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Clinical Note |

Inflammatory Pseudotumor of the Nasopharynx and Skull Base:  Mimicking an Aggressive Neoplasm or Infection

Wilson B. Chwang, MD, PhD; Ruchika Jain, MD; Ananth Narayan, MD; Jonathan McHugh, MD; Tamer Ghanem, MD; Michael Seidman, MD; Rajan Jain, MD
Arch Otolaryngol Head Neck Surg. 2012;138(8):765-769. doi:10.1001/archoto.2012.1540.
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Inflammatory pseudotumor of the nasopharynx and skull base is a benign, idiopathic disease that is often mistaken for a neoplasm or infection owing to its aggressive behavior and clinical presentation. It can present as a progressively destructive mass and should be considered when repeated tissue biopsies reveal acute or chronic inflammation without evidence of malignant disease or infection. We present 4 cases of nasopharyngeal inflammatory pseudotumor with skull base invasion occurring in patients with diabetes mellitus (DM). These patients had repeated negative results from biopsies and cultures, and none had associated cervical lymphadenopathy despite having an aggressive destructive mass. We suggest that these findings, coupled with clinical suspicion, will be helpful in making the correct diagnosis of inflammatory pseudotumor. This is critical in the management of these patients to institute the correct treatment plan.

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Figure 1. Case 1, a 48-year-old man presenting with right-sided facial paralysis and pain in the right side of the face and neck regions. A, Postcontrast T1 axial magnetic resonance imaging (MRI) demonstrates an ill-defined enhancing infiltrative soft-tissue mass around the right mastoid tip, with intracranial extension and involvement of the right carotid space. Arrows demonstrate the extent of the mass. B, Axial T2 MRI demonstrates fluid opacification of the right mastoid air cells owing to eustachian tube obstruction. Arrows point to the mastoid air cells which are high signal on T2. C, Follow-up axial computed tomographic scan demonstrates progressively increasing mass in the right nasopharynx with extension to the prevertebral space, and also causing osseous erosion of the clivus. D, Also seen are postsurgical changes of right mastoidectomy. Arrows point to the right side of the clivus, which is partially eroded by the mass.

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Figure 2. The biopsy specimen from 44-year-old woman (case 2) presenting with left nasopharyngeal mass (hematoxylin-eosin). A, Photomicrograph (fibrous; original magnification ×10) demonstrates a paucicellular benign spindle cell proliferation with abundant collagenous stroma with chronic inflammation. B, Higher power, fibrous; original magnification ×40. C, Photomicrograph (original magnification ×20) near the mucosal surfaces demonstrates mixed acute and chronic inflammation with granulation tissue. Results from fungal, bacterial, and acid-fast stains were negative, and cultures yielded normal nasopharyngeal flora.

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Figure 3. Case 2, a 44-year-old woman presenting with left-sided headache and otalgia. A, Axial T1 magnetic resonance imaging demonstrates an ill-defined soft-tissue mass involving the nasopharynx and infiltrating the prevertebral space and skull base with vascular invasion. Arrow points to the ill-defined mass in the left prevertebral space. B, Three-dimensional time-of-flight magnetic resonance angiography demonstrates absence of the bilateral internal carotid arteries, which were occluded. Arrows point to the expected location of the carotid arteries, which are not seen.

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