1/ 🧵 21 yo F with neurofibromatosis is adm to ICU after a left suboccipital crani and C1-2 lami for resx of a neurofibroma at the cervicomedullary junction/C1-C2. No peri-op issues. BP 124/78, HR 80s, sat 100% on RA. Neuro intact.
~ 3 hours later: rapidly ⬆️⬆️ right neck mass
~ 3 hours later: rapidly ⬆️⬆️ right neck mass
2/ Welcome to an #EmoryNCCTweetorial on a rare entity of rapidly expanding neck mass in the post op neurosurgical patient.
Relevant for #ENT #anesthesia #criticalcare #neurosurgery #neurology #neurointensivists #intensivists #infectiousdisease #FOAMncc #FOAM
Relevant for #ENT #anesthesia #criticalcare #neurosurgery #neurology #neurointensivists #intensivists #infectiousdisease #FOAMncc #FOAM
3/ 🥅Goals for the scroll
✅ List ddx of expanding neck mass
✅ Recognize importance of emergent airway
✅Review a rare cause of expanding neck mass in the neurosurgical patient undergoing posterior fossa surgery
✅ List ddx of expanding neck mass
✅ Recognize importance of emergent airway
✅Review a rare cause of expanding neck mass in the neurosurgical patient undergoing posterior fossa surgery
4/ Let’s revisit the patient. The neck mass is expanding. She sounds stridorous. What’s your next step?
5/ Secure the airway! Given the expanding neck, the airway could become surgical. You may need #anesthesia, #ENT, #surgery (depending on where you practice).
6/ The team does a fiberoptic nasal intubation in the OR. The airway is secure. Now we can think!
FYI: consent given for this case & all photos. 💕
FYI: consent given for this case & all photos. 💕
7/ What’s the ddx for expanding neck mass?
💡Benign neoplasms (salivary gland tumors, nerve sheath tumors, paragangliomas)
💡Infectious process
💡Malignancy (lymphoma can grow fast)
💡Congenital cysts
💡Vascular lesion
💡Sialadenitis
💡Benign neoplasms (salivary gland tumors, nerve sheath tumors, paragangliomas)
💡Infectious process
💡Malignancy (lymphoma can grow fast)
💡Congenital cysts
💡Vascular lesion
💡Sialadenitis
8/ But this was incredibly rapid expansion (less than hours). So that really narrows this down to inflammatory or infectious processes vs. vascular lesion.
9/ You obtain the CT of the neck. Review carefully. Quiz in the next tweet.
10/ What’s the diagnosis?
11/ Acute submandibular sialadenitis! This has been reported in case series reviewing complications of posterior fossa surgeries! Thanks to @EmoryInfectDis and @JayKinariwala for help cracking the case!
✅ncbi.nlm.nih.gov
✅pubmed.ncbi.nlm.nih.gov
✅ncbi.nlm.nih.gov
✅pubmed.ncbi.nlm.nih.gov
12/ Here’s another look at the massive right submandibular gland and surrounding tissue inflammation of the CT neck. Vascular structures intact. The gland is the problem.
13/ Fast facts about post operative acute sialadenitis after posterior fossa surgery
➡️Incidence ~0.8%
➡️ Usually NOT evident immediately post op
➡️Evident w/ in 4-8 hours after surgery
➡️Submandib gland swelling always contral to crani side
➡️Usually req emergent reintubation
➡️Incidence ~0.8%
➡️ Usually NOT evident immediately post op
➡️Evident w/ in 4-8 hours after surgery
➡️Submandib gland swelling always contral to crani side
➡️Usually req emergent reintubation
14/ Mechanism? Obstruction of the salivary duct from surgical positioning!
✅Rot and flx of neck during retrosig and far-lateral surg → occl of submandib duct + direct gland compression → ischemia and edema
✅Leads to salivary status and 2' bacterial infx
✅Rot and flx of neck during retrosig and far-lateral surg → occl of submandib duct + direct gland compression → ischemia and edema
✅Leads to salivary status and 2' bacterial infx
15/ Example of park-bench position sometimes used for far lateral approach. Not well pictured is contralateral head rotation & flexion. This positioning allows access to craniocervical jx.
For those inclined (& pic credit), read more here: tinyurl.com
For those inclined (& pic credit), read more here: tinyurl.com
16/ Note that cases of acute submandibular sialadenitis have reported in patients in various positions for p fossa surgeries including prone, supine, lateral, park-bench & sitting.
17/ 🚨Certain medical conditions predispose pts to salivary stasis.
DM
Liver failure
Renal failure
Hypothyroidism
Sjogren’s
Malnutrition
Anticholinergic meds
Dehydration
DM
Liver failure
Renal failure
Hypothyroidism
Sjogren’s
Malnutrition
Anticholinergic meds
Dehydration
18/ Treatment (after securing the airway): supportive!
✅Hydration (to improve salivary duct secretions)
✅Antibiotics (gram 🟣 +)
✅Time
✅+/- steroids (done in our patient but not in all cases in lit)
✅If ongoing gland obstruction → ductal dilation or sialolithotomy
✅Hydration (to improve salivary duct secretions)
✅Antibiotics (gram 🟣 +)
✅Time
✅+/- steroids (done in our patient but not in all cases in lit)
✅If ongoing gland obstruction → ductal dilation or sialolithotomy
19/ Prevention? Sparse literature advocates for ensuring ETT tube on ipsilateral side of mouth (of crani) during p fossa surgery to prevent further compression of duct by ETT. Thoughts from #anesthesiologists?
20/ Our patient did great. The neck swelling resolved and she was extubated on POD 4. Most patients in case series do well and are extubated in 5-7 d.
21/ What have we learned?
🚨Acute submandibular sialadenitis can occur after posterior fossa surgery due to neck positioning and duct obstruction
🚨First step is to secure the airway (PRN)
🚨Antibiotics and hydration are mainstays of tx (+ time)
🚨It gets better (avg. 5-7 d)
🚨Acute submandibular sialadenitis can occur after posterior fossa surgery due to neck positioning and duct obstruction
🚨First step is to secure the airway (PRN)
🚨Antibiotics and hydration are mainstays of tx (+ time)
🚨It gets better (avg. 5-7 d)
22/ Other than this rare acute sialadenitis, what are other posterior fossa surgery complications neurointensivists should know?
@caseyalbin @Capt_Ammonia @drdangayach @pouyeah @subinmatthews @JimmySuhMD @Emcrit @JackieKraft4 @maness_caroline @caseyhall @CajalButterfly
@caseyalbin @Capt_Ammonia @drdangayach @pouyeah @subinmatthews @JimmySuhMD @Emcrit @JackieKraft4 @maness_caroline @caseyhall @CajalButterfly
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