A 74-year-old gentleman complained of a right neck swelling that had been increasing gradually in size for the past 2 years. He had no pain, dysphagia, dyspnea or dysphonia. He also did not complain of any shortness of breath, foul-smelling breath, fever, weight loss or loss of appetite. He had no symptoms of hyperthyroidism or hypothyroidism. Interestingly, he complained of cough whenever the neck mass was touched. The patient was a diabetic with hyperlipidemia and hypertension. He also had a cerebral insult in the previous year with right hemiparesis which had resolved. He had no history of tuberculosis or any contact with such patients. The patient was a chronic smoker.
The patient was alert and conscious and oriented to time and place. All cranial nerves were intact. The oral cavity and oropharyngeal examination was unremarkable. The neck examination revealed a fullness on the right Level III measuring 4 cm x 3 cm (Figure 1). There were no skin changes and the fullness was not tender and soft on palpation. However, during the palpation of the mass, the patient developed bouts of coughing. Otoscopy and nasoendoscopy showed normal findings. On examination of the larynx and hypopharynx, all structures were normal, and the bilateral vocal cords were mobile.
A computed tomographic (CT) scan demonstrated a well-defined, solitary mass in the right carotid space, posterior to the carotid artery and internal jugular vein (Figure 2). The mass was hypodense to the skeletal muscles and showed mild enhancement post-contrast. There was no calcification or necrosis within it. The mass measured 2.3 cm x 2.4 cm x 7.6 cm and extended from the level of C2/C3 to C6/C7. It compressed the right internal jugular vein, abutted the common carotid artery and stretched the adjacent sternocleidomastoid muscle. However, the vein was still patent and was not separated from the common carotid artery. These features were suggestive of a right vagal schwannoma.
Microscopically, the smears of high cellularity were composed of clusters of uniform spindle cells in a bloody background. The spindle cells had oval nuclei, inconspicuous nuclei and a moderate amount of cytoplasm. Blood vessels were also seen intermingled with these clusters. No mitosis or bizarre cells were seen. No lymphoid or squamous elements were noted. Sections from the cell block showed sheets of spindle cells arranged in a hypercellular pattern. Some cells exhibited palisading and formed vague Verrocay bodies. The fine needle aspirate of the mass showed the presence of spindle cells, indicating that it was most probably a schwannoma.
An attempt to perform fine needle aspiration for cytology (FNAC) failed due to coughing induced by palpation of the mass. In view of risk to the adjacent vascular structures, an ultrasound-guided FNAC was performed with difficulty due to the patient's paroxysmal cough during the procedure. The ultrasound reported a homogenous hyperechoic solid lesion measuring 2.3 cm x 2.6 cm in the right neck lateral to the right internal jugular vein and internal carotid artery. No calcification or vascular activity was noted within it.
Based on the patient's age and co-morbidities, we discussed the treatment plan with the patient and his family. In consideration of the patient's multiple co-morbidities; possible complications, such as hoarseness and injury to the adjacent structures; and the patient's preferences, we agreed to conservative watchful management, as the tumor was benign and slow-growing. As of now, the patient has been under our observation for the past year, tumor growth has been static and no compression symptoms or airway compromise have been exhibited.