Authors: Shrinivas S. Chavan*, Sunil Deshmukh**, Vasant Pawar***, Kaustabh Sarvade****, Vaibhav Kirpan****, N.R Kumbhakarna*****, Mangala Sonavani******
*Assistant Professor ENT, **Professor & Head ENT, ***Senior Resident, ****Resident, *****Professor Pathology, ******Professor & Head Internal Medicine
Institution: Government Medical College and Hospital, Maharashtra, India.
Corresponding Author:
Shrinivas S. Chavan (Contact Author)
Aurangabad, 431001.
Maharashtra, India.
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Abstract:
In this retrospective prospective study, 147 various cases of benign nasal mass (BNM), both common and rare were encountered. In each case it was a challenge for us to arrive at a clinical diagnosis in the first glance, which was scrutinized with histopathological examination later on. In our case study, we have used both an endoscopic approach and an external surgical approach, for managing the cases depending upon the extent of the lesion with due respect given to its apparent gross pathology. The aim of our study is to put forward clinical diagnosis and histopathological features of various benign nasal masses in front of the clinician so as to enable them to diagnose the condition as early as possible and also to draw the attention to the fact that not all cases of rhinitis and nasal obstruction are due to infective rhinitis and allergic rhinitis and hence must be dealt with diligence.
Introduction:
A mass anywhere in the body is like a riddle to both physician and surgeon alike, similarly a mass in the sinonasal area holds no exception, where an otorhinolaryngologist tries to gauge the mass using variables like history, clinical examination, radiological examination, gross appearance of mass, etc. and construes an opinion which is either confirmed or refuted on histopathological examination.
Benign nasal mass is an age old disease known to mankind since the days of ancient Egyptians, but because of the lack of existence of operating microscopes- an idea later theorized by Nylen (1921-1922) and popularized by Holmgren[1]- and heavy reliance on traditional clinical methods of inspection and palpation, no wonder many cases might have gone undetected and were stereotypically treated by snare method as documented from the days of Hippocrates.
But in today’s world with the availability of sophisticated endoscopes, high-end microscopes coupled with newer immunohistochemical techniques have opened the Pandora Box to include as many probable types of benign nasal mass (BNM) as one can think of and hereby we present only a fraction of the wide array of BNM conditions with respect to clinical features and histopathology. Our study attempts to address the issue of creating awareness and generating a high index of suspicion amongst clinicians so as to diagnose BNMs in early stages.
Methods:
A study of prospective and retrospective nature was conducted by the ‘Department of Otorhinolaryngology’ in collaboration with the ‘Department of Pathology’ and ‘Department of Internal Medicine’, Government Medical College, Aurangabad from January 2007 to September 2011. All cases of BNM which were clinically and radiologically diagnosed and histopathology report proven are included in our study.
Amongst the study population of 147 patients, 86 were female and 70 were male. Inclusion criteria was entirely based on clinical signs and symptoms, laboratory tests, and radiological investigation with histopathology report conformation of the benign nature of the nasal mass. For our study and for the sake of simplicity, the BNM has been defined as a mass of benign origin, e.g., capillary hemangioma as well as a mass of non-neoplastic origin, e.g., antrochoanal polyp. Thus, all non-malignant masses are included in the study purview. All malignant nasal masses are excluded from the study domain.
All patients were subjected to nasal endoscopy and computed tomography of the paranasal sinuses, preoperatively. All cases required surgical intervention and the mode of approach – external or endoscopic was entirely based on the extent of the lesion documented on paranasal sinus CT Scan and also on gross pathology.
Clinical Cases: Click on the Case Number to view Case
Case 1: Capillary Hemangioma
View Surgery YouTuve Video
Case 2: Nasopharyngeal Angiofibroma
Case 3: Extra-nasopharyngeal Angiofibroma
Case 4: Nasal Schwannoma
Case 5A: Schneiderian Papilloma - Everted Papilloma
Case 5B: Schneiderian Papilloma - Inverted Papilloma
View Surgery YouTube Video
Case 6A: Tropical Disease - Rhinosporidiosis
Case 6B: Tropical Disease - Rhinoscleroma
Case 7: TB of Maxillary Sinus (Nasal Tuberculosis)
Case 8: Fibrous Dysplasia
Case 9: Dermoid Cyst
Case 10: Antrochoanal Polyp
Results:
Data, both retrospective and prospective, were compiled over the specified period. Analysis of 147 cases of benign nasal mass (BNM) revealed that 88 cases (59.9%) were females and 59 cases (40.1%) were males.
Maximum numbers of 69 cases (46.93%) were seen in the 3rd decade followed by 42 cases (29%), 27 cases (18.36%), 5 cases (3.40%) in 2nd, 4th, 5th and 1 case each in (0.68%) 1st, 6th, and 8th decade.
Mean age of presentation was 27.3 years with the youngest patient being only 7 days old and the eldest being 75 years old. In 82 cases (55.78%), the right side was involved, left side was seen to be affected in 54 cases (36.73%) whereas 11 cases were of bilateral nature (7.48%).
As shown in the Table and Figure below: Nasal polyps contributed the most to the number of cases (51.7%). They produced symptoms of nasal obstruction with or without nasal discharge. Nasal obstruction and drainage were the most common symptoms observed in this study and were found in 83 cases (56.46%), whereas the least common symptom was diplopia, observed in a sole case of maxillary tuberculosis.
Table 1: Distribution of Cases As Per Histopathological Nature of the Lesion.
Discussion:
Although not so uncommon in clinical practice, the condition of a benign mass in the sinonasal cavity is often neglected by the clinician suspecting the early symptoms of nasal obstruction and rhinorrhea to be associated with infective or allergic rhinitis. Incidence of ‘benign nasal mass ‘ in the Indian subcontinent is poorly documented but western figures of overall nasal tumors including malignant tumors are estimated to be 1 in 1,00,000 people per year with males twice as much affected as females.2 Amongst which half are benign in nature.3
In our case study of 147 patients, the youngest patient was a 7-day-old newborn with a nasal dermoid cyst. Nasal dermoid is a congenital developmental anomaly with an incidence of 1:20000 to 1:40000 births.4,5 Some dermoid lesions can present as cystic lesions with or without intracranial extensions.6 We witnessed a single case of nasal dermoid cyst in a 7 day old neonate.
The oldest patient in the study was a 75-year-old female suffering from capillary hemangioma. Typically, such a patient presents with epistaxis and nasal obstruction as the most common symptoms.7 We encountered four cases of capillary hemangioma, all showing attachment to the nasal septum. All the patients were female. Hence, the role of strong hormonal influence for the pathology must be suspected and further evaluated.8 Surgical excision is the treatment of choice which was followed in this case.
By far the most common BNM encountered in our case study was the nasal polyp; 51.7 % of the cases revealed ethmoid polyp and 20.4% revealed an antrochoanal polyp. A study on BNM by Aminu Bakari, et. al, and Abu Humayun, et. al, reported the incidence to be 1.3% and 10%, respectively.9,10 In our study, there was a statistically significant (P< 0.05) preponderance of cases of ethmoidal polyp. Also, an incidence of 28.3 % was reported for cases of antrochoanal polyp compared to an incidence of 13.2% and 16% reported by the aforesaid authors, respectively. 78% of the ethmoid polyp cases showed dramatic improvement after a short course of a systemic steroid and local steroid nasal spray given preoperatively, a finding congruent with a study conducted by Rasp, G., et. al.11 It was obvious on the films of computed tomography of the paranasal sinuses done preoperatively. Three patients were not given systemic steroids due to systemic contraindication for intermediate to long-term administration of corticosteroids. Five patients with ethmoid polyp refused surgery as they were symptom free. All other patients underwent Functional Endoscopic Sinus Surgery (FESS) and were subjected to postoperative local steroids, intranasally.
The second most common BNM in our case study was nasopharyngeal angiofibroma. In all, 18 cases (12.24% cases) were documented by the authors. K.V. NarayanSwamy, et. al, studied eight cases of angiofibroma in a series of 30 cases of benign nasal masses (26.66%).12 All the cases encountered in this study were young adolescent males having a history of profuse epistaxis. With the aid of imaging modality, 7 cases (38.88%) were staged as grade I (tumor confined to nasopharynx), 5 cases (27.5%) as grade II (tumor extending into nasal cavity or sphenoid sinus), and the remaining 6 cases (33.3%) as grade III (tumor extending into pterygomaxillary, infratemporal fossa, cheek). None of the patients had extension into the ethmoid sinuses, orbit or cranium. However, a case study done exclusively on angiofibroma (18 cases), by M Jacobsson et al found only 2 cases in stage I(11.1%), 7 cases in stage II (35.35%), 8 cases in stage III (40.40%), and 1 case with intracranial extension, i.e. stage IV (5.05%).13 All patients underwent surgery, although the mode of approach [Trans-palatine, Lateral Rhinotomy and Weber-Ferguson] was chosen depending upon the extension of the lesion documented on CT scan done preoperatively. None of our patients had undergone embolization of the feeding vessel as we lacked the facility of interventional radiology in our institute.
In our case study, in the five cases of Schneiderian papilloma there were 4 cases were of inverted papilloma and one rare case that was an everted papilloma. The inverted papilloma was exclusively seen in females. All patients underwent surgery and none of them showed recurrence or malignant transformation.
In our case study, there were 7 cases of Tropical disease, 3 cases of rhinosporidiosis and 4 cases of rhinoscleroma were encountered. The 3 cases of rhinosporidiosis gave strong history of taking a bath in river/pondwater and among the 3 patients one was a driver by occupation. All cases of rhinosporidiosis underwent surgical excision taking all necessary aseptic precaution in the operation theater.
Among the 4 cases of rhinoscleroma which were in the nodular stage, three patients underwent excision of the nodule and were subjected to nasal tubation for 2 months. All the cases of rhinoscleroma were kept on a long-term course of Rifampicin.
The only case in our BNM study showing orbital involvement was maxillary sinus TB. The only way to diagnose this condition was surgical debridement and HPR confirmation. The patient was kept on Anti Koch's Treatment (AKT) for 9 months and was further continued with robust AKT therapy.
The other cases encountered in our study were nasal schwannoma, fibrous dysplasia, and extra nasopharyngeal angiofibroma. In our case study, 3 cases required imummohistochemistry examination. The purpose for the use of the special stain was to rule out other probable diagnoses of BNM and to come closer to a definitive diagnosis.
Conclusion:
Our case study represents the tip of the iceberg for the enormous number of benign nasal masses cases. The purpose of our study is not only to present the various differentials of BNM and correlate them histopathologically but also to generate a high index of suspicion in the physician’s mind to enable them to catch these lesions in early stage of their natural course.
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