Giant hypopharyngeal fibroepithelial polyp: A case report and literature review

Giant hypopharyngeal and esophageal polyps are rarely encountered in clinical practice. They represent approximately 0.03% of all hypopharyngeal/esophageal neoplasms. ⁶ The vast majority of these lesions originate in the upper third of the esophagus and extremely rarely in the hypopharynx. ⁸ The differential diagnosis of intraluminal polyps are lipomas, fibrolipomas, fibromas, fibromixomas, hamartomas, and fibroepithelioma. ⁸ The most common sites of FEP are the skin and the genitourinary tract. Regarding the head and neck region, FEPs are reported in the oropharynx, hypopharynx, nasal cavity, external auditory canal, trachea, bronchus, and orbit.^9-11 The etiology of FEP is uncertain. ⁹ Two theories have been described regarding the etiology: [1] fibrous connective tissue hyperplasia, [2] chronic inflammatory hyperplasia.^12,13 However, FEP could have traumatic, infectious, and congenital origins. ⁹ According to Peric and colleagues, FEP could occur as a result of mucosal trauma. ² However, our patient denied any previous surgical interventions in the hypopharyngeal region. The malignant transformation of these lesions is extremely low. ¹² The slow growth of FEP delays the onset of symptoms until they become large enough and cause symptoms due to the local mass effect. Various symptoms have been reported depending on the size and location of the lesion, including feeling something in the throat, difficulty breathing, snoring, aural fullness, and disturbed sleep.^7,9,11 Regarding our patient, she complained about dysphagia about 2 months ago. She consulted several physicians, including otolaryngologists and internists, who misdiagnosed the condition as chronic pharyngitis and described some medications, such as antibiotics and analgesics, without any benefit. Fibroepithelial polyps of the pharynx or tracheobronchial tree could be a life-threatening situation due to obstruction of the upper airways.^7,14 Airway security must be provided as the first step in management in the presence of airway obstruction. Fortunately, although the polyp was giant, our patient was stable with no airway compromise because the thin stalk of the polyp did not cause any airway obstruction. We reviewed the medical literature through Medline and found that only three cases of hypopharyngeal FEP have been reported, two of them arising from the pyriform sinus.^5,7,12 Mangar et al documented a case of airway obstruction and choking due to a large FEP that originated in the right pyriform sinus. ⁵ Jabbour et al reported a case of FEP that originated in the posterior pharyngeal wall, leading to intermittent glottic obstruction. ⁷ Janjatov et al described an unusual case of two FEPs that originated in the right and left pyriform sinus sequentially. The first polyp measured approximately 60 × 20 × 20 mm and the second lesion was approximately 95 × 20 × 20 mm in size. ¹² Depending on the aforementioned data, our case should be the third case of FEP originating in the pyriform sinus and the largest case of hypopharyngeal FEP reported in the literature (Table 1). Previous studies showed that FEPs tend to occur in men between 40 and 70 years of age.^2,4,12 This is consistent with the reported cases of hypopharyngeal FEP since the three documented cases affected men (Table 1). However, that does not correspond to our case because our patient is a woman. Several studies suggested morbid obesity and insulin resistance as a risk factor for FEP formation.^15,16 In fact, the present case was neither obese nor diabetic, suggesting that obesity and insulin resistance could not be a factor in the growth of FEP. The treatment of choice for hypopharyngeal FEP is surgical excision, and the definitive diagnosis is confirmed by histological examination. ⁹ When possible, surgical resection of hypopharyngeal FEP should be performed under general anesthesia to precisely define the origin of the stalk and achieve complete resection to avoid recurrence. ¹⁷ This approach was used by Mangar et al, ⁵ Jabbour et al, ⁷ and by us in our case. Histopathologically, these lesions are lined by a squamous epithelium with epithelial hyperplasia, dyskeratosis, and lymphocytic epitheliotropism. The polyp stroma consists of smooth muscle, collagen, and adipocytes. ⁵

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Table 1.

Previous reported cases of hypopharyngeal fibroepithelial polyps.

	Reference	Age/gender	Number of polyps	Origin	Size (mm)	Anesthesia	Year
1	Mangar et al. 5	60/M	1	R pyriform sinus	60 × 35 × 5	General anesthesia	2004
2	Janjatov et al. 12	57/M	2	R pyriform sinus	60 × 20 × 20	Local anesthesia	2012
				L pyriform sinus	95 × 20 × 20	Local anesthesia
3	Jabbour et al. 7	39/M	1	R posterior pharyngeal wall	30 × 22 × 18	General anesthesia	2019
4	Present case	56/F	1	R pyriform sinus	210 × 40 × 50	General anesthesia	2022