SIC notes javellana by Udc4XK1S


									                                     SIC INCOMING NOTES (3/6/10)
                                Javellana, Carl Geoffrey    W10 B18

S>       Patient is a 29 y/o male from Iloilo City, married, Catholic, who was admitted last February 26,
2010 due to an orpharyngeal mass. Patient has no known comorbids, but has an 8-packyear smoking
history, and is an alcoholic beverage drinker.

        Present illness started 1 ½ years PTA when patient’s cousin noted of voice changes in the
patient, further described as hypernasal speech. Concomitantly noted was a gradually enlarging right
parapharyngeal mass.
        1 year PTA, due to persistence of symptoms, patient sought consult at Western Visayas Hospital.
Biopsy of the mass was done, which showed findings consistent with fibrous tumor, t/c nasopharyngeal
angiofibroma (possibly with malignant change) vs. well-differentiated sarcoma, vs. malignant fibrous
histiocytoma. He was then referred to PGH for surgery.
        9 months PTA, patient consulted at PGH ORL OPD. Slide review was done which had findings
consistent with fibromuscular tissues and fragment of unremarkable squamous epithelium. Deep punch
biopsy of the mass was done which later showed fibrocollagenous and skeletal muscle tissue.
Impression then was t/c neurofibroma/schwannoma, R parapharyngeal area. He was also advised
surgery, and was later admitted.

(-) fever, wt. loss, anorexia, headache, cough/colds, dys/odynophagia, trismus, oral/throat pain, DOB
(+) hypernasal speech, otalgia, snoring, occ. tinnitus

O> (drawings to ff.)

        intact TM, AU                    septum midline                   posterior rhinoscopy and
        good COL                         (-) masses                       indirect laryngoscopy could not
        (-) discharge                    (-) discharge                    be performed due to large
                                                                          parapharyngeal mass

        (+) R parapharyngeal bulge/mass (~7x5 cm)                 (-) CLADs
        Tongue midline                                            (+) bulge, R mandibular area

        CT scan 3/5/09: R parapharyngeal mass with R nasopharynx and pterygoid space invasion, R
        maxillary sinus polyp with sinusitis

A>      T/C Neurofibroma vs. Schwannoma, Right Parapharyngeal Area
P>      Excision of mass/GA
Case Discussion: Neurofibroma/Schwannoma, R parapharyngeal area

         The parapharyngeal area, a potential space lateral to the upper (oro)pharynx, is an uncommon
site of tumors of the head and neck (<1%). Although tumors in this location can be both benign and
malignant, 70-80% are benign, most of which are salivary (40-50%) or neurogenic (25-30%) in origin.
The latter occurs most commonly in the poststyloid parapharyngeal space, of which the ff. are the most
commonly encountered lesions (in decreasing frequency): neurilemomas/schwannomas,
paragangliomas, neurofibromas.

         Schwannomas in the parapharyngeal space most commonly arise from the vagus nerve and the
sympathetic chain. They are slow-growing, encapsulated, and histologically distinct from the nerve of
origin thus rarely causing palsy. Neurofibromas, on the other hand, are unencapsulated and intimately
involved with the nerve of origin. They are often multiple, associated with neurofibromatosis I
syndrome, and in so being increases the incidence of malignant transformation.

        In this patient, its presentation was that of a gradually enlarging oropharyngeal mass, common
with this disease entity. Patient did not complain of dysphagia and dyspnea, but snoring may be a sign
of obstructive sleep apnea. No CN deficits were noted with this case, which may lean towards the
diagnosis of schwannoma. No pain or trismus was also noted, nor symptoms of catecholamine excess
(but hypertension?) which may indicate a paraganglioma type of tumor.

        Complete surgical excision remains the standard for treatment, and is such the case for this
patient, who has no comorbid illnesses/contraindications for surgery. Patient should be counseled
preoperatively about possible CN function losses particularly affecting speech and swallowing which he
may encounter post-surgery. Parotidectomy or mandibulotomy may also be options for better exposure
intraoperatively, and these too should be explained to the patient.

                                                                              Intern Regina G. Quiogue
                                                                                          Block U 2010

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