Facial pain: a rare presenting symptom of sympathetic chain schwannoma

<p>Schwannoma is a nerve sheath tumour that usually presents as an asymptomatic lump. We report a case where facial pain was the only symptom of the tumour. Surgical excision was done. Intraoperative findings and Horner syndrome confirmed the diagnosis of cervical sympathetic chain schwannoma. Histopathology was also consistent with the diagnosis. The patient did well postoperatively.</p>

The superior cervical ganglia modulate ventilatory responses to hypoxia independently of pre-ganglionic drive from the cervical sympathetic chain

Superior cervical ganglia (SCG) post-ganglionic neurons receive pre-ganglionic drive via the cervical sympathetic chain (CSC). The SCG projects to structures like the carotid bodies (e.g., vasculature, chemosensitive glomus cells), upper airway (e.g., tongue, nasopharynx) and to parenchyma and cerebral arteries throughout the brain. We previously reported that a hypoxic gas challenge elicited an array of ventilatory responses in sham-operated (SHAM) freely-moving adult male C57BL6 mice and that responses were altered in mice with bilateral transection of the cervical sympathetic chain (CSCX). Since the CSC provides pre-ganglionic innervation to the SCG, we presumed that mice with superior cervical ganglionectomy (SCGX) would respond similarly to hypoxic gas challenge as CSCX mice. However, while SCGX mice had altered responses during hypoxic gas challenge that occurred in CSCX mice (e.g., more rapid occurrence of changes in frequency of breathing and minute ventilation), SCGX mice displayed numerous responses to hypoxic gas challenge that CSCX mice did not, including reduced total increases in frequency of breathing, minute ventilation, inspiratory and expiratory drives, peak inspiratory and expiratory flows, and appearance of non-eupneic breaths. In conclusion, hypoxic gas challenge may directly activate sub-populations of SCG cells, including sub-populations of post-ganglionic neurons and small intensely fluorescent (SIF) cells, independently of CSC drive, and that SCG drive to these structures dampens the initial occurrence of the hypoxic ventilatory response, while promoting the overall magnitude of the response. The multiple effects of SCGX may be due to loss of innervation to peripheral and central structures with differential roles in breathing control.

Loss of Cervical Sympathetic Chain Input to the Superior Cervical Ganglia Affects the Ventilatory Responses to Hypoxic Challenge in Freely-Moving C57BL6 Mice

The cervical sympathetic chain (CSC) innervates post-ganglionic sympathetic neurons within the ipsilateral superior cervical ganglion (SCG) of all mammalian species studied to date. The post-ganglionic neurons within the SCG project to a wide variety of structures, including the brain (parenchyma and cerebral arteries), upper airway (e.g., nasopharynx and tongue) and submandibular glands. The SCG also sends post-ganglionic fibers to the carotid body (e.g., chemosensitive glomus cells and microcirculation), however, the function of these connections are not established in the mouse. In addition, nothing is known about the functional importance of the CSC-SCG complex (including input to the carotid body) in the mouse. The objective of this study was to determine the effects of bilateral transection of the CSC on the ventilatory responses [e.g., increases in frequency of breathing (Freq), tidal volume (TV) and minute ventilation (MV)] that occur during and following exposure to a hypoxic gas challenge (10% O2 and 90% N2) in freely-moving sham-operated (SHAM) adult male C57BL6 mice, and in mice in which both CSC were transected (CSCX). Resting ventilatory parameters (19 directly recorded or calculated parameters) were similar in the SHAM and CSCX mice. There were numerous important differences in the responses of CSCX and SHAM mice to the hypoxic challenge. For example, the increases in Freq (and associated decreases in inspiratory and expiratory times, end expiratory pause, and relaxation time), and the increases in MV, expiratory drive, and expiratory flow at 50% exhaled TV (EF50) occurred more quickly in the CSCX mice than in the SHAM mice, although the overall responses were similar in both groups. Moreover, the initial and total increases in peak inspiratory flow were higher in the CSCX mice. Additionally, the overall increases in TV during the latter half of the hypoxic challenge were greater in the CSCX mice. The ventilatory responses that occurred upon return to room-air were essentially similar in the SHAM and CSCX mice. Overall, this novel data suggest that the CSC may normally provide inhibitory input to peripheral (e.g., carotid bodies) and central (e.g., brainstem) structures that are involved in the ventilatory responses to hypoxic gas challenge in C57BL6 mice.

When Options are Limited: Case Report of an Ultrasound Guided Stellate Ganglion Block at Bedside

Background: Stellate ganglion block is an option for refractory ventricular tachyarrhythmia. Approaches include using anatomical landmarks or image-guidance with fluoroscopy, computerized tomography, magnetic resonance imaging, or ultrasonography. Case Report: We describe a case of a 70-year-old man with multiple comorbidities presenting with sustained ventricular tachycardia (VT) who received a cervical sympathetic chain block at bedside. This resulted in ablation of his refractory VT and return to a paced rhythm, allowing him to be discharged from the intensive care unit. Conclusion: This case shows the advantages of targeting the cervical sympathetic chain to block the stellate ganglion in a high-risk patient. Doing the procedure under ultrasound guidance allows for real-time visualization with the advantage of being performed at the bedside. Therefore, a cervical sympathetic chain block should be considered for treatment of refractory ventricular arrhythmias. Key words: Cervical sympathetic chain, refractory ventricular tachyarrhythmia, stellate ganglion block, ultrasound guidance

First Bite Syndrome Following Rhytidectomy: A Case Report

Background: First bite syndrome (FBS) is a known complication of parotid gland resection, parapharyngeal space dissection, and cervical sympathetic chain injury. It can be described as severe cramping or spasms in the parotid region triggered by the first bite of a meal, with the pain lessening during each subsequent bite. Although dissection for a rhytidectomy is in the vicinity of the parotid parenchyma, face-lift is not typically characterized as a procedure that can lead to FBS. Case description: A 53-year-old female underwent a deep plane face-lift to address her goals of improving jowls, nasolabial folds, and cervicomental angle. Intraoperatively, the dissection proceeded without any complications. Initially, her postoperative course was uneventful; 3 weeks after surgery, she noticed pain at the start of mastication that would improve throughout the course of a meal. She elected to proceed with observation. At 6 months after surgery, she began to experience improvement in her symptoms, and shortly thereafter had complete resolution. Discussion: First bite syndrome is a complication associated with deep lobe parotid resection, first described in 1998. The innervation of the parotid gland is complex and includes contributions from the auriculotemporal nerve, the great auricular nerve, and the cervical sympathetic chain. During rhytidectomy, dissection occurs along the parotidomasseteric fascia in order to elevate a flap of the superficial musculoaponeurotic system. Inadvertent injury to the parotid parenchyma can lead to damage to the postganglionic sympathetic fibers innervating the myoepithelial cells. Ultimately, expectant management is the mainstay of treatment and symptoms typically resolve within 6 months to 1 year. Conclusion: First bite syndrome is a complication that can be seen with a variety of facial surgeries. In the case of rhytidectomy, FBS should be considered a potential risk, as dissection into the parenchyma of the parotid gland can result in postoperative autonomic dysfunction.