a) Eyelet wire placement (b) subluxating the mandible with wires (c) after subluxation|
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The primary surgical team found that, in this retrospective study, that one patient who underwent mandibular swing and 2 of the 13 patients for whom mandibular subluxation was performed had transient hypoglossal nerve palsy and all of the recovered completely over 3–7 days. The ICA required reconstruction in 5 of the 16 cases and was performed using the contralateral, proximal, great saphenous vein. In other cases, the craniocaudal approach to the ICA was made easier because of the additional space provided by the maneuvers.
The maxillofacial surgery team found that, postoperatively, all the three patients for whom a mandibular swing was performed had an acceptable scar on the chin. One of the patients lost one of the lower anterior teeth because of the mandibular osteotomy performed during the swing procedure. None of them developed marginal mandibular nerve palsy. All the patients were on nasogastric (NG) feeds till the speech and swallow team decided that it was safe to remove the tube. The longest a patient needed NG feeds was 3 months. There were no cases of vocal cord palsy.
Thirteen patients underwent a mandibular subluxation, of which one patient developed TMJ pain postoperatively. TMJ symptoms persisted for 3 weeks postoperatively and then gradually subsided over the subsequent visits.
| Discussion|| |
Status of dentition
The dentition was evaluated as its status would determine what procedure would be most suited for the patient. It is difficult to do a mandibular subluxation for edentulous patients or patients with artificial dentures at the contralateral canine and premolar regions. For a mandibular subluxation, the condyle of the mandible on the planned side of surgery has to be translocated anteroinferiorly out of the glenoid fossa and moved medially over to the opposite side. To maintain this position, eyelets are placed on the upper and lower contralateral canines and secured with tie wires for the entire duration of the surgery. Edentulous patients or patients with fixed partial dentures or removable partial dentures for missing teeth and patients with carious or fractured teeth in this region may not be suitable candidates for mandibular subluxation. The use of intermaxillary fixation (IMF) screws could, however, overcome this constraint. Usually, multiple IMF screws are used to achieve immobilization at a stable occlusion during operative procedures for fixing mandibular fractures, which is a relatively passive condition. We have not tried using IMF screws, and so we are not sure if two IMF screws can withstand the strain, of translocated mandible for the duration of surgery.
Another aspect of dentition we consider is the lower anterior crowding or spacing. Radiographs are evaluated to see the roots of the lower anterior teeth. When the plan is to do a mandibular swing, the space between the anterior roots are evaluated to decide the location of mandibular osteotomy. When space between two roots is very narrow, an osteotomy placed in between them could expose the roots or could even damage them, resulting in loss of either or both of the teeth. Hence, osteotomy is planned, so that it is between the roots of anterior teeth which have maximum inter radicular spacing in between them.
Temporomandibular joint disorder
Patients with preexisting TMJ disorders such as internal derangement of disk or TMJ arthritis would not do well postoperatively with respect to jaw movements if a mandibular subluxation was performed. This would result in a severe morbidity and may even necessitate another surgery to the TMJ., Hence, TMJ disorders would be an absolute contraindication for mandibular subluxation even if the primary treating surgeons had decided for it. It would be prudent to offer a mandibular swing which would go much easier on the TMJ.
Other previous or present medical conditions of the patient could also influence the decision. Previous irradiation of the mandible would have reduced its vascularity and increase the risk of osteoradionecrosis. Hence, a mandibular swing which requires an osteotomy is avoided, if possible. For patients with bone-related metabolic disorders such as osteoporosis, mandibular subluxation can be the first option, unless the primary surgeon feels the complexity of the CBT deems it necessary for a mandibular swing. Patients being treated with bisphosphonates for various bone lesions such as myelomas would do better with a mandibular subluxation. Some of the indications and contra indications for Mandibular subluxation and Mandibular swing are given in [Table 1] and [Table 2].
| Conclusions|| |
Mandibular swing or a mandibular subluxation offers wider operative boundaries, increases the ease of preservation or reconstruction of ICA, minimizes the risk of nerve damage, and, therefore, shortens hospital stay.
Mandibular subluxation would be suitable for patients with a slim neck, having at least 1.5 cm length of ICA from the base of the skull, while a mandibular swing would be preferred in redo cases, short necks or those patients unable to extend the neck and with a short stump of ICA (1 cm or less distally). Both subgroups could include those patients that require ICA reconstruction.
In our combined experience, we found that factors complicating CBT excision as previously known are negotiated better with one of the abovementioned procedures, and we also propose that the factors that influence the decision between a mandibular swing and a mandibular subluxation from a maxillofacial surgeon's perspective should be considered while planning the surgical procedure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arun D, Edwin S, Sadhu D, Agarwal S. Surgical management of carotid body tumors: A 15-year review. Indian J Surg N
Salins SR, Kumar PP, Stephen E, Selvaraj D. Anaesthetic management in the excision of large carotid body tumours: Surgeons perspectives. Int J Med Res Rev 2016;4:1493-501. Available from: http://medresearch.in/index.php/IJMRR/article/view/918
. [Last accessed on 2018 Nov 27].
Kasper GC, Welling RE, Wladis AR, CaJacob DE, Grisham AD, Tomsick TA, et al.
Amultidisciplinary approach to carotid paragangliomas. Vasc Endovascular Surg 2006;40:467-74.
Sen I, Stephen E, Malepathi K, Agarwal S, Shyamkumar NK, Mammen S. Neurological complications in carotid body tumors: A 6-year single-center experience. J Vasc Surg 2013;57:64S-8S.
Lim JY, Kim J, Kim SH, Lee S, Lim YC, Kim JW, et al.
Surgical treatment of carotid body paragangliomas: Outcomes and complications according to the shamblin classification. Clin Exp Otorhinolaryngol 2010;3:91-5.
Spiro RH, Gerold FP, Strong EW. Mandibular "swing" approach for oral and oropharyngeal tumors. Head Neck Surg 1981;3:371-8.
Fisher DF Jr., Clagett GP, Parker JI, Fry RE, Poor MR, Finn RA, et al.
Mandibular subluxation for high carotid exposure. J Vasc Surg 1984;1:727-33.
Simonian GT, Pappas PJ, Padberg FT Jr., Samit A, Silva MB Jr., Jamil Z, et al.
Mandibular subluxation for distal internal carotid exposure: Technical considerations. J Vasc Surg 1999;30:1116-20.
Sahoo NK, Mohan R. IMF screw: An ideal intermaxillary fixation device during open reduction of mandibular fracture. J Maxillofac Oral Surg 2010;9:170-2.
Hashemi HM, Parhiz A. Complications using intermaxillary fixation screws. J Oral Maxillofac Surg 2011;69:1411-4.
Coburn DG, Kennedy DW, Hodder SC. Complications with intermaxillary fixation screws in the management of fractured mandibles. Br J Oral Maxillofac Surg 2002;40:241-3.
Vikatmaa P, Mäkitie AA, Railo M, Törnwall J, Albäck A, Lepäntalo M. Midline mandibulotomy and interposition grafting for lesions involving the internal carotid artery below the skull base. J Vasc Surg 2009;49:86-92.
de Leeuw R. Internal derangements of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 2008;20:159-68, v.
Mayne JG, Hatch GS. Arthritis of the temporomandibular joint. J Am Dent Assoc 1969;79:125-30.
Dimitroulis G. Temporomandibular joint surgery: What does it mean to India in the 21st
century? J Maxillofac Oral Surg 2012;11:249-57.
Dimitroulis G, Austin S, Sin Lee PV, Ackland D. A new three-dimensional, print-on-demand temporomandibular prosthetic total joint replacement system: Preliminary outcomes. J Craniomaxillofac Surg 2018;46:1192-8.
Jereczek-Fossa BA, Orecchia R. Radiotherapy-induced mandibular bone complications. Cancer Treat Rev 2002;28:65-74.
Stefanidis S. Osteoradionecrosis, a side effect of radiotherapy of malignant neoplasms of the head and neck – A review. Odontostomatol Proodos 1989;43:475-85.
Friedman RB. Osteoradionecrosis: Causes and prevention. NCI Monogr 1990;9:145-9.
Pazianas M, Miller P, Blumentals WA, Bernal M, Kothawala P. A review of the literature on osteonecrosis of the jaw in patients with osteoporosis treated with oral bisphosphonates: Prevalence, risk factors, and clinical characteristics. Clin Ther 2007;29:1548-58.
Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: A review of 63 cases. J Oral Maxillofac Surg 2004;62:527-34.
[Figure 1], [Figure 2]
[Table 1], [Table 2]