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Clinical Challenge
October 2018

A Slow-Growing Fibrous Parapharyngeal Mass

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
  • 2Department of Pathology, Michigan Medicine, Ann Arbor
JAMA Otolaryngol Head Neck Surg. 2018;144(10):944-945. doi:10.1001/jamaoto.2018.1570

An otherwise healthy woman in her 60s presented with a right neck and facial lesion that had been growing slowly for more than 20 years. She was a former smoker and had unilateral conductive hearing loss associated with the mass. On examination, a large, nonmobile, and firm tumor extended from the postauricular region to the parotid gland, scalp, and a portion of the neck. There was no palpable lymphadenopathy. On otoscopy, the growth occluded view of the tympanic membrane. Computed tomographic imaging (Figure, A and B) demonstrated a mass emanating from the parapharyngeal space, measuring approximately 10 × 7.3 × 1.5 cm. There was no radiographic evidence of osseous extension or destruction. The patient underwent a staged procedure, including a radical resection of the scalp and neck mass, followed by a transcervical and transparotid approach to the parapharyngeal space. The tumor was noted to stretch the pes anserinus to 4 times its normal length and had to be resected off the internal carotid artery, as well as the fascia overlying the medial pterygoid muscle and the tympanomastoid suture. The patient recovered well with only temporary marginal mandibular weakness. Microscopy (Figure, C) demonstrated a well-circumscribed, paucicellular spindle cell neoplasm with abundant myxocollagenous matrix. The scattered tumor cells were spindled to stellate shaped and had the morphology of myofibroblasts. Rare vessels were identified, and the tumors focally infiltrated subcutaneous fat and skeletal muscle.

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