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Hairy polyp in the oropharynx of a 5-week-old infant with sudden-onset respiratory distress
Otolaryngology–Head and Neck Surgery (2007) 136, 491-492
CLINICAL PHOTO
Hairy polyp in the oropharynx of a 5-week-old infant with sudden-onset respiratory distress Joseph Shvidler, MD, Benjamin B. Cable, MD, and Mark Sheridan, MD, Tripler Army Medical Center, HI
A
Brown-Kelly1 is credited for the first report of a hairy polyp in 1918. To date, there have been fewer than 150 cases reported, making it the most common congenital nasopha-
ryngeal mass. Hairy polyps are six times more common in female patients than in male patients. About 60% are found in the nasopharynx, and the remainder of these originate in the tonsillar region and pharynx.2,3 Arnold4 was first to define a classification scheme for nasopharyngeal malformations. He organized them into four groups: dermoids, teratoids, teratomas, and epignathi. Dermoids were described as pedunculated outgrowths covered by epithelium and derived from epidermal and mesodermal germ layers. Hairy polyps fall into this category. Teratomas are larger, well-differentiated tumors derived from all three germinal layers and are often associated with anencephaly, hemicranial palatal fissures, and other craniofacial deformities. Teratoids are poorly differentiated counterparts of teratomas. Epignathi represent the most differentiated form of trigeminal layers and resemble a parasitic fetus with gross development of limbs and organs and are rarely compatible with life.4 Hairy polyps are usually described as being gray to white or pink and fleshy and are often found protruding into the oral cavity (Fig 1). Upper GI studies may reveal dysfunction of the swallowing mechanism with nasopharyngeal regurgitation and tracheal aspiration. There have been only few reported cases of hairy polyps arising from the tonsil. Hairy polyps are covered by an epithelial layer often containing hair follicles, sebaceous glands, and sweat glands. Deeper tissue is composed of multiple histologies, which include fibrofatty tissue, striated muscle, cartilage, blood vessels, nerve tissue, lymph follicles, mucous, and serous glands (Fig 2).
From the Department of Otolaryngology–Head and Neck Surgery, Tripler Army Medical Center, HI. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. Presented at the Annual Meeting of the American Academy of
Otolaryngology–Head and Neck Surgery, in Los Angeles, California, September 25 to 28, 2005. Reprint requests: Joseph Shvidler, MD, Department of Otolaryngology– Head and Neck Surgery, MCHK-DSH, 1 Jarrett White Road, Tripler AMC, HI 96859. E-mail address: [email protected].
5-week-old boy presented with sudden onset respiratory distress. The child was born at term by spontaneous vaginal delivery. He had no prior episodes of respiratory or feeding difficulties. On further questioning, the child’s mother noted that the patient seemed to spit up frequently but that he also had been gaining weight appropriately. At the time of initial intubation, no masses or lesions were noted. Direct laryngoscopy and bronchoscopy were performed without any identifiable lesion except for a fullness found in the membranous tracheal wall. Esophagoscopy was attempted but could not be completed because of a mass that was obstructing the esophagus. The mass appeared to be pedicled from the oropharynx. The patient was kept intubated, and a CT scan was performed. This examination revealed a mass originating in the oropharynx and extending into the esophageal inlet. The patient was returned to the operating room, where the mass was found to originate from the superior portion of palatopharyngeus. It was excised in total. The patient recovered uneventfully and had no further episodes of respiratory difficulty or dysphagia. Final pathology revealed a hairy polyp.
DISCUSSION
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.10.019
492
Otolaryngology–Head and Neck Surgery, Vol 136, No 3, March 2007
Figure 2 Hairy polyp lined with squamous epithelium. Hair follicles with pilosebaceous units are present as well as stroma and multiple blood vessels.
Figure 1 Pedunculated oval mass was found in the oropharynx, causing intermittent obstruction of the airway.
Associated symptoms may include vomiting, feeding difficulties, intermittent dyspnea, congestion, stridor, asphyxia, cyanosis, costal retractions, hemoptysis, unilateral eustachian tube dysfunction, and unilateral nostril drainage. Associated anomalies include clefts of the hard and soft palate, agenesis of the uvula and auricle, ankyloglossia, facial hemihypertrophy, left carotid artery atresia, and osteopetrosis.3 Traditional methods of evaluating newborn infants with respiratory or feeding difficulties include plain radiographs, barium swallow studies, and laryngoscopy. As previous
case reports have demonstrated, these studies may overlook broad tissue abnormalities. Masses such as the hairy polyp may be misinterpreted as soft tissue edema. CT or MRI evaluations are best suited to distinguish between hamartomas such as a hairy polyp and cystic, vascular, or neurogenic masses presenting in the oropharynx. Treatment of these lesions must focus control of the airway, often with intubation. Once the airway is secured, the mass may be excised and the stalk ligated as needed.
REFERENCES 1. Brown-Kelly A. Hairy or dermoid polyp of the pharynx and nasopharynx. J Laryngol Rhinol Otol 1918;33:65–70. 2. Kelly A, Bough ID Jr, Luft JD, et al. Hairy polyp of the oropharynx: case report and literature review. J Pediatr Surg 1996;31:704 – 6. 3. McShane D, El Sherif I, Doyle-Kelly W, et al. Dermoids (’hairy polyps’) of the oro-nasopharynx. J Laryngol Otol 1989;103:612–5. 4. Arnold J. A case of congenital compound lipoma of the tongue and pharynx with perforation into the head cave. Virchows Arch 1870;50: 482–516.
CLINICAL PHOTO
Hairy polyp in the oropharynx of a 5-week-old infant with sudden-onset respiratory distress Joseph Shvidler, MD, Benjamin B. Cable, MD, and Mark Sheridan, MD, Tripler Army Medical Center, HI
A
Brown-Kelly1 is credited for the first report of a hairy polyp in 1918. To date, there have been fewer than 150 cases reported, making it the most common congenital nasopha-
ryngeal mass. Hairy polyps are six times more common in female patients than in male patients. About 60% are found in the nasopharynx, and the remainder of these originate in the tonsillar region and pharynx.2,3 Arnold4 was first to define a classification scheme for nasopharyngeal malformations. He organized them into four groups: dermoids, teratoids, teratomas, and epignathi. Dermoids were described as pedunculated outgrowths covered by epithelium and derived from epidermal and mesodermal germ layers. Hairy polyps fall into this category. Teratomas are larger, well-differentiated tumors derived from all three germinal layers and are often associated with anencephaly, hemicranial palatal fissures, and other craniofacial deformities. Teratoids are poorly differentiated counterparts of teratomas. Epignathi represent the most differentiated form of trigeminal layers and resemble a parasitic fetus with gross development of limbs and organs and are rarely compatible with life.4 Hairy polyps are usually described as being gray to white or pink and fleshy and are often found protruding into the oral cavity (Fig 1). Upper GI studies may reveal dysfunction of the swallowing mechanism with nasopharyngeal regurgitation and tracheal aspiration. There have been only few reported cases of hairy polyps arising from the tonsil. Hairy polyps are covered by an epithelial layer often containing hair follicles, sebaceous glands, and sweat glands. Deeper tissue is composed of multiple histologies, which include fibrofatty tissue, striated muscle, cartilage, blood vessels, nerve tissue, lymph follicles, mucous, and serous glands (Fig 2).
From the Department of Otolaryngology–Head and Neck Surgery, Tripler Army Medical Center, HI. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. Presented at the Annual Meeting of the American Academy of
Otolaryngology–Head and Neck Surgery, in Los Angeles, California, September 25 to 28, 2005. Reprint requests: Joseph Shvidler, MD, Department of Otolaryngology– Head and Neck Surgery, MCHK-DSH, 1 Jarrett White Road, Tripler AMC, HI 96859. E-mail address: [email protected].
5-week-old boy presented with sudden onset respiratory distress. The child was born at term by spontaneous vaginal delivery. He had no prior episodes of respiratory or feeding difficulties. On further questioning, the child’s mother noted that the patient seemed to spit up frequently but that he also had been gaining weight appropriately. At the time of initial intubation, no masses or lesions were noted. Direct laryngoscopy and bronchoscopy were performed without any identifiable lesion except for a fullness found in the membranous tracheal wall. Esophagoscopy was attempted but could not be completed because of a mass that was obstructing the esophagus. The mass appeared to be pedicled from the oropharynx. The patient was kept intubated, and a CT scan was performed. This examination revealed a mass originating in the oropharynx and extending into the esophageal inlet. The patient was returned to the operating room, where the mass was found to originate from the superior portion of palatopharyngeus. It was excised in total. The patient recovered uneventfully and had no further episodes of respiratory difficulty or dysphagia. Final pathology revealed a hairy polyp.
DISCUSSION
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.10.019
492
Otolaryngology–Head and Neck Surgery, Vol 136, No 3, March 2007
Figure 2 Hairy polyp lined with squamous epithelium. Hair follicles with pilosebaceous units are present as well as stroma and multiple blood vessels.
Figure 1 Pedunculated oval mass was found in the oropharynx, causing intermittent obstruction of the airway.
Associated symptoms may include vomiting, feeding difficulties, intermittent dyspnea, congestion, stridor, asphyxia, cyanosis, costal retractions, hemoptysis, unilateral eustachian tube dysfunction, and unilateral nostril drainage. Associated anomalies include clefts of the hard and soft palate, agenesis of the uvula and auricle, ankyloglossia, facial hemihypertrophy, left carotid artery atresia, and osteopetrosis.3 Traditional methods of evaluating newborn infants with respiratory or feeding difficulties include plain radiographs, barium swallow studies, and laryngoscopy. As previous
case reports have demonstrated, these studies may overlook broad tissue abnormalities. Masses such as the hairy polyp may be misinterpreted as soft tissue edema. CT or MRI evaluations are best suited to distinguish between hamartomas such as a hairy polyp and cystic, vascular, or neurogenic masses presenting in the oropharynx. Treatment of these lesions must focus control of the airway, often with intubation. Once the airway is secured, the mass may be excised and the stalk ligated as needed.
REFERENCES 1. Brown-Kelly A. Hairy or dermoid polyp of the pharynx and nasopharynx. J Laryngol Rhinol Otol 1918;33:65–70. 2. Kelly A, Bough ID Jr, Luft JD, et al. Hairy polyp of the oropharynx: case report and literature review. J Pediatr Surg 1996;31:704 – 6. 3. McShane D, El Sherif I, Doyle-Kelly W, et al. Dermoids (’hairy polyps’) of the oro-nasopharynx. J Laryngol Otol 1989;103:612–5. 4. Arnold J. A case of congenital compound lipoma of the tongue and pharynx with perforation into the head cave. Virchows Arch 1870;50: 482–516.