Hemodynamic challenges during the anesthetic management of a patient presented with cervical vagal schwannoma in Southern Ethiopia, a rare clinical case

Tajera Tageza Ilala^*Gudeta Teku AyanoMengistu Yinges Kebede

• Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia

Background: Vagal schwannoma is a benign tumor of Schwann cells of the vagus nerve.Therefore, surgery is a viable treatment option for patients undergoing tumor excision. However, anesthetic management of patients presenting with vagal schwannoma may pose a significant challenge to anesthetists because of an increased risk of intraoperative hemodynamic instability, cardiac arrhythmias, and postoperative functional impairment of the vocal cords, resulting in lifethreatening airway compromise.Case description: A 68-year-old female patient was referred to the otorhinolaryngology outpatient department of our institution with a history of lateral left neck swelling for 2 years, which started incidentally and gradually increased to attain the current size. Computed tomography (CT) of the neck revealed a schwannoma of the vagus nerve. General anesthesia was induced with propofol and succinylcholine following adequate preparation and premedication for surgical excision of vagal schwannoma. She developed hemodynamic instability (a sudden decrease of the heart rate from 109 beats/min to 54 beats/min) and significant hypotension (arterial blood pressure dropped from 168/87 mmHg to 78/36 mmHg) 30 minutes after the surgery, which was successfully treated with intravenous injection of atropine sulfate (0.5 mg), volume expanders, followed by vasopressor support (100 mcg intermittent bolus dose of epinephrine per 5 minutes twice), and the surgeon stopped traction. The patient was awaken, extubated, and successfully transferred to the postanesthesia care unit at the end of the procedure. No complication was appreciated during the postoperative period, and home discharge was made on the 4 days of post-operative period.Resection of vagal schwannoma may pose significant challenges to the anesthetist during the intraoperative course due to manipulation of the vagus nerve, mimicking the risk of hemodynamic instability. Hence, anesthetists should conduct adequate preoperative assessment and evaluation, be properly prepared, closely monitored, and aggressively manage hemodynamic instability to reduce morbidity and mortality during vagus nerve schwannoma resection.