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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 69  |  Issue : 2  |  Page : 113-115

Cartilaginous choristoma at nasopharynx


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India

Date of Submission31-Aug-2020
Date of Acceptance22-May-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JASI.JASI_120_19

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  Abstract 


A 26-year-old man attended the outpatient department of Otorhinolaryngology with complaint of nose block. He was presented with nonspecific clinical presentations except nasal block. Mass was present at the nasopharynx and completely excised and sent for biopsy which confirmed the diagnosis of cartilaginous choriostoma. The histopathological report revealed cartilaginous tissue with surrounding of seromucous salivary glands under cover of respiratory epithelium. The choristoma is a tumor like lesion consisting of normal cells present in the abnormal site. It is most often seen in oral cavity structures such as tongue, gingival, buccal mucosa and soft palate. Cartilage choristoma is rarely found at the nasopharynx. It is developmental in origin. Definite diagnosis is done by histopathological findings. The treatment is usually done by the surgical excision.

Keywords: Cartilage, choristoma, endoscopic excision, nasopharynx


How to cite this article:
Swain SK, Samal S, Mohanty JN. Cartilaginous choristoma at nasopharynx. J Anat Soc India 2020;69:113-5

How to cite this URL:
Swain SK, Samal S, Mohanty JN. Cartilaginous choristoma at nasopharynx. J Anat Soc India [serial online] 2020 [cited 2020 Sep 21];69:113-5. Available from: http://www.jasi.org.in/text.asp?2020/69/2/113/288671




  Introduction Top


Choristoma is a benign lesion consisting of normal tissue found in abnormal location. It is found in different sites of the head and neck area like oral cavity, oropharynx, hypopharynx and middle ear.[1] Choristoma may originate in bone, cartilage, glial tissue, salivary gland and thyroid gland. Most common site for origin of this lesion is the tongue followed by gingiva, buccal mucosa of the oral cavity and soft palate.[2] Cartilaginous choristoma at the nasopharynx is extremely rare. It is usually developmental in origin, few of them occurs due to local trauma. It is reported in infant of 1 day age to 90-year-old lady, with mean age of 47 years.[3] The clinical presentation of this lesion is often painless mass and may give rise to local dysfunction. The definite diagnosis is done from histopathological examination. Due to the rarity of the cartilage choristoma at the nasopharynx, the diagnosis is unsuspected until the excised mass is sent for pathological report. Treatment of this lesion is complete surgical excision. Here, we report a case of cartilaginous choristoma at the nasopharynx.


  Case Report Top


A 26-year-old man attended the outpatient department of Otorhinolaryngology with complaints of chronic postnasal discharge and nasal block. He had also frequent throat irritation due to postnasal drip. He had no history of nasal bleeding, headache and swallowing difficulty. He had specific past surgical or medical history except adenotonsillectomy underwent during childhood. The patient had no history of any other trauma to the nasopharyngeal area. Diagnostic nasal endoscopy was done which revealed a mass of 15 mm × 5 mm on the undersurface of the soft palate. Computed tomography (CT) scan of the nose and paranasal sinus was done which showed a mass at the nasopharynx without any extension beyond the nasopharynx [Figure 1]. The patient was explained about details of the lesion including site and size of the mass.
Figure 1: Computed tomography scan picture showing nasopharyngeal cartilage choristoma (yellow arrow mark)

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Then with the help of endoscope, mass [Figure 2] was excised under general anesthesia. Macroscopically it appears as polypoidal mass with dimension of 1.5 cm × 0.5 cm × 0.4 cm. Mass was excised and sent for histopathological examination. Grossly the mass was firm to hard in consistency and globular in shape. The outer surface was glistening and shiny. The cut surface of the specimen was showing myxoid areas. The histopathological picture revealed respiratory epithelium over the surface and matured hyaline cartilage tissue beneath the epithelium and cartilage surrounded by sero-mucous glands. Chondrocytes varied from small to large size without presence of nuclear atypia [Figure 3]. The lesion was diagnosed as cartilage choristoma originating from the minor salivary gland of the nasopharynx. Postoperative endoscopic examination showed normal anatomical appearance at the nasopharynx and undersurface of the soft palate after 3 months of surgery. There was no recurrence in follow up visit after 6 months of surgery. Patient consent was obtained and this case report was also approved by Institutional Ethical Committee for publication.
Figure 2: Endoscopic picture showing mass of cartilage choristoma at the nasopharynx (yellow arrow mark)

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Figure 3: Photomicrograph of the histopathological study showing hyaline cartilage (yellow arrow mark) (H and E, ×50)

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  Discussion Top


Heterotopia is a phenomenon where the normal tissue is found in an abnormal anatomical location. These mass are usually benign in nature. Choristoma is a type of heterotopias where histologically normal tissue is seen in an embryologically abnormal site. So, Choristoma is characterized as presence of the tissue or mass which not normally found in a site. It is often found in the distal extremities but rarely seen in the head and neck region.[4] The cartilaginous choristoma was documented by Berry in 1890.[5] There is certain confusion regarding the names of similar types of lesions like choristoma. The names of these lesions were used variably such as hamartoma, hairy polyp, epiganthus, true teratoma, teratoid and dermoid. Teratomas and teratoids are derived from all the three germinal layers whereas teratoids are poorly differentiated.[6] Presence of teratoma in the oral cavity is called as epignathus. Hamartomas are focal, excessive and over growth of the cells natural to the body part in which they occur. Dermoid consists of ectodermal and mesodermal germ cells. Choristoma is often called as a hairy polyp where mesodermal layer is covered by ectoderm. Present medical literature support that choristoma and hairy polyp are developmental malformations than teratoma.[7] The classification of choristoma is based on the tissue it contains. Our case such as cartilaginous choristoma is not described as salivary type or mixed type as minor salivary glands are expected to be seen in this anatomical site whereas a mature hyalaine cartilage is not to be present. There are multiple theories for explaining the origin of cartilaginous choristoma. Embryonic theory support towards heterotopic cartilage is due to fetal remnants.[8] The origin of the choristoma from embryonic rests postulates that the lesion arise from heterotopic cartilage remnants of the first four branchial arches. Metatplastic theory suggests trauma may be a cause for heterotopic cartilage from mesenchymal cells. Few support vestigial remnants as the origin for this choristoma.[9] There are different types of choristomas such as cartilage, bone, glial tissue, thyroid tissue and salivary gland.[10] Choristoma of cartilaginous tissue is usually called as cartilaginous choristoma.[11] Cartilage choristoma at the nasopharynx is incidentally found in adult age as in our case, which might may be due to origin of metaplastic theory due to injury by previous adenoidectomy surgery during pediatric age.

The clinical presentations of cartilaginous choristoma are often seen in adult age group. It is often seen in oral cavity as submucosal mass and clinically asymptomatic. It is often present with painless mass and may shows local discomfort. In present case, the mass was present in the nasopharynx causing nasal block and sometimes nasal discharge with postnasal drip. Congenital cartilaginous choristoma at the nasopharynx often present with emergency respiratory difficulty. The diagnostic nasal endoscopy is helpful for assessment of the nasopharyngeal mass and its exact location. CT scan is the ideal imaging to find out the site of the mass and its extension. The endoscopic biopsy can be done under local anesthesia in adult and general anesthesia in children. The definitive diagnosis of cartilaginous choristoma is done by biopsy and histopathological examination. Histopathological picture shows mixture of mature adipocytes or myxoid tissue with islands of cartilage inside a well defined capsule. Although most of the cases show pure cartilaginous proliferations, few lipocartilaginous and osteocartilaginous lesions also have been documented.[12] The differential diagnosis of cartilaginous choristoma is soft tissue chondroma, pleomorphic adenoma, traumatic chondroid tumor and ectomesenchymal chondromyxoid tumor.[13] The difference between the cartilage choristoma and true neoplasm is a challenging issue for clinicians. It can be easily misdiagnosed and can be reported as a true neoplasm.[14] Cartilaginous choristoma sometimes mimics with cartilaginous metaplasia which often seen in soft tissue due to long standing minimal trauma as beneath ill-fitting denture in the oral cavity.[15] The histological characteristics of the cartilaginous metaplasia is deposition of the calcium and scattered cartilaginous cells arranged in different stages of maturation in cluster or single focus. But in present case the histopathological picture shows no metaplasia and was almost entirely hyaline cartilage.

Treatment of this pathology is surgical excision. In pediatric cases with inadequate nasopharyngeal airway, immediate surgery is required. In our case, endoscopic excision of the mass was done without any evidence of remnant. If the mass is very large, along with trans-nasal route, trans-oral rout is also approached without damaging the soft palate. Complete removal of this mass along with perichondrium and adjacent soft tissue is the treatment of choice. Removal of the perichondrium is required to stop recurrences as perichondrium may develop new cartilage. Damage to soft palate may lead to velopharyngeal insufficiency. Cartilage choristomas are extremely rare at the nasopharynx but the distinct clinical features and should be differentiated from neoplasms as o their developmental origin and benign nature of the lesion. They usually do not show recurrence after complete removal of the mass.


  Conclusion Top


Cartilage choristoma at the nasopharynx is an extremely rare and benign lesion which should be kept in mind during examining a mass at the nasopharynx. It is developmental in origin. Although the cartilage choristoma is an uncommon lesion at the nasopharynx but it is not an unheard clinical entity. It is usually diagnosed by histopathological report as many times it mimics to other lesions at the nasopharynx. The treatment of choice is surgical excision. During the excision of the mass, the perichondrium should be excised. It should be differentiated from the neoplasms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee FP. Cartilaginous choristoma of the bony external auditory canal: A study of 36 cases. Otolaryngol Head Neck Surg 2005;133:786-90.  Back to cited text no. 1
    
2.
Desmedt M, Weynand B, Reychler H. Cartilaginous choristoma of the oral cavity: A report of two cases. B-ENT 2007;3:87-91.  Back to cited text no. 2
    
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4.
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Berry J. Fibro-chondroma of tongue. Trans Pathol Soc Lond 1890;41:81-2.  Back to cited text no. 5
    
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Karatayli Ozgursoy S, Umudum H, Beriat GK, Kaya S. A rare case: Cartilaginous choristoma of the soft palate. Indian J Otolaryngol Head Neck Surg 2015;67:444-6.  Back to cited text no. 6
    
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Burns BV, Axon PR, Pahade A. 'Hairy polyp' of the pharynx in association with an ipsilateral branchial sinus: Evidence that the 'hairy polyp' is a second branchial arch malformation. J Laryngol Otol 2001;115:145-8.  Back to cited text no. 7
    
8.
Moore K, Worthington P, Campbell RL. Firm mass of the tongue. J Oral Maxillofac Surg 1990;48:1206-10.  Back to cited text no. 8
    
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Unal T, Ertürk S. Cartilaginous choristoma of the gingiva. Report of two cases; review of the literature of both gingival choristomas and intraoral chondromas. Ann Dent 1994;53:19-27.  Back to cited text no. 9
    
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Kannar V, Prabhakar K, Shalini S. Cartilaginous choristoma of tonsil: A hidden clinical entity. J Oral Maxillofac Pathol 2013;17:292-3.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Bansal R, Trivedi P, Patel S. Cartilaginous choristoma of the tongue-report of twocases and review of literature. Oral Oncol Extra 2005;41:25-9.  Back to cited text no. 11
    
12.
Perrotti V, Fioroni M, Rubini C, Piattelli A. Cartilaginous choristoma of the gingival. Oral Oncology EXTRA 2005;41:216-18.  Back to cited text no. 12
    
13.
Mosqueda-Taylor A, González-Guevara M, de la Piedra-Garza JM, Díaz-Franco MA, Toscano-García I, Cruz-León A. Cartilaginous choristomas of the tongue: Review of the literature and report of three cases. J Oral Pathol Med 1998;27:283-6.  Back to cited text no. 13
    
14.
Bedir R, Erdivanli ÖC, Erdivanli B, Sehitoglu İ, Dursun E. Cartilaginous choristoma of the tonsil: Three case reports. Iran J Otorhinolaryngol 2015;27:325-8.  Back to cited text no. 14
    
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Matsushita K, Tahara M, Sato H, Nakamura E, Fujiwara T. Cartilaginous choristoma deep in the upper midline oral vestibule. Br J Oral Maxillofac Surg 2004;42:436-8  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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