Neurofibroma of the parapharyngeal space By H. K. KUKREJA, D. L. CHHANGANI and

K. C. JOSHI (Jaipur, India) TUMOURS of the parapharyngeal space are not very common. Smirnova (1962) reviewed 15 tumours of the parapharyngeal space and found neurofibroma to be the most common. The split up was as follows:

Neurofibroma Paraganglionoma of carotid body Sarcoma Chordoma Fibroma Lymphangioma

6 3 2 2 1 1

Solitary neurofibroma and carotid body tumour thus form the commonest of these raie but interesting swellings encountered in the upper part of the neck. Their clinical differentiation may be quite impossible and in some quarters these tumours are jegarded as being related, an opinion in keeping with the widely held but debatable view that the carotid body tumour is of neural origin (Cullen and Monro, 1952). Solitary neurofibroma of the parapharyngeal space can, rarely, protrude into the lateral wall of the pharynx without being detectable in the neck. Only two such cases have been reported by Lukovskii and Dzyza (1962). The present case of ours also came with a swelling in the pharynx in the peritonsillar region. Case report M.R., a 45-year-old Hindu male, was admitted to the E.N.T. Ward of S.M.S. Hospital, Jaipur, on 10.11.76 with the following complaints: 1. 2. 3. 4.

Sticking of phlegm in the throat—duration 3 months. Swelling in the right side of the throat—duration 3 months. Difficulty in swallowing—duration 3 months. Occasional pain in the throat—duration 1 month.

On noticing the swelling in the throat the patient consulted an E.N.T. surgeon at the District Hospital, Ganganagar, who incised the swelling thinking it to be a periotonsillar abscess and put him on a course of antibiotics. The patient did not get any relief. Examination of the throat revealed a peritonsillar swelling simulating that of a quinsy. Palpation revealed it to be firm. The borders of the swelling could not be defined. There was no swelling in the neck, no lymphadenopathy, no swelling in relation with any peripheral nerves. Examination of other systems 809

H. K. Kukreja, D. L. Chhangani and K. C. Joshi was normal. Dental check up did not reveal any abnormality. He was admitted, with a provisional diagnosis of malignancy of the tonsil. As there was no ulceration over the swelling, excision biopsy of the right tonsil was decided upon.

Blood

Urine X-ray X-ray

Investigations Hb. 13-6 G.% TLC 11,750/c.mm DLC P - 72%, L - 27%, M - 1% ESR 10 mm 1st hour (Wintrobe) —NAD chest —NAD neck (Lat.)—NAD Management

He was operated on 16.11.76 under general anaesthetic. Right tonsillectomy was done, but the tonsil looked normal and the swelling in the peritonsillar space persisted. With a view to exploring the space, an incision was made in the anterior faucial pillar 0-5 cm away from the margin. After splitting the palatoglossus muscle a white shining swelling was seen. Further dissection all round the swelling revealed it to be an encapsulated tumour which could be shelled out without much difficulty. The pillar was stitched back. The patient made an uneventful recovery and was discharged on 3.12.76. The patient was symptomfree when he came for check-up one month after discharge. There was no evidence of Homer's syndrome, thus excluding the possibility of an origin of the tumour from the sympathetic trunk. The tumour was egg-shaped, measuring 4 cm. X2 cm. (Fig. 1) It was well encapsulated. The cut surface showed a homogeneous greyish white appearance. Histologically the tumour consisted of highly cellular areas of spindle-shaped cells with long processes with narrow and pointed nuclei. A portion of the tumour showed an interlacing fascicular pattern with a palisading arrangement of the nuclei at places (Fig. 2).

351 FIG. 1. Microscopic appearance of the tumour. 8lO

Clinical records

FIG. 2. Microscopic appearance of the tumour.

Discussion Cervical neurofibromata have been recorded arising from the cervical sympathetic chain (Cullen and Monro, 1952; Mayo and Barber, 1934; Callum, 1949; George et al., 1967), from the vagus and glossopharyngeal nerves (Cutler and Gross, 1936; Goodsitt and Sudimack, 1945; Murley, 1948) and from branches of these nerves to the carotid body (Gordon-Taylor, 1940). Despite the histological pleomorphism of parapharyngeal space tumours, these, on account of their similar location and anatomical features of the space, manifest themselves by common symptoms related to the pharynx, neck and nerves. The point of interest in the case under consideration is that it presented as a peritonsillar swelling and was misdiagnosed as a quinsy and later as a tonsillar malignancy. Summary A case of neurofibroma of an unusual site (peritonsillar space) is described. Acknowledgements We would like to thank the Principal and Controller, S.M.S. Medical College and attached hospitals, Jaipur, for kindly permitting us to publish this case record. REFERENCES CALLUM, E. N. (1947) British Journal of Surgery, 37, 117. CULLEN, T. H., and MONRO, R. S. (1952) British Journal of Surgery, 39, 454. CUTLER, E. G., and GROSS, R. E. (1936) Archives of Surgery, Chicago, 33, 733. GEORGE, A. T., KUKREJA, H. K., and PARMAR, O. M. (1967) Indian Journal of

Otolaryngology, 19, 35. GOODSITT, E., and SUDIMACK, G. (1945) American Journal of Surgery, 67, 131. GORDON-TAYLOR, G. (1940) British Journal of Surgery, 28, 163. LUKOBSKII, L. A., and DZYZA, V. G. (1962) Zhurnal ushnykh nosovykh i gorlovykh boleznei, 3, 60.

H. K. Kukreja, D. L. Chhangani and K. C. Joshi MARANGOS, G. (1939) Chirurg, 11, 222. I MAYO, C. W., and BARBER, K. W. (1934) Surgery, Gynaecology & Obstetrics, 59, 671. • % MURLEY, R. S. (1948) British Journal of Surgery, 36, 101. I SMIRNOVA, I. N. (1962) Zhurnal ushnykh nosovyhh i gorlovykh boleznei, 3, 57. 1

i Department of E.N.T., S.M.S. Hospital, Jaipur, India. Department of Pathology and Bacteriology, S.M.S. Medical College, Jaipur, India.

812

Neurofibroma of the parapharyngeal space.

Neurofibroma of the parapharyngeal space By H. K. KUKREJA, D. L. CHHANGANI and K. C. JOSHI (Jaipur, India) TUMOURS of the parapharyngeal space are no...
298KB Sizes 0 Downloads 0 Views