A 12 year boy presented with slow growing lateral neck mass beneath left sternocleidomastoid muscle. Preoperative diagnosis was uncertain so tumor was excised and it came out to be schwannoma.

1. Cevical Schwannoma in 12
year boy
Moderator:
Prof. Rahul Khanna
Dr. RN Meena
Department of General Surgery
Institute of Medical Sciences
Banaras Hindu University
Varanasi -221005
Presenter:
Dr. Vipul Srivastava

2. History
12 years boy, resident of Azamgarh presented
in SOPD with C/O –
• Swelling over left side of neck x 4 months

3. Swelling was :
 Insidious onset
 Gradually progressive
 Painless

4. No history of :
 Fever
 Difficulty in deglutition
 Change in voice
 Discharge from ear
 Birth Trauma

5. Past History:
No h/o similar illness in past
No h/o any chronic illness
Family History:
No h/o similar illness in any of the family
member

6. Immunization and development history:
 Immunization is as per NIS
 Developmental milestones were achieved at
appropriate age
Personal history:
 Mixed diet
 Not addicted to tobacco or alcohol in any form
 Normal bowel and bladder habit

7. • Dietary history:
Calorie intake: 2000 kcal/day
Protein intake: 40 gm/day
• Socioeconomic status:
Middle lower middle
Pukka house
Sanitary toilet

8. General Physical Examination
Child was conscious, co-operative, well-
oriented to time, place and person sitting
comfortably on couch with vitals of :
Afebrile
Pulse : 96/min
BP : 110/60 mm Hg
RR : 18/min

9. Pallor/ Icterus/ Cyanosis/ Clubbing/
Lymphadenopathy/ Pedal edema : Absent
Hydration : Adequate, JVP : Not raised
Average Built
Head to toe examination is normal

10. Ht- 140 cm (10-50th centile)
Wt- 35 kg (10-50th centile)
BMI : 17.8 kg/m2
Oral hygiene was adequate

11. Systemic Examination
CNS :
Higher mental functions normal
No sensory/motor deficit
CVS :
S1, S2 heard
No added sounds present

12. RESPIRATORY SYSTEM :
B/L air entry equal
No added sounds present
PER ABDOMEN:
Abdomen soft, non-tender
Liver and spleen are not palpable
No shifting dullness or fluid thrill
Bowel sounds normal

13. Local Examination
Neck region:
• Inspection -
 A Globular
swelling of size
approx. 3x3 cm
present 4 cm
below left
mastoid process
and 2 cm below
angle of left
mandible

14. Non-pulsatile
Skin over the swelling was normal
Does not moves with deglutition
No discharging sinus present

15. • Palpation-
No local rise of
temperature
Non tender
4x3 cm
Swelling
disappears when
SCM of same side
was taut

16. Smooth surface
Well defined margins
Firm and mobile side to side
No cervical, axillary or Inguinal lymph
nodes palpable
Non compressible

17. No other lump palpable in neck region
Intra oral examination was normal
Carotid and Superficial temporal
pulsations were normal
• Auscultation –
No bruit or hum heard

18. Differential Diagnosis
Tubercular lymph node
Lymphoma
Branchial cyst
Neurofibroma
Carotid body tumor

19. Investigations
04/01/19
Hb 13.4 RBS 98
TLC 6110 TP/ALB 8.3/4.9
DLC 54(N)/37(L) Creat 0.8
PLT 1,67,000 Urea 21.9
SGPT/OT 56/35 Na+ 143.4
STB/SDB 1.0/0.3 K+ 4.9
ALKP 543.5

20. USG Neck
LN mass in left
upper anterior
cervical region,
with increased
vascularity.

22. USG guided FNAC
• ? Benign
salivary gland
tumor.

23. Steps of Surgery
After giving general
anaesthesia
Neck extended and
patient’s face
turned toward
right.

24. Proper painting and
draping done
5 cm skin incision
given 2 cm below
and parallel to
ramus of mandible
Subcutaneous tissue
and platysma cut.

25. Sterno-
cleidomastoid
muscle divided to
reach the mass.
Fine tissue
dissection was
carried out after
dividing deep
cervical fascia

26. Carotid sheath was
identified and care
was taken to avoid
any injury
Tumor was
dissected out in its
plane using blunt
and sharp dissection

27. CCA, its bifurcation
and Vagus nerve
was identified
separately from
tumor
Tumor was
removed
Minivac Drain was
placed

28. Sterno-cleidomastoid
repaired with vicryl
2-0 CRB
Platysma closed with
vicryl 2-0 CRB and
skin closed with
prolene 4-0 CCN

29. OT Findings
• A 4x3 cm well encapsulated mass present in
left cervical region
• Not adhered to adjacent nerve or vessel
• Left Vagus nerve was displaced anteriorly

30. Post op Course
On POD 1 pt. vitals were stable and Drain
output was 20 ml sero-sanguinous and
hoarseness of voice was present.
On POD2 drain output was minimal. Drain
was removed.
On POD3 patient was discharged.

31. Follow up
• 7 days after discharge patient was called for
follow up
• He was referred to ENT OPD and it came to
be left vocal cord palsy
• Conservative treatment with speech therapy
was started

32. Histopathological Examination
• Neural tumor s/o
Schwannoma

33. Discussion : Schwannoma
• Peripheral nerve tumors of nerve sheath
origin
• First established as pathological entity by
Verocay in 1908
• Can arise from any nerve which has schwann
cells
• Except Optic and Olfactory nerves
• Mostly solitary
• 25-45% occur in head and neck (Ishtyaque
Ansari et al., 2018 )

34. • Incidence is 2-5%
• 90% are sporadic, 3% with
neurofibromatosis type 2, 2% with
schwannomatosis, 5% with
meningiomatosis with or without
neurofibromatosis type 2
(http://www.pathologyoutlines.com/topic/
softtissueschwannoma.html)
• May occur spontaneously
• Loss of function of the tumor suppressor
gene merlin (schwannomin)

35. • Benign and slow growing
• Malignant transformation is very rare
• Nerve of origin is not identified in 10-40%
of cases (Ishtyaque Ansari et al., 2018 )
• Among cranial nerves most common is
acoustic neuroma of VIII nerve
• Mostly occur between 30 to 50 years
• Only 10% occur in patients less than 21
years
• Males and females equally affected

36. • Clinically present as asymptomatic slow
growing lateral neck mass
• Along medial border of SCM
• If symptoms are present hoarseness of voice
is commonly present
• Occasionally paroxysmal cough may be
produced on palpating the mass (Jyotiranjan
Das et al., 2016 )
• Pre operative diagnosis is difficult
• MRI is the IOC
• Usefulness of FNAC is controversial

37. • Treatment is complete surgical excision
• Intra-capsular enucleation done to preserve
nerve fibres (Józef Mierzwińskia et al.,
2018)
• Radioresistant
• Complications: Hoarseness of voice,
coughing, Horner’s syndrome
• Microscopically : Spindle shaped cells in
Antoni-A & Antoni-B arrangement
interspersed with Verocay bodies
• Strong positivity for S-100

38. Difference b/w Schwannoma and
Neurofibroma
Schwannoma Neurofibroma
Encapsulated Lacks capsule
Degenerative changes present Not present
Involves single fascicle of nerve May involve multiple fascicles
S100 strong positive CD 34 strong positive
Antoni A and Antoni B
Alternating hypercellular and
hypocellular areas
Spindle cells, shredded carrot collagen,
mast cells
Hypocellular, myxoid areas without
hypercellular areas

39. Take Home Message
 Though rare Cervical Schwannomas are to be
kept in mind as a differential diagnosis of
unilateral neck swellings
Medial SCM swelling along with paroxysmal
cough on palpating the mass should raise a
high suspicion for vagal schwannoma
FNAC may be risky and is controversial

40. References
• M.G. Chiofalo, F. Longo, U. Marone, R. Franco, A.
Petrillo, L. Pezzullo. Cervical vagal
schwannoma: A case report. ACTA
OTORHINOLARYNGOL ITALICA 2009;29:33-35
• Ishtyaque Ansari, Ashfaque Ansari, Arjun
Antony Graison , Anuradha J. Patil, and
Hitendra Joshi. Head and Neck Schwannomas:
A Surgical Challenge—A Series of 5 Cases. Case
Reports in Otolaryngology Volume 2018
• http://www.pathologyoutlines.com/topic/soft
tissueschwannoma.html

41. • Jyotiranjan Das, Jayant saha, Shantanu Dutta
and Ajay manickam. Cervical Schwannoma-
A Case Report. Otolaryngol (Sunnyvale)
2016, 6:2
• Józef Mierzwińskia, Iwona Wrukowskaa,
Justyna Tyraa, Dariusz Paczkowskib, Tomasz
Szcześniaka, Karolina Habera. Diagnosis and
management of pediatric cervical vagal
schwannoma. International Journal of
Pediatric Otorhinolaryngology 114 (2018)
9–14