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Clinical Challenge
December 2018

Rapidly Enlarging Parapharyngeal Mass

Author Affiliations
  • 1USC Tina and Rick Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles
JAMA Otolaryngol Head Neck Surg. 2018;144(12):1178-1179. doi:10.1001/jamaoto.2018.2371

A man in his 40s with Poland syndrome presented with a 6-month history of left throat pain and enlarging oropharyngeal mass. The patient had been seen repeatedly for odynophagia that persisted despite multiple courses of antibiotics, reflux medications, and steroids prescribed at clinics and emergency departments. Over the course of 5 months, he underwent a tonsillectomy and 3 separate biopsies at multiple institutions. All showed inconclusive results, and the mass progressively enlarged. At presentation for the present report, physical examination showed a 2-cm, well-mucosalized, left oropharyngeal mass not extending to the hard palate (Figure, A). Computed tomography (CT) revealed a 58-mm parapharyngeal mass lateralizing and narrowing the left carotid artery against the styloid process (Figure, B). A CT-guided fine-needle aspiration biopsy was performed but again was nondiagnostic. Further confounding the clinical picture, a pacemaker was required for multiple episodes of sinus asystole due to mass effect on the carotid body. To obtain the diagnosis of the parapharyngeal mass, the patient had a transcervical resection with transoral partial glossectomy, palatectomy, and pharyngectomy with reconstruction. Results of immunohistochemical analysis of the removed tissue were positive for CD4 (weak), CD21, CD23, and vimentin with a low proliferation rate (Figure, C and D).

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