Abstract
Angiolipoma is a benign mesenchymal tumor and its occurrence in head and neck region is very rare. Only 2 cases of Laryngeal angiolipomas have been reported in the medical literature. We present one such rare case in a 32-year-old male who presented with complaints of change in voice and foreign body sensation in the throat since past 9 months along with features suggestive of obstructive sleep apnoea and dysphagia. Contrast enhanced CT scan of the neck showed a cystic lesion arising from right ventricle extending superiorly till the vallecula, partially obstructing the airway. Suspecting a supraglottic cyst, trans-oral microlaryngoscopic KTP-532 laser assisted excision was planned, intraoperatively a solid tumor was encountered. We discuss herein the clinical presentation and management of this rare neoplasm with review of literature.
Keywords: Angiolipoma, Lipoma, Larynx, Laser, Excision
Introduction
Angiolipomas are benign mesenchymal tumors, rubbery in nature containing blood vessels and grows usually under the skin. It is a rare benign fatty tumour, composed of mature lipocytes and multiple areas containing angiomatous elements. It is quite rare in the head and neck region. In the medical literature there were only 19 cases of angiolipoma described in the head and neck region [1].
These tumors in the head and neck, have been reported to be seen in oral cavity, nasal cavity and nasopharynx [2]. They can be non-infiltrating type which is benign and a less frequently encountered type i.e., infiltrating angiolipomas [3]. The typical age for these tumors to manifest is in the 5th to 6th decade of life [4].
Only two cases with laryngeal angiolipoma are reported in the medical literature [5]. The laryngeal angiolipoma interfere with breathing, speech and swallowing. Though its a benign neoplasm, its occurrence in the larynx may cause death due to airway obstruction. Symptoms include globus sensation, obstructive sleep apnoea, hoarseness, dysphagia, and airway obstruction [6].
Histological features of these tumours showing any sign of malignancy only become visible in cases of recurrent neoplasm(s) [7]. The definitive treatment is surgery as untreated laryngeal angiolipoma can cause airway obstruction and can be fatal. We report the largest encountered angiolipoma of the larynx in the literature. To our knowledge this is the first report in the literature wherein the angiolipoma of the larynx is managed by a trans-oral microlaryngoscopic KTP 532 laser assisted technique.
Case Report
A 32-year-old man presented to our out-patient setting with complaints of change in voice, dysphagia and foreign body sensation in the throat since 9 months. He also had symptoms suggestive of obstructive sleep apnea and difficulty in breathing on supine position since 2 months. Indirect laryngoscopic examination revealed a well-defined globular mass in the supraglottis. Contrast enhanced computed tomography (CECT) showed cystic lesion arising from right ventricle extending superiorly till the vallecula, of size ~ 2.6 × 3.4 × 3.6 cm (AP × TRANS × CC) (Fig. 1a, b). Patient was planned for microlaryngoscopic excision of right supraglottic cyst. After fiberoptic guided nasotracheal intubation, a Kleinsasser laryngoscope was introduced, suspended and lesion was focussed using microscope and intraoperatively a well-defined globular mass with dilated vessels over its surface was noted (Fig. 2a). KTP-532 (Potassium Titanyl Phosphate) laser assisted partial supraglottectomy was carried out (Fig. 2b). Histopathological features were suggestive of Angiolipoma (Fig. 3a–c). The patient was discharged from the hospital on the 2nd post-operative day with a nasogastric tube. On post-operative day 7, patient reported blood-stained sputum and an oral bleeding episode. Videolaryngoscopy showed a suspicious residual ventricular lesion covered with slough, obstructing the view of right arytenoid and adjacent pyriform fossa. Revision microlaryngoscopic excision of the residual lesion was performed using KTP-532 laser and utility of KTP-532 laser in revision surgery avoided an open approach and associated morbidity. He had transient aspiration which settled in 2 weeks. The nasogastric tube was removed and full oral feeds were resumed. Patient is currently on regular follow up with no evidence of clinical and radiological recurrence after 6 months. (Figs. 1c and 4).
Fig. 1.
a: Axial CECT neck image showing the well-defined lesion of size ~ 2.6 × 3.4 × 3.6 cm in the right laryngeal wall of supraglottic larynx. b: Sagittal CECT image showing the mass in the supraglottic region. c: Postoperative sagittal CECT image showing no residual tumor and patent airway
Fig. 2.
a: Intraoperative image showing the globular mass with prominent vessels on its surface extending till the Vallecula obscuring the airway. b: Microlaryngoscopic image showing KTP-532 laser assisted tumor excision
Fig. 3.
a: Lobules of mature adipose tissue with intervening fibrous septae [H&E, × 50]. b: Lobules of mature adipose tissue with proliferating peripheral rim of capillary-sized vessels [H&E, × 100]. c: Peripheral rim of capillary-sized vessels, few with luminal fibrin thrombi [H&E, × 200]
Fig. 4.
Videolaryngoscopic image showing post-operative status with adequate laryngeal inlet
Discussion
The upper respiratory and digestive tract is very unusual site for lipomas. It usually leads to functional deficits such as dysphagia, dysphonia, sleep apnoea, throat pain [8]. Endoscopic preoperative histopathological diagnosis is difficult due to development of the tumor submucosally. Other tumors of adipose tissue (angiolipoma, liposarcoma) and angioleiomyoma should be taken into consideration in the microscopic differential diagnosis initially. Angiolipoma lacks myoid differentiation and angioleiomyoma lacks lipoid component. To avoid misdiagnosing a liposarcoma, lipoid component must be searched carefully for lipoblasts [9].
The surgical approach to benign laryngeal masses is variable depending on the location and size of the lesion. Small lesions may be excised through endolaryngeal microsurgery, while an external approach (laryngofissure, lateral pharyngotomy, or thyrotomy) may be used for large lesions [10] (Table 1).
Table 1.
Published cases of Laryngeal angiolipoma and their management techniques
| Study by | Site of Angiolipoma | No. of patients | Approach | Technique | |
|---|---|---|---|---|---|
| 1 | Devinder Rai et al. [1] | Left aryepiglottic fold | 1 | Elective Tracheostomy + lateral pharyngotomy | Cold knife |
| 2 | Mesolella et al. [11] | Left aryepiglottic fold | 1 | Microlaryngoscopic approach | CO2 laser |
| 3 | Our study | Right ventricle | 1 | Microlaryngoscopic approach | KTP-532 laser |
Myssiorek et al. [10] describes lateral pharyngotomy approaches without tracheostomy. An external approach without tracheotomy allows for good exposure with minimal functional disability. But external scar and postoperative drain and prolonged hospital stay and fistula formation are the potential disadvantages.
Mesolella et al. [11] performed CO2 laser assisted excision of the tumor in the left aryepiglottic fold. In our patient we approached through transoral endolaryngeal route with KTP-532 laser. In vascular tumors such as angiolipoma where there is possibility of bleeding from the tumor, an angiolytic laser like KTP-532, gives excellent hemostasis. This laser is a powerful cutting tool and hence helps in quicker surgery compared to CO2 laser. Other advantages of this approach is that there is less postoperative morbidity and shorter duration of hospital stay.
Conclusion
Diagnosis of Laryngeal Angiolipoma can be done only after the histopathological report as it lies in the submucosal region. Treatment includes microlaryngoscopic surgery as untreated lipomas can cause airway obstruction and can be fatal. Complete excision is a must as there is high probability of recurrence and bleeding due to its enhanced vascularity. KTP 532 laser is a very helpful tool as it gives excellent hemostasis and avoids open approach.
Acknowledgements
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Funding
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Declarations
Conflict of interest
The authors declare that they have no competing interests.
Ethical approval
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Consent to participate
Not applicable.
Consent for publication
Written informed consent was obtained from the patient for the publication of this case report and accompanying images.
Footnotes
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