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A retropharyngeal mass
European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 57–58
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
A retropharyngeal mass C.A. Righini ∗ , I. Atallah Pôle TCCR, clinique universitaire d’ORL, CHU de Grenoble, 1, avenue des-Maquis-du-Grésivaudan, 38043 Grenoble cedex, France
1. Description A 32-year-old male, without previous history, presented with a sensation of pharyngeal foreign body without other functional signs. There was no alcohol or nicotine intoxication. General health status was satisfactory, with weight stable at 78 kg and height 1.8 m. Clinical examination found an oval mass, hard on instrumental (tongue depressor) palpation, in the right posterior pharyngeal
wall. Oral cavity, rhinopharynx, hypopharynx and larynx examination was normal. Cranial nerve examination was normal. Axial and coronal T1-weighted contrast-enhanced MRI (Fig. 1a and b) found a regularly contoured 35 × 27 mm oval mass in the retropharyngeal space, with heterogeneous contrast uptake. En bloc resection was performed on a transoral approach, with 2-plane suture of the pharyngeal mucosa. Postoperative course was simple, with resumption of oral feeding at D+1 and discharge home at D+2.
Fig. 1. Axial and coronal T1-weighted contrast-enhanced MRI.
What is your diagnosis?
∗ Corresponding author. Tel.: +33 4 76 76 56 93; fax: +33 4 76 76 51 20. E-mail address: [email protected] (C.A. Righini). http://dx.doi.org/10.1016/j.anorl.2014.01.008 1879-7296/© 2014 Elsevier Masson SAS. All rights reserved.
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C.A. Righini, I. Atallah / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 57–58
2. Replies Pathologic examination diagnosed Antoni A type schwannoma, with no signs of degeneration; resection had been complete. At 50 months’ regular clinical follow-up, there were no signs of relapse. The retropharyngeal space is a medial space lying between the right and left retrostyloid parapharyngeal spaces laterally, the prevertebral fascia of the prevertebral muscles posteriorly, and the pharyngobasilar fascia in contact with the pharyngeal constrictor muscles anteriorly [1]. It contains fat, lymph nodes and fibers of the glossopharyngeal (IX) and vagus (X) nerve branches. The most frequent tumors in this space are: • lipoma and liposarcoma; • lymphoid tumor (sarcoidosis, lymphomatous and metastatic adenopathy in upper aerodigestive tract cancer); • benign and malignant schwannoma [2]. The differential diagnoses are: • retropharyngeal abscess; • vascular loop involving the internal carotid artery; • vertebral osteophytes in case of cervical osteoarthritis, or Forestier’s disease in case of associated prevertebral ligament calcification [2]. Schwannoma develops from nerve fibers originating in IX and X [3] and is rare in this location, presenting in almost all cases as a single mass. Presenting symptoms are sensation of pharyngeal foreign body and, in larger forms, dysphagia [2]. Paresthesia and/or neuralgia suggest malignancy [4]. As in the present case, clinical examination finds a mass of variable shape and size, covered by healthy mucosa, firm or slightly elastic on oral palpation by tongue depressor. There are no other signs of neurologic involvement and examination of the cranial nerves is normal.
The reference radiology examinations are CT with iodized contrast medium and MRI with gadolinium. MRI in particular diagnoses schwannoma, but both also serve to rule out internal carotid loop or other vascular pathology such as paraganglioma that might contraindicate an oral surgical approach [5]. On MRI, the tumor is well-delineated, with low-intensity signal on T1 and high-intensity signal on T2-weighted sequences and heterogeneous gadolinium uptake. Treatment is surgical, consisting in en bloc tumor resection. The most frequent approach, for small tumors strictly localized within the retropharyngeal space and remote from the internal carotid, is transoral, as in the present case. Other surgical approaches (transparotid, cervical or association of both) have also been described for large lateral tumors displacing the retrostyloid space and thus coming into proximity with the internal carotid artery. When resection is complete, recurrence is rare. Follow-up should be based on clinical examination and imaging (MRI) if relapse is suspected. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Shirakura S, Tsunoda A, Akita K, et al. Parapharyngeal space tumors: anatomical and image analysis findings. Auris Nasus Larynx 2010;37:621–5. [2] Kumagai M, Endoi S, Shiba K, et al. Schwannoma of the retropharyngeal space. Tohoku J Exp Med 2006;210:161–4. [3] Les espaces visceraux de la tête in Eduard Pernkopf-Atlas d’anatomie humaine sous la direction de H. Ferner, traduit de l’allemand par S. Demetran et G. Villey. Tome I, tête et cou, 2nd ed, Vigot, Paris, 1983:153. [4] Weber AL, Montandon C, Robson CD. Neurogenic tumors of the neck. Radiol Clin North Am 2000;38:1077–90. [5] Carinci F, Carls FP, Grasso DL. Schwannoma of the pharyngeal space. J Craniofac Surg 2000;114:119–24.
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
A retropharyngeal mass C.A. Righini ∗ , I. Atallah Pôle TCCR, clinique universitaire d’ORL, CHU de Grenoble, 1, avenue des-Maquis-du-Grésivaudan, 38043 Grenoble cedex, France
1. Description A 32-year-old male, without previous history, presented with a sensation of pharyngeal foreign body without other functional signs. There was no alcohol or nicotine intoxication. General health status was satisfactory, with weight stable at 78 kg and height 1.8 m. Clinical examination found an oval mass, hard on instrumental (tongue depressor) palpation, in the right posterior pharyngeal
wall. Oral cavity, rhinopharynx, hypopharynx and larynx examination was normal. Cranial nerve examination was normal. Axial and coronal T1-weighted contrast-enhanced MRI (Fig. 1a and b) found a regularly contoured 35 × 27 mm oval mass in the retropharyngeal space, with heterogeneous contrast uptake. En bloc resection was performed on a transoral approach, with 2-plane suture of the pharyngeal mucosa. Postoperative course was simple, with resumption of oral feeding at D+1 and discharge home at D+2.
Fig. 1. Axial and coronal T1-weighted contrast-enhanced MRI.
What is your diagnosis?
∗ Corresponding author. Tel.: +33 4 76 76 56 93; fax: +33 4 76 76 51 20. E-mail address: [email protected] (C.A. Righini). http://dx.doi.org/10.1016/j.anorl.2014.01.008 1879-7296/© 2014 Elsevier Masson SAS. All rights reserved.
58
C.A. Righini, I. Atallah / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 57–58
2. Replies Pathologic examination diagnosed Antoni A type schwannoma, with no signs of degeneration; resection had been complete. At 50 months’ regular clinical follow-up, there were no signs of relapse. The retropharyngeal space is a medial space lying between the right and left retrostyloid parapharyngeal spaces laterally, the prevertebral fascia of the prevertebral muscles posteriorly, and the pharyngobasilar fascia in contact with the pharyngeal constrictor muscles anteriorly [1]. It contains fat, lymph nodes and fibers of the glossopharyngeal (IX) and vagus (X) nerve branches. The most frequent tumors in this space are: • lipoma and liposarcoma; • lymphoid tumor (sarcoidosis, lymphomatous and metastatic adenopathy in upper aerodigestive tract cancer); • benign and malignant schwannoma [2]. The differential diagnoses are: • retropharyngeal abscess; • vascular loop involving the internal carotid artery; • vertebral osteophytes in case of cervical osteoarthritis, or Forestier’s disease in case of associated prevertebral ligament calcification [2]. Schwannoma develops from nerve fibers originating in IX and X [3] and is rare in this location, presenting in almost all cases as a single mass. Presenting symptoms are sensation of pharyngeal foreign body and, in larger forms, dysphagia [2]. Paresthesia and/or neuralgia suggest malignancy [4]. As in the present case, clinical examination finds a mass of variable shape and size, covered by healthy mucosa, firm or slightly elastic on oral palpation by tongue depressor. There are no other signs of neurologic involvement and examination of the cranial nerves is normal.
The reference radiology examinations are CT with iodized contrast medium and MRI with gadolinium. MRI in particular diagnoses schwannoma, but both also serve to rule out internal carotid loop or other vascular pathology such as paraganglioma that might contraindicate an oral surgical approach [5]. On MRI, the tumor is well-delineated, with low-intensity signal on T1 and high-intensity signal on T2-weighted sequences and heterogeneous gadolinium uptake. Treatment is surgical, consisting in en bloc tumor resection. The most frequent approach, for small tumors strictly localized within the retropharyngeal space and remote from the internal carotid, is transoral, as in the present case. Other surgical approaches (transparotid, cervical or association of both) have also been described for large lateral tumors displacing the retrostyloid space and thus coming into proximity with the internal carotid artery. When resection is complete, recurrence is rare. Follow-up should be based on clinical examination and imaging (MRI) if relapse is suspected. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Shirakura S, Tsunoda A, Akita K, et al. Parapharyngeal space tumors: anatomical and image analysis findings. Auris Nasus Larynx 2010;37:621–5. [2] Kumagai M, Endoi S, Shiba K, et al. Schwannoma of the retropharyngeal space. Tohoku J Exp Med 2006;210:161–4. [3] Les espaces visceraux de la tête in Eduard Pernkopf-Atlas d’anatomie humaine sous la direction de H. Ferner, traduit de l’allemand par S. Demetran et G. Villey. Tome I, tête et cou, 2nd ed, Vigot, Paris, 1983:153. [4] Weber AL, Montandon C, Robson CD. Neurogenic tumors of the neck. Radiol Clin North Am 2000;38:1077–90. [5] Carinci F, Carls FP, Grasso DL. Schwannoma of the pharyngeal space. J Craniofac Surg 2000;114:119–24.