Wk 8, Case 1 - Review

Patient History
Pulsatile neck mass.

Findings
Pre- and postcontrast MR was performed from the skull base to the thoracic inlet.

There is a 6cm left carotid sheath mass which is posterior to the left carotid bifurcation and displaces the left ICA anteriorly. The mass is hypervascular, contains multiple flow voids and partially surrounds the left ICA. The mass is separate from the left jugular foramen. The findings are most compatible with a left glomus vagale tumor.

There is a second 2cm hypervascular mass centered to the left jugular foramen occluding the left jugular vein, most compatible with a left glomus jugulare tumor.

There is a third hypervascular 15mm mass which contains multiple flow voids located in the right carotid bifurcation splaying the right ICA and ECA compatible with a right carotid body tumor.

There is a fourth 2cm hypervascular mass at the C1 level in the right carotid space which anteriorly displaces the right ICA. This mass also contains multiple flow voids and partially surrounds the right internal carotid artery. These findings are consistent with a glomus vagale tumor.

There is prominent adenoidal tissue in the nasopharynx which is normal for age. There is also prominence of the palatine tonsils which is also normal for age. No evidence of aggressive lesions is identified involving the floor of mouth or tongue base. The larynx and hypopharynx appear within normal limits without evidence of displaced vocal cord.

The thyroid gland appears to be within normal limits.

Conclusions
1. Multiple paragangliomas involving the neck which include glomus vagale (x2), carotid body tumor and glomus jugulare tumor. Multiple glomus tumors raise the possibility of syndromic causes which includes multiple endocrine neoplasia syndrome and hereditary forms of paraganglioma (paraganglioma syndrome).
2. No obvious evidence of thyroid masses to suggest presence of medullary carcinoma which must be considered in a patient with multiple paragangliomas.