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Clinical Problem Solving: Pathology
February 2005

Pathology Quiz Case 1

Author Affiliations


Arch Otolaryngol Head Neck Surg. 2005;131(2):172. doi:10.1001/archotol.131.2.172

An 18-month-old girl presented to a local ophthalmologist for evaluation of progressive left-sided ptosis and anisocoria. Her parents had first noticed the eyelid droop 8 months earlier, and the constricted left pupil had been present for 3 months. The patient was otherwise healthy, without any remarkable medical or surgical history.

Horner syndrome was diagnosed, and the patient underwent magnetic resonance imaging (MRI) of her neck (Figure 1). A cervical mass was identified, and the patient was referred for further evaluation. Physical examination confirmed the original findings, and a diffuse enlargement of the left side of the neck was also noted. The results of the rest of the examination, including cranial nerve function, were normal. The neck MRI demonstrated a large mass with low T1 and high T2 signal characteristics that filled the left retropharyngeal, parapharyngeal, and posterior cervical spaces, extending from the nasopharynx to the level of C4. The mass measured 3.9 × 2.1 × 4.5 cm, and its medial bulk shifted the midline nasopharyngeal and oropharyngeal tissues to the contralateral side, while its lateral aspect encased the left internal carotid artery. The patient underwent MRI of the head, computed tomographic scans of the chest and abdomen, and bone marrow biopsies, all of which were negative for disease. Urinary catecholamines revealed elevated levels of vanillymandelic acid and normal levels of homovanillic acid.

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