European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 167–169
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
High dysphagia: A case report D. Rivière ∗ , L. Vatin , J.-B. Morvan Service d’ORL et de chirurgie cervico-faciale, hôpital d’instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 600, 83800 Toulon Naval, France
1. Description Mr. M., 36 years old, with no medical history, presented to our outpatients department with pharyngeal discomfort and a foreign body sensation present for several weeks with no deterioration of his general state of health. Clinical examination revealed high dysphagia to solids and liquids with several episodes of aspiration, but no associated dysphonia or dyspnoea. Neck palpation did not reveal any abnormality. Fiberoptic nasolaryngoscopy revealed a supraglottic, submucosal, rounded mass with regular margins, arising at the expense of the left aryepiglottic fold and protruding into the ipsilateral pyriform sinus. The mucosa in contact with the mass appeared to be healthy and laryngeal mobility was preserved.
∗ Corresponding author. E-mail address: dam [email protected] (D. Rivière). http://dx.doi.org/10.1016/j.anorl.2015.02.002 1879-7296/© 2015 Elsevier Masson SAS. All rights reserved.
Contrast-enhanced computed tomography of the neck and MRI of the pharyngolarynx were performed (Fig. 1a). Endoscopic laser resection was performed for diagnostic purposes. The operative specimen was sent for histological examination. The histological section (HES ×25) is presented in Fig. 1b. 2. Questions • What is your radiological interpretation? • What is your differential diagnosis? • What does the histological examination reveal and what is the final diagnosis?
168
D. Rivière et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 167–169
Fig. 1. a: contrast-enhanced CT scan of the neck and MRI of the pharyngolarynx; b: histological section of the tumour (HES ×25).
What is your diagnosis?
D. Rivière et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 167–169
3. Answers
169
Histology revealed a non-encapsulated tumour containing numerous more or less dilated vessel walls with the presence of endothelial cells with no signs of atypia. This is a supraglottic laryngeal haemangioma.
case) and the vascular malformation may be situated underneath a smooth and perfectly pink mucosa. Haemangioma classically increases in size during Valsalva manoeuvre or with the head down, as a result of increased venous pressure. Histological examination typically reveals the presence of normal venous structures with an ectatic appearance of the vessels. The real incidence of haemangiomas is probably underestimated, as they are frequently asymptomatic. More rarely, they can be observed at an advanced stage in a context of sleep apnoea syndrome, dyspnoea or dysphagia. Biopsy of typical lesions is not essential, but when biopsy is performed, it must be performed cautiously due to the respiratory and haemorrhagic risks [3]. Magnetic resonance imaging is currently the preferred diagnostic and staging examination in this disease and demonstrates a high-intensity signal on T2-weighted sequences and an isosignal on T1-weighted sequences [4]. Adult laryngeal haemangioma does not regress spontaneously. The tumour can remain stable or increase in size to variable degrees with a risk of upper airway obstruction. Clinical and radiological surveillance may be sufficient in asymptomatic forms [1]. Treatment is based on endolaryngeal laser or instrumental microsurgery for small haemangiomas and open surgery for very large malformations [5]. Supraglottic sites can then be accessed via a midline or lateral pharyngotomy with temporary tracheotomy. In some exceptional cases, partial laryngectomy or even total pharyngolaryngectomy may be necessary. Regular clinical and radiological follow-up is required after surgery due to the high recurrence rate regardless of the treatment modality chosen.
4. Discussion
Disclosure of interest
Laryngeal haemangiomas in adults are rare benign vascular tumours [1] that differ from supraglottic angioma of infants in terms of aetiopathogenesis, histology and natural history, and can raise diagnostic and therapeutic difficulties. Mulliken and Glowacki differentiated infantile haemangioma characterized by a rapid growth phase related to endothelial cell proliferation, followed by a spontaneous involution phase, from vascular malformations, composed of dysplastic vessels with endothelial cells presenting a normal turnover, corresponding to adult forms. These adult forms are present at birth and can remain stable or progress during life [2]. Adult haemangioma is therefore a submucosal venous malformation. The mucosa may be intact or thickened and inflammatory. The highly suggestive bluish colour may be absent (as in our
The authors declare that they have no conflicts of interest concerning this article.
3.1. What is your radiological interpretation? Contrast-enhanced CT scan of the neck revealed a low-density supraglottic, rounded, regular mass with peripheral contrast enhancement, centered on the left aryepiglottic fold. The lateral surface of the mass was situated in contact with the left thyroid cartilage with no signs of cartilage thickening or lysis. MRI of the hypopharynx: demonstration of a high-intensity tumour on T2-weighted sequences with an isosignal on T1weighted sequences with a mulberry-like appearance presenting fine septa inside the mass. 3.2. What is your differential diagnosis? • • • • • • •
Solitary fibrous tumour; schwannoma of the recurrent laryngeal nerve; papilloma; pleiomorphic adenoma of an accessory salivary gland; haemangioma; muscle tumour; laryngomucocele.
3.3. What are the histological findings and what is your final diagnosis?
References [1] Prasad SC, Prasad KC, Bhat J. Vocal cord hemangioma. Med J Malaysia 2008;63(5):419–20. [2] Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982;69(3):412–22. [3] Martins RH, Lima Neto AC, Semenzate G, et al. Laryngeal hemangioma. Braz J Otorhinolaryngol 2006;72(4):574. [4] Kawakami M, Hayashi I, Yoshimura K, et al. Adult giant hemangioma of the larynx: a case report. Auris Nasus Larynx 2006;33(4):479–82 [Epub 2006 Aug 24]. [5] Lomeo P, McDonald J, Finneman J. Adult laryngeal hemangioma: report of four cases. Ear Nose Throat J 2000;79:594 [597–8].
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
High dysphagia: A case report D. Rivière ∗ , L. Vatin , J.-B. Morvan Service d’ORL et de chirurgie cervico-faciale, hôpital d’instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 600, 83800 Toulon Naval, France
1. Description Mr. M., 36 years old, with no medical history, presented to our outpatients department with pharyngeal discomfort and a foreign body sensation present for several weeks with no deterioration of his general state of health. Clinical examination revealed high dysphagia to solids and liquids with several episodes of aspiration, but no associated dysphonia or dyspnoea. Neck palpation did not reveal any abnormality. Fiberoptic nasolaryngoscopy revealed a supraglottic, submucosal, rounded mass with regular margins, arising at the expense of the left aryepiglottic fold and protruding into the ipsilateral pyriform sinus. The mucosa in contact with the mass appeared to be healthy and laryngeal mobility was preserved.
∗ Corresponding author. E-mail address: dam [email protected] (D. Rivière). http://dx.doi.org/10.1016/j.anorl.2015.02.002 1879-7296/© 2015 Elsevier Masson SAS. All rights reserved.
Contrast-enhanced computed tomography of the neck and MRI of the pharyngolarynx were performed (Fig. 1a). Endoscopic laser resection was performed for diagnostic purposes. The operative specimen was sent for histological examination. The histological section (HES ×25) is presented in Fig. 1b. 2. Questions • What is your radiological interpretation? • What is your differential diagnosis? • What does the histological examination reveal and what is the final diagnosis?
168
D. Rivière et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 167–169
Fig. 1. a: contrast-enhanced CT scan of the neck and MRI of the pharyngolarynx; b: histological section of the tumour (HES ×25).
What is your diagnosis?
D. Rivière et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 167–169
3. Answers
169
Histology revealed a non-encapsulated tumour containing numerous more or less dilated vessel walls with the presence of endothelial cells with no signs of atypia. This is a supraglottic laryngeal haemangioma.
case) and the vascular malformation may be situated underneath a smooth and perfectly pink mucosa. Haemangioma classically increases in size during Valsalva manoeuvre or with the head down, as a result of increased venous pressure. Histological examination typically reveals the presence of normal venous structures with an ectatic appearance of the vessels. The real incidence of haemangiomas is probably underestimated, as they are frequently asymptomatic. More rarely, they can be observed at an advanced stage in a context of sleep apnoea syndrome, dyspnoea or dysphagia. Biopsy of typical lesions is not essential, but when biopsy is performed, it must be performed cautiously due to the respiratory and haemorrhagic risks [3]. Magnetic resonance imaging is currently the preferred diagnostic and staging examination in this disease and demonstrates a high-intensity signal on T2-weighted sequences and an isosignal on T1-weighted sequences [4]. Adult laryngeal haemangioma does not regress spontaneously. The tumour can remain stable or increase in size to variable degrees with a risk of upper airway obstruction. Clinical and radiological surveillance may be sufficient in asymptomatic forms [1]. Treatment is based on endolaryngeal laser or instrumental microsurgery for small haemangiomas and open surgery for very large malformations [5]. Supraglottic sites can then be accessed via a midline or lateral pharyngotomy with temporary tracheotomy. In some exceptional cases, partial laryngectomy or even total pharyngolaryngectomy may be necessary. Regular clinical and radiological follow-up is required after surgery due to the high recurrence rate regardless of the treatment modality chosen.
4. Discussion
Disclosure of interest
Laryngeal haemangiomas in adults are rare benign vascular tumours [1] that differ from supraglottic angioma of infants in terms of aetiopathogenesis, histology and natural history, and can raise diagnostic and therapeutic difficulties. Mulliken and Glowacki differentiated infantile haemangioma characterized by a rapid growth phase related to endothelial cell proliferation, followed by a spontaneous involution phase, from vascular malformations, composed of dysplastic vessels with endothelial cells presenting a normal turnover, corresponding to adult forms. These adult forms are present at birth and can remain stable or progress during life [2]. Adult haemangioma is therefore a submucosal venous malformation. The mucosa may be intact or thickened and inflammatory. The highly suggestive bluish colour may be absent (as in our
The authors declare that they have no conflicts of interest concerning this article.
3.1. What is your radiological interpretation? Contrast-enhanced CT scan of the neck revealed a low-density supraglottic, rounded, regular mass with peripheral contrast enhancement, centered on the left aryepiglottic fold. The lateral surface of the mass was situated in contact with the left thyroid cartilage with no signs of cartilage thickening or lysis. MRI of the hypopharynx: demonstration of a high-intensity tumour on T2-weighted sequences with an isosignal on T1weighted sequences with a mulberry-like appearance presenting fine septa inside the mass. 3.2. What is your differential diagnosis? • • • • • • •
Solitary fibrous tumour; schwannoma of the recurrent laryngeal nerve; papilloma; pleiomorphic adenoma of an accessory salivary gland; haemangioma; muscle tumour; laryngomucocele.
3.3. What are the histological findings and what is your final diagnosis?
References [1] Prasad SC, Prasad KC, Bhat J. Vocal cord hemangioma. Med J Malaysia 2008;63(5):419–20. [2] Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982;69(3):412–22. [3] Martins RH, Lima Neto AC, Semenzate G, et al. Laryngeal hemangioma. Braz J Otorhinolaryngol 2006;72(4):574. [4] Kawakami M, Hayashi I, Yoshimura K, et al. Adult giant hemangioma of the larynx: a case report. Auris Nasus Larynx 2006;33(4):479–82 [Epub 2006 Aug 24]. [5] Lomeo P, McDonald J, Finneman J. Adult laryngeal hemangioma: report of four cases. Ear Nose Throat J 2000;79:594 [597–8].
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