• This month’s case was submitted by Drs. Jabbour and Sharan, Department of Neurosurgery, Thomas Jefferson University.

    History & Physical: The patient is a 60 year old male with a 6 week history of headaches and history of left tongue deviation and difficulty swallowing for the past 2 weeks. On exam, he has left tongue deviation, right uvular deviation, decreased left shoulder shrug, and decreased hearing on the left. There is a firm, mobile, 2 cm left retromastoid mass as well as a 1 cm lymph node papable in the neck.

    Follow up: 
    A neck lymph node biopsy was performed which yielded a diagnosis of lymphoma. He was started on chemotherapy. At his 2 month follow up, his XI and XII had improved. He is scheduled to have an MRI in 1 month to evaluate his response to chemotherapy.

    Imaging reveals a 2 cm left sided skull base mass. (figures 1-3 Below)

    Figure 1: T1 with gadolinium

    Figure 2: T2

    Figure 3: CT

    1. Is further imaging warranted?

    2. If yes, what would you order:

    3. Does this patient need full body imaging at this time?

    4. What is the next step in the management of this patient?

    5. Given the presence of a palpable lymph node, is a radical neck dissection warranted?

    6. If you do decide to perform an open operation would you plan on doing a fusion?

    7. Please add any suggestions or comments regarding this case:

    This patient may have secondary deposit elsewhere in the body. So full body screening is mandatory. After then his modality of treatment can be determined.

    I think it could be a Paraganglioma (typical history of the patient, left-sided foramen-jugulare-syndrome: paresis of CN IX&XI plus paresis of CN XII within canalis nervi hypoglossi and ipsilateral hearing deficit)also being delinated as tumor mass in the images in the area of jugular foramen below posterior cranial fossa. If it is really a Paraganglioma, I would suggest to order angiography and interventional radiology to embolize the tumor to support minimal surgical intervention. Neck dissection: I thought neck disection was indicated in patients with tumor metastases, esp. malign tumors of the naso- and oropharynx. Dear Sirs, I hope I did not write extremely wrong suggestions (I am only a young medical student who is interested in Neurosurgery) Sincerely (a student from Germany)

    Possible paraganglioma

    Firt otion is metastatic disease given the quick progresion, litic nature and adenopaties

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