Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 1362  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::  Article in PDF (1,418 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed4466    
    Printed36    
    Emailed0    
    PDF Downloaded13    
    Comments [Add]    

Recommend this journal


 


 
  Table of Contents     
CASE SNIPPET
Year : 2012  |  Volume : 58  |  Issue : 4  |  Page : 301-302

A second tongue?


Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication4-Jan-2013

Correspondence Address:
J A Ebenezer
Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.105457

Rights and Permissions




How to cite this article:
Ebenezer J A, Mathew J, George M. A second tongue?. J Postgrad Med 2012;58:301-2

How to cite this URL:
Ebenezer J A, Mathew J, George M. A second tongue?. J Postgrad Med [serial online] 2012 [cited 2020 Apr 3];58:301-2. Available from: http://www.jpgmonline.com/text.asp?2012/58/4/301/105457


A 32-year-old man presented to the ENT outpatient clinic complaining of a persistent, progressively worsening, "choking sensation" in the throat for past 2 years. He had no difficulty in swallowing or breathing, no voice change, retrosternal burning, hemoptysis, anorexia, or loss of weight. Indirect laryngoscopy showed a smooth mucosa covered bulge in the right lateral pharyngeal wall. He was able to regurgitate an elongated mass into his mouth [Figure 1]. Barium swallow was normal. An MRI scan showed a mass from the right lateral pharyngeal wall, extending from a level just below the arytenoids, to the level of the lower pole of the thyroid [Figure 2].
Figure 1: The patient with a "second tongue", which was fixed outside the mouth with a stay suture prior to intubation, in order to prevent airway compromise during induction of anesthesia

Click here to view
Figure 2: MRI (T1weighted, axial section) showing an intraluminal soft tissue mass arising from the right lateral pharyngeal wall (see arrow)

Click here to view


The patient was taken up for endoscopy and excision of the mass under general anesthesia. Preoperatively, the patient was asked to regurgitate the mass, which was fixed outside his mouth with a stay suture, thus securing the airway. The patient was then intubated with a No 6 cuffed nasotracheal tube and mouth held open with a Boyle Davis mouth gag, in the tonsillectomy position.

The pedicle, which was located at the right lateral pharyngeal wall using a zero degree endoscope, was cauterized, ligated, the mass excised in toto and sent for histopathological examination [Figure 3] and [Figure 4]. The postoperative period was uneventful and he remained asymptomatic till latest follow up. Haematoxylin and Eosin stain showed lobules of adipocytes interspersed with spindle cells set in fine collagenous matrix, with scattered blood vessels, covered by stratified squamous epithelium, suggestive of a benign fibrovascular polyp.

Giant lipomatous or fibrovascular polyps are rare benign submucosal tumors of the hypopharynx and esophagus. [1] These tumors almost always arise from the submucosa of the upper third of the esophagus, near the cricopharyngeus, and are pulled down, along with their mucosal lining, to become polypoidal due to the constant propulsive forces of swallowing and peristalsis. [2],[3]
Figure 3: The specimen for biopsy: A smooth mucosa covered polypoidal soft tissue mass 7.5 × 2.5 × 1.5 cm, with a stalk. Note the stay suture still attached at its distal end

Click here to view
Figure 4: Hemotoxylin and Eosin, ×50: The polyp, composed of lobules of adipocytes interspersed with spindle cells set in fine collagenous matrix, scattered thick, and thin-walled blood vessels, epithelial inclusions, and lymphoid aggregates, covered by stratified squamous epithelium, suggestive of a benign lipomatous polyp

Click here to view


Caceres et al., in 2006, in a review of 110 cases described in world literature, reported that giant (>5 cm) fibrovascular polyps presented most commonly in elderly males, with long-term dysphagia (62%), regurgitation of a mass (38%), persistent lump in the throat (25%), weight loss, regurgitation of food, chest pain, persistent cough, vomiting, sore throat, and malena. [3]

Polyps may be missed on endoscopy as their smooth mucosa covered surface blends in well with the esophageal wall. [2] Barium swallow may show a smooth, intraluminal filling defect, or it may show nothing, as in our case. A thorough endoscopic and radiological evaluation, including CT scan and MRI of the entire upper gastrointestinal tract has been advocated. [3]

Their tendency to cause fatal airway compromise is reason enough for the recommendation that all such polyps should be surgically excised. [3] A hypopharyngeal or upper esophageal polyp can be excised either endoscopically with snare or laser, or by the open transcervical or transthoracic route. [2] The surgical approach is to be decided taking into consideration access to the base of the pedicle, and the risk of bleeding and airway compromise. [4] A tracheostomy may be performed to secure the airway prior to surgery. [5]

We recommend that a high index of suspicion be maintained and appropriate imaging be done (CT/MRI) while dealing with a patient whose symptoms point toward the upper aero-digestive tract; however, ambiguous his complaints may seem, as a negative initial work up does not exclude a potentially fatal, but easily treatable pathology.

 
 :: References Top

1.Fries MR, Galdhino RL, Flint PW, Abraham SC. Giant fibrovascular polyp of the oesophagus: A lesion causing upper airway obstruction and syncope. Arch Pathol Lab Med 2003;127:485-7.  Back to cited text no. 1
    
2.Alobid I, Vilaseca I, Fernandez J, Bordas JM. Giant fibrovascular polyp of the oesophagus causing sudden dyspnoea: Endoscopic treatment. Laryngoscope 2007;117:944-5.  Back to cited text no. 2
    
3.Caceres M, Steeb G, Wilks SM, Edward Garrett H Jr. Large pedunculated polyps originating in the oesophagus and hypopharynx: A review. Ann Thorac Surg 2006;81:393-6.  Back to cited text no. 3
    
4.Zevallos JP, Shah RP, Baredes S. Giant fibrovascular polyp of the hypopharynx. Laryngoscope 2005;115:876-8.  Back to cited text no. 4
[PUBMED]    
5.Ozdemir S, Gorgulu O, Selcuk T, Akbas Y, Sayar C, Sayar H. Giant fibrovascular polyp of the hypopharynx: per-oral endoscopic removal. J Laryngol Otol 2011;125:1087-90  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
Print this article  Email this article
 
Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow