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Clinical Challenge
July 2016

Parapharyngeal Space Mass

Author Affiliations
  • 1The Ohio State University College of Medicine, Columbus
  • 2Department of Pathology, The Ohio State University, Columbus
  • 3Department of Otolaryngology–Head and Neck Surgery, The Ohio State University, Columbus
JAMA Otolaryngol Head Neck Surg. 2016;142(7):701-702. doi:10.1001/jamaoto.2015.3697

An elderly man with history of squamous cell carcinoma of the forehead presented with 6-month history of a slowly enlarging left facial mass. He did not have facial pain, weakness, numbness, trismus, or difficulty chewing. He had no history of dysphagia and/or odynophagia, hoarseness, vision changes, dry mouth, decreased ipsilateral sweating, weight loss, fevers, chills, or a history of tobacco or alcohol use. Physical examination revealed a palpable nontender mass in the left parapharyngeal space. Cervical lymphadenopathy was not palpable. Nasopharyngoscopy revealed slight bulging of the lateral pharyngeal wall into the oropharynx with no discrete masses seen. Computed tomography–guided fine-needle aspiration biopsies were nondiagnostic. Axial T2-weighted MRI showed a lesion arising from the left parapharyngeal space, arising from the deep lobe of the parotid gland. The lesion caused loss of the fat plane between the parapharyngeal space and masticator space with subsequent inflammation of the pterygoid space. The pharyngeal mucosa of the left lateral pharyngeal wall was effaced owing to mass effect (Figure, A). The mass was surgically resected in its entirety. Hematoxylin-eosin staining showed sections of confluent amorphous eosinophilic masses with surrounding foreign-body giant cell reaction and lymphoplasmacytic infiltrates (Figure, B). Sheets of plasma cells were positive for κ and CD138 and negative for λ, consistent with clonal κ light-chain restricted plasma cell infiltrates around amorphous tissue (Figure, C). Congo red stain showed apple-green birefringence demonstrated on polarized microscopy (Figure, D).

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