Clinical Review & Education
Clinical Challenge | RADIOLOGY
Oropharyngeal Mass Causing Obstructive Sleep Apnea Jeong Hong Kim, MD; Ju Wan Kang, MD
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B
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D
Figure. A, Photograph of an oropharyngeal mass. B, Computed tomographic image showing a segmented bony lesion located at the odontoid process and the body of the C2 vertebra. C, T1-weighted magnetic resonance image (MRI) of an oropharyngeal mass. D, T2-weighted MRI of an oropharyngeal mass.
A woman in her 60s presented with a 10-year history of oropharyngeal discomfort and recent episodes of snoring and obstructive sleep disturbance. Although she had been experiencing a gradually increasing lumpy feeling on swallowing for at least 6 months, she did not experience of dysphagia, dyspnea, or pain. Physical examination revealed a mass measuring approxiQuiz at mately 4 × 3 cm and covered with normal mucosa on the jamaotolaryngology.com posterior oropharyngeal wall. This tumor was firm, nontender, and firmly adherent (Figure, A). Computed tomography (CT) showed a segmented bony lesion located at the odontoid process and the body of the C2 vertebra (Figure, B). This mass showed high signal intensity with a hypointense rim in both T1- and T2-weighted magnetic resonance images (MRI) (Figure, C and D, respectively). Polysomnography was performed and showed an apnea-hypopnea index of 58.7/h and a minimal oxygen saturation of 76%, which led to a diagnosis of obstructive sleep apnea. The mass was considered causative of obstructive sleep apnea. Hence, we performed total excision of the mass using a per-oral approach.
jamaotolaryngology.com
WHAT IS YOUR DIAGNOSIS?
A. Exuberant osteophytes B. Diffuse idiopathic skeletal hyperostosis C. Osteochondroma D. Osteoid osteoma
(Reprinted) JAMA Otolaryngology–Head & Neck Surgery April 2015 Volume 141, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/19/2015
393
Clinical Review & Education Clinical Challenge
Diagnosis C. Osteochondroma
Discussion Osteochondroma is the most common benign bone tumor that generally affects long bones. However, osteochondroma rarely show spinal involvement, and this finding is reported in less than 5% of solitary osteochondromas.1 When osteochondromas present as multiple lesions, a diagnosis of hereditary multiple exostoses, an autosomal dominant hereditary disease, can be made.2 The C2 vertebra is the most common site of spinal osteochondroma, and approximately half of the spinal osteochondromas occur in the cervical spine.3 Although most spinal osteochondromas are located in the posterior element of the spine, involvement of the anterior element may occurs, as observed in this patient. Osteochondromas are usually asymptomatic in the early phase, and symptoms slowly progress along with an increase in the size of the tumor. Osteochondromas that occur in the posterior spine can cause cord or nerve compression, giving rise to myelopathy or radiculopathy. On contrast, osteochondromas arising from the anterior elements of the cervical spine can present with symptoms such as dysphagia, throat discomfort, or obstructive sleep apnea.4 Both CT and MRI are used to confirm the diagnosis of osteochondroma. Computed tomography can reveal the appearance of the marrow and cortical continuity with its relationship to the vertebra.1 On CT images, spinal osteochondromas generally present as round, sharply outlined masses with scattered calcification and density similar to that of the bones.2 Osteosclerotic changes may also be seen in neighboring bones.2 This type of tumor does not show ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Otorhinolaryngology, Jeju National University School of Medicine, Jeju, South Korea (Kim); Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea (Kang).
1. Rodallec MH, Feydy A, Larousserie F, et al. Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics. 2008;28(4): 1019-1041.
Corresponding Author: Ju Wan Kang, MD, Department of Otorhinolaryngology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea ([email protected]). Section Editor: Rebecca S. Cornelius, MD. Published Online: February 5, 2015. doi:10.1001/jamaoto.2014.3729. Conflict of Interest Disclosures: None reported.
394
contrast enhancement.2 Magnetic resonance imaging is much more valuable than CT in evaluating the relationship between the tumor and soft tissue and generally demonstrates a peripheral rim of low signal intensity corresponding to the cortical bone, and a signal for fatty marrow in the central area of the tumor.1 A cartilaginous cap, which may be observed with osteochondroma, appears as isointense to hyperintense on T1-weighted MRI, and hyperintense on T2-weighted MRI.2 However, cartilaginous caps become thinner and disappear with age. Therefore, malignant neoplasm should be considered in adults with a cartilaginous cap more than 1 cm in thickness.1 Exuberant osteophytes, diffuse idiopathic skeletal hyperostosis (DISH), and osteoid osteoma have been reported as bony masses causing oropharyngeal symptoms.3-5 However, osteophytes and DISH, which do not show the marrow and cartilaginous cap, could be distinguished from osteochondroma.1 Osteoid osteoma usually shows a nidus (a radiolucent center surrounded by sclerotic bone).1,3 Also, solitary malignant tumors rarely occur in the cervical spine. However, metastatic malignant diseases, compared with primary malignant neoplasms, develop more commonly in patients older than 30 years.1 Complete removal of tumors, including the cartilaginous cap, is the recommended treatment approach for osteochondroma.6 Incomplete removal of the cartilaginous cap can increase the risk of tumor recurrence.7,8 In addition, transformation of solitary osteochondromas into malignant tumors, such as chondrosarcoma and osteosarcoma, may occur. Although the exact risk of malignant changes is not known, the incidence may be about 1% in solitary osteochondromas.9
2. Kouwenhoven JW, Wuisman PI, Ploegmakers JF. Headache due to an osteochondroma of the axis. Eur Spine J. 2004;13(8):746-749. 3. Biswas D, Mal RK. Dysphagia secondary to osteoid osteoma of the transverse process of the second cervical vertebra. Dysphagia. 2007;22(1): 73-75. 4. Verlaan JJ, Boswijk PF, de Ru JA, Dhert WJ, Oner FC. Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction. Spine J. 2011;11 (11):1058-1067.
5. Hwang JS, Chough CK, Joo WI. Giant anterior cervical osteophyte leading to Dysphagia. Korean J Spine. 2013;10(3):200-202. 6. Yoshida T, Matsuda H, Horiuchi C, et al. A case of osteochondroma of the atlas causing obstructive sleep apnea syndrome. Acta Otolaryngol. 2006;126 (4):445-448. 7. Wang V, Chou D. Anterior C1-2 osteochondroma presenting with dysphagia and sleep apnea. J Clin Neurosci. 2009;16(4):581-582. 8. Zinna SS, Khan A, Chow G. Solitary cervical osteochondroma in a 9-year-old child. Pediatr Neurol. 2013;49(3):218-219. 9. Reckelhoff KE, Green MN, Kettner NW. Cervical spine osteochondroma: rare presentation of a common lesion. J Manipulative Physiol Ther. 2010; 33(9):711-715.
JAMA Otolaryngology–Head & Neck Surgery April 2015 Volume 141, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/19/2015
jamaotolaryngology.com
Clinical Challenge | RADIOLOGY
Oropharyngeal Mass Causing Obstructive Sleep Apnea Jeong Hong Kim, MD; Ju Wan Kang, MD
A
B
C
D
Figure. A, Photograph of an oropharyngeal mass. B, Computed tomographic image showing a segmented bony lesion located at the odontoid process and the body of the C2 vertebra. C, T1-weighted magnetic resonance image (MRI) of an oropharyngeal mass. D, T2-weighted MRI of an oropharyngeal mass.
A woman in her 60s presented with a 10-year history of oropharyngeal discomfort and recent episodes of snoring and obstructive sleep disturbance. Although she had been experiencing a gradually increasing lumpy feeling on swallowing for at least 6 months, she did not experience of dysphagia, dyspnea, or pain. Physical examination revealed a mass measuring approxiQuiz at mately 4 × 3 cm and covered with normal mucosa on the jamaotolaryngology.com posterior oropharyngeal wall. This tumor was firm, nontender, and firmly adherent (Figure, A). Computed tomography (CT) showed a segmented bony lesion located at the odontoid process and the body of the C2 vertebra (Figure, B). This mass showed high signal intensity with a hypointense rim in both T1- and T2-weighted magnetic resonance images (MRI) (Figure, C and D, respectively). Polysomnography was performed and showed an apnea-hypopnea index of 58.7/h and a minimal oxygen saturation of 76%, which led to a diagnosis of obstructive sleep apnea. The mass was considered causative of obstructive sleep apnea. Hence, we performed total excision of the mass using a per-oral approach.
jamaotolaryngology.com
WHAT IS YOUR DIAGNOSIS?
A. Exuberant osteophytes B. Diffuse idiopathic skeletal hyperostosis C. Osteochondroma D. Osteoid osteoma
(Reprinted) JAMA Otolaryngology–Head & Neck Surgery April 2015 Volume 141, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/19/2015
393
Clinical Review & Education Clinical Challenge
Diagnosis C. Osteochondroma
Discussion Osteochondroma is the most common benign bone tumor that generally affects long bones. However, osteochondroma rarely show spinal involvement, and this finding is reported in less than 5% of solitary osteochondromas.1 When osteochondromas present as multiple lesions, a diagnosis of hereditary multiple exostoses, an autosomal dominant hereditary disease, can be made.2 The C2 vertebra is the most common site of spinal osteochondroma, and approximately half of the spinal osteochondromas occur in the cervical spine.3 Although most spinal osteochondromas are located in the posterior element of the spine, involvement of the anterior element may occurs, as observed in this patient. Osteochondromas are usually asymptomatic in the early phase, and symptoms slowly progress along with an increase in the size of the tumor. Osteochondromas that occur in the posterior spine can cause cord or nerve compression, giving rise to myelopathy or radiculopathy. On contrast, osteochondromas arising from the anterior elements of the cervical spine can present with symptoms such as dysphagia, throat discomfort, or obstructive sleep apnea.4 Both CT and MRI are used to confirm the diagnosis of osteochondroma. Computed tomography can reveal the appearance of the marrow and cortical continuity with its relationship to the vertebra.1 On CT images, spinal osteochondromas generally present as round, sharply outlined masses with scattered calcification and density similar to that of the bones.2 Osteosclerotic changes may also be seen in neighboring bones.2 This type of tumor does not show ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Otorhinolaryngology, Jeju National University School of Medicine, Jeju, South Korea (Kim); Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea (Kang).
1. Rodallec MH, Feydy A, Larousserie F, et al. Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics. 2008;28(4): 1019-1041.
Corresponding Author: Ju Wan Kang, MD, Department of Otorhinolaryngology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea ([email protected]). Section Editor: Rebecca S. Cornelius, MD. Published Online: February 5, 2015. doi:10.1001/jamaoto.2014.3729. Conflict of Interest Disclosures: None reported.
394
contrast enhancement.2 Magnetic resonance imaging is much more valuable than CT in evaluating the relationship between the tumor and soft tissue and generally demonstrates a peripheral rim of low signal intensity corresponding to the cortical bone, and a signal for fatty marrow in the central area of the tumor.1 A cartilaginous cap, which may be observed with osteochondroma, appears as isointense to hyperintense on T1-weighted MRI, and hyperintense on T2-weighted MRI.2 However, cartilaginous caps become thinner and disappear with age. Therefore, malignant neoplasm should be considered in adults with a cartilaginous cap more than 1 cm in thickness.1 Exuberant osteophytes, diffuse idiopathic skeletal hyperostosis (DISH), and osteoid osteoma have been reported as bony masses causing oropharyngeal symptoms.3-5 However, osteophytes and DISH, which do not show the marrow and cartilaginous cap, could be distinguished from osteochondroma.1 Osteoid osteoma usually shows a nidus (a radiolucent center surrounded by sclerotic bone).1,3 Also, solitary malignant tumors rarely occur in the cervical spine. However, metastatic malignant diseases, compared with primary malignant neoplasms, develop more commonly in patients older than 30 years.1 Complete removal of tumors, including the cartilaginous cap, is the recommended treatment approach for osteochondroma.6 Incomplete removal of the cartilaginous cap can increase the risk of tumor recurrence.7,8 In addition, transformation of solitary osteochondromas into malignant tumors, such as chondrosarcoma and osteosarcoma, may occur. Although the exact risk of malignant changes is not known, the incidence may be about 1% in solitary osteochondromas.9
2. Kouwenhoven JW, Wuisman PI, Ploegmakers JF. Headache due to an osteochondroma of the axis. Eur Spine J. 2004;13(8):746-749. 3. Biswas D, Mal RK. Dysphagia secondary to osteoid osteoma of the transverse process of the second cervical vertebra. Dysphagia. 2007;22(1): 73-75. 4. Verlaan JJ, Boswijk PF, de Ru JA, Dhert WJ, Oner FC. Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction. Spine J. 2011;11 (11):1058-1067.
5. Hwang JS, Chough CK, Joo WI. Giant anterior cervical osteophyte leading to Dysphagia. Korean J Spine. 2013;10(3):200-202. 6. Yoshida T, Matsuda H, Horiuchi C, et al. A case of osteochondroma of the atlas causing obstructive sleep apnea syndrome. Acta Otolaryngol. 2006;126 (4):445-448. 7. Wang V, Chou D. Anterior C1-2 osteochondroma presenting with dysphagia and sleep apnea. J Clin Neurosci. 2009;16(4):581-582. 8. Zinna SS, Khan A, Chow G. Solitary cervical osteochondroma in a 9-year-old child. Pediatr Neurol. 2013;49(3):218-219. 9. Reckelhoff KE, Green MN, Kettner NW. Cervical spine osteochondroma: rare presentation of a common lesion. J Manipulative Physiol Ther. 2010; 33(9):711-715.
JAMA Otolaryngology–Head & Neck Surgery April 2015 Volume 141, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/19/2015
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