Sympathetic Chain Schwannoma Masquerading as a Vagus Nerve Schwannoma Complicated by Postoperative Horner’s Syndrome and Facial Neuralgia: A Case Report
Baker, Terry MD
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Background: Schwannomas of the carotid sheath are rare neoplasms and schwannomas of the cervical sympathetic chain are the least common subtype. Despite predictive radiologic patterns, Cervical sympathetic chain schwannomas (CSCS) have been known to masquerade as other neoplasms on CT and MRI making preoperative diagnosis difficult. Postoperative complications are common. We present a rare case of a misdiagnosed CSCS with unusual complications of permanent Horner’s syndrome and facial neuralgia. Case Information: A 36-year-old female presented with a right neck mass. CT and MRI confirmed the mass in the parapharyngeal space. The positioning of the mass in conjunction with the common carotid artery and the internal jugular vein lead to a diagnosis of vagus nerve schwannoma (VNS). During surgical treatment, dissection to the mass revealed the preoperative diagnosis of VNS to be incorrect as the mass was found to be involved with the cervical sympathetic chain. A new diagnosis of CSCS was made and the nerve was enucleated along with the mass. The patient presented postoperatively with Horner’s syndrome and severe facial neuralgia. Despite maximal medical management for two years, these complications have proved permanent. Conclusions: Imaging is the mainstay for preoperative diagnosis of CSCS. While imaging trends allowing distinction between VNS, CSCS, and other tumors are helpful, recent studies have shown considerable variability in these trends making preoperative diagnosis difficult. Our case reflects this difficulty as preoperative imaging led to an incorrect diagnosis. In addition, post-operative complications, such as temporary Horner’s syndrome are common in CSCS. The patient in our case presented with more severe and unique complications of facial neuralgia and permanent Horner’s syndrome. These complications are not often seen in the literature. Future research should be undertaken to determine if a link between an incorrect preoperative diagnosis and an increased complication rate exists. In addition, this case serves to heighten clinician consciousness of a rare but important diagnosis and the difficulties involved with initial diagnosis and potential complications. We hope that such knowledge will prompt physicians to prepare thoroughly for possibly alternative diagnoses during surgical intervention which may lead to improved patient outcomes.