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Large retropharyngeal tumour in a young adultSuhail Amin Patigaroo1, Haris Qadri1, Showkat Ahmad Showkat1, Tabish Maqbool1, Summaiya Farooq2 Patient description A 27-year-old male patient came to our outpatient department with the complaints of difficulty in swallowing and new onset snoring for the last 6 months. On examination a well-defined swelling was seen in the posterior pharyngeal wall causing a smooth bulge (Figure 1). Contrast enhanced computed tomography showed a heterogeneously enhancing mass located predominantly in the retropharyngeal space extending from basispehnoid to C5-C6 vertebra causing oropharyngeal obstruction. The mass was also seen extending to left parapharyngeal space (Figures 2-4). MR angiography was unremarkable. needle aspiration showed the aspirate to be mucinous with scattered mucinophages and lymphocytes seen in a mucinous background. Mass was excised via transcervical suprahyoid pharyngotomy approach (Figures 5-8). The excised mass was sent for histopathology. After 3 weeks, the oropharyngeal mucosa healed completely. Histopathology on HE 100× revealed cellular areas of spindle cells with verocay body (Figure 9). High magnification (400×) of the same showed verocay body with nuclear palisading (Figure 10). Histopathology was suggestive of a schwannoma. The final diagnosis turned out to be a retropharyngeal schwannoma. Treatment Mass was excised via transcervical suprahyoid pharyngotomy approach (Figures 5-8). The excised mass was sent for histopathology. After 3 weeks, the oropharyngeal mucosa healed completely. Histopathology on HE 100× revealed cellular areas of spindle cells with verocay body (Figure 9). High magnification (400×) of the same showed verocay body with nuclear palisading (Figure 10). Histopathology was suggestive of a schwannoma. The final diagnosis turned out to be a retropharyngeal schwannoma. Discussion with conclusion Schwannomas are rare, slow-growing, encapsulated and submucosal tumours. About 25-45% of schwannomas occur in the head and neck region and they may arise from some cranial nerves, especially from the 9th, 10th, 11th, 12th cranial nerves or the cervical sympathetic chain [1]. The parapharyngeal space is the most common site of occurrence, followed by the oral cavity, nasal cavity and paranasal sinuses [2]. Fat appears to be the main content of the retropharyngeal space; thus, lipoma appears to be the most common primary tumour in this space [3]. Schwannoma, on the other hand, has only been very rarely reported to occur in retropharyngeal space [4]. As on 2022, a systematic search of the English literature in the Medline, PubMed, and Google Scholar databases revealed only nineteen published cases of retropharyngeal schwannoma [5]. Tumours arising in the retropharyngeal space produce signs and symptoms related to the mass effect with dysphagia being the most frequent, followed by dyspnoea, and impairment in phonation [2]. The schwannoma may arise at any age and there is no gender and race predilection. Though there are no known predisposing factors but Hatziotis and Aspiudes [6] believe that the trauma may be the cause. Diagnosis is challenging since in the retropharyngeal space, which contains essentially fat and lymph nodes, the most frequent diseases are metastasis from primary head, neck cancer, lipomas, neuroblastomas and pleomorphic adenomas [2]. MRI and CT scans may be very helpful in diagnosing schwannomas. The imaging findings, such as displacement of the local structures, circumscribed margins and smooth expansion of the osseous foramina reflect the slow growth of schwannomas [7] The choice of surgical approach is dictated by the size of the tumour, its location, its relationship to the great vessels, and the suspicion of malignancy. The gold standard in treating retropharyngeal schwannoma is through total resection of the tumour [4]. Transcervical, transparotid and transoral excisions are the most reviewed surgical approaches in the literature to remove retropharyngeal tumours [8]. We found transcervical suprahyoid approach as the most feasible approach in view of the size and extend of the tumour. The post-surgical recurrence of a schwannoma is almost nil [9]. However, a study by Liu et al. [10] stated that follow-up MRI of a patient who underwent a debulk operation showed a slow progression of the tumour at 2 years.  Figure 1. A well-defined bulge seen in posterior pharyngeal wall with intact mucosa (black star). [please click on the image to enlarge]  Figure 2. Axial CT picture showing enhancing mass in retropharyngeal region. [please click on the image to enlarge]  Figure 3. Coronal CT showing mass extending from oropharynx to laryngopharynx. [please click on the image to enlarge]  Figure 4. Sagittal CT showing mass extending from oropharynx to laryngopharynx. [please click on the image to enlarge]  Figure 5. Submucosal mass seen after suprahyoid pharyngotomy (black star). Also seen are epiglottis (blue arrow) and base of tongue (black triangle). [please click on the image to enlarge]  Figure 6. Mass seen after mucosal incision (black star). [please click on the image to enlarge] |
 Generate PDF/or right-click and save as.../  Figure 7. Mass being removed from pharynx. [please click on the image to enlarge]  Figure 8. About 15 cm lobulated mass after removal. [please click on the image to enlarge]  Figure 9. Histopathology suggestive of schwannoma (100×). [please click on the image to enlarge]  Figure 10. Histopathology suggestive of schwannoma (400×). [please click on the image to enlarge] References [1] Wax MK, Shiley SG, Robinson JL, Weissman JL. Cervical sympathetic chain schwannoma. Laryngoscope 2004; 114:2210-3. [2] Gallo S, Bandi F, Maffioli M-P, Giudice M, Castelnuovo P, Fazio E, Karligkiotis A. Retropharyngeal Space Schwannoma: A Rare Entity. Iran J Otorhinolaryngol 2017; 29:353-7. [3] Righini CA, Atallah I. A retropharyngeal mass. Diagnosis: Antoni A type schwannoma. Eur Ann Otorhinolaryngol Head Neck Dis 2015; 132:57-8. [4] Chia YH, Jong KH, Cheng PW. Retropharyngeal schwannoma excised through a transoral approach: a case report. Kaohsiung J Med Sci 2006; 22:465-9. [5] El-Fattah AMA, Attia M, Ebada HA. Endoscopic assisted transoral approach with palatal splitting for a giant retropharyngeal schwannoma: a challenging case. J Korean Assoc Oral Maxillofac Surg 2022; 48:111-6. [6] Hatziotis JCh, Aspiudes H. Neurilemmoma (Schwannoma) of oral cavity. Oral Surg Oral Med Oral Pathol 1967; 24:510-26. [7] Akheel M, Mohd Athar I, Ashmi W. Schwannomas of the head and neck region. A report of two cases with a narrative review of the literature. Cancer Res Stat Treat 2020; 3:517-25. [8] Ying C, Ngu V, Gan CC, Tang IP. Transoral excision of retropharyngeal schwannoma: Case report. Acta-Oto-Laryngologica Case Reports 2017; 2. [9] Dosemane D, Kabekkodu S, Jaipuria B, Sreedhara S, Shenoy V. Extracranial non-vestibular head and neck schwannomas: a case series with the review of literature. Braz J Otorhinolaryngol 2022; 88: S9-S17. [10] Liu HL, Yu SY, Li GKH, Wei WI. Extracranial head and neck schwannomas: a study of the nerve of origin. Eur Arch Otorhinolaryngol 2011; 268:1343-7. Conflict of interest: none declared. Authors’ affiliations: 1 Department of ENT and HNS, Government Medical College, Srinagar, India 2 Department of Pathology, Government Medical College, Srinagar, India Corresponding author: Dr Suhail Amin Patigaroo, MBBS MS MFHNO Associate professor Department of ENT and HNS Government Medical College Srinagar India e-mail: Dr_suhail_jnmc@yahoo.co.in To cite this article: Suhail Amin Patigaroo, Haris Qadri, Showkat Ahmad Showkat, Tabish Maqbool, Summaiya Farooq. Large retropharyngeal tumour in a young adult. World J Med Images Videos Cases 2023; 9:e17-27. Submitted for publication: 3 January 2023 Accepted for publication: 30 January 2023 Published on: 1 March 2023 |
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