My Strangest Case: The Patient Whose Shirts Stopped Fitting

David Goldenberg, MD; Darrin V. Bann, MD, PhD

Disclosures

July 16, 2020

Background

A 53-year-old man presented to us because his shirts were no longer fitting at his collar. In addition, he noted that he had weakness in his right upper arm and new-onset snoring. He reported no other symptoms.

His past medical and surgical history were significant for hypertension and the removal of multiple fatty tumors over the past 15 years, as well as excision of a right ankle cyst 30 years previously. A review of his family history was unremarkable. At the time, he was employed as a production worker. He had quit smoking more than a decade prior and consumed alcohol socially.

His current medications at the time included hydrochlorothiazide, lisinopril, loratadine, and vitamin D3 supplementation.

Physical Examination and Workup

Upon presentation, the patient was well developed, well nourished, and in no acute distress. He was able to communicate without assistance and had no dyspnea, respiratory distress, stridor, or wheezing. His head was normocephalic and atraumatic, and his face had normal symmetry.

Palpation of the neck revealed diffuse fullness but no palpable lymphadenopathy or thyromegaly. Examination of the oral cavity demonstrated no masses or lesions. His cranial nerves were grossly intact, although he did have difficulty abducting his right arm. However, no atrophy of the trapezius was apparent. Direct fiberoptic laryngoscopy was performed and revealed some fullness of the posterior pharyngeal wall and intact vocal cord motion.

Although the differential diagnoses for neck masses are vast, few produce seemingly normal physical examination findings, as was the case in this patient. Furthermore, the location of a mass in his retropharyngeal space ruled out many of the more commonly occurring neck masses. Based on his workup, we could not easily determine what was causing this patient's increasing neck size and newly presenting physical restraints.

To determine a definitive diagnosis, we chose to obtain MRI, with and without contrast. MRI revealed a large retropharyngeal mass, extending from the level of C1 to C2 in the intervertebral space to the level of T1 in the vertebral body (Figures 1-3).

Figure 1.

Figure 2.

Figure 3.

The mass measured 9.2 x 7.7 cm in coronal dimensions and 8 x 3.1 cm in axial dimensions. It contained a predominantly large, solid, poorly enhancing soft-tissue component, as well as lipomatous components that extended from the suprahyoid to the infrahyoid neck. The MRI also discerned no pathologic lymphadenopathy by size or morphologic criteria. The findings also included a mass effect upon the existing cervical roots, no intraspinal extension of the mass, and no adenopathy.

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