Carotid body tumors (CBTs) are rare, highly vascular neoplasms arising from paraganglionic tissue at the carotid bifurcation. These tumors may present as a slow-growing neck mass but pose major intraoperative challenges due to proximity to vital vascular and neural structures, including the internal and external carotid arteries and cranial nerves IX, X, XI, and XII.
Surgical excision is the definitive treatment. However, the risk of massive blood loss, hemodynamic instability from carotid sinus manipulation, and potential cranial nerve injuries makes anesthetic management complex. Preoperative embolization of feeding vessels is commonly performed to reduce intraoperative bleeding and facilitate dissection.
A 61-year-old male presented with a left-sided neck swelling of one-year duration, which had gradually increased in size. The patient was a known case of systemic hypertension and hypothyroidism, both well-controlled on medication.
CT angiography revealed a highly vascular mass at the left carotid bifurcation, splaying the internal and external carotid arteries—consistent with a Shamblin Type II carotid body tumor. In view of its vascularity, preoperative embolization of the left ascending pharyngeal and maxillary arterial feeders was performed to minimize intraoperative blood loss one prior to the surgery.
Airway examination was normal. Cardiovascular and respiratory evaluations were unremarkable. Routine hematological and biochemical investigations were within normal limits. ECG showed no ischemic changes, and echocardiography revealed good left ventricular function. Thyroid function tests were within therapeutic range.
Adequate blood and blood products were reserved preoperatively. The patient was optimized with antihypertensives and thyroxine and was deemed fit for surgery under general anaesthesia.
The patient was taken up for left carotid body tumor excision under general anaesthesia with endotracheal intubation.
Induction: Propofol (2 mg/kg), fentanyl (2 mcg/kg), and cisatracurium (0.1 mg/kg).
Maintenance: Desflurane in a mixture of oxygen and nitrous oxide, with cisatracurium infusion (4 mg/hr) for muscle relaxation.
Monitoring: Standard ASA monitors, including ECG, SpO₂, ETCO₂, and temperature, along with invasive arterial blood pressure monitoring.
Drugs kept ready: Noradrenaline and nitroglycerin infusions were prepared to counter possible hemodynamic fluctuations during tumor manipulation.
Ryle’s tube was inserted after intubation and retained postoperatively in view of potential aspiration risk following cranial nerve handling.
The surgical approach involved a longitudinal incision along the anterior border of the sternocleidomastoid muscle, with careful dissection of the tumor from the carotid bifurcation. The external carotid artery (ECA) and internal carotid artery (ICA) were identified, and the hypoglossal and glossopharyngeal nerves were meticulously preserved.
Duration of surgery: 4 hours 20 minutes Fluids administered: 1,200 ml crystalloids Estimated blood loss: ~400 ml Urine output: Adequate
Hemodynamics remained stable throughout, with brief episodes of hypotension managed with titrated noradrenaline infusion. The patient was extubated uneventfully at the end of surgery and shifted to the recovery room for close monitoring.
The patient was kept under close observation in the recovery area, followed by transfer to the ward. Ryle’s tube was retained postoperatively to prevent aspiration until swallowing was assessed to be safe.
Postoperatively, the patient developed mild hoarseness of voice and deviation of the tongue to the left, suggestive of transient cranial nerve X and XII neuropraxia from intraoperative traction. There were no other neurological deficits.
At discharge, the patient was clinically stable, able to swallow, and had no new neurological deficit. Blood pressure was well controlled (140/80 mmHg), and the wound site was healthy.
Carotid body tumor excision poses significant anesthetic challenges due to its vascular nature and close anatomical relation to major vessels and cranial nerves. The anesthesiologist plays a pivotal role in ensuring hemodynamic stability, minimizing blood loss, and preventing neurological complications.
In this case, preoperative embolization, vigilant intraoperative monitoring, and multidisciplinary coordination between the surgical and anesthesia teams contributed to a stable perioperative course. The transient postoperative cranial nerve deficits improved with conservative management.
Comprehensive preoperative optimization, careful anesthetic planning, and postoperative vigilance are the cornerstones for safe and successful outcomes in carotid body tumor surgeries.
Dr. Mohamed arsath buhari saleem MBBS,DA(nbe) Secondary DNB postgraduate Kauvery Hospital, Alwarpet, Chennai.
Dr. Mahalakshmi Senior consultant anesthetist Kauvery Hospital, Alwarpet, Chennai.
