Myxolipoma of the epiglottis in an adult: a case report.

Abstract

Lipomas of the larynx are rare. When they do occur, they are important because some require that the surgeon perform a tracheotomy to prevent a fatal airway obstruction. We report a case of myxolipoma--that is, a lipoma with foci of myxomatous degeneration--of the epiglottis in a 56-year-old woman. We successfully treated the tumor with intubation and surgery; tracheotomy was not necessary. To the best of our knowledge, myxolipoma of the epiglottis in an adult has not been previously reported in the English-language literature.

Introduction

Laryngeal lipomas are rare, as fewer than 100 cases have been reported in the English-language literature. Most of these cases were isolated occurrences and were not associated with systemic lipomatosis. When lipomas do occur, they are important because, even though they are benign, they can cause a fatal airway obstruction, particularly during the induction of general anesthesia. (1)

A myxolipoma is a lipoma that contains foci of myxomatous degeneration. In this article, we report our successful management of a case of myxolipoma of the epiglottis in a middle-aged woman. To the best of our knowledge, this case represents the first reported instance of an epiglottal myxolipoma in an adult.

Case report

A 56-year-old woman presented to our clinic with a 5-month history of dysphagia with solid foods. The onset of the dysphagia had been insidious, and its course had been gradually progressive. The patient had also noticed a discrete, insidious, and gradually progressive change in her voice during the previous month. She reported no pain or dyspnea. She had no history of trauma or weight loss, but she was a known diabetic whose disease was controlled with regular treatment.

Oral examination revealed that the mouth opening was adequate and that the patient was edentulous. The tongue, floor of the mouth, buccal mucosa, palate, bilateral tonsillar fossae, and posterior wall of the oropharynx were normal. Indirect laryngoscopy identified a single, round, cystic swelling that involved the valleculae and the anterior surface of the epiglottis. Both vocal folds were normal and mobile. Laryngeal crepitus was present. Findings on routine hematologic testing and systemic evaluation were within normal limits. Based on these findings, we reached a presumptive diagnosis of a vallecular/epiglottic cyst.

A lateral x-ray of the soft tissue of the neck revealed that a mass had arisen from the anterior surface of the epiglottis. The aryepiglottic folds and the arytenoids were normal on x-ray. Computed tomography (CT) confirmed that the irregular soft-tissue mass had arisen in the area of the valleculae from the right side (figure 1). The dense mass--which measured 24 x 18 x 30 mm--extended into the pre-epiglottic space. The pharyngeal lumen was partially eroded. The major vascular structures were normal, and no clearly enlarged cervical lymph nodes were detected. The patient could not afford to undergo magnetic resonance imaging (MRI), and it was not performed.

[FIGURE 1 OMITTED]

Excision of the cyst under general anesthesia was planned. The patient was counseled that she might require a tracheotomy just prior to the procedure in case we encountered difficulty intubating her; the tracheotomy would be performed in order to prevent the cyst from rupturing. When the patient was taken to the operating room, the anesthesiologist was able to successfully intubate her, thereby obviating the need for the tracheotomy.

A wide-mouth direct laryngoscope was introduced and fixed with a chest support. The swelling was visualized arising from the anterior surface of the epiglottis on the right side. It was dissected free from the surrounding structures with cold instruments. Part of the epiglottis on the right side where swelling was present was also resected. The mass was delivered en toto without any rupture or leakage. The patient's postoperative course was uneventful, and she was discharged 2 days later.

Naked-eye examination of the excised specimen revealed that it was a gray-white and gray-brown, externally encapsulated, nodular soft-tissue mass measuring 3.5 x 2.5 x 1.0 cm. Cut section was lobulated and gray-brown, gray-yellow, and gray-white. Histopathologic examination identified the mass as a benign encapsulated mesenchymal tumor. The tumor was made up of lobules of mature fat separated by oval to spindle-shaped cell septae that exhibited abundant myxoid change and mild lymphocytic infiltration (figure 2). These findings established a diagnosis of myxolipoma.

[FIGURE 2 OMITTED]

At a regular follow-up visit 2 years later, no sign of recurrence was evident (figure 3).

[FIGURE 3 OMITTED]

Discussion

Lipomas of the larynx are rare benign neoplasms derived from adipose tissue. On gross examination, they are encapsulated, smooth, and usually pedunculated. (2) Histologically, they are made up of mature adipocytes. (3) A myxolipoma is a variant of a lipoma in which myxoid change has taken place. Malignant transformation of solitary lipomas has not been reported, but it has occurred in cases of multiple lipomas of the larynx.

Small lipomas and even those of some size may remain asymptomatic, only to be discovered serendipitously on routine laryngopharyngeal examination. In most cases, lipomas cause mild symptoms, such as a lump in the throat, voice alterations, dysphagia, or respiratory distress, depending upon their size. (4) Clinically, they can be difficult to differentiate from other benign lesions such as laryngoceles and retention cysts.

CT and MRI are used to aid in the diagnosis. These modalities reveal not only the extent of the tumor, but its lipomatous nature, as well. Compared with CT, MRI offers superior soft-tissue definition and better visualization of the laryngeal musculature.

Treatment depends on the tumor's size and anatomic location and on the degree of respiratory compromise. Tracheotomy may be necessary to ensure and protect a patent airway prior to definitive treatment. Surgical excision is the treatment of choice; again, the approach is dictated by the size and location of the tumor. (5,6) Incomplete removal inevitably leads to recurrence.

Reprint requests: Dr. Ramandeep S. Virk, House No. 2168, Sector 15C, Chandigarh 160015, India. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

References

(1.) Welinder NR, Ibsen M, Andreassen UK, Berthelsen PG. [Large epiglottic lipoma. Intubation method for large tumors in the pharynx and larynx]. Ugeskr Laeger 1996;158:3325-7.

(2.) Wenig BM. Lipomas of the larynx and hypopharynx: A review of the literature with the addition of three new cases. J Laryngol Otol 1995;109:353-7.

(3.) Eckel HE, Jungehulsing M. Lipoma of the hypopharynx: Preoperative diagnosis and transoral resection. J Laryngol Otol 1994;108:174-7.

(4.) Kapur TR. Recurrent lipomata of the larynx and the pharynx with late malignant change. J Laryngol Otol 1968;82:761-8.

(5.) Henderson LT, Denneny JC III, Teichgraeber J. Airway-obstructing epiglottic cyst. Ann Otol Rhinol Laryngol 1985;94:473-6.

(6.) Keenleyside HB, Greenway RE. Management of pre-epiglottic cysts: A report of nine cases. Can Med Assoc J 1968;99:645-9.

From the Department of Otolaryngology-Head and Neck Surgery, Government Medical College and Hospital, Chandigarh, India.