Discussion:
An asymmetrical mass in the oropharynx of a young patient typically raises the possibility of malignancy and benign neoplasms, lymphovascular lesions, and inflammatory or infection etiologies.4 The age of our patient, imaging features and presentation suggested a benign etiology, but the discovery of an accessory tragus was still an unexpected rare finding. The histopathological characteristics of hair follicles, numerous fat lobules, and cartilage were features that helped determine that the excised lesion was an accessory tragus.5 Previous studies on the origins of congenital ear malformations reveal a complex interplay between environmental and genetic factors.6The rare developmental anomaly of an accessory tragus in the oropharynx highlights the intricacies of embryological development in the head and neck region.
The first pharyngeal arch plays a crucial role in development, giving rise to the maxilla, mandible, malleus, and incus, and the muscles of mastication.1,7 Anomalies in the development of this arch can result in a spectrum of presentations, from minor deformities to significant congenital syndromes such as Treacher Collins and Pierre Robin syndromes.8,9 While an accessory tragus is commonly an isolated deformity, it is also found in association with congenital syndromes such as Goldenhar syndrome.9
In addition to the rare finding of an oropharyngeal accessory tragus, the patient’s hearing conductive loss was attributed to a congenital ossicular discontinuity where middle ear exploration revealed anomalies in the incus and stapes capitulum. A general correlation between the severity of auricle and middle ear malformations with resultant conductive hearing loss has been noted and highlighted by conditions such as congenital aural artesia.6 Specific to this case, it is curious that the incus and tragus are both derivatives of the same first pharyngeal arch and thus, both are likely manifestations of a singular malformation.
As far as we are aware, there is only one other reported case of a nasopharyngeal accessory tragus, which presented in a 9-year-old with expected nasal breathing issues.3