Instramuscular Myxoma - A Mysterious Neck Swelling

Take-Home Pearl: Intramuscular myxomas pose a challenge for clinicians to diagnose and detect.

Article Reviewed: Kalsi JS, Pring M, et al. Presentation of Instramuscular Myxoma as an Unusual Neck Lump. J Oral Maxillofac Surg 2013;71 (May): e210-e214.

Background: Instramuscular myxomas (IMs) are benign, soft tissue, infiltrative tumors that accur in muscle tissue. They present in patients from age 40 to 70 years and affect the larger muscle groups such as the thigh muscle.These benign, slow growing, asymptomatic swellings have a gender predilection for women versus men at a radio of 14:3. They occur at a rate of 1 per million people, and thus,  are quite rare. In this case report,a 70-year-old woman with an intense gag reflex upon palpation presented to the oral surgery department. She had a4-month history of a smooth, well-circumscribed swelling in the left neck. She had no past history of weight loss, tremors, hoarse voice, dysphagia, or injury. The patient also felt a pulsatile swelling in the lower neck right side. Her past medical history included asthma, hypertension, osteoporosis, and spinal stenosis. Upon clinical examination, a 20-mm firm mass was noted in level 3 of the neck. It was fixed, mobile, and nontender. From the right hemithyroid, a pulse was noted.

Objective: To present a case of IM in the neck.

Design: Case report and literature citings.

Case Report: An ultrasound (US)-guided fine-needle aspiration cytology test was done. The US depicted a 15-mm cystic lesion located in front of the strenocleidomastoid muscle that pushed on the internal jugular vein. Blood tests showed normal results. CT scans depicted tortuous vessels, which may account for the right thyroid pulsation. MRI showed a 20- x 12- x 16x mm cystic lesion in the front part of the left sternocleidomastoid muscle with cystic features. Excisional biopsy was done to achieve a definitive diagnosis and improve the patient's quality of life. Complete excision of the mass was done.

Results: After histology and immunochemistry tests, a diagnosis of IM was made, and no mitotic activity was noted in the cells. The gag reflex disappeared completely after the tumor excision; at 5-years after surgery, there was no recurrence of swelling or gag reflex issues.

Conclusions: IM often present as asymptomatic, slow growin masses and rarely occur in the head and neck region. Clinicians need to diagmose and detect the tumor so that proper treatment can be rendered to the patient.

Reviewer's Comments: In this instriguing case report, the management of an older woman with an IM was presented. Various other tumors that could have been part of the differential diagnosis were discussed in detail. In the addition, there were histology slides as well as CT images and clinical photos of the slow-growing bening tumor, which added to the article's content.

Reviewer: Gargi Mukherji, DDS


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