Retropharyngeal Lipoma - A Common Tumour with Rare Presentatjon: A - PDF document

Case Report ISSN: 2250-0359 Volume 6 Issue 3: 125 2016 Retropharyngeal Lipoma - A Common Tumour with Rare Presentatjon: A Case Report Rajesh Kumar* and Amber Kesarwani Department of E.N.T., I.M.S., B.H.U., Varanasi, India *Corresponding author: Rajesh Kumar, Associate Professor, Department of E.N.T., I.M.S., B.H.U., Varanasi, India, Tel: +919452562800; E-mail: rajesh_8k@yahoo.com Received: April 06, 2016; Accepted: May 18, 2016; Published: May 25, 2016 ABSTRACT of abnormal sensatjon in the throat and progressive dysphagia, more with solid foods. Patjent also Retropharyngeal lipoma is a very rare benign notjced a swelling in lefu retromandibular region and tumor of retropharyngeal space. The direct in the posterior pharyngeal wall for last 18 months, correlatjon between head and neck lipoma with which was gradually increasing in size. Patjent also obstructjve sleep apnea syndrome is again extremely stated that from last 18 months he had more snoring, rare. Such fatuy tumors also carry rare possibility of disturbed sleep and daytjme sleepiness, for last 8-9 being liposarcoma, which further warrants their months he notjced a change in his voice. Diffjculty surgical excision. We describe a case of lipoma in breathing started 2-3 months back, which used to of retropharyngeal space that extends from get aggravated in supine positjon and during sleep. nasopharynx to hypopharynx causing symptoms of On physical and endoscopic examinatjon a sofu to obstructjve sleep apnea. Mini Polysomnography, fjrm swelling in lefu retromandibular region, which MRI and histopathological examinatjon confjrmed was not fjxed to undersurface, and a bulge on the the obstructjve sleep apnea syndrome is due to posterior pharyngeal wall that reach up to piriform retropharyngeal space lipoma. Surgical removal of fossa was observed. The X-Ray neck with barium lipoma cured the obstructjve sleep apnea syndrome. swallow showed a large sofu tjssue mass pushing the Keywords: Lipoma, Retropharyngeal space, larynx and trachea forward. The Magnetjc Resonance Obstructjve sleep apnea syndrome, Rare tumor Imaging revealed a sharply circumscribed lesion measuring 9.5 × 6.7 × 3.8 cm mass that was hyper Introductjon: intense on T1W and T2W images (Figure 1) and Lipomas, benign tumor of the fat, are the most hypo intense on fat suppressed mode suggestjve of common sofu tjssue tumors of the adulthood but the fat (Figure 2). The mass was well encapsulated and lipoma of retropharyngeal space is very rare. Usually extended from superior border of C1 to C6 cervical they do not give rise to symptoms and rarely obstruct vertebra and both common carotjd artery and airway untjl they are of large size. Such fatuy tumors internal jugular vein were displaced posterolateraly. also carry rare possibility of being liposarcoma, However, there was no alteratjon of fmow signal. which further warrants their surgical excision. We Although a Polysomnographic or full sleep study was are reportjng an interestjng case of retropharyngeal not done but on “Mini Sleep Study” with observatjon lipoma that remained asymptomatjc for long tjme, during sleep with Oximeter monitoring of Oxygen and then patjent gradually developed the obstructjve saturatjon and ECG for 4 hours showed that he had sleep apnea 1 and respiratory distress. Apnea-hypopnea index 6 of 18. The FNAC diagnosis Case Report: was lipoma. A 48 year old man presented with 4-5 years history The tumor was removed through upper cervical Otolaryngology online

crease incision afuer retractjng sternocleidomastoid reports available in literatures, and retropharyngeal muscle laterally. The tumor was well encapsulated lipoma as a cause of obstructjve sleep apnea and adhesion to carotjd artery, jugular vein and syndrome is even more rare 2 , The tumor described muscle were very few. The tumor was removed in one here was in retropharyngeal space, this space is piece. The histopathological examinatjon revealed bounded by pharynx anteriorly, the prevertebral an encapsulated tumor comprising of lobules of fascia posteriorly, base of skull superiorly and is mature adipocytes separated by fjne fjbrovascular contjnuous with mediastjnum inferiorly. It remains septa confjrming the diagnosis of lipoma (Figure 3). fjlled with loose areolar tjssue and is divided by midline raphe that extends from the fascia covering In his second follow up he had no problem of the constrictor muscle to the prevertebral fascia. snoring, disturbed sleep and daytjme somnolence. Obstructjve sleep apnea is a sleep disorder typifjed On Mini Sleep Study his Apnea index was 4 and very by a functjonal narrowing of the pharynx. Most litule fmuctuatjon in oxygen saturatjon level. commonly this is caused by bulky or retropostjoned Discussion: sofu tjssue of the palate, base of tongue, or The lipoma is relatjvely common benign tumor retropharynx. Patjents with sleep apnea frequently in head and neck region and it only produce few have multjple anatomic abnormalitjes and, symptoms. On the other hand retropharyngeal neuromuscular dysfunctjon causing airway collapse. lipoma are extremely rare and there are only few Less common causes of obstructjve sleep apnea Figure 1: MRI of Neck showing sharply circumscribed lesion measuring 9.5 × 6.7 × 3.8 cm mass that was hyper intense on T1W and T2W images extending from superior border of C1 to C6 cervical vertebra in axial, coronal and sagitual plane. Figure 2: Shows mass is hypo intense on T2W sagitual fat suppressed Figure 2: Shows mass is hypo intense on T2W sagitual fat suppressed mode suggestjve of fat. mode suggestjve of fat. Otolaryngology online

Figure 3: Shows Histopathological picture of cut sectjon of tumor comprising of lobules of mature adipocytes separated by fjne fjbrovascular septa establishing diagnosis of Lipoma. include tumors of pharynx and larynx 3 . In present years before his symptomatjc presentatjon. The case complete polysomnograghy was not done, he liposuctjon and surgical excision of the mass are the had the typical sign and symptoms of obstructjve two alternatjves 6 of the treatment. In this case we sleep apnea; loud snoring at night, apneic episode chosen the surgical excision because in liposuctjon while sleeping and day tjme somnolence 4 . “Mini there are always chances to redevelop the lipoma, sleep study” test confjrmed the obstructjve sleep secondly we wanted to rule out the possibility of apnea syndrome 5 . liposarcoma. Liposuctjon, although is less invasive than open surgical excision but our patjent also Fine needle aspiratjon cytology of lipoma yields opted for surgical excision on afuer explaining the fragments of benign adipocytes that cannot be pros and cons of both the procedures. The surgical distjnguished cytologically from normal fat. The MRI excision of lipoma in this patjent led to resolutjon of (in fat suppression mode) is very much diagnostjc all the symptoms including obstructjve sleep apnea of lipoma and useful in preoperatjve assessment of syndrome and dysphagia. the size of tumor and adherences to the adjacent structures. Conclusion: The lipoma usually preset as slow growing Large retropharyngeal lipoma can be challenging mass, and deeply situated lipoma may remain and diffjcult to resect because of their locatjon undiagnosed for years because patjent usually and proximity to the vital structures. Preoperatjve become habituated to their symptoms. Our patjent assessment of the tumor size and its adhesion to had symptomatjc history of 5 years before he adjacent structure like carotjd artery, jugular vein was diagnosed as retropharyngeal lipoma. It is and muscles are must for hassle free complete likely that the patjent developed the lipoma many excision. Otolaryngology online

References: 4. Koopman CF, Feld PA, Coulthard SW (1981) Sleep apnea syndrome associated with neck 1. Aland JW (1996) Retropharyngeal Lipoma causing mass. Otolaryngol Head and Neck Surgery 89: symptoms of obstructjve sleep apnea. Otolaryngol 949-952 Head Neck Surgery 114: 628-630 5. Smith TC, Proops DW, Pearman K, Hutuon P 2. Barry B, Charlier JB, Ameline E (2000) Lipomes (1992) Hypoxia in sleeping children: Overnight retropharynges at du pharyngolarynx. Ann studies can be reduced to 4 hours without loss of Otolaryngol Chir Cervicofac 117: 322-326. clinical signifjcances. Clinical Otolaryngology 17: 3. Hockstein NG, Anderson TA (2002) Retropharyngeal 243-245. Lipoma causing obstructjve sleep apnea: Case 6. Younis M (1980) Retropharyngeal Lipoma. J report including fjve year follow up. Laryngoscope Laryngol Otol 94: 321-325. 112: 1603-1605. Otolaryngology online