A Palatal Mass

Abstract

A 19 year old female patient presented to the ENT department with complaints of slow growing, painless palatal mass for three months duration. On examination, there was a smooth surface 3x3 cm mass arising from the left side of hard palate (Fig. 1) which was firm in consistency on palpation. The rest of ENT examinations were normal. Figure 1 Pre-operative clinical photograph showing the palatal mass The Computed tomography (CT) showed a well defined contrast enhancing mass with no obvious bony erosion, (Fig. 2). The fine needle aspiration cytology from the lesion showed the histological features of epithelial and myoepithelial elements arranged in a variety of patterns and embedded in a mucopolysaccharide stroma. Figure 2 Showing a soft tissue mass arising from the hard palate at the level of ethmoid sinus Questions What is the likely diagnosis in this patient? What is the role of Fine needle aspiration cytology (FNAC) in such lesion? How would you manage this case and what is the role of CT scan in such lesions? Answer Pleomorphic adenoma of minor salivary gland arising from hard palate. The other rare differential diagnosis includes malignant minor salivary gland tumor, neurogenic tumors. Preoperatively, the FNAC has a diagnostic role in such lesions. The mass lesion arising from the hard palate can be a malignant lesion requiring a radical approach. Complete surgical excision under general anesthesia is the treatment of choice for such a lesion (Fig. 3). The preoperative CT scan not only helps in delineating the extent of lesion but also is useful in assessing any bony erosion of hard palate. Figure 3 Post operative scan of the patient showing a clear hard palate at the level of ethmoid sinus Discussion The palate has the highest concentration of minor salivary glands in the upper aero-digestive tract.1 The pleomorphic adenoma is the most common benign minor salivary gland tumor arising from the palate.2 The clinical presentation of such a lesion is typically a firm or rubbery submucosal mass without ulceration or surrounding inflammation. The exact etiology of this tumor is unknown but it is hypothesized that it originates from the intercalated and myoepithelial cell.2 Preoperatively, the fine needle aspiration cytology has a definite diagnostic role and shows epithelial, myoepithelial, and stromal components. The CT scan and magnetic resonance imaging (MRI) showed, always performed to asses for the presence of any bony erosion, soft tissue or nerve involvement. Since the majority of minor salivary gland neoplasms arising from palate are malignant, a detailed history, examination and investigations are essential before the excision of such lesions.3 The complete surgical excision is the treatment of choice in cases such as pleomorphic adenoma. The lesion in the current case was excised completely under general anesthesia and patient was symptoms free in the six months follow up.