CASE 11800 Published on 09.05.2014

Inflammatory pseudotumor of the carotid artery causing vocal cord palsy with co-existent ipsilateral papillary thyroid carcinoma (ECR 2014 Case of the Day)

Section

Head & neck imaging

Case Type

Clinical Cases

Authors

Laura Zilinskiene1, Steve Colley2

1. Radiology Registrar, Queen Elizabeth Hospital Birmingham, Birmingham, UK
2. Consultant Head and Neck Radiologist, Queen Elizabeth Hospital Birmingham, Birmingham, UK

Patient

55 years, female

Categories
Area of Interest Head and neck ; Imaging Technique MR, CT, Ultrasound
Clinical History

Adult woman with a short history of hoarse voice.

Imaging Findings

A 55-year-old lady presented to ENT clinic with a hoarse voice after an episode of severe left-sided headache. Initial examination with flexible naso-endoscopy revealed left vocal cord palsy. Contrast enhanced CT of the neck and thorax demonstrated concentric soft tissue thickening encasing the left common carotid artery and a left thyroid mass with punctate calcification (Fig. 1). Subsequent fine needle aspiration of the thyroid mass and core biopsy of the carotid artery lesion were performed (Fig. 2).

Pathology revealed an inflammatory pseudotumour of the carotid artery and Thy 5 cytology for the thyroid mass. Subsequent left hemithyroidectomy confirmed papillary thyroid cancer. The patient received a short course of steroids and follow-up neck MRI demonstrated almost complete resolution of the carotid abnormality (Fig. 3).

Discussion

Idiopathic inflammatory pseudotumour is a rare benign inflammatory mass of unknown origin [1]. It can occur in any part of the body, most commonly the lung and orbit, with only few cases reported in the carotid space [2-5]. Amongst other rare head and neck locations, it may occur in sinonasal cavity, parapharyngeal space, skull base and temporal bone [1].

Imaging demonstrates a homogeneous fusiform soft tissue mass encasing the common carotid artery with various degrees of vessel narrowing. The mass is typically avascular with little or no enhancement on contrast enhanced images, and low signal on T2 weighted MRI images (as opposed to high signal of tumours and inflammatory process). Histologically pseudotumour is identified as fibrotic tissue containing spindle cells and infiltrated with lymphocytes and plasmacytes, with no granulomatous or necrotic changes [3-5].

Differential diagnoses includes carotid wall haematoma due to dissection, carotid body or glomus jugulare tumour, or a malignant process e.g. lymphoma or metastases. Although imaging features of the inflammatory pseudotumour are non-specific, it is the role of the radiologist to suggest it amongst the differential diagnoses. The pre-operative recognition of this benign lesion is important to avoid unnecessary radical surgery, since the majority of the cases will respond to treatment with steroids. The prognosis of inflammatory pseudotumour is considered favourable with only rare reports of malignant transformation or metastatic disease [1].

Differential Diagnosis List
Inflammatory pseudotumour of the carotid artery.
Carotid wall haematoma / dissection
Carotid body tumour
Lymphoma
Metastasis from thyroid cancer
Final Diagnosis
Inflammatory pseudotumour of the carotid artery.
Case information
URL: https://eurorad.org/case/11800
DOI: 10.1594/EURORAD/CASE.11800
ISSN: 1563-4086