|Year : 2017 | Volume
| Issue : 2 | Page : 92-94
Giant Lipoma of the Neck: A Case Report
Kavungal Nambillath Arif, Ruchika Juneja, Swati Tandon, Vikas Malhotra, Praveen Kumar Rathore
Department of ENT, Maulana Azad Medical College, New Delhi, Delhi, India
|Date of Web Publication||28-Jun-2017|
Registrar ENT, Maulana Azad Medical College, ENT Office, 3rd Floor, BLTaneja Block, New Delhi - 110 002, Delhi
Source of Support: None, Conflict of Interest: None
Lipomas are benign mesenchymal tumours, which are composed of the fat cells of adult type. Lipomas have been identified in all age groups, but they are mostly seen between 40 and 60 years of age. They are usually solitary tumours, more common in females, most often located on the posterior neck and on the back, but they can also be multiple and small tumours all over the body and extremities. Anterior neck lipomas are rare. We report a case of a giant subcutaneous solitary lipoma of anterior neck in a 60-year-old male managed surgically.
Keywords: Giant neck mass, lipoma, liposarcoma
|How to cite this article:|
Arif KN, Juneja R, Tandon S, Malhotra V, Rathore PK. Giant Lipoma of the Neck: A Case Report. MAMC J Med Sci 2017;3:92-4
| Introduction|| |
Lipomas are benign tumours composed of adipose tissue, usually found subcutaneously. They can occur anywhere in the body where there is an accumulation of fat cells; thus, they are often called as a ‘universal tumour’. Lipomas are generally slow-growing tumours with a firm rubbery consistency. In the head and neck region, where only 13% of the lipomas are seen, posterior cervical space is the most common site. The common sites for lipoma are the back, the arms, the shoulder, the anterior chest wall, the breasts, the thighs, the abdominal wall, the legs, the forehead and the face. They are usually asymptomatic but can cause pain when they compress nerves. They are usually subcutaneous but may develop in other places, for example, intermuscular, subfascial, parosteal, subserous, submucous, intra-articular, subsynovial, subendocardium, subepicardiac, myocardium, subdural or extradural. Lipomas have been identified in all age groups but usually appear between 40 and 60 years of age. Solitary lipomas are more common in women, and multiple tumours (referred to as lipomatosis) are more common in men. Treatment modalities for lipomas range from liposuction, steroid injection to surgical excisions. Fine needle aspiration cytology (FNAC) and sonography help in making early diagnosis, which can be supported with computed tomography (CT) and confirmed with histopathology report. Surgical intervention is challenging in anterior neck lipomas because of the proximity to the great vessels and vagus nerve and is reserved for patients coming for cosmesis (most common indication), pressure effects to rule out malignancy.
| Case Report|| |
A 60-year-old male presented to outpatient department of otolaryngology clinic (ENT OPD) of our hospital with a huge swelling in the anterior and right lateral aspect of the neck since 7 years, which gradually enlarged in size. There was no history of difficulty in breathing, swallowing or change in voice. The swelling did not move with deglutition or protrusion of the tongue. On examination, the swelling was 12 cm × 12 cm in size extending superiorly till the lower border of the mandible, inferiorly till the clavicle, anteriorly till the midline and posteriorly till the posterior border of trapezius on the right side. It was soft-to-firm in consistency, mobile, nontender, overlying skin was of normal colour, stretched and not adhered to tumour, and dilated veins were present over the swelling. The surface of the mass was lobulated, and margins were well defined. There was no mediastinal extension of the swelling on palpation [Figure 1].
Ultrasonography of the neck showed a large, well-circumscribed hypoechoic mass lesion noted in the front and the right side of the neck. Thyroid was found to be normal and the left carotid artery was displaced anteromedially due to mass lesion. On colour Doppler study, no increase in vascularity was seen. All features were suggestive of lipomatous lesion. X-ray soft tissue neck showed a large soft tissue swelling in anterior aspect and the right side of the neck causing mild deviation of trachea to the left side but with no mediastinal extension. X-ray of the chest was normal. Contrast enhanced computed tomography (CECT) of the neck revealed a large, well-defined hypodense fat attenuation lesion measuring 12 cm × 12 cm × 11.3 cm on the right side of the neck with thin septations and ill-defined soft tissue nodular areas within causing smooth contour bulge of overlying skin. The mass was involving posterior cervical space, carotid space and right masticator space with an anteromedial displacement of carotid sheath structures and a smooth contour bulge of the right lateral pharyngeal and laryngeal wall. Inferiorly, it was extending till the level of medial end of the clavicle and laterally beneath the right trapezius muscle [Figure 2]. FNAC was performed, and a report suggested benign lipomatous lesion. The patient was planned for the excision of the mass under general anaesthesia.
|Figure 2: CECT of the neck showing extension of tumour and relation to vital structures|
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Operative details: A single vertical lazy S incision was made over the tumour and the flaps were raised, and the tumour was exposed. The tumour mass was smooth, soft, yellow, mobile, shining and encapsulated. The tumour was found to push carotid sheath medially with maintained tissue planes. Superiorly, it was extending till the mastoid tip, and posteriorly, it was extending below trapezius muscle.
Enucleation of the tumour mass was performed, followed by excision of the excess skin [Figure 3]. Histopathology report suggested it to be a lipoma. Post-operative period was uneventful with no recurrence at 6 months follow-up.
| Discussion|| |
The lipomas constitute 5% of all benign tumours of the body and can be found anywhere in the body. Among the head and neck lipomas, the most common location is the posterior neck. The anterior neck is a rare location for the head and neck lipoma.
The lipomas are slow growing, painless, mobile, non-fluctuant, soft masses and are generally well encapsulated. The lipomas can be singular or multiple and are typically asymptomatic, unless they compress neurovascular structures. Besides frequent aesthetic consequences, lipomas can also exert pressure on surrounding tissues and structures. Patients with neck lipoma extending to mediastinum may present with a complaint of dyspnea or dysphagia.
Giant lipomas are defined by Sanchez et al. as lesions with a size of at least 10 cm in one dimension or weighing a minimum of 1000 g. The mechanism behind such gigantic growth is unclear and is a matter of debate. A few studies have postulated the role of trauma suggesting that blunt trauma can cause rupture of the fibrous septa and anchorage connections between the skin and deep fascia allowing the adipose tissue to proliferate rapidly. One theory suggests that trauma-related fat herniation through tissue planes creates so-called pseudolipomas. It has also been suggested that trauma-induced cytokine release triggers preadipocyte differentiation and maturation. A large neck mass (>10 cm) with a rapid growth rate should raise concerns about a possible malignancy. A long-standing lipoma may undergo myxomatous degeneration, saponification, calcification, infection, ulceration due to repeated trauma and malignant change. A malignant transformation of lipoma into liposarcoma has rarely been described.
Sometimes the lipomas are associated with syndromes such as multiple lipomatosis, Gardner’s syndrome, Dercum’s disease (multiple painful subcutaneous lipomas), and Madelung’s disease (lipomatosis of the neck, the head, the shoulders and the proximal extremities). Histologically, the lipomas are composed of mature adipose tissue, and several subtypes occur when other mesenchymal elements are present, for example, fibrous tissue, nervous tissue or vascular tissue.
CT is the modality of choice to confirm lipoma. The lipomas appear as homogenous low-density areas with a CT value of −50 to −150 HU with no contrast enhancement. On CT scans, a capsule of lipoma is barely visible or an adjacent mass effect may be the only clue to its presence. Larger lesions may contain blood vessels. A significant soft tissue element or heterogeneity of attenuation within a fatty lesion raises the possibility of liposarcoma. On magnetic resonance imaging (MRI), the lipomas have well-defined margins with a uniform signal intensity of fat on all sequences (best confirmed using fat-suppressed sequences). The margin of lipoma is clearly defined as ‘black rim’, distinguishing them from surrounding fat. Calcification is rare, forms centrally within an area of ischaemic necrosis but more commonly it is a feature of a liposarcoma.
Surgical excision of lipoma is the definitive treatment. Surgery is reserved for patients coming for cosmesis (most common indication) and pressure effects and to rule out malignancy. Smaller lipomas can be excised easily with low recurrence rate, because they usually grow expansively between different fascial planes without infiltrating the neighbouring structures. Surgical intervention of the giant lipoma of anterior neck with mediastinal extension is quite challenging because of proximity to the great vessels, the vagus and spinal accessory nerves, the lungs and the heart. Preoperative consent regarding possible complications such as injury to neurovascular structures must be taken. Surgical intervention in these tumours is very challenging because, sometimes, an extension to the spinal cord and malignant transformation may occur especially in old age.
Lipomas may be lobulated, and it is essential that all lobules be removed. Complete surgical excision with the capsule is advocated to prevent local recurrence. Other modalities of treatment have been reported such as liposuction and steroid injections. Liposuction is sometimes preferred, because there is less scarring following the procedure, but there is a higher chance of recurrence compared to excision, if residual tumour or capsule remains after the procedure. For smaller lipomas, steroid injections may also be used, but several injections are required and the overlying skin may be depigmented.
| Conclusion|| |
Common condition such as lipomas can have unusual presentations. Giant lipomas in an elderly patient may mimic malignancy. Therefore, otolaryngologists must be aware of it. Enucleation is the treatment of choice.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
El-Monem MH, Gaafar AH, Magdy EA. Lipomas of the head and neck: Presentation variability and diagnostic work-up. J Laryngol Otol 2006;120:47-55.
Rapidis AD. Lipoma of the oral cavity. Int J Oral Surg 1982;11:30-5.
Salam G. Lipoma excision. Am Fam Physician 2002;65:901-4.
Sanchez MR, Golomb FM, Moy JA, Potozkin JR. Giant lipoma: Case report and review of the literature. J Am Acad Dermatol 1993;28:266-8.
Signorini M, Campiglio GL. Posttraumatic lipomas: Where do they really come from? Plastic Reconstr Surg 1998;101:699-705.
Mentzel T. Cutaneous lipomatous neoplasms. Semin Diagn Pathol 2001;18:250-7.
Kenawi MM. ‘Squeeze delivery’ excision of subcutaneous lipoma related to anatomic site. Br J Surg 1995;82:1649-50.
Austin R, Mack G. Infiltrating (intramuscular) lipoma and angiolipoma − A clinicopathologic study of six cases. Arch Surg 1980;115:281-4.
Chikui T, Yonetsu K, Yoshiura K, Miwa K, Kanda S, Ozeki S et al.
Imaging findings of lipomas in the orofacial region with CT, US, and MRI. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:88-95.
Jones AP, Lewis CJ, Dildey P, Hide G, Ragbir M. Lipoma or liposarcoma? A cautionary case report. J Plast Reconstr Aesthet Surg 2012;65:e11-4.
Patel S, Jindal S, Singh M. Giant lipoma of the posterior neck – A rare entity. JIMSA 2012;25:245.
[Figure 1], [Figure 2], [Figure 3]