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They Said Surgery Wasn’t an Option: Houston Methodist Proved Otherwise

After her tumor was deemed unresectable by medical facilities around the world due to size and position, a patient from Qatar turned to the experts at Houston Methodist for help. The Qatar Embassy reached out on the patient’s behalf to Houston Methodist’s Global Health Care Services, and Nadia Mohyuddin, MD, FACS, otolarygologist/head and neck surgeon, answered the call. The patient’s long-standing history of neurofibromatosis had resulted in several deforming tumors throughout her body, including her brain stem, both sides of her neck and right thoracic space. Her right neck lesion was of particular concern.

Nadia Mohyuddin, MD, FACS

“The tumor was precluding her from keeping her head straight. She would have to tilt her head in a dependent and awkward position, unable to turn her head to the right side,” Mohyuddin said. “She was having difficulty talking and swallowing due to vocal cord weakness.” After a clinical trial chemotherapy agent had to be discontinued due to elevation of her liver enzymes, surgery became her only hope. Mohyuddin consulted with colleagues in the Texas Medical Center and Houston Methodist ENT Department before meeting with the patient. “Especially for international patients, we want to begin assembling the team and looking closely at all the intricacies beforehand,” Mohyuddin said. “We knew other facilities had declined the case, and we didn’t want to get the patient’s hopes up.” Despite the complexities of the case, the team decided to bring the patient in for a workup in March 2020. The advent of the pandemic put an abrupt stop to the process, and the patient was required to return home to Qatar. For the next eight months, her condition deteriorated: She was losing weight and unable to speak due to vocal cord paralysis, and her tumor had grown dramatically, making it difficult to breathe or swallow.

The Time Is Now

When she returned to Houston in November 2020, a new biopsy suggested a transformation of the right neck mass to a malignant peripheral nerve sheath tumor. Mohyuddin knew time was of the essence. “I presented the case to our Head and Neck Tumor Board. I knew her only meaningful opportunity to control or treat the tumor would be surgery,” Mohyuddin said. “The ability to have many different specialists review the case, from radiation oncology, medical oncology, pathology and so on, enables us to see the details from many different angles. Each person sees different things depending on the glasses they’re wearing.”

Mohyuddin worked with subspecialists from across Houston Methodist before, during and after surgery, collaborating with Apurva Thekdi, MD, laryngologist, on the tumor resection as well as Yin Yiu, MD, laryngologist at the Texas Voice Center, for vocal fold rehabilitation. Interventional radiology, anesthesia and speech therapy also played key roles on the team, along with Houston Methodist’s Arabic interpreters, to ensure the patient and her family fully understood the risks and complexities of the surgery.

“When you think about a tumor of this size — stretching from jaw to collarbone — there are a lot of potential risks and complications to discuss,” Mohyuddin said. “For example, access to intubate would be challenging given the tumor location in the neck, and so we discussed our approach step by step with anesthesia.”

On the day of surgery, neuro-interventional radiologist Richard Klucznik, MD, performed a preoperative embolization in an effort to minimize blood loss, followed immediately by surgery with Mohyuddin and Thekdi. Intraoperatively, the tumor was extremely bulky, involving critical structures of the carotid sheath. The carotid artery itself was distorted; however, it was able to be protected, and the tumor was removed successfully. Yiu performed a vocal fold injection during surgery to help support the vocal cord.

World-Renowned Care

Postoperatively, the patient received radiation therapy at Houston Methodist with Brian Butler, MD, radiation oncologist. She has been closely followed by Nesreen Alawami, speech-language pathologist, and has undergone several additional surgeries to remove her smaller neurofibromas. Now, just over a year after her initial surgery, the patient can swallow safely, has improved speech and communication, and is pain free. She and her family are incredibly grateful for her results and the care she received at Houston Methodist when no other facility would take her case. “Houston Methodist is in a unique position to help in these types of cases. From an international perspective, our Global Health Care Services has strong relationships with embassies and consulates, and the infrastructure to support global medicine,” Mohyuddin said. “From a case perspective, we have specialists and subspecialists in every critical field of medicine and surgery, so we’re equipped to take on patients with unique pathologies.” Physicians seeking secondary or tertiary opinions for their patients are invited to contact the Houston Methodist ENT Department at 713.441.1368.