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A pigmented lesion of the nasopharynx
G Model
ARTICLE IN PRESS
ANORL-688; No. of Pages 2
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
A pigmented lesion of the nasopharynx J.-W. Kim , S.-D. Kim , K.-S. Cho ∗ Department of Otorhinolaryngology and Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, 179, Gudeok-Ro, Seo-gu, Busan 602-739, Republic of Korea
1. Description A 73-year-old woman was referred to our clinic, with right otalgia and dysphagia for 3 weeks. The patient’s medical history was otherwise unremarkable. Nasal endoscopy revealed a blackcolored necrotic lesion around right Eustachian tube orifice and nasopharynx extending to the oropharynx (Fig. 1a). Computed tomography (CT) scan of the paranasal sinuses was performed
(Fig. 1b). Histological examination of the specimen confirmed the diagnosis (Fig. 1c). 2. Questions How would you interpret the radiological and histological examinations? What diagnosis would you propose?
Fig. 1. a: nasal endoscopy of nasopharynx; b: CT of the paranasal sinuses, axial section; c: histological examination of the specimen (haematoxylin-eosin stain, ×200).
What is your diagnosis?
∗ Corresponding author. E-mail address: [email protected] (K.-S. Cho). http://dx.doi.org/10.1016/j.anorl.2016.11.013 1879-7296/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Kim J-W, et al. A pigmented lesion of the nasopharynx. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), http://dx.doi.org/10.1016/j.anorl.2016.11.013
G Model ANORL-688; No. of Pages 2
ARTICLE IN PRESS J.-W. Kim et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
2
3. Answers CT images showed asymmetric thickening of the right nasopharynx and oropharynx with diffuse mucosal enhancement. Small sized lymph nodes at both neck I, II, III, V level were noted. Transnasal endoscopic biopsy was performed. Histopathologic examination showed chronic ulcer with extensive necrosis. Nasopharyngitis is an acute, benign disease, and very common in children, but that can also affect adults. Due to the inflammatory nature of pharyngitis, sore throat and pharyngeal erythema are common presentations in acute pharyngitis, and pharyngeal exudates and neck lymphadenopathy may also be seen. Although viral infections are the most common cause of acute pharyngitis, bacterial organisms are also capable of pharyngitis and they usually involve more severe disease processes [1]. The most common bacterial organisms inducing pharyngitis include group A -hemolytic streptococci [1,2]. A differential diagnosis for a clinically pigmented lesion may include an array of traumatic, reactive, neoplastic pathologies as well as pigmentation associated with systemic disease [3]. Although pigmented nasopharyngeal inflammation due to postinflammatory reactive hypermelanosis is an exceedingly rare pathology with obscure clinical presentation, it should be distinguished from primary nasopharyngeal melanoma, which is a malignant mucosal tumor and has more serious consequences. Clinically, it is not easy to differentiate an early nasopharyngeal melanoma from pigmented nasopharyngeal inflammation. Therefore, the biopsy followed by histological analysis is the only reliable method to make an accurate diagnosis. Immunohistochemistry remains the diagnostic gold standard for mucosal melanoma [4]. In this case, immunochemical staining revealed that the pigmented lesions were negative for CD 56, HMB-45, and Melan-A.
We used third-generation cephalosporin to cover a broad range of organisms. However, because it was not effective in our case, we changed antibiotics with newer fluoroquinolones (levofloxacin), having a broader spectrum of activity. Although the standard duration of antibiotic therapy is 10 days, it may differ according to the severity of inflammation [1,2]. Antibiotic irrigation was also performed to flush out pathogenic bacteria and decrease the bacterial load within the mucosal surfaces of the nasopharynx [5], and the lesion responded well to the treatment. Disclosure of interest The authors declare that they have no competing interest. Acknowledgements This work was supported by the year 2017 clinical research grant from Pusan National University Hospital. References [1] Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am 2007;21:449–69. [2] Bisno AL. Acute pharyngitis. N Engl J Med 2001;344:205–11. [3] Alawi F. Pigmented lesions of the oral cavity: an update. Dent Clin North Am 2013;57:699–710. [4] Bekci T, Aslan K, Gunbey HP, Incesu L. Primary malignant mucosal melanoma of the nasopharynx: an unusual cause of unilateral hearing loss. J Craniofac Surg 2014;25:e567–9. [5] Seiberling KA, Aruni W, Kim S, Scapa VI, Fletcher H, Church CA. The effect of intraoperative mupirocin irrigation on Staphylococcus aureus within the maxillary sinus. Int Forum Allergy Rhinol 2013;3:94–8.
Please cite this article in press as: Kim J-W, et al. A pigmented lesion of the nasopharynx. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), http://dx.doi.org/10.1016/j.anorl.2016.11.013
ARTICLE IN PRESS
ANORL-688; No. of Pages 2
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
A pigmented lesion of the nasopharynx J.-W. Kim , S.-D. Kim , K.-S. Cho ∗ Department of Otorhinolaryngology and Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, 179, Gudeok-Ro, Seo-gu, Busan 602-739, Republic of Korea
1. Description A 73-year-old woman was referred to our clinic, with right otalgia and dysphagia for 3 weeks. The patient’s medical history was otherwise unremarkable. Nasal endoscopy revealed a blackcolored necrotic lesion around right Eustachian tube orifice and nasopharynx extending to the oropharynx (Fig. 1a). Computed tomography (CT) scan of the paranasal sinuses was performed
(Fig. 1b). Histological examination of the specimen confirmed the diagnosis (Fig. 1c). 2. Questions How would you interpret the radiological and histological examinations? What diagnosis would you propose?
Fig. 1. a: nasal endoscopy of nasopharynx; b: CT of the paranasal sinuses, axial section; c: histological examination of the specimen (haematoxylin-eosin stain, ×200).
What is your diagnosis?
∗ Corresponding author. E-mail address: [email protected] (K.-S. Cho). http://dx.doi.org/10.1016/j.anorl.2016.11.013 1879-7296/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Kim J-W, et al. A pigmented lesion of the nasopharynx. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), http://dx.doi.org/10.1016/j.anorl.2016.11.013
G Model ANORL-688; No. of Pages 2
ARTICLE IN PRESS J.-W. Kim et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
2
3. Answers CT images showed asymmetric thickening of the right nasopharynx and oropharynx with diffuse mucosal enhancement. Small sized lymph nodes at both neck I, II, III, V level were noted. Transnasal endoscopic biopsy was performed. Histopathologic examination showed chronic ulcer with extensive necrosis. Nasopharyngitis is an acute, benign disease, and very common in children, but that can also affect adults. Due to the inflammatory nature of pharyngitis, sore throat and pharyngeal erythema are common presentations in acute pharyngitis, and pharyngeal exudates and neck lymphadenopathy may also be seen. Although viral infections are the most common cause of acute pharyngitis, bacterial organisms are also capable of pharyngitis and they usually involve more severe disease processes [1]. The most common bacterial organisms inducing pharyngitis include group A -hemolytic streptococci [1,2]. A differential diagnosis for a clinically pigmented lesion may include an array of traumatic, reactive, neoplastic pathologies as well as pigmentation associated with systemic disease [3]. Although pigmented nasopharyngeal inflammation due to postinflammatory reactive hypermelanosis is an exceedingly rare pathology with obscure clinical presentation, it should be distinguished from primary nasopharyngeal melanoma, which is a malignant mucosal tumor and has more serious consequences. Clinically, it is not easy to differentiate an early nasopharyngeal melanoma from pigmented nasopharyngeal inflammation. Therefore, the biopsy followed by histological analysis is the only reliable method to make an accurate diagnosis. Immunohistochemistry remains the diagnostic gold standard for mucosal melanoma [4]. In this case, immunochemical staining revealed that the pigmented lesions were negative for CD 56, HMB-45, and Melan-A.
We used third-generation cephalosporin to cover a broad range of organisms. However, because it was not effective in our case, we changed antibiotics with newer fluoroquinolones (levofloxacin), having a broader spectrum of activity. Although the standard duration of antibiotic therapy is 10 days, it may differ according to the severity of inflammation [1,2]. Antibiotic irrigation was also performed to flush out pathogenic bacteria and decrease the bacterial load within the mucosal surfaces of the nasopharynx [5], and the lesion responded well to the treatment. Disclosure of interest The authors declare that they have no competing interest. Acknowledgements This work was supported by the year 2017 clinical research grant from Pusan National University Hospital. References [1] Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am 2007;21:449–69. [2] Bisno AL. Acute pharyngitis. N Engl J Med 2001;344:205–11. [3] Alawi F. Pigmented lesions of the oral cavity: an update. Dent Clin North Am 2013;57:699–710. [4] Bekci T, Aslan K, Gunbey HP, Incesu L. Primary malignant mucosal melanoma of the nasopharynx: an unusual cause of unilateral hearing loss. J Craniofac Surg 2014;25:e567–9. [5] Seiberling KA, Aruni W, Kim S, Scapa VI, Fletcher H, Church CA. The effect of intraoperative mupirocin irrigation on Staphylococcus aureus within the maxillary sinus. Int Forum Allergy Rhinol 2013;3:94–8.
Please cite this article in press as: Kim J-W, et al. A pigmented lesion of the nasopharynx. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), http://dx.doi.org/10.1016/j.anorl.2016.11.013