2024 FSA Podium and Poster Abstracts
P090: TAPIA SYNDROME: BEYOND OROTRACHEAL INTUBATION - A CASE OF SCHWANNOMA-INDUCED PERIPHERAL PALSY
Hala Baaj1; Armaan Sobhan2; Anwar Khan3; William Crook, MD4; John T. Lanza, MD5; 1Florida International University, Herbert Wertheim College of Medicine; 2St. George's University School of Medicine; 3Florida State University College of Medicine; 4Saint Lucie Medical Center; 5ENT and Allergy Associates of Florida
Introduction: Tapia Syndrome (TS) is the ipsilateral palsy of both the hypoglossal nerve and the recurrent laryngeal branch (RLN) of the vagal nerve. The clinical findings are a deviated tongue toward the affected nerve and dysphagia/dysphonia due to unilateral paralysis of the intrinsic tongue muscles and vocal cords, respectively1-4. Tapia Syndrome can be classified as central and peripheral. Peripherally induced TS are on the rise but causes outside of direct trauma from orotracheal intubation or injury have rarely been reported. This report highlights a case of peripherally induced TS from a schwannoma compressing the hypoglossal and vagal nerve and the preventive measures necessary for patient intubation.
Case: We present the case of a 77-year-old female with a history of diabetes, hypothyroidism, and CVD who presents to the ENT clinic complaining of progressively worsening hoarseness for the past two months. She also reports dysphagia to solids and liquids, dry mouth, right ear pain, globus sensation, and throat pain. Examination of the oral cavity showed atrophy of the right tongue with deviated tongue to the right and no other abnormalities. A rigid laryngoscopy revealed bowing of the right vocal fold free edge, severely decreased mobility of the right true vocal cord, and moderate phase asymmetry. A CT scan of the neck showed no masses. An MRI of the brain showed a 3.2 by 1.7 cm mass located near the hypoglossal canal extending into the right neck.
Discussion: Patient presents with clinical signs classic for Tapia Syndrome as seen in Figure 1. Physical exam findings of the atrophied and deviated tongue suggest palsy of CN XII. The bowing of the right vocal fold free edge, severely decreased mobility of the right true vocal cord, and moderate phase asymmetry shown on laryngoscopy are all suggestive of a lesion on RLN of CN X. An MRI of the brain showed a mass located at the hypoglossal canal. The Vagal and hypoglossal nerve come into close proximity near the hypoglossal canal and its junction with the carotid sheath. The descending portion of the hypoglossal nerve exits the canal medially to the internal carotid artery and internal jugular vein and travels posterior to the vagus nerve located in the carotid sheath. The MRI and CT indicate a possible neural tumor located near the hypoglossal canal, creating a mass effect and consequently an ipsilateral CN X and CN XII palsy. Since TS can be associated with significant comorbidities, preventive measures are crucial during intubation: the intubated patient’s head needs to be kept in the most neutral position possible and the performance of a tracheotomy needs to be considered after a maximum of 10 days of orotracheal intubation5.
Conclusion: TS is the ipsilateral paralysis of both CNX and XII. Peripheral TS induced by a suspected schwannoma or neurofibroma has rarely been reported in the literature. This case highlights the symptoms and anatomical relationships associated with a schwannoma compressing both the hypoglossal and vagal nerve, as well as the preventive measures during intubation.
%20(1).jpeg)
1)PMID:35829719
2)PMID:24078360
3)PMID:23265562
4)PMID:35410105
5)PMID:34969313