Lipoma is the most common benign mesenchymal tumor of soft tissue in adults. Although approximately 13%–25% of all lipomas occur in the head and neck, involvement of the nasopharynx is unusual. Since Fagan et al. [1] described nasopharyngeal lipoma as a “rare clinico-pathological entity” in 1996, fewer than 30 cases have been reported in the English-language literature [2–4].

Most nasopharyngeal lipomas originate from submucosal adipose tissue within the nasopharynx or from fat surrounding the Eustachian tube, and they usually appear as pedunculated or sessile masses [2–4]. Small lesions are often asymptomatic and are therefore discovered incidentally during nasal endoscopy. We report the case of a 43-year-old woman with a nasopharyngeal lipoma located immediately anterior to the left Eustachian tube orifice; in this location, the posterior inferior turbinate restricted direct visualization of the tumor pedicle and made endoscopic excision technically challenging.

A 43-year-old woman was referred to our department after a nasopharyngeal mass was incidentally found during nasal endoscopy at a local otolaryngology clinic, where she had presented with a 2-week history of upper respiratory symptoms. She had no nasal or otologic symptoms. Her medical history included two prior malignancies. Nine years before presentation, she had undergone robot-assisted radical trachelectomy for cervical cancer, and 6 years before presentation, she had undergone wide local excision for cutaneous malignant melanoma of the abdomen. Both malignancies had been monitored with surveillance imaging, and the most recent available imaging showed no evidence of recurrence.

At presentation, her vital signs were stable, and examination of the external ears and oropharynx revealed no abnormalities. Nasal endoscopy showed an approximately 1.5-cm, smooth, yellowish, pedunculated mass anterior to the left torus tubarius (Fig. 1). Noncontrast paranasal sinus computed tomography (CT) demonstrated a well-demarcated, homogeneous lesion with fat attenuation of approximately −90 Hounsfield units anterior to the left Eustachian tube orifice on axial and sagittal images; the maximal diameter was 1.5 cm (Fig. 2). Metastatic disease and atypical lipomatous tumor/well-differentiated liposarcoma were not strongly suspected radiologically, but imaging alone could not establish a definitive histologic diagnosis. Because the lesion was small, pedunculated, and suitable for complete transnasal endoscopic removal, excisional biopsy was performed under general anesthesia to provide diagnosis and treatment in a single procedure.

A 0-degree rigid endoscope was advanced transnasally, and the lesion was visualized in the left lateral nasopharynx. The posterior end of the left inferior turbinate partially covered the Eustachian tube orifice and obscured the pedicle. To widen the lateral nasopharyngeal corridor, limited resection of the posterior one-third of the inferior turbinate was performed while preserving the torus tubarius and peritubal mucosa. The Eustachian tube orifice remained continuously visible throughout the procedure and was not directly manipulated. After the pedicle was identified, the lesion was excised at its base. Focal monopolar cautery was then applied to the pedicle base to achieve hemostasis, with care taken to avoid the Eustachian tube orifice and adjacent peritubal mucosa. Bleeding was minimal, and an absorbable nasal pack was placed.

Gross examination showed a 1.5×1.2×1.0 cm yellow, smooth-surfaced, pedunculated polypoid mass with a homogeneous cut surface. Low-power microscopy (×40) showed mature adipocytes in the subepithelial layer beneath intact respiratory epithelium, accompanied by thin fibrous septa and scant stromal components (Fig. 3A). At higher magnification (×100), the adipocytes showed no nuclear atypia, mitotic figures, or lipoblastic features (Fig. 3B). These findings supported the diagnosis of conventional lipoma. Ancillary testing for MDM2 amplification testing was not performed because the lesion was small and well circumscribed and showed mature adipocytes without nuclear atypia, lipoblasts, thick septa, or non-adipose components.

The nasal pack was removed on postoperative day 2, and the patient was discharged without complications later that day. At the 1-month outpatient visit, the surgical bed had healed without granulation tissue, synechiae, crusting, or Eustachian tube–related symptoms (Fig. 4). During subsequent follow-up, the patient remained free of nasal and otologic symptoms, and no recurrence was observed at 12 months.

Nasopharyngeal lipoma is rare, and only a few cases have been reported in Korean patients. Hong et al. [5] reported a chondrolipoma in a 63-year-old woman, which was removed through a transoral approach. Lee and Oh [6] described a nasopharyngeal fibrolipoma treated with endoscopic excision. Hwang et al. [7] reported a radiologic case involving a 74-year-old woman in whom CT identified a fat-attenuation submucosal mass that was later confirmed pathologically (Table 1). Unlike these previous Korean cases, the lesion in the present case was located immediately anterior to the Eustachian tube orifice, an anatomic site that has not been emphasized in the domestic literature.

Reported nasopharyngeal lipomas have most often arisen from the posterior nasopharyngeal wall, the nasopharyngeal roof, or the region of the torus tubarius (Table 1). A related but anatomically distinct lesion is lipoma arising within the Eustachian tube lumen. Inoue et al. [4] described a lipoma completely embedded in the Eustachian tube, probably originating from the Ostmann fat pad, that extended into the nasopharynx and caused nasal congestion and aural fullness. By contrast, the tumor in the present case arose from the lateral nasopharyngeal wall immediately anterior to the Eustachian tube orifice, and neither CT nor endoscopy showed an intraluminal Eustachian tube component. This anatomic distinction is clinically relevant because intraluminal lesions may impair tubal function and produce otologic symptoms, whereas the present tumor caused no such symptoms.

Previously reported nasopharyngeal lipomas have been treated by transoral excision [5] or endoscopic stalk excision with electrocautery [6]. In the present case, the site of the lesion created a specific technical challenge: the mass was located immediately anterior to the Eustachian tube orifice, the posterior end of the inferior turbinate obscured the pedicle, and conventional retraction did not provide sufficient exposure. Limited resection of the posterior one-third of the inferior turbinate enlarged the lateral nasopharyngeal corridor and permitted safe excision under direct vision, without the morbidity associated with a transoral or external approach. To our knowledge, the use of limited posterior inferior turbinectomy as an access adjunct has not been specifically described in the reported cases reviewed. This adjunct is not necessary in all cases, but it may be useful when a lesion arises from the lateral nasopharyngeal wall immediately anterior to the Eustachian tube orifice and the posterior turbinate prevents direct visualization of the pedicle. Because the resection was confined to the posterior one-third of the inferior turbinate and the torus tubarius and peritubal mucosa were preserved, the risk of postoperative Eustachian tube dysfunction was considered low. At 1 month, the Eustachian tube orifice remained patent, both tympanic membranes were normal, and no otologic symptoms had developed.

The decision to perform excisional biopsy rather than observation was based mainly on the feasibility of obtaining histologic confirmation and definitive treatment with minimal additional morbidity. CT showed unequivocal macroscopic fat attenuation, homogeneous internal architecture, and no thick septa, nodular non-adipose components, bone erosion, or invasive features; therefore, conventional lipoma was the leading diagnosis. Although the patient’s prior oncologic history was considered, the imaging findings did not suggest recurrence or metastatic disease. Because the lesion was small, pedunculated, and readily accessible through a transnasal endoscopic route, complete excision was considered a reasonable strategy for achieving histologic confirmation and definitive treatment in a single procedure. Magnetic resonance imaging (MRI) can be useful when the diagnosis is uncertain, particularly for differentiating benign lipoma from malignant adipocytic neoplasms such as atypical lipomatous tumor/well-differentiated liposarcoma; Chakraborty et al. [8] described MRI features that may aid this distinction. In the present case, however, MRI was not obtained because CT clearly showed a simple fat-containing lesion, and additional MRI was unlikely to change the decision to proceed with complete endoscopic excision. Atypical lipomatous tumor/well-differentiated liposarcoma was therefore considered a low-probability histologic differential rather than a radiologically suspected diagnosis [9,10].

Histopathologic examination showed mature adipocytes without nuclear atypia, lipoblasts, thick fibrous septa, or non-adipose components, confirming conventional lipoma. MDM2 amplification testing, which is typically performed by fluorescence in situ hybridization, may help resolve cases in which the morphologic findings are equivocal or inconsistent with the clinical or radiologic features [11]. In this case, the completely excised specimen showed unequivocally benign morphology, so additional MDM2 testing was not considered necessary.

Although nasopharyngeal lipoma is benign, complete excision is preferred when the lesion is symptomatic or when the diagnosis remains uncertain. Recurrence after complete excision of ordinary lipoma is uncommon and is usually associated with incomplete resection [12]; accordingly, recurrence was expected to be unlikely in this completely excised lesion. The patient had no recurrence at 12 months but was subsequently lost to follow-up. This interval was adequate to document complete healing and absence of early recurrence, but it does not constitute long-term follow-up. Longer endoscopic surveillance, particularly of the Eustachian tube orifice and adjacent resection bed, would have been preferable.

This report has several limitations. First, because it describes a single case, it cannot support generalizable conclusions. Second, follow-up was limited to 12 months because the patient was lost to follow-up thereafter. Third, the literature review was narrative rather than systematic, so additional cases may have been missed.

We report a conventional lipoma arising from the lateral nasopharyngeal wall immediately anterior to the Eustachian tube orifice. Although CT strongly favored benign lipoma, complete endoscopic excision established the histologic diagnosis and treated this small, pedunculated lesion. Limited posterior inferior turbinectomy may serve as a useful access adjunct in selected cases when the posterior turbinate obstructs visualization of the tumor pedicle, provided that the torus tubarius and peritubal mucosa can be preserved.