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| Journal of the New Zealand Medical Association,
20-January-2012, Vol 125 No 1348
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Case reportA 42-year-old Māori man presented to a rural New
Zealand emergency department after coughing up a globular, mobile,
sausage-shaped tissue mass that appeared to be “stuck” at the back
of his throat. He held it forward out of his mouth to prevent it slipping
backwards in to the oropharynx, which caused anxiety and respiratory distress
(Figure 1). He gave a one-day history of recurrent, intermittent choking and
gagging lasting for a few seconds at a time with the sensation of a pharyngeal
foreign body that he was unable to cough up. A similar episode had occurred one
year previously. Since then he had mild pharyngeal irritation and discomfort
without dysphagia. He was a heavy cigarette smoker.
Fiberoptic nasopharyngoscopy demonstrated that the lesion
was attached to the right nasopharyngeal wall anterior to the opening of the
eustachian tube (Figure 2). No other obvious abnormalities were noted and the
decision to remove this mass urgently was made. After securely clamping the mass
under general anaesthesia, the soft palate was retracted, the lesion was
cauterised at its base and completely excised. A formal rigid
pharyngoesophagoscopy revealed no further abnormality. The postoperative
recovery was uneventful.
Macroscopically the lesion was a sausage-shaped mass
appearing to be covered with congested pharyngeal mucosa and measuring
11×3cm. Microscopically it was consistent with a fibroepithelial polyp
covered by respiratory epithelium. The stroma comprised elasto-fibrous tissue
and inflammatory cells. There was no thickening of the basement membrane or
evidence of malignancy (Figure 3).
Figure 1. Pre-op securing of polyp with ribbon
gauze
 Figure 2. Intraoperative, macroscopic
appearances of nasopharyngeal polyp
 Figure 3. Microscopic appearances consistent
with fibroepithelial polyp covered with respiratory epithelium
 DiscussionPolyps of the upper digestive tract are classified according
to their predominant histological component and include fibroma, fibromyxoma,
fibrolipoma, angiolipoma or fibroepithelial polyps. Fibroepithelial polyps of
the pharynx and upper airways are rare in medical literature and, to our
knowledge they have not previously been described in the adult nasopharynx.
Fibroepithelial polyps are benign polypoid lesions
originating from mesodermal tissue and are comprised of varying amounts of loose
fibrovascular connective tissue interspersed with fat cells, covered by a
squamous epithelium.1,2 They are most commonly
found in the skin, gastrointestinal, lower respiratory and genitourinary systems
and are predominantly seen in males aged 40 to 70, although cases involving
women and children have also been
described.1–3 Malignant transformation
has been reported but is extremely rare.2
The exact aetiology of fibroepithelial polyps is unknown
although a few theories have been proposed. One such theory relates to
development of polyps following focal loss of elastic
tissue.4 Another theory is that the polyps are
a mixture of various tissue elements that could represent a slowly enlarging
haemartoma of the lamina propria. 3 In the
upper airway, documented lesions have been mostly been reported in the
literature as arising from the hypopharynx at Killan’s dehiscence between
the superior and inferior cricopharyngeal muscles or at Laimer’s triangle
between the cricopharyngeus muscle and the proximal end of the
oesophagus.2,5
Polyps of the hypopharynx in children and neonates are often
discovered as asymptomatic masses by routine examinations. Extremely rare cases
exist with polyps arising from the tonsillar region of the oropharynx and nasal
turbinates.1,5,6 The differential diagnosis for
polyps in the nasopharynx should include hairy polyps, which are also rare and
usually seen in infants, although cases in adults have been
described.7
Our case highlights several key points. Despite the high
risk of asphyxiation, this patient remained relatively asymptomatic for several
years. Oesophageal extension of the polyp was causing some mild intermittent
dysphagia. The location of the polyp in the nasopharynx enabled flexible
nasopharyngoscopy to visualise the attachment of the polyp, however a barium
swallow or CT scan would have delineated between the more common hypopharyngeal
polyps.
In this case we felt early management was paramount due to
the threat of impending airway compromise. Radiographic studies were not waited
for. Multiple cases have been described in recent literature of laryngeal polyps
becoming impacted in the airway with subsequent asphyxiation, cerebral anoxia
and death.2,8 We therefore emphasise the need
of early recognition and resection of these polyps for future cases.
Author information: Ravi Jain, Department
of Otolaryngology – Head and Neck Surgery, North Shore Hospital, Auckland;
Subhaschandra Shetty, Department of Otolaryngology, Head and
Neck Surgery, Northland DHB, Whangarei
Correspondence: Dr Subhaschandra Shetty,
Department of Otolaryngology, Head and Neck Surgery, Northland DHB, Private Bag
9742, Whangarei, New Zealand. Email: subhash@nhl.co.nz
References:
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