IntroductionInflammatory myofibroblastic tumor(IMT) is a rare mesenchymal tumor1. The etiology of IMT is contentious and a debate occurred as to whether IMT was benign or malignant1-3. Some IMTs are found to be associated with systemic inflammatory disorders1,4, autoimmune diseases5 or neoplasms6. The prognosis and behaviors are controversial. Most patients with IMT have good prognoses and can be cured by resection. Recent evidence shows that IMTs may have a different etiology and clinicopathologic features in different site3,7-8. In previous reports, we also found that the biological behaviors of the tumours are correlated with the site of IMT9-11. IMT of tonsil is rare. We reviewed English-literature regarding IMT in the tonsil. There were only five previous reports covered this topic12-16. Two of the five were taking immunosuppressants and one was pregnant being in an immunomodulated state. Herein, we reporrt the sixth case in the English-language literature of inflammatory myofibroblastic tumor of the tonsil in an immunocompetent patient and first describe imaging features of computed tomography of tonsillar IMT . Case ReportA 51-year-old woman presented with a three-year history of a progressive enlarged mass in the left palatine tonsil. The mass was found that the size was about 0.5cm×0.5cm in the left tonsil during a routine check-up three years ago. She denied sore throat, fever, malaise, dysphagia, dyspnea. She was no history of any generalized immune deficiency, leukaemia, malignant disease, diabetes mellitus oruse of immunosuppressive drugs, including corticosteroids. She also denied alcohol and tobacco abuse or any previous surgery or trauma. She did not visit a doctor about this. Six months ago, she felt dry, itching in the throat and felt the mass enlarged progressively. In June 2011, she attended our department. Physical examination showed a 2.5cm×2cm irregular mass in the upper pole of the left palatine tonsil. There was no adenopathy. The rest of the physical examination was normal. A computed tomography(CT) of pharynx showed that a 2.6cm×1.8cm irregular soft tissue mass between the left tonsil and the base of the tongue(Fig.1A), with no enhanced on contrast-enhanced imaging and no enlargement of lymph nodes(Fig.1B).Laboratory examination revealed normal complete blood count and normal erythrocyte sedimentation rate. Serological tests were positive for anti-EBV IgG and anti-CMV- IgG, and negative for anti-EBV IgM, anti-CMV IgM and anti-human immunodeficiency virus (HIV) antibodies. There was no other abnormality on systemic or dermatological examinations. The results of chest X-ray and ultrasonography (USG) scan of the whole abdomen were normal.On June 17, 2011, the mass and left tonsil were excised completely without any complication under general anesthesia(Fig.1C). The pathologic result of frozen sections showed inflammatory pseudotumor. Routine pathological examination demonstrated that the tumour was composed of short spindle cells arranged as weaving. The spindle cells in some areas were rich and some cells were atypia and mitotic, mixed with inammatory cells such as lymphocytes and plasma cells arranged as cluster(Fig.2A). Immunohistochemical analysis was positive for the expression of desmin(Fig.2B) and AKT(Fig.2C),focal positive for S-100 protein(Fig.2D), whereas anaplastic lymphoma kinase-1 (ALK-1),CD117,CD34, smooth muscle actin (SMA),Caldesmon, Cytokeratin were negative. The expression of Ki-67 was less 5%(Fig.3).Further molecular pathological investigation by polymerase chain reaction (PCR) did not reveal CMV or EBV infection.There was no evidence of recurrence after three months of follow-up.DiscussionIMT may occur in nearly every site of the body8, including the lung3, Abdomen,7 orbit7, extremity7, central nervous system5, oral cavity8, nasal and paranasal sinus9,10, hypopharynx.4 IMTs in the tonsil are rare. Weilbaecher et al in 1984 was the first to report IMTs of the tonsil.15 We reviewed the English-language literature regarding IMTs of the tonsil from 1984 to 2011 and only six cases reported(including the case described)(Table 1).12-16 The patient group consisted of two males, four females. The age of the patients ranged from 10 to 63 years at initial presentation, with a mean age of 43 years. The symptoms included sore throat, odynophagia, pain in the neck region, cough with vomiting, dyspnoea(in a girl). Two patients were not symptoms at initial presentation, one was only found an enlarged tonsil and one was a mass in the left tonsil. 4 cases with IMT located in the left tonsil, two cases in the right tonsil. Although a debate occurred as to whether IMT was a pseudotumour or a neoplasm, the concept of IMT as a neoplasm was solidified7 with the discovery of cytogenetic aberrations and the subsequent recognition of ALK gene rearrangements on the short arm of chromosome as a recurrent aberration in IMT recently8. However, the etiology, benign or malignant and prognosis of IMT remain unknown and controversial. Our previous reports as other studies revealed that IMTs originating in different organs may lead to a diverse etiology and clinicopathologic features.2,3,7-11,17 The etiology in the other sites maybe associated with infectious, autoimmune, syndromic or traumatic. In lung, IMTs may be relationship with carcinoma6, infection19. In liver, it maybe associated with malignant diseases20, livercirrhosis21,foreign body22, Papillon-Lefevre syndrome23, severe congenital neutropenia (Kostmann’s disease)24, gall stones25 or inflammatory bowel disease26.Viruses that are suspected to be involved in the development of IMTs include HIV27, HHV-84 and EBV28,29. Some investigators considering it as an immunologic response to an infectious agent27,28. In the tonsil, two patients were in immunodepressive state14,15 and one patient was a pregnant woman13. The patient with IMT of the tonsil reported by Newman and Shinn (1995) had been on long-term prednisone for asthma and retroperitoneal fibrosi15. Gangopadhyay et al. reported that the patient received long-term prednisone and other immunosuppressants following cadaveric renal transplant nine years ago14. Magill et al reported a pregnant woman with a IMT in the right tonsil13. They suggested pregnancy is known to be an immunomodulated state, even during the earliest gestational period13.The present case is immunocompetent. Magill et al only mentioned that CT scan confirmed the presence of an enlarged right tonsil along with right sided nodes, but did not supply any imaging of CT13. We first describe imaging of CT in the tonsillar IMT. CT revealed that a 2.6cm×1.8cm irregular soft tissue mass between the left tonsil and the base of the tongue and did not invade surrounding structures, with no enhanced on contrast-enhanced imaging. This finding suggested the mass may be a benign tumour. The results were confirmed by surgery and pathology. The surgical specimen showed that the surface was smooth and some small nodules in the surface, which lead to the irregular soft tissue mass in the imaging of CT. Thus, the preoperative recognition of this benign lesion on CT is important to avoid unnecessary radical resection. Our imaging findings were not similar with these in IMTs of other head and neck30. Most IMTs on contrast enhanced images show early enhancement 30,31. Sinonasal IMTs have a more aggressive appearance9,10,30. On CT, a moderately enhancing mass is usually seen in orbital IMTs, accompanied by fat infiltration or edema30. Laryngeal IMT was a well-enhanced lesion on CT scan32. Our case on CT showed no enhanced on contrast-enhanced imaging and did not involve surrounding tissue. IMTs arising in mesenteric, omental, peritoneal, pelvic, retroperitoneal sites17 and maxillary sinus9,10 tend to recur, with a potential for metastatic spread in rare instances.2,3,9,10 Most of lung IMTs have favorable prognosis, but recent some studies had showed that pulmonary IMT may occur distant metastasis2,7. In the six tonsillar IMTs, there were no recurrence and metastasis. This suggested the tonsillar IMTs may be a benign process and have a good outcome. However, the prognosis, recurrence and the metastatic rate has not been confirmed in a larger series and lack of long-term follow-up.The optimal treatment of IMTs in other sites is still controversial, but the excision of tonsil with IMT, either tonsillectomy or excision by CO2 laser, seems to be an effective treatment from the four tonsillar IMTs that had a follow-up outcome13-15.The experience of treatment will continue to accumulate along with the increase of the number of tonsillar IMTs.
患者,女,64岁,因““鸡骨”卡喉半年,发现左颈部肿块两月”入院。患者半年前不慎“鸡骨”卡喉,一直觉咽痛,双侧均痛,吞咽时明显,觉喉部异物感,无明显吞咽困难,无咯血,无呼吸困难,无畏寒发热,至当地卫生院就诊,检查未见明显咽喉异物,予口服消炎药治疗(药名不详),咽痛稍好转,8天后再次就诊,仍未见异物,继续消炎治疗20多天左右,咽痛好转后未引起重视,2月前发现左颈前肿块,无自发痛,有压痛,无吞咽困难,无吞咽痛,无痰中带血,无咯血,无胸闷气急,无呼吸困难,去“当地县医院就诊,颈部B超检查:异物肉芽肿,建议上级医院手术治疗,患者遂来本院门诊就诊,查颈部B超:左侧颌下颌下腺下方片状低回声区异物肉芽肿可能,建议手术治疗,遂收入院。入院查体:左侧颈前可及2.5*3.0cm大小肿块,轻压痛,活动欠佳,间接喉镜下咽喉部未见明显新生物、异物。辅助检查:2011.06.27本院颈部B超:左侧颌下颌下腺下方片状低回声区异物肉芽肿可能。2011.6.30我院颈部CT:口咽左侧相当于左侧舌骨体内外软组织肿胀伴其内细条状较高密度影,请结合临床病史除外异物伴周围慢性感染可能。左侧颌下腺肿大。双侧颈血管鞘周围多发淋巴结增大。入院后2011-7-1在全麻下行左颈部肿物切除术,左侧胸锁乳突肌前缘上段可及2.5*3.0cm大小肿块,质地较硬,活动欠佳。沿包块表面纵行切开皮肤,皮下组织及颈阔肌。用电刀完整切除包块,包块位于胸锁乳突肌与肩胛舌骨肌之间,向上与左颌下腺相贴,深部位于甲状软骨上外侧,切除包块后发现包块内有一骨性异物,长约2.0cm,直径约1mm。术腔冲洗后,放置负压引流,分层间断缝合切口术后诊断:左颈部游走性异物肉芽肿,术后病理报告:2011-07-05:(左颈部)脓肿伴肉芽肿反应。术后患者恢复可,诉咽部异物感及咽痛明显好转,术后2天患者出院。讨论:颈部游走性异物罕见。 颈部异物游走需有一定条件: 异物的物理形状是异物游走的基本条件, 作为异物( 细长骨头) 完全符合这一条件。异物的游走需要动能, 从颈部游走性异物的动能来看, 可能与下列因素有关, 呼吸运动及吞咽运动,甚至食物的反复摩擦和压迫作用。本例中异物游走的路线:异物可能最初卡在下咽,因为咽侧壁组织较软,加之反复吞咽和食物的压迫作用,使得异物刺入咽侧壁,并经咽侧壁进入颈前。游走至甲状软骨板上缘、胸锁乳突肌前缘及肩胛舌骨肌后缘之间,因肌肉较粘膜软组织不易突破,且下方为甲状软骨板,故异物在该间隙停留并逐渐形成异物肉芽肿。如该异物并未停留在该间隙处,继续往胸锁乳突肌深面游走,则有可能刺入颈总动脉及颈内静脉甚至随血管游走至心脏从而引起严重并发症,故颈部游走性异物应及时取出。术前误诊原因:1、患者半年前有“鸡骨卡喉”的经历,应立即就医,但患者未引起重视,拖延病情,错过最佳诊疗时机,导致异物残留。2、就医后,医务人员经验不足,仅予患者消炎抗感染治疗。3、予患者消炎抗感染治疗后,患者咽痛缓解,即未予重视,进一步拖延病情,导致肉芽肿的形成。经验与教训:异物卡喉的病人应及时就医,这样可以第一时间将异物取出。对医务人员而言,若患者主诉明确,症状反复出现,即使体检未发现异物,亦不能轻易排除异物残留的可能,应行进一步的检查,如CT及B超等相关检查。B超对定性检查有较大的意义,CT对定位和定性都有很好的帮助。在操作上,术前应行CT检查明确定位,术中先暴露出该肉芽肿,找到肉芽肿的边界,然后将该肿物完整剥离。术中应仔细操作,尽量不要损伤到相应的肌肉及血管神经。
患者:化验、 甲状腺结节术后已有8天了,但声音不好,有点哑,且出声轻,说话困难 何因,如何治疗恢复?浙江省第一医院耳鼻咽喉科周水洪:您提供的资料不完整,我无法给出具体建议,请补充以下资料:当地医院喉部检查的情况,如双侧声带运动的情况怎样? 1.如果双侧声带运动正常,则可能是急性喉炎或者手术后人体质虚弱所致的可能性较大 2.如果一侧声带运动受限,则考虑以下情况的可能(1)可能是手术损伤了喉返神经(2)可能是杓状关节的问题但总之,你得补充材料或到我们医院就诊。
探讨鼻内镜进路治疗鼻咽癌放疗后局限性残留可行性。方法:我们尝试对1例放疗后鼻咽局限性残留的鼻咽癌患者,进行经鼻内镜鼻咽切除术, 将鼻咽肿瘤和足够的安全边缘连续、整块切除。观察其疗效和并发症。结果: 患者在鼻内镜进路下按肿瘤外科手术原则进行根治性整块切除, 鼻咽创面愈合良好,未追加术后放疗。无张口、吞咽、发音困难和其他手术并发症发生,术后半年鼻内镜随访见鼻咽顶部小肉芽生长,活检报告为“肉芽增生”,复查鼻咽部CT及MRI未见复发。结论 对放疗后鼻咽局限性残留的鼻咽癌患者在鼻内镜进路鼻咽癌切除是一种值得推荐的补救手段。2008-05-21 9:00结束时间:2008-05-21 11:15 全程时间:2时15分术后诊断:鼻咽癌放化疗后残留 手术经过: 患者平卧位,全麻完成后,常规消毒铺巾,1%利多卡因+肾上腺素局部收缩双侧鼻腔各3次,在鼻内镜检查见鼻咽顶前壁处隆起,大小约0.5×0.5cm,因鼻咽腔较狭小,用导尿管从双侧鼻腔至鼻咽部拉起软腭,暴露扩大鼻咽腔,鼻内镜从右侧鼻腔照至鼻咽部,口腔用张口器撑开口腔,hammmer从咽部伸向鼻咽部,在直视下吸刮鼻咽顶壁肿块,质地较脆,予以切除,至鼻咽顶壁颅底骨质,周围刮至咽隐窝处,见双侧咽隐窝处黏膜正常,并咬双侧咽隐窝黏膜、顶部黏膜送病检,彻底止血后手术完毕。术后复查4个月未见复发。