While lipomas on the trunk and limbs are common, they are rare in the upper aerodigestive tract. A case is reported of an 18 cm long pedunculated lipoma arising from the hypopharynx in a 73 year old man. The tumour was asymptomatic until it appeared in the mouth of the patient after a coughing episode.
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A fit and healthy 73 year old man presented to the accident and emergency department with a pendulous mass protruding from his mouth (fig 1). The mass appeared after a coughing episode during a meal. Until this time the patient was asymptomatic with no history of airway obstruction, throat discomfort or dysphagia. The patient was referred to the on call ENT team.
Examination of the oral cavity and throat revealed a long pendulous mobile mass arising from the posterior hypopharyngeal wall. It was removed transorally under general anaesthesia.
Macroscopically, the elongated piece of tissue was 18 cm long and 1 cm wide at it greatest diameter at the base. It was covered with mildly inflamed hyperplastic squamous mucosa with the centre consisting of mature adipose cells and a vascular mesh work. The overall appearance of the mass was consistent with a pedunculated lipoma.
Lipomas are benign slow growing neoplasms composed of mature white fat cells.1 The discovery of a lipoma in the subcutaneous tissue of the body does not usually evoke much interest, except when it is large enough to cause a cosmetic problem or interfere with function as a result of its anatomical position. While 13% of lipomas occur in the head and neck region, only rarely do they occur in the pharynx.2
In our case it is most intriguing that a space occupying lesion arising from the hypopharynx can grow to a length of 18 cm without causing any specific symptoms. In the presence of such a long pharyngeal mass one would expect at least some degree of dysphagia, throat discomfort or occasional respiratory embarrassment associated with coughing episodes if the tumour became lodged in the upper airway. The first reported case of an elongated epiglottic lipoma resulted in multiple choking episodes before the death of the patient.3 In 1952 Penfold documented a case of a fatal laryngeal obstruction secondary to a lipoma attached to the posterior cricoid area.4 More recently a lipoma arising from the left aryepiglottic fold and flopping into the laryngeal inlet was thought to be responsible for a sudden fatal respiratory arrest.5 It is fortunate that our patient did not experience any upper airway obstruction during his coughing episode.
From the size of the tumour and well known slow growth rate of a lipoma, it is our conjecture that it was present for a considerable period of time before diagnosis. We did not immediately consider lipoma in the differential diagnosis of the mass because lipomas tend to be soft, spherical, and cystic and this lesion was firm and pendulous. Furthermore, lipomas occur most frequently where fat cells are abundant and the pharynx is a muscular tube with very little fatty tissue. So although lipomas in the pharynx are rare, this case highlights the need to consider it in the differential diagnosis of throat masses. This case also illustrates that a lipoma of the pharynx can reach a considerable size without causing any symptoms until it appears in the mouth. The first port of call for such patient is usually the accident and emergency department.
This case illustrates a rare addition to our differential of oral cavity masses. We recommend immediate referral to the ENT team and complete surgical excision as soon as possible to prevent serious complications such as airway obstruction and death.
Ricardo Persaud reviewed the literature and wrote the paper. Rohit Kotnis contributed to the discussion of core ideas and to the revision of the penultimate version. Chun Ong admitted and operated on the patient. David Bowdler initiated the idea to write up the paper and was the consultant responsible for the patient and overall supervision. Ricardo Persaud is the guarantor.
Conflicts of interest: none.
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