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Retropharyngeal lipoma causing symptoms of obstructive sleep apnea
CASE REPORTS SERGE A. MARTINEZ,MD Case Report Editor
Retropharyngeal lipoma causing symptoms of obstructive sleep apnea JACK W. ALAND,JR, MD, Birmingham, Alabama R~
~ e t r o p h a r y n g e a l lipomas are rare. Because of their slow growth rate, they can reach large size before causing airway symptoms. A case of retropharyngeal lipoma causing symptoms of obstructive sleep a p n e a is described. CASE REPORT
A 36-year-old man came for treatment with the main symptoms of a stuffy nose and decreased sense of smell. He also noticed increasing difficulty swallowing for about 3 years and that his speech was getting harder to understand. He believed his problem was caused by allergies. On further questioning his girlfriend noted that he was a very loud snorer. She noticed that he seemed to struggle for air sometimes when he was sleeping, and he would frequently "nod out" during the day. On examination the patient was seen to have an approximately 8 x 4 x 6 cm soft, submucosal mass pushing the posterior pharyngeal wall forward. The mass completely filled the nasopharynx and extended down to the level of the epiglottis. He had a hyponasal voice and, in fact, had no nasal airflow. Computed tomography (CT) scan showed a low attenuation retropharyngeal mass compatible with lipoma. The mass was predominantly on the right side, and the margins were sharply demarcated (Figs. 1 and 2). The mass was removed transorally and was confirmed to be a lipoma histologically (Figs. 3 and 4). After surgery his snoring went away, he was able to breathe well through his nose, and he no longer had daytime somnolence. DISCUSSION
The most striking feature of this case is that a space-occupying lesion in this area could grow to a
Received for publication Sept. 20, 1994; revision received April 13, 1995; accepted May 5, 1995. Reprint requests: Jack W. Aland, Jr, MD, 833 St. Vincent's Dr., Building III, Suite 402, Birmingham, AL 35205. OTOLARYNGOLHEAD NECKSURG 1996;114:628-30. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 + 0 23/4/66090 628
huge size before prompting the patient to seek medical care. This patient's main symptom was a stuffy nose, which he believed was caused by allergies. H e was not even aware of the large retropharyngeal mass. A review of similar cases in the literature reveals that lipomas of the retropharyngeal area will usually grow to large size before they are discovered, and the initial symptom is often related to the airway. Sore and Wolff 1reported a 52-year-old m a n who had sudden onset of dyspnea with a feeling of complete asphyxiation for about 30 seconds after bending over. A large pedunculated lipoma was found in the lumen of the esophagus, which had rotated into the larynx causing temporary airway obstruction. Younis 2 described a 71-year-old man who had noisy breathing for 18 months and a sensation of a lump in the throat, who had a 12 × 8 x 4 cm lipoma in the retropharyngeal space. This mass was removed with an external approach. Johnson and Curtin 3 reported a 57-year-old man who had insidious onset of hoarseness and dysphagia and weight loss, but no respiratory distress, even though a retropharyngeal lipoma was pushing the posterior pharyngeal wall up against the tongue base. The tumor was in a similar location to the one in the patient described here and was removed through a submandibular incision. A retrospective review of head and neck lipomas indicated that most were initially found on CT scan. On CT scan a lipoma is seen as a homogeneous, low attenuation mass with no clearly defined capsule. T h e r e usually is a sharp demarcation between the lipoma and the surrounding tissue. CT is usually diagnostic. M o r e heterogeneity or density on CT may indicate a liposarcoma. In the intramuscular lipoma, this sharp demarcation between lipoma and surrounding tissue is not seen. Intramuscular lipoma is a rare variant in which the lipoma infiltrates skeletal muscle. There is a high
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Fig. t. CT scan at level of nasopharynx.
Fig. 2. CT scan at level of oropharynx.
recurrence rate after resection of the intramuscular lipoma. 4 The tumor in the patient described here was located in the retropharyngeal space. This space is bounded by the pharynx anteriorly, the prevertebral fascia posteriorly, and the base of the skull superiorly, and is continuous with the mediastinum inferiorly. It is; filled with loose areolar tissue and is divided by a median raphe that extends from the fascia covering the constrictor muscles to the pre-
vertebral fascia. This could explain why this patient's tumor was primarily on one side of his retropharyngeal area. Although this patient did not have polysomnography, he did have the typical signs and symptoms of obstructive sleep apnea-namely, loud snoring and snorting at night, apneic episodes while sleeping, and daytime somnolence. 5 Obstructive sleep apnea from head and neck lipoma has been described before, in a 63-year-old with an 11 x 11 x 2 cm
630
Otolaryngology Head and Neck Surgery April 1996
ALAND
Fig. 3. Representative histologic slide showing mature fat ceils.
Fig. 4. Representative histologic slide [higher magnification].
lipoma in the left paraesophageal area. Removing the lipoma cured the obstructive sleep apnea. 2 Removing the lipoma in the patient described here also led to the resolution of his obstructive sleep apnea symptoms. SUMMARY
A case of retropharyngeal lipoma that caused symptoms of obstructive sleep apnea is described. Retropharyngeal lipomas are usually quite large when they are discovered, and the CT scan is usually diagnostic. The lipoma can be removed through a transoral or an external approach.
REFERENCES 1. Som ML, Wolff L. Lipoma of the hypopharynx producing menacing symptoms. Arch Otolaryngol 1952;56:524-31. 2. Younis M. Retropharyngeal lipoma. J Laryngol Otol 1980;94: 321-5. 3. Johnson JT, Curtin HD. Deep neck lipoma. Ann Otol Laryngol 1987;96:472-3. 4. Som PM, Scherl MP, Rao VM, Biller HF. Rare presentations of ordinary lipomas of the head and neck: a review. AJNR Am J Neuroradiol 1986;7:657-64. 5. Koopman CF, Feld RA, Coulthard SW. Sleep apnea syndrome associated with a neck mass. OTOLARYnCOLHEAD NECKSURG 1981;89:949-52.
Retropharyngeal lipoma causing symptoms of obstructive sleep apnea JACK W. ALAND,JR, MD, Birmingham, Alabama R~
~ e t r o p h a r y n g e a l lipomas are rare. Because of their slow growth rate, they can reach large size before causing airway symptoms. A case of retropharyngeal lipoma causing symptoms of obstructive sleep a p n e a is described. CASE REPORT
A 36-year-old man came for treatment with the main symptoms of a stuffy nose and decreased sense of smell. He also noticed increasing difficulty swallowing for about 3 years and that his speech was getting harder to understand. He believed his problem was caused by allergies. On further questioning his girlfriend noted that he was a very loud snorer. She noticed that he seemed to struggle for air sometimes when he was sleeping, and he would frequently "nod out" during the day. On examination the patient was seen to have an approximately 8 x 4 x 6 cm soft, submucosal mass pushing the posterior pharyngeal wall forward. The mass completely filled the nasopharynx and extended down to the level of the epiglottis. He had a hyponasal voice and, in fact, had no nasal airflow. Computed tomography (CT) scan showed a low attenuation retropharyngeal mass compatible with lipoma. The mass was predominantly on the right side, and the margins were sharply demarcated (Figs. 1 and 2). The mass was removed transorally and was confirmed to be a lipoma histologically (Figs. 3 and 4). After surgery his snoring went away, he was able to breathe well through his nose, and he no longer had daytime somnolence. DISCUSSION
The most striking feature of this case is that a space-occupying lesion in this area could grow to a
Received for publication Sept. 20, 1994; revision received April 13, 1995; accepted May 5, 1995. Reprint requests: Jack W. Aland, Jr, MD, 833 St. Vincent's Dr., Building III, Suite 402, Birmingham, AL 35205. OTOLARYNGOLHEAD NECKSURG 1996;114:628-30. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 + 0 23/4/66090 628
huge size before prompting the patient to seek medical care. This patient's main symptom was a stuffy nose, which he believed was caused by allergies. H e was not even aware of the large retropharyngeal mass. A review of similar cases in the literature reveals that lipomas of the retropharyngeal area will usually grow to large size before they are discovered, and the initial symptom is often related to the airway. Sore and Wolff 1reported a 52-year-old m a n who had sudden onset of dyspnea with a feeling of complete asphyxiation for about 30 seconds after bending over. A large pedunculated lipoma was found in the lumen of the esophagus, which had rotated into the larynx causing temporary airway obstruction. Younis 2 described a 71-year-old man who had noisy breathing for 18 months and a sensation of a lump in the throat, who had a 12 × 8 x 4 cm lipoma in the retropharyngeal space. This mass was removed with an external approach. Johnson and Curtin 3 reported a 57-year-old man who had insidious onset of hoarseness and dysphagia and weight loss, but no respiratory distress, even though a retropharyngeal lipoma was pushing the posterior pharyngeal wall up against the tongue base. The tumor was in a similar location to the one in the patient described here and was removed through a submandibular incision. A retrospective review of head and neck lipomas indicated that most were initially found on CT scan. On CT scan a lipoma is seen as a homogeneous, low attenuation mass with no clearly defined capsule. T h e r e usually is a sharp demarcation between the lipoma and the surrounding tissue. CT is usually diagnostic. M o r e heterogeneity or density on CT may indicate a liposarcoma. In the intramuscular lipoma, this sharp demarcation between lipoma and surrounding tissue is not seen. Intramuscular lipoma is a rare variant in which the lipoma infiltrates skeletal muscle. There is a high
Otolaryngolo(jy Head and Neck Surgery Volume 114 Number 4
ALAND
629
Fig. t. CT scan at level of nasopharynx.
Fig. 2. CT scan at level of oropharynx.
recurrence rate after resection of the intramuscular lipoma. 4 The tumor in the patient described here was located in the retropharyngeal space. This space is bounded by the pharynx anteriorly, the prevertebral fascia posteriorly, and the base of the skull superiorly, and is continuous with the mediastinum inferiorly. It is; filled with loose areolar tissue and is divided by a median raphe that extends from the fascia covering the constrictor muscles to the pre-
vertebral fascia. This could explain why this patient's tumor was primarily on one side of his retropharyngeal area. Although this patient did not have polysomnography, he did have the typical signs and symptoms of obstructive sleep apnea-namely, loud snoring and snorting at night, apneic episodes while sleeping, and daytime somnolence. 5 Obstructive sleep apnea from head and neck lipoma has been described before, in a 63-year-old with an 11 x 11 x 2 cm
630
Otolaryngology Head and Neck Surgery April 1996
ALAND
Fig. 3. Representative histologic slide showing mature fat ceils.
Fig. 4. Representative histologic slide [higher magnification].
lipoma in the left paraesophageal area. Removing the lipoma cured the obstructive sleep apnea. 2 Removing the lipoma in the patient described here also led to the resolution of his obstructive sleep apnea symptoms. SUMMARY
A case of retropharyngeal lipoma that caused symptoms of obstructive sleep apnea is described. Retropharyngeal lipomas are usually quite large when they are discovered, and the CT scan is usually diagnostic. The lipoma can be removed through a transoral or an external approach.
REFERENCES 1. Som ML, Wolff L. Lipoma of the hypopharynx producing menacing symptoms. Arch Otolaryngol 1952;56:524-31. 2. Younis M. Retropharyngeal lipoma. J Laryngol Otol 1980;94: 321-5. 3. Johnson JT, Curtin HD. Deep neck lipoma. Ann Otol Laryngol 1987;96:472-3. 4. Som PM, Scherl MP, Rao VM, Biller HF. Rare presentations of ordinary lipomas of the head and neck: a review. AJNR Am J Neuroradiol 1986;7:657-64. 5. Koopman CF, Feld RA, Coulthard SW. Sleep apnea syndrome associated with a neck mass. OTOLARYnCOLHEAD NECKSURG 1981;89:949-52.