Giant hypopharyngeal fibroepithelial polyp: A case report and literature review

Abstract

Hypopharyngeal fibroepithelial polyp is a rare entity. It could extend along the esophagus, leading to dysphagia. In rare cases, this polyp could present as airway compromise due to occlusion of the inlet of the larynx. The treatment of choice is surgical resection. Accurate defining of the origin of such polyp is mandatory in order to achieve complete resection and avoid recurrence. Although hypopharyngeal FEP is rare, physicians must keep this in mind when a patient presents dysphagia or airway compromise. In the current case, we present a rare case of giant hypopharyngeal FEP originating from the right pyriform sinus detected in a Caucasian female. The patient threw up the polyp after severe vomiting. This case should be the fourth and largest case of hypopharyngeal FEP reported in the literature.

Background

Fibroepithelial polyps (FEPs) are rare entities resulting from hyperplasia of fibrous connective tissue. ¹ Most of them are seen in men between 40 and 70 years of age. ² Fibroepithelial polyps are benign tumors and the rate of malignant transformation is low.^1,3 These polyps are most commonly originating from the skin. However, some cases have been reported to arise from the mucosa of the oropharynx, hypopharynx, and oral cavity. ⁴ Hypopharyngeal FEP can vary significantly in size. It can grow slowly and extend along the esophagus leading to dysphagia. In some cases, it could be life-threatening due to obstruction and subsequent respiratory distress. In some rare situations, large polyps can cause asphyxiation if regurgitated or bleed.^5,6 These lesions may manifest with dyspnea, choking, and sleep-disordered breathing. ⁷ In the present case, we reported a giant FEP originating in the right pyriform sinus. To the best of our knowledge, this is the fourth and largest case of hypopharyngeal FEP reported in the literature, making our case unique. We presented our patient along with the review of the current literature.

Case presentation

A 56-year-old Caucasian woman came to the emergency department shocked and afraid because a tissue mass was coming out of the mouth after severe vomiting. On examination, the patient was in a state of extreme fear and confusion due to the view of the mass, but was hemodynamically stable and systemically well. There was no stridor or dyspnea. The patient reported a history of foreign body sensation in her throat with difficulty swallowing solid food two months ago. She denied any symptoms of difficulty breathing or airway compromise. According to her medical records, the patient had a negative medical history, except for hypertension, which was medically controlled. Flexible fiber optic laryngoscopy was performed. We discovered a giant pedunculated polyp with a thin stalk originating from the right pyriform sinus. The polyp was extending from the pyriform sinus and protruding outside the mouth. The patient denied previous surgeries in the oropharynx, hypopharynx, or upper aerodigestive tract. Magnetic resonance imaging (MRI) revealed a giant mass arising from the right pyriform sinus with a thin stalk and extending out of the oral cavity. The mass was isointense in the T1-weighted images (T1WI) and hyperintense in the T2-weighted images (T2WI) (Figure 1). Laboratory tests were unremarkable. The larynx was not compressed by the polyp, therefore, the decision was made to remove the polyp through endoscopic laryngeal surgery under general anesthesia with endotracheal intubation (Figure 2). We moved the patient to the operating room. Using bipolar diathermy, the polyp stalk was coagulated and then resected. After resection, we performed a rigid pharyngoesophagoscopy that revealed complete resection of the mass. The patient was placed on a semi-liquid diet and discharged on the next postoperative day. A week later, the patient was re-evaluated by flexible fiber optic laryngoscopy and all findings were within normal limits.

Figure 1.

Axial T1-weighted (A) and T2-weighted (B) images show a lobulated mass originating from the right pyriform sinus with a thin stalk (yellow arrow) and extending out of the oral cavity (red arrow). The mass was isointense on T1WI and hyperintense on T2WI.

Figure 2.

Intraoperative photos.

Pathological findings

Macroscopic examination showed a giant soft tissue polyp measuring approximately 21 × 4 × 5 cm. The specimen was sectioned and multiple sections were submitted for histologic examination. Microscopic examination revealed inflammatory changes covered with reactive hyperplastic squamous epithelium without neoplastic changes. The mentioned findings consist with benign FEP.

Discussion

Giant hypopharyngeal and esophageal polyps are rarely encountered in clinical practice. They represent approximately 0.03% of all hypopharyngeal/esophageal neoplasms. ⁶ The vast majority of these lesions originate in the upper third of the esophagus and extremely rarely in the hypopharynx. ⁸ The differential diagnosis of intraluminal polyps are lipomas, fibrolipomas, fibromas, fibromixomas, hamartomas, and fibroepithelioma. ⁸ The most common sites of FEP are the skin and the genitourinary tract. Regarding the head and neck region, FEPs are reported in the oropharynx, hypopharynx, nasal cavity, external auditory canal, trachea, bronchus, and orbit.^9-11 The etiology of FEP is uncertain. ⁹ Two theories have been described regarding the etiology: [1] fibrous connective tissue hyperplasia, [2] chronic inflammatory hyperplasia.^12,13 However, FEP could have traumatic, infectious, and congenital origins. ⁹ According to Peric and colleagues, FEP could occur as a result of mucosal trauma. ² However, our patient denied any previous surgical interventions in the hypopharyngeal region. The malignant transformation of these lesions is extremely low. ¹² The slow growth of FEP delays the onset of symptoms until they become large enough and cause symptoms due to the local mass effect. Various symptoms have been reported depending on the size and location of the lesion, including feeling something in the throat, difficulty breathing, snoring, aural fullness, and disturbed sleep.^7,9,11 Regarding our patient, she complained about dysphagia about 2 months ago. She consulted several physicians, including otolaryngologists and internists, who misdiagnosed the condition as chronic pharyngitis and described some medications, such as antibiotics and analgesics, without any benefit. Fibroepithelial polyps of the pharynx or tracheobronchial tree could be a life-threatening situation due to obstruction of the upper airways.^7,14 Airway security must be provided as the first step in management in the presence of airway obstruction. Fortunately, although the polyp was giant, our patient was stable with no airway compromise because the thin stalk of the polyp did not cause any airway obstruction. We reviewed the medical literature through Medline and found that only three cases of hypopharyngeal FEP have been reported, two of them arising from the pyriform sinus.^5,7,12 Mangar et al documented a case of airway obstruction and choking due to a large FEP that originated in the right pyriform sinus. ⁵ Jabbour et al reported a case of FEP that originated in the posterior pharyngeal wall, leading to intermittent glottic obstruction. ⁷ Janjatov et al described an unusual case of two FEPs that originated in the right and left pyriform sinus sequentially. The first polyp measured approximately 60 × 20 × 20 mm and the second lesion was approximately 95 × 20 × 20 mm in size. ¹² Depending on the aforementioned data, our case should be the third case of FEP originating in the pyriform sinus and the largest case of hypopharyngeal FEP reported in the literature (Table 1). Previous studies showed that FEPs tend to occur in men between 40 and 70 years of age.^2,4,12 This is consistent with the reported cases of hypopharyngeal FEP since the three documented cases affected men (Table 1). However, that does not correspond to our case because our patient is a woman. Several studies suggested morbid obesity and insulin resistance as a risk factor for FEP formation.^15,16 In fact, the present case was neither obese nor diabetic, suggesting that obesity and insulin resistance could not be a factor in the growth of FEP. The treatment of choice for hypopharyngeal FEP is surgical excision, and the definitive diagnosis is confirmed by histological examination. ⁹ When possible, surgical resection of hypopharyngeal FEP should be performed under general anesthesia to precisely define the origin of the stalk and achieve complete resection to avoid recurrence. ¹⁷ This approach was used by Mangar et al, ⁵ Jabbour et al, ⁷ and by us in our case. Histopathologically, these lesions are lined by a squamous epithelium with epithelial hyperplasia, dyskeratosis, and lymphocytic epitheliotropism. The polyp stroma consists of smooth muscle, collagen, and adipocytes. ⁵

Table 1.

Previous reported cases of hypopharyngeal fibroepithelial polyps.

	Reference	Age/gender	Number of polyps	Origin	Size (mm)	Anesthesia	Year
1	Mangar et al. 5	60/M	1	R pyriform sinus	60 × 35 × 5	General anesthesia	2004
2	Janjatov et al. 12	57/M	2	R pyriform sinus	60 × 20 × 20	Local anesthesia	2012
				L pyriform sinus	95 × 20 × 20	Local anesthesia
3	Jabbour et al. 7	39/M	1	R posterior pharyngeal wall	30 × 22 × 18	General anesthesia	2019
4	Present case	56/F	1	R pyriform sinus	210 × 40 × 50	General anesthesia	2022

M: male; F: female; R: right; L: left.

Conclusion

Hypopharyngeal FEPs are extremely rare and those originating in the pyriform sinus are even rarer. Physicians should keep these cases on the list of differential diagnoses when complaints such as dysphagia or airway compromise are found. Surgical excision is the treatment of choice and should be performed as soon as possible to avoid sudden airway obstruction. When possible, general anesthesia is preferred to local anesthesia to accurately define the origin of its stalk, which is necessary to achieve complete resection of these lesions and decrease the rate of recurrence.