The pleomorphic adenoma is the most common benign tumour of the major and minor salivary glands. We report a 40-year-old female patient, who presented ...
Undiagnosed foreign body oesophagus
163
Figure 1: Barium-swallow X-ray oesophagus showing 10-paise coin and a pouch above that
Figure 3: Post-operative (1 month later) Barium-swallow X-ray showing reduced size of the pouch
or missed FB (though blunt) may end in thoracotomy instead of much less - hazardous endoscopic removal. REFERENCES 1.
Granell J, Domingo C, Crespo J, et al. An unusual complication of oesophageal foreign body. Acta Otorhinolaryngologica 2000;51:3658.
2.
Markov G, Kondarev G. Foreign body in the oesophagus not removable endoscopically - the surgical procedure and treatment. Khirurgiia
Figure 2: Coin removed by thoracotomy - peroperative photograph
(Sofiia) 1999;54:25-8.
PLEOMORPHIC ADENOMA OF NASAL SEPTUM S. Sen, S. Saha, N Basu*
ABSTRACT: The pleomorphic adenoma is the most common benign tumour of the major and minor salivary glands. We report a 40-year-old female patient, who presented with progressive swelling and deformity of the left side of her nose for last 2 years. On a lateral rhinotomy a mass (4 cm X 3 cm in size) was found to be arising from the cartilaginous part of the nasal septum. The mass was enucleated from its capsule and the walls excised. The histopathological examination revealed it to be pleomorphic adenoma. Key Words: Mass on nasal septum, nasal septum, pleomorphic adenoma
Department of ENT and Head Neck Surgery, *Department of Pathology, Medical College and Hospitals, Calcutta, India Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 2, April - June 2005
164
Pleomorphic Adenoma of Nasal Septum
The pleomorphic adenoma is the most common benign tumour of the major and minor salivary glands. The minor salivary glands are distributed throughout the upper respiratory tract. There are about 250 glands on the hard palate, 100 on the soft palate, and 10 on the uvula. Other glands are found in the submucosa of the inner surface of the lips, around the opening of the parotid duct, in the mucous membrane of the cheek, in the floor of the mouth, in the palatoglossal folds, on the inferior surface of the tongue, near the frenulum and within the palatine tonsil. Other glands are found in the nose, the nasal sinuses, the larynx, the trachea, and bronchi (Stell and Maran, 1993). Pleomorphic adenomas have been seen to occur in oral cavity, pharynx, paranasal sinus, and lacrimal glands.[1] They have reported a case of pleomorphic adenoma in larynx and have found 20 such cases on review of literature. Approximately 10% of salivary neoplasms arise in the minor salivary glands of palate, lip and cheek and in the sublingual glands. Only 40% of these are benign but virtually all-benign tumours are pleomorphic adenomas (Bailey and Love, 1995). It is, however, uncommon in the nasal cavity. In 1900, Hasslauer[2] found four adenomas amongst 160 tumours of the nasal septum. Gill and Rekhi[3] reported a case of pleomorphic adenoma involving the anterior and middle ethmoidal cells. Frable and Elzay[4] in a review of 42 cases of benign-mixed tumours of ectopic salivary glands found none arising from the nasal cavity. Ronald et al. (1973) in their study, for 2 years, on tumours of minor salivary glands at Memorial Hospital for cancer and allied diseases, New York, found 58 benign tumours out of a total of 492 (11.8%). Three of these cases were involving the nasal cavities.
or bleeding from the nose. There was no history of trauma to the nose. On clinical examination, external nose showed a firm swelling on the left-hand side of the nose filling left nasofacial furrow [Figure 1]. No fluctuation or transillumination was present. Anterior rhinoscopy revealed a firm mass completely filling the left nasal cavity above the level of the inferior turbinate. The probe could be passed along the lateral aspect of the mass. There was no mass in the choana. The rest of the ENT examination was within normal limits. X-ray of the paranasal sinuses showed a soft tissue shadow in
Figure 1: Showing clinical photograph with swelling on the left-side of nose filling the left nasofacial furrow
Sharma and Prasad (1974) reported a case of pleomorphic adenoma arising from lateral wall and floor of the nose with its extension into the maxilla. Throughout the period of 19741981 no case of pleomorphic adenoma was found in the nasal cavity.[5] Singhal et al (1989) described a case of pleomorphic adenoma arising from side of the tip of the nose. Dutta et al[6] reported a case of pleomorphic adenoma involving the right lateral side of nose with discharging sinus on the skin. Khurana et al[7] reported a pleomorphic adenoma of the nasal septum just posterior to the mucocutaneous junction. Another case of pleomorphic adenoma of the nasal septum was reported by Mundra et al.[8] These tumours arise from the minor salivary glands of the nose. The large majority arises from the mucosa of bony or cartilaginous septum.[9] CASE REPORT A 40-year-old female patient, was presented to the ENT Outpatients Department of Medical College and Hospitals, Calcutta, with the complaint of progressive swelling and deformity of the left side of her nose for last 2 years. There was no complaint of accompanying pain, nasal obstruction
Figure 2: CT scan areal view showing mass arising from the left side of the septum
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 2, April - June 2005
Pleomorphic Adenoma of Nasal Septum
165
the left nasal cavity. X-ray of the skull 39º lateral oblique view for Ethmoidal sinuses (Rheese view) was within normal limit. CT scan of the paranasal sinuses showed a soft tissue mass arising from the nasal septum in the anterior aspect of the left nasal cavity [Figure 2]. The patient was admitted and a lateral rhinotomy was done under general anaesthesia. The mass (4 cm u 3 cm in size) was found to be arising from the cartilaginous part of the nasal septum. The mass was enucleated from its capsule and the walls excised. The histopathological examination revealed it to be pleomorphic adenoma [Figure 3]. The post-operative period was uneventful for 6 months after which patient did not turn up for follow up. DISCUSSION Mixed salivary tumours have been found to arise from almost everywhere in the upper alimentary and respiratory tract. It is, however, uncommon in the nasal cavity. Origin of intranasal mixed salivary tumour from nasal septum is unusual because majority of minor mucous and serous glands are located on the lateral nasal wall. According to Mathew et al[10] the aberrant origin of these tumours from the mucous membrane of septum probably results from misplaced embryonic epithelial cells, derived from ectoderm and carried via the nasal pits into the septal region. But, Stevenson[11] pointed out that growths of embryonic origin are rare in the nasal septum. He prefers to consider mixed tumour in this area as originating from remnants of the vomeronasal organ, an epithelium lined duct in the septum that degenerates in early human foetal life. Conversely Evans and Cruickshank[12] stated that, at present mixed salivary tumours are almost universally accepted as being entirely of epithelial origin and that they arise in fully developed salivary gland tissue rather than in embryonic remnants.
Figure 3: Microphotograph of pleomorphic adenoma (H/E, x100)
In most of the patients these tumours are identified as intranasal mass with no characteristic clinical features. ACKNOWLEDGEMENT We are grateful for the guidance received from Late Prof. L. M. Ghosh, Formerly Head of the Department of ENT and Head Neck Surgery Medical College Hospital, Calcutta.
REFERENCES 1.
Dubey SP, Banerjee S, Ghosh LM, Roy S. Benign pleomorphic adenoma of larynx: Report of a case and review and analysis of 20 additional cases in the literature : Ear Nose Throat J 1997;76:548-57.
2.
Hasslauer. Quoted by Kamal SA. Pleomorphic adenoma of the nose. J Laryngol Otol 1984;98:917.
3.
Gill BS, Rekhi BM. Pleomorphic adenoma of the Nose - A Report, Indian J Otolaryngol 1968;20:132.
4.
Frable JW, Elzay PR. Tumours of Minor Salivary Glands, Cancer 1970;25:932.
5.
Kamal SA. Pleomorphic adenoma of the nose. J Laryngol Otol 1984;98:917.
6.
Dutta TK, Chakraborty S, Ghosh LM. Pleomorphic adenoma in the Nose, Indian J Otolaryngol Head Neck Surg 1993;2:167-8.
Intranasal mixed tumours have a relatively low rate of recurrence (10%) as compared to high rate recurrence (50%) in parotid gland mixed tumour and 25% for intra-oral mixed tumours. According to Kroll and Boyer’s,[13] this is due to the very cellular pattern with few areas of stromal predominance in mixed salivary tumours of nasal fossa. In cases of recurrent lesion the histological characteristics most frequently associated was a myxoid stroma, which could be easily spilled into the surgical field, providing a focus for recurrence.
7.
Clinically, it appears that removal of these lesions by local but adequate surgical excision is the treatment of choice and that radical procedures to prevent recurrence is unwarranted.
11. Stevenson HN. Quoted by Compango J, Wong RT. Intranasal mixed
Khurana AS, Bawa GW, Sharma KK, Khurana A. Pleomorphic Adenoma of the nasal septum, Indian J Otolaryngol 1989;41:74.
8.
Mundra RK, Pal P, Bandi A, Munjal S. Pleomorphic Adenoma of the nasal septum, Indian J Otolaryngol 1991;43:82-3.
9.
Compangno J, Wong RT. Intranasal mixed tumours (pleomorphic adenoma): A clinical pathological study of 40 cases, Am J Clin Pathol 1977;78:213-8.
10. Mathew, et al. Quoted by Compango J, Wong RT. Intranasal mixed tumours (pleomorphic adenoma): A clinical pathological study of 40 cases. Am J Clin Pathol 1977;68:213-8. tumours (pleomorphic adenoma): A clinical pathological study of 40 cases. Am J Clin Pathol 1977;68:213-8.
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 2, April - June 2005
166
Pleomorphic Adenoma of Nasal Septum
12. Evan RW, Cruickshank AH. Quoted by Compango J, Wong RT.
Practice of Surgery, 22nd Ed. ELBS with Chapman and Hall; p. 470-80.
Intranasal mixed tumours (pleomorphic adenoma): A clinical pathological study of 40 cases. Am J Clin Pathol 1977;68:213-8. 13. Krolls SO, Boyers RC. Quoted by Compango J, Wong RT. Intranasal mixed tumours (pleomorphic adenoma): A clinical pathological study of 40 cases. Am J Clin Pathol 1977;68:213-8. 14. Charles MV, Russell RCG, Norman WS. Bailey and Love’s Short
Address for Correspondence: Dr. S. Sen BD-325, Salt Lake City, Calcutta 700064, India
AN EXRATHORACIC PRESENTATION OF CASTLEMAN’S DISEASE A. H. Kansara, S. P. Mehta
ABSTRACT: Castleman’s disease, also known as angiofollicular hyperplasia, usually occurs in the mediastinum and rarely in cervical region as solitary mass. Histopathologically four variants have been recognized (Castleman et al. Cancer 1954;9:822-30) hyaline vascular type – most common type (Keller et al. Cancer 1972;29:670-83) plasma cell type (Salisbury, Pediatric Pathol 1990;10:609-15) transitional type (Shahidi, Mayo Clinic Proc 1995;70:969-77) stromal rich type. We report a case of Castleman’s disease of typical histopathological picture of angio follicular hyperplasia arising from the right carotid triangle of neck in 12-year-old child without any associated systemic illness. Key Words: Castlman’s disease, angio follicular hyperplasia, neck
The Castleman’s disease, a type of chronic lymphadenopathy, usually presents as a mediastinal mass. In 1954 Castleman first encountered this type of lesion in thoracic masses. Clinically it is divided in two types, one is localized, which is usually asymtomatic and presented as a mass or swelling. The other is multicentric type characterized by fever with chills, generalized lymphadenopathy, anaemia, and hepatosplenomegaly. Histopathologically most common type is the hyaline vascular type and other types are less common. Localized Castleman’s diseases have an excellent prognosis with surgical resection. Generalized disease have poor prognosis and requires chemotherapy and radiotherapy in addition to surgery. Castleman’s disease is commonly found in mediastinum and lung hila. Extrathoracic site of disease is uncommon but not unknown. CASE REPORT A 12-year-old male child was brought to the ENT OPD of L.G. General hospital, Maninagar, Ahmedabad, in July 2000 with the chief complains of a painless, slowly growing swelling at left upper neck region in the anterior triangle of neck with a weight loss of about 5 kg in 3 months. There was no fever, cough, throat pain or any other noticeable swelling all over body.
On clinical examination swelling found in left. anterior triangle of neck underneath the left sternocleido mastoid muscle. Swelling was nontender, firm to hard, 4 cm u 6 cm in size with ill-defined margins and with normal skin overlying it. Oral cavity, pharynx, and larynx were found normal. No other lymphnode in the axillary or inguinal region was palpable. All routine laboratory investigations were normal. X-ray of chest and ESR were within normal range. A provisional diagnosis of benign cervical lymphadenopathy was made and excision biopsy of the swelling was planned. The excision of the swelling was done under general anaesthesiaby splitting the sternocleidomastoid muscle. The mass was just above and lateral to carotid arteries and jugular vein but was not firmly attached to them. Postoperatively patient recovered uneventfully [Figures 1 and 2]. The histopathological examination revealed extensive lymphocytic hyperplasia with hyperplastic follicles containing clear germinal centre, intrafollicular zone contained neocapillary formation [Figure 3]. This was unique picture of Castleman’s disease not usually mistaken with others. DISCUSSION Described by Castleman in 1954[1] the disease usually involved
Department of ENT, L. G. General Hospital and N.H.L. Municipal Medical College, Ahmedabad, India Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 2, April - June 2005
