A second tongue?

JA Ebenezer, J Mathew, M George 
 Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu, India

Correspondence Address:
J A Ebenezer
Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu
India

Full Text

A 32-year-old man presented to the ENT outpatient clinic complaining of a persistent, progressively worsening, "choking sensation" in the throat for past 2 years. He had no difficulty in swallowing or breathing, no voice change, retrosternal burning, hemoptysis, anorexia, or loss of weight. Indirect laryngoscopy showed a smooth mucosa covered bulge in the right lateral pharyngeal wall. He was able to regurgitate an elongated mass into his mouth [Figure 1]. Barium swallow was normal. An MRI scan showed a mass from the right lateral pharyngeal wall, extending from a level just below the arytenoids, to the level of the lower pole of the thyroid [Figure 2].{Figure 1}{Figure 2}

The patient was taken up for endoscopy and excision of the mass under general anesthesia. Preoperatively, the patient was asked to regurgitate the mass, which was fixed outside his mouth with a stay suture, thus securing the airway. The patient was then intubated with a No 6 cuffed nasotracheal tube and mouth held open with a Boyle Davis mouth gag, in the tonsillectomy position.

The pedicle, which was located at the right lateral pharyngeal wall using a zero degree endoscope, was cauterized, ligated, the mass excised in toto and sent for histopathological examination [Figure 3] and [Figure 4]. The postoperative period was uneventful and he remained asymptomatic till latest follow up. Haematoxylin and Eosin stain showed lobules of adipocytes interspersed with spindle cells set in fine collagenous matrix, with scattered blood vessels, covered by stratified squamous epithelium, suggestive of a benign fibrovascular polyp.

Giant lipomatous or fibrovascular polyps are rare benign submucosal tumors of the hypopharynx and esophagus. [1] These tumors almost always arise from the submucosa of the upper third of the esophagus, near the cricopharyngeus, and are pulled down, along with their mucosal lining, to become polypoidal due to the constant propulsive forces of swallowing and peristalsis. [2],[3]{Figure 3}{Figure 4}

Caceres et al., in 2006, in a review of 110 cases described in world literature, reported that giant (>5 cm) fibrovascular polyps presented most commonly in elderly males, with long-term dysphagia (62%), regurgitation of a mass (38%), persistent lump in the throat (25%), weight loss, regurgitation of food, chest pain, persistent cough, vomiting, sore throat, and malena. [3]

Polyps may be missed on endoscopy as their smooth mucosa covered surface blends in well with the esophageal wall. [2] Barium swallow may show a smooth, intraluminal filling defect, or it may show nothing, as in our case. A thorough endoscopic and radiological evaluation, including CT scan and MRI of the entire upper gastrointestinal tract has been advocated. [3]

Their tendency to cause fatal airway compromise is reason enough for the recommendation that all such polyps should be surgically excised. [3] A hypopharyngeal or upper esophageal polyp can be excised either endoscopically with snare or laser, or by the open transcervical or transthoracic route. [2] The surgical approach is to be decided taking into consideration access to the base of the pedicle, and the risk of bleeding and airway compromise. [4] A tracheostomy may be performed to secure the airway prior to surgery. [5]

We recommend that a high index of suspicion be maintained and appropriate imaging be done (CT/MRI) while dealing with a patient whose symptoms point toward the upper aero-digestive tract; however, ambiguous his complaints may seem, as a negative initial work up does not exclude a potentially fatal, but easily treatable pathology.

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