Abstract
Case
A 57 year old female patient presented with a painful right-sided neck mass that on MRI was shown to be adherent to the posterior aspect of the sternocleidomastoid muscle. The mass was surgically resected en bloc without complications. Histopathologic analysis revealed the mass to be a myxoma.
Review
To date, there have been several case reports of myxomas, although very few involving the head or neck. The majority of the literature available concurs that myxomas are benign neoplasms that exhibit characteristic qualities on MRI imaging. The definitive treatment by consensus is surgical excision.
Conclusions
Although the incidence of head and neck myxomas is low, it is important to include in the differential of a neck mass with certain radiographic findings.
1
Introduction
The term “myxoma” was originally utilized by Virchow in 1871 in his descriptions of tumors histologically resembling tissue of the umbilical cord . Stout further clarified the term by establishing criteria for the classification of tumors as myxomas: a mesenchymal non-metastatic neoplasm composed solely of undifferentiated stellate cells, surrounded by a loose mucoid stroma . Myxomas are benign, rare, locally invasive tumors of connective tissue that may arise in both somatic soft tissues and bone. In the head and neck, myxomas are most commonly found in the maxilla, mandible and soft tissues of the face. The subtype of intramuscular myxoma, that is, myxomas arising from skeletal muscle, was first described by Enzinger in 1965 . There have been fewer than 200 reported cases of myxoma of the head or neck since the establishment of diagnostic criteria in 1948. Fifteen of these have been noted to be intramuscular, with four arising from cervical paraspinal musculature. A rare case of an intramuscular myxoma of the cervical paraspinal musculature and a comprehensive review of the literature to date are presented.
2
Case
A 57 year old female patient presented with a painful lump on the right side of her neck that had developed over 3 months. She stated that she had a tingling sensation that radiated up to the top of her head when this lump was depressed. The patient had undergone right sided microvascular decompression for trigeminal neuralgia four years prior. There was no history of trauma, fever, dysphagia, hoarseness, weight loss, and no other remarkable medical or familial history. Clinical examination revealed a firm, fixed mass posterior to the sternocleidomastoid muscle with no other significant lymphadenopathy. She exhibited right V3 distribution numbness that remained unchanged since her prior surgery. All other cranial nerve functions were intact and symmetric.
MRI of the neck revealed a 2 cm mass at the level of C3-4, just lateral to the right C3 lateral mass The lesion was T2 hyperintense and T1 hypointense with heterogenous enhancement ( Figs. 1–3 ).
Surgical resection was accomplished through a vertical incision in the high posterior triangle of the neck. The mass was found to be firm, encapsulated and gray-white in appearance. It was easily dissected off the surrounding soft tissues and completely excised ( Fig. 4 ). The patient was discharged the same day and reported complete resolution of her symptoms at follow-up.
Final histologic examination demonstrated stellate and small spindle cells and fibers surrounded by myxoid stroma, consistent with a diagnosis of intramuscular myxoma.
3
Discussion
Myxomas are benign mesenchymal tumors of fibroblastic origin which produce excess mucopolysaccharide, are incapable of producing mature collagen, and histologically resemble the umbilical cord . To date, a definitive etiology for intramuscular myxomas has not yet been described; however, it is commonly thought that malfunctioning fibroblasts are responsible for both the presence of immature collagen fibers and the abundance of glycosaminoglycans . They may occur in many locations in the body, including the bones, heart, skin, genitourinary tract, retroperitoneal tissues, intestinal tract, pharynx, joints, and skeletal muscles . Intramuscular myxomas usually arise in large skeletal muscles, and have an estimated incidence of 1 in 1,000,000 . Roughly half of intramuscular myxomas are found in the large muscles of the thigh, with less common locations including the buttock, shoulder, lower leg, arm, and trunk . Intramuscular myxomas of the head and neck are rare, with only fifteen cases reported in the literature to date ( Table 1 ). Of these, only four of these cases were localized to the cervical paraspinal musculature .
| Reference | Age | Sex | Location | |
|---|---|---|---|---|
| 1 | Enzinger | 55 | M | Sternocleidomastoid |
| 2 | Rosin | 44 | M | Geniohyoid |
| 3 | Cannalis et al. | 46 | F | Lateral part of neck |
| 4 | Feldman | 62 | F | Cervical paraspinal musculature |
| 5 | Nishijima et al. | 16 | F | Anterior part of neck |
| 6 | Shugar et al. | 68 | F | Cervical paraspinal musculature |
| 7 | Andrews et al. | 61 | F | Neck (no detailed information provided) |
| 8 | Crankson et al. | 5 | F | Cervical paraspinal musculature |
| 9 | Ozawa et al. | 22 | M | Scalene |
| 10 | Robin | 43 | F | Temporalis |
| 11 | Ischoo | 2 | F | Trapezius |
| 12 | Papadogeorgakis | 74 | M | Masseter |
| 13 | Falavigna | 64 | F | Cervical paraspinal musculature |
| 14 | Patsiaoura et al. | 52 | M | Musculature of nasal vestibule |
| 15 | Li et al. | 43 | F | Trapezius |
| 16 | Kalsi | 70 | F | Sternocleidomastoid |
| 17 | Case reported | 57 | F | Cervical paraspinal musculature |
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