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Inflammatory pseudotumor: An unusual presentation in the neck
Otolaryngology Head and Neck Surgery Volume 113 Number 2
Scientific Posters
P 195
122
124
Approaches to Atypical Presentations of Adenoid Cystic Carcinoma of the Head and Neck SANJAY KANTU, MD, BHUVANESH SINGH, MD, ANTONIO E. ALFONSO, MD, and GADY HAR-EL, MD, Brooklyn, N.Y.
Amyloidosis of the Tongue Presenting as Airway Obstruction ANGELA DAMIANO, MD, ALEXANDER B. GLICKMAN, DMD, MD, ANTOINE TARAZl, MD, and ALAN F. COHEN, MD, Bronx, N.Y.
Adenoid cystic carcinoma (ACC) is an unusual tumor of salivary glands. Sixty-six percent of ACC are found in the head and neck outside the major salivary glands. We present a series of five cases of ACC, each unique in presentation of location. These cases include ACC of the maxillary sinus presenting as a cheek mass; ACC of the larynx and trachea presenting as a thyroid mass with vocal cord paralysis; ACC of the nasopharynx presenting with conductive hearing loss; and ACC of the parotid gland presenting with resolving facial nerve paresis. ACC of minor salivary glands may be difficult to diagnose, especially in unusual sites. In addition, superimposed infection may result in delay in diagnosis. We discuss these cases along with a review of the literature and management of those tumors. 123
Inflammatory Pseudotumor: An Unusual Presentation in the Neck NORMAN R. FRIEDMAN, MD, and SCOT MANNING, MD, Dallas, Tex.
Pseudotumors are unusual idiopathic neoplasms in the head and neck. The most familiar sites for inflammatory pseudotumors are the orbit and respiratory tract. Specific sites that have been reported in the literature include the paranasal sinuses, larynx, parapharyngeal space, buccal tissue, esophagus, clavicle, and cervicle spine. Before making this diagnosis, infectious and neoplastic lesions must be ruled out. We report the case of a 15-year-old Oriental male patient who presented with a 2-month history of a slowly enlarging right neck mass without any associated inflammatory or consfautional symptoms of systemic illness. Evaluation included a nonreactive PPD, normal complete blood cell count, normal chest x-ray, and a nondiagnostic fine-needle aspiration. Computerized tomography of the neck revealed a 3 cm soft tissue mass in the anterior triangle with an irregular low-density center. At surgery the mass was adherent t o the sternocleidomastoid muscle and was invading the internal jugular vein. Intraoperative cultures were negative, and special stains of the specimen for fungus and acid-fast bacilli were also normal. Histologic examination demonstrated spindle cells enmeshed in a dense, hyalinized collagenous stroma. Scattered throughout the lesion was an inflammatory infiltrate that consisted primarily of plasma cells with lesser numbers of lymphocytes, eosinophils, and neutrophils. This predominantly fihroproliferative process with a prominent mixed inflammatory infiltrate is characteristic of an inflammatory pseudotumor. To the best of our knowledge, this is the first inflammatory pseudotumor to present in the neck.
Amyloidosis, a systemic disease characterized by the deposition of fibrillar proteins in the extracellular space, has been known to affect the tongue. Typically, the tongue is firm, indurated, and diffusely enlarged with yellow nodules along the lateral border. Mastication may induce hemorrhagic bullae, which may bleed or ulcerate with trauma. This bleeding is usually mild and is treated expectantly unless an underlying coagulopathy coexists. We present a case of acute airway obstruction secondary to an expanding hemorrhagic bullae of the tongue in a 60-year-old woman with primary amyloidosis. Management of this lesion required an emergent tracheotomy for airway stabilization, followed by resection of the hemorrhagic bullae and diseased portion of the tongue. This is the first report of such a dramatic hemorrhagic lesion of the tongue from amyloidosis. The clinical presentation will be demonstrated and the literature will be reviewed. 125
Dermatofibrosarcoma Protuberans of the Head and Neck R. PATRICK CECOLA, MD, and JEFFREYJ. JOSEPH, MD, New Orleans and Lake Charles, La.
Dermatofibrosarcoma Protuberans (DFSP) is a rare, locally aggressive malignant neoplasm of the skin that is not related to dermatofibroma, fibrosarcoma, or malignant fibrous histiocytoma. Local recurrence rates after complete surgical excision range from 10% to 75%. Numerous resections are not uncommon. Uncontrolled locoregional disease can be fatal. Metastatic spread is unusual but can occur, usually late in the course of disease. The pathogenesis of DFSP is unknown, with some reports in the literature of antecedent trauma. The histiogenesis is undetermined, with reports of a fihrohistiocytic cell of origin but other reports of a perineural cell of origin. Complete surgical excision with wide local margins (>3 cm) is the recommended treatment. However, clear margins can be difficult to ascertain secondary to pseudopod-like projections from the primary tumor. Elective lymphadenectomy is not indicated. Radiotherapy as treatment is controversial. We will present a case of DFSP of the cheek, a review of the literature, and the differential diagnosis of DFSP.
Scientific Posters
P 195
122
124
Approaches to Atypical Presentations of Adenoid Cystic Carcinoma of the Head and Neck SANJAY KANTU, MD, BHUVANESH SINGH, MD, ANTONIO E. ALFONSO, MD, and GADY HAR-EL, MD, Brooklyn, N.Y.
Amyloidosis of the Tongue Presenting as Airway Obstruction ANGELA DAMIANO, MD, ALEXANDER B. GLICKMAN, DMD, MD, ANTOINE TARAZl, MD, and ALAN F. COHEN, MD, Bronx, N.Y.
Adenoid cystic carcinoma (ACC) is an unusual tumor of salivary glands. Sixty-six percent of ACC are found in the head and neck outside the major salivary glands. We present a series of five cases of ACC, each unique in presentation of location. These cases include ACC of the maxillary sinus presenting as a cheek mass; ACC of the larynx and trachea presenting as a thyroid mass with vocal cord paralysis; ACC of the nasopharynx presenting with conductive hearing loss; and ACC of the parotid gland presenting with resolving facial nerve paresis. ACC of minor salivary glands may be difficult to diagnose, especially in unusual sites. In addition, superimposed infection may result in delay in diagnosis. We discuss these cases along with a review of the literature and management of those tumors. 123
Inflammatory Pseudotumor: An Unusual Presentation in the Neck NORMAN R. FRIEDMAN, MD, and SCOT MANNING, MD, Dallas, Tex.
Pseudotumors are unusual idiopathic neoplasms in the head and neck. The most familiar sites for inflammatory pseudotumors are the orbit and respiratory tract. Specific sites that have been reported in the literature include the paranasal sinuses, larynx, parapharyngeal space, buccal tissue, esophagus, clavicle, and cervicle spine. Before making this diagnosis, infectious and neoplastic lesions must be ruled out. We report the case of a 15-year-old Oriental male patient who presented with a 2-month history of a slowly enlarging right neck mass without any associated inflammatory or consfautional symptoms of systemic illness. Evaluation included a nonreactive PPD, normal complete blood cell count, normal chest x-ray, and a nondiagnostic fine-needle aspiration. Computerized tomography of the neck revealed a 3 cm soft tissue mass in the anterior triangle with an irregular low-density center. At surgery the mass was adherent t o the sternocleidomastoid muscle and was invading the internal jugular vein. Intraoperative cultures were negative, and special stains of the specimen for fungus and acid-fast bacilli were also normal. Histologic examination demonstrated spindle cells enmeshed in a dense, hyalinized collagenous stroma. Scattered throughout the lesion was an inflammatory infiltrate that consisted primarily of plasma cells with lesser numbers of lymphocytes, eosinophils, and neutrophils. This predominantly fihroproliferative process with a prominent mixed inflammatory infiltrate is characteristic of an inflammatory pseudotumor. To the best of our knowledge, this is the first inflammatory pseudotumor to present in the neck.
Amyloidosis, a systemic disease characterized by the deposition of fibrillar proteins in the extracellular space, has been known to affect the tongue. Typically, the tongue is firm, indurated, and diffusely enlarged with yellow nodules along the lateral border. Mastication may induce hemorrhagic bullae, which may bleed or ulcerate with trauma. This bleeding is usually mild and is treated expectantly unless an underlying coagulopathy coexists. We present a case of acute airway obstruction secondary to an expanding hemorrhagic bullae of the tongue in a 60-year-old woman with primary amyloidosis. Management of this lesion required an emergent tracheotomy for airway stabilization, followed by resection of the hemorrhagic bullae and diseased portion of the tongue. This is the first report of such a dramatic hemorrhagic lesion of the tongue from amyloidosis. The clinical presentation will be demonstrated and the literature will be reviewed. 125
Dermatofibrosarcoma Protuberans of the Head and Neck R. PATRICK CECOLA, MD, and JEFFREYJ. JOSEPH, MD, New Orleans and Lake Charles, La.
Dermatofibrosarcoma Protuberans (DFSP) is a rare, locally aggressive malignant neoplasm of the skin that is not related to dermatofibroma, fibrosarcoma, or malignant fibrous histiocytoma. Local recurrence rates after complete surgical excision range from 10% to 75%. Numerous resections are not uncommon. Uncontrolled locoregional disease can be fatal. Metastatic spread is unusual but can occur, usually late in the course of disease. The pathogenesis of DFSP is unknown, with some reports in the literature of antecedent trauma. The histiogenesis is undetermined, with reports of a fihrohistiocytic cell of origin but other reports of a perineural cell of origin. Complete surgical excision with wide local margins (>3 cm) is the recommended treatment. However, clear margins can be difficult to ascertain secondary to pseudopod-like projections from the primary tumor. Elective lymphadenectomy is not indicated. Radiotherapy as treatment is controversial. We will present a case of DFSP of the cheek, a review of the literature, and the differential diagnosis of DFSP.