A 32-year-old Chinese woman presented to the ENT clinic with a nonhealing ulcer in the oral cavity that had been present for 3 months. Examination revealed the presence of leukoplakia on the left anterior tonsillar pillar; a punch biopsy of the pillar showed mild chronic inflammation. We also made an incidental finding of a mass that had arisen from the left posterior wall of the postnasal space (figure 1). A biopsy of the postnasal space again revealed chronic inflammation. Magnetic resonance imaging (MRI) demonstrated a left-sided nasopharyngeal mixed lipomatous tumor that was submucosal in origin.
[FIGURE 1 OMITTED]
The patient underwent endoscopic resection of the tumor. The operative finding was that of a 3-cm nasopharyngeal mass that has arisen from the posterior wall of the nasopharynx and obstructed the eustachian tube.
Histology identified an immature teratoma that was made up of tissue derived from various germ-cell layers and comprised mature glial/neurofibrillary tissue with scattered neurons predominant (figure 2). Mature adipose tissue, fibrous tissue, and a few apocrine glands were also present. Abundant calcifications were surrounded by an area of a foreign-body giant-cell reaction. In addition, an area containing immature neuroepithelial tissue was also noted; the tissue was characterized by round, hyperchromatic nuclei, a rosette-like arrangement, and a fibrillary background. The immature area constituted approximately 10% of the tumor mass. No somatic malignancy was evident.
[FIGURE 2 OMITTED]
On immunohistochemistry, the immature cells stained positively for synaptophysin but not for chromogranin, glial fibrillary acid protein (GFAP), and S- 100 protein. The glial tissue was positive for GFAP, and the neurons expressed synaptophysin. There were no malignant sarcomatous or carcinomatous areas.
True teratomas are neoplasms that are made up of tissue from the ectoderm, mesoderm, and endoderm. These tissues are usually alien to the site in which they arise. They are arranged in a haphazard fashion, and their degree of maturity varies. Teratomas usually originate in the midline of the sacrococcygeal, gonadal, retroperitoneal, and mediastinal regions.
Head and neck teratomas account for fewer than 10% of all teratomas; when they do occur, most arise in the cervical region: (1-3) They are usually present at birth, and affected patients manifest signs and symptoms of airway obstruction. The second most common location of head and neck teratomas is the nasopharynx, usually arising from the superior or lateral wall. (1) Affected patients typically present with nasal obstruction.
Teratomas in childhood are usually benign. Some authors believe that these immature tissues are consistent with the immaturity of the host, but others believe that tissue immaturity suggests a malignant change.
Treatment is usually surgical excision. Surgery should be undertaken on an urgent basis, especially in a patient who presents with signs and symptoms of airway obstruction.
References
(1.) Ward RF, April M. Teratomas of the head and neck. Otolaryngol Clin North Am 1989;22:621-9.
(2.) Billmire DF, Grosfeld JL. Teratomas in childhood: Analysis of 142 cases. J Pediatr Surg 1986;21:548-51.
(3.) Carr MM, Thorner P, Phillips JH. Congenital teratomas of the head and neck. J Otolaryngol 1997;26:246-52.
Chan Meng Lim, MBBS; Chi-Shern Bernard Ho, MBBS; Kenny Peter Pang, MRCS; Siok Bian Ng, FRCPA; Hood Keng Christopher Goh, FRCS
From the Department of Otolaryngology (Dr. Lim, Dr. Pang, and Dr. Goh) and the Department of Pathology (Dr. Ho and Dr. Ng), Singapore General Hospital.
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