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Dyspnea and choking as presenting symptoms in primary medulla oblongata germinoma.

Yip CM, Tseng HH, Hsu SS, Liao WC, Chen JY, Chen CH, Chang CY - Surg Neurol Int (2014)

Bottom Line: The latest brain MRI and whole spine MRI done 1 year after surgery showed neither residual nor recurrent tumor in the whole axis.Intracranial germ cell tumors originate from extragonadal seminal cells and have been found in 0.4-3.4% of patients with primary central nervous system (CNS) tumors in Western countries, while the incidence is reported to be 5-8 times greater in Japan and the Far East.Although germinoma of medulla oblongata is rare and difficult to diagnose preoperatively, it should be included in the differential diagnosis of medulla masses with fourth ventricle extension, especially in Asian population.

View Article: PubMed Central - PubMed

Affiliation: Division of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R. O. C.

ABSTRACT

Background: The medulla oblongata is the lower half of the brainstem. It contains the cardiac, respiratory, vomiting, and vasomotor centers and deals with autonomic functions such as breathing, heartbeat, and blood pressure. Primary medulla oblongata germinoma is very rare and less than 20 cases have been reported in the English literature.

Case description: A 22-year-old female without any particular past medical history presented to us in October 2012 with the chief complaint of dyspnea and frequent choking for 1 month. Neurological examination revealed lower cranial nerve palsies and nystagmus. Her brain computed tomography (CT) and brain magnetic resonance imaging (MRI) demonstrated a mass lesion at the dorsal surface of medulla oblongata with extension into the inferior fourth ventricle and foramen magnum. She underwent bilateral suboccipital craniotomy and C1 laminoplasty with the grossly total resection of the tumor. The histological examination of the tumor proved germinoma. Postoperative adjuvant radiotherapy was arranged. The latest brain MRI and whole spine MRI done 1 year after surgery showed neither residual nor recurrent tumor in the whole axis. She is regularly followed-up at our outpatient department and is doing well except having left vocal cord palsy, which occurred before surgery.

Conclusion: Medulloblastoma, ependymoma, glioma, hemangioblastoma, and cavernous angioma are common intraaxial tumors in the medulla oblongata and fourth ventricle. Intracranial germ cell tumors originate from extragonadal seminal cells and have been found in 0.4-3.4% of patients with primary central nervous system (CNS) tumors in Western countries, while the incidence is reported to be 5-8 times greater in Japan and the Far East. Although germinoma of medulla oblongata is rare and difficult to diagnose preoperatively, it should be included in the differential diagnosis of medulla masses with fourth ventricle extension, especially in Asian population.

No MeSH data available.


Related in: MedlinePlus

Schematic diagram of respiratory centers. (+): stimulate. (-): inhibit. (Source of the diagram: from Anatomy and Physiology, OpenStax College resource Unit 5 Chapter 22)
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Figure 6: Schematic diagram of respiratory centers. (+): stimulate. (-): inhibit. (Source of the diagram: from Anatomy and Physiology, OpenStax College resource Unit 5 Chapter 22)

Mentions: The medulla oblongata is the lower half of the brainstem. It contains the cardiac, respiratory, vomiting, and vasomotor centers and deals with autonomic functions such as breathing, heartbeat, and blood pressure. Surgery on this vital area remains a challenge to most neurosurgeons. Medulloblastoma, ependymoma, glioma, hemangioblastoma, and cavernous angioma are common intraaxial tumors in the medulla oblongata and fourth ventricle.[15] There are no significant differences in the clinical presentation among all medulla oblongata fourth ventricle lesions. Lower cranial nerves dysfunction, disturbance of breathing and cerebellar function, headache, nystagmus, sensory and motor disturbance, visual disturbance, and hiccups are the key symptoms reported.[39] From preoperative brain MRI of our patient, the tumor was located at the dorsal side of medulla oblongata with extension into the fourth ventricle and foramen magnum. This tumor was large and could compress the vagal trigone, hypoglossal trigone as well as the respiratory center in the medulla oblongata: Nucleus ambiguous and nucleus tractus solitarii. Respiratory center is divided into four major cliques: Inspiratory centre (dorsal respiratory group), expiratory centre (ventral respiratory group), pneumotaxic centre, and apneustic centre [Figure 6]. Pneumotaxic centre and apneustic centre are located in the upper part of pons and lower part of pons, respectively, which are not closed to the tumor location of our patient. However, inspiratory centre and expiratory centre locate at the dorsal portion and anterolateral part of medulla respectively and their corresponding nuclei are nucleus tractus solitarii and nucleus ambiguous. Before operation, our patient's neurological examination revealed left vocal cord palsy, weak gag reflex, tongue fasciculation, which reflected the dysfunction of glossopharyngeal nerve, vagus nerve, and hypoglossal nerve. Due to the dysfunction of her low cranial nerves, she suffered from swallowing disturbance and choking with resultant aspiration pneumonia. Respiratory center compression and aspiration pneumonia contributed to her dyspnea.


Dyspnea and choking as presenting symptoms in primary medulla oblongata germinoma.

Yip CM, Tseng HH, Hsu SS, Liao WC, Chen JY, Chen CH, Chang CY - Surg Neurol Int (2014)

Schematic diagram of respiratory centers. (+): stimulate. (-): inhibit. (Source of the diagram: from Anatomy and Physiology, OpenStax College resource Unit 5 Chapter 22)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4109171&req=5

Figure 6: Schematic diagram of respiratory centers. (+): stimulate. (-): inhibit. (Source of the diagram: from Anatomy and Physiology, OpenStax College resource Unit 5 Chapter 22)
Mentions: The medulla oblongata is the lower half of the brainstem. It contains the cardiac, respiratory, vomiting, and vasomotor centers and deals with autonomic functions such as breathing, heartbeat, and blood pressure. Surgery on this vital area remains a challenge to most neurosurgeons. Medulloblastoma, ependymoma, glioma, hemangioblastoma, and cavernous angioma are common intraaxial tumors in the medulla oblongata and fourth ventricle.[15] There are no significant differences in the clinical presentation among all medulla oblongata fourth ventricle lesions. Lower cranial nerves dysfunction, disturbance of breathing and cerebellar function, headache, nystagmus, sensory and motor disturbance, visual disturbance, and hiccups are the key symptoms reported.[39] From preoperative brain MRI of our patient, the tumor was located at the dorsal side of medulla oblongata with extension into the fourth ventricle and foramen magnum. This tumor was large and could compress the vagal trigone, hypoglossal trigone as well as the respiratory center in the medulla oblongata: Nucleus ambiguous and nucleus tractus solitarii. Respiratory center is divided into four major cliques: Inspiratory centre (dorsal respiratory group), expiratory centre (ventral respiratory group), pneumotaxic centre, and apneustic centre [Figure 6]. Pneumotaxic centre and apneustic centre are located in the upper part of pons and lower part of pons, respectively, which are not closed to the tumor location of our patient. However, inspiratory centre and expiratory centre locate at the dorsal portion and anterolateral part of medulla respectively and their corresponding nuclei are nucleus tractus solitarii and nucleus ambiguous. Before operation, our patient's neurological examination revealed left vocal cord palsy, weak gag reflex, tongue fasciculation, which reflected the dysfunction of glossopharyngeal nerve, vagus nerve, and hypoglossal nerve. Due to the dysfunction of her low cranial nerves, she suffered from swallowing disturbance and choking with resultant aspiration pneumonia. Respiratory center compression and aspiration pneumonia contributed to her dyspnea.

Bottom Line: The latest brain MRI and whole spine MRI done 1 year after surgery showed neither residual nor recurrent tumor in the whole axis.Intracranial germ cell tumors originate from extragonadal seminal cells and have been found in 0.4-3.4% of patients with primary central nervous system (CNS) tumors in Western countries, while the incidence is reported to be 5-8 times greater in Japan and the Far East.Although germinoma of medulla oblongata is rare and difficult to diagnose preoperatively, it should be included in the differential diagnosis of medulla masses with fourth ventricle extension, especially in Asian population.

View Article: PubMed Central - PubMed

Affiliation: Division of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R. O. C.

ABSTRACT

Background: The medulla oblongata is the lower half of the brainstem. It contains the cardiac, respiratory, vomiting, and vasomotor centers and deals with autonomic functions such as breathing, heartbeat, and blood pressure. Primary medulla oblongata germinoma is very rare and less than 20 cases have been reported in the English literature.

Case description: A 22-year-old female without any particular past medical history presented to us in October 2012 with the chief complaint of dyspnea and frequent choking for 1 month. Neurological examination revealed lower cranial nerve palsies and nystagmus. Her brain computed tomography (CT) and brain magnetic resonance imaging (MRI) demonstrated a mass lesion at the dorsal surface of medulla oblongata with extension into the inferior fourth ventricle and foramen magnum. She underwent bilateral suboccipital craniotomy and C1 laminoplasty with the grossly total resection of the tumor. The histological examination of the tumor proved germinoma. Postoperative adjuvant radiotherapy was arranged. The latest brain MRI and whole spine MRI done 1 year after surgery showed neither residual nor recurrent tumor in the whole axis. She is regularly followed-up at our outpatient department and is doing well except having left vocal cord palsy, which occurred before surgery.

Conclusion: Medulloblastoma, ependymoma, glioma, hemangioblastoma, and cavernous angioma are common intraaxial tumors in the medulla oblongata and fourth ventricle. Intracranial germ cell tumors originate from extragonadal seminal cells and have been found in 0.4-3.4% of patients with primary central nervous system (CNS) tumors in Western countries, while the incidence is reported to be 5-8 times greater in Japan and the Far East. Although germinoma of medulla oblongata is rare and difficult to diagnose preoperatively, it should be included in the differential diagnosis of medulla masses with fourth ventricle extension, especially in Asian population.

No MeSH data available.


Related in: MedlinePlus