A Clinicopathological Radiological Correlation of Unilateral Sinonasal Masses

INTRODUCTION

The occurrence of a nasal mass is a frequently observed condition in the outpatient ENT department of any hospital. These masses cause a variety of symptoms, including nasal blockage, headaches, nosebleeds, and damage to nearby structures. The presence of masses causes inflammation to the surrounding tissue, leading to alterations in the local anatomy and physiology, which complicates the clinical presentation. The first symptomatology of both benign and malignant tumors is nearly identical. Therefore, a comprehensive clinical and radiological evaluation is crucial for establishing an accurate diagnosis. However, the clinician must consider the possibility of underlying malignancies when noticing a unilateral nasal mass. Patients presenting with such findings should have a thorough endoscopic examination. If there is any suspicion, imaging techniques should be employed to establish an accurate differential diagnosis. Unless proven otherwise, all unilateral mass lesions should be considered as malignant lesions.¹ Sinonasal masses can be categorized into malignant tumors, benign tumors, and non-neoplastic lesions. The most commonly observed malignant tumors are squamous cell carcinomas, while benign lesions are often nasal polyps.² In addition to this, a diverse range of nasal conditions, such as mucocele, inverted papilloma, and fungal diseases can manifest as a unilateral nasal tumor.

The objective of this study was to provide a comprehensive analysis of the symptoms, clinical findings, lesion sites, histological investigation results, and therapeutic options for unilateral sinonasal masses.

MATERIALS AND METHODS

An observational study was carried out on 81 patients who presented with unilateral masses in their nasal cavities. These patients were examined in the outpatient department of ENT at Command Hospital Bengaluru over 3 years, from 2014 to 2016. A detailed history was recorded, including information about the individual’s age, gender, occupation, place of residence, symptoms, and the time at which they first appeared. Standard biochemical and hematological assessments were conducted. The procedure involves examining the nasal cavity using an endoscope, as well as obtaining computed tomography (CT) scans of the nose and paranasal sinuses (PNS). The CT scans are taken from different angles, including coronal and axial views. A provisional clinical diagnosis was established. An endoscopic biopsy was performed in cases when the clinical examination raised suspicion of a non-benign lesion. The tissues underwent histological examination and were stained using hematoxylin and eosin stains. Immunohistochemistry was performed if necessary. Informed written consent was obtained from all patients for the study. Approval was received from the Institutional Ethics Committee. The final histological diagnosis was compared with the provisional clinical diagnosis.

RESULTS

The study revealed that the average age of the patients was 43, and there were 8 males for every 1 female in the sample. The most often reported symptom upon presentation was nasal blockage (Table 1). The mean duration of the presentation was 4 months. During anterior rhinoscopy, a unilateral nasal mass was observed in 74 patients, accounting for 91% of the cases. The nasal mass exhibited a polypoidal appearance in 63 cases, a fleshy feature in 7 cases, and a proliferative appearance in 4 cases. After rhinoscopy, a mass was observed in 40 patients. Probing was conducted on all patients presenting with nasal masses, the majority of which showed a soft consistency. Three patients experienced spontaneous bleeding upon touch. One patient exhibited a palatal bulge, while two patients experienced proptosis and diplopia. A palpable cervical lymph node was observed in two patients, whereas cranial nerve involvement was observed in one patient.

All cases underwent a CT scan of the paranasal sinuses, with or without contrast. Magnetic resonance imaging (MRI) of the PNS was performed in 26 cases. PET-CT was performed in five cases, while angiography was performed in one case. Endoscopic biopsy had been taken in 30 cases. However, the results were inconclusive in 3 cases, notably 1 case of neurofibroma, 1 case of solitary fibrous tumor, and 1 case of non-Hodgkin’s lymphoma. Additionally, the biopsy results were incorrect in five cases of inverted papilloma, which were erroneously labeled as inflammatory polyps. Additionally, two cases of adenoid cystic carcinoma were incorrectly identified as inverted papilloma. One individual underwent a repeated endoscopic biopsy, which was followed by the use of immunohistochemistry to confirm the diagnosis of non-Hodgkins lymphoma.

The provisional clinical diagnosis based on imaging and biopsy (Table 2) revealed nasal polyposis in 49 cases, malignancy in 7 cases, and inverted papilloma in 16 cases. Functional endoscopic sinus surgery (Table 3) was performed to manage nasal polyps, fungal sinusitis, and five cases of inverted papilloma that presented with symptoms similar to nasal polyps. Additionally, one case of odontogenic keratocyte was also treated. Endoscopic medial maxillectomy was performed as a revision procedure in all five cases of inverted papilloma.

Endoscopic medial maxillectomy was performed in 8 cases of inverted papilloma. Three cases of squamous cancer underwent total maxillectomy. Medial maxillectomy was performed on 13 patients, including 7 cases of inverted papilloma, 1 case of angiofibroma, 3 cases of adenoid cystic carcinoma, 1 case of neurofibroma, and 1 case of a solitary fibrous tumor. An endoscopic Draf 2b procedure was performed in one case of adenocarcinoma. Infrastructure maxillectomy was performed for a case of acinic cell tumor. A single patient diagnosed with non-Hodgkin’s lymphoma was referred for chemotherapy treatment.

The histopathology findings (Table 4) revealed the presence of 44 cases of inflammatory polyp, 3 cases of adenoid cystic carcinoma, 1 case of solitary fibrous tumor, 19 cases of inverted papilloma, 1 case of angiofibroma, 5 cases of fungal sinusitis, 3 cases of squamous carcinoma, 1 case of odontogenic keratinizing tumor, and 1 case of acinic cell tumor. The occurrence of numerous etiologies leading to pyomucocele (as seen on MRI) was observed in 2 patients with inverted papilloma and chronic noninvasive fungal sinusitis, 1 patient with nasal polyp, and 1 case of odontogenic keratocyte during surgery.

OBSERVATIONS

A histopathological study was performed on a total of 81 individuals. Among them, 52 patients had non-neoplastic conditions, 20 patients had intermediate tumors, and 9 patients had neoplastic tumors. Immunohistochemistry was performed in three patients to confirm the diagnosis. One case of recurrent fibrous nasal tumor, neurofibroma (s-100 positive), and non-Hodgkin’s lymphoma (Fig. 1) were confirmed.

The histopathological result modified the clinical diagnosis in 7 out of 81 individuals (8.6%). The clinical and histological diagnosis remains constant. Five individuals with clinically benign lesions were first diagnosed as having inflammatory polyps. However, after histopathological examination, all of these lesions were reclassified as inverted papillomas. Therefore, a revision procedure called endoscopic medial maxillectomy was performed. Two instances of adenoid cystic carcinoma were first diagnosed as inverted papilloma based on clinical radiological examination, while the biopsy results were equivocal. However, both cases underwent medial maxillectomy and the final histological diagnosis confirmed adenoid cystic carcinoma. However, in each of these cases, the margins were clear and so did not necessitate further surgical modification. Revision surgery was performed on five individuals with inverted papilloma due to a discrepancy between the initial clinical and radiological findings of a polyp and the final histological diagnosis of inverted papilloma. Revision endoscopic medial maxillectomy was performed in these cases. Oral antifungals were prescribed to treat chronic noninvasive fungal sinusitis in five patients. Adjuvant radiation was administered to six patients with carcinoma.

DISCUSSION

Lesions in the nasal cavity, PNS, and nasopharynx are a group of masses that exhibit a wide range of histological characteristics. Clinical differentiation of various non-neoplastic and neoplastic lesions is challenging. Failure to differentiate between benign and malignant conditions during the initial presentation might lead to a delay in diagnosing and treating the condition.

The objective of this study was to investigate the symptoms, clinical findings, location, histological test results, and the application of immunohistochemistry in unilateral nasal growths.

Unilateral sinonasal mass lesions account for 6% of all paranasal diseases.³ Inflammatory or neoplastic etiologies play a role in its etiology. Kahveci et al.⁴ conducted a study on 127 cases and observed that 25.2% of the cases with unilateral sinonasal masses were attributed to neoplastic origins, while 74.8% were attributed to inflammatory reasons.

The average age of the patients in our study was 43 years, with a male-to-female ratio of 8 to 1. The most frequent symptom reported was nasal obstruction, with an average time of presentation occurring 4 months following the onset of symptoms. A unilateral polypoidal growth was the most common finding during the examination.

Radiological studies may help understand the type of pathology, the extent of the condition, and any accompanying sinus-related complications. Magnetic resonance imaging was performed on a cohort of 24 individuals to assess the extent of sinonasal masses within the orbit and intracranial cavity, to visualize the precise extent of soft tissue involvement in individuals with suspected malignant masses extending into the orbit or intracranial region. The reliability of CT scans in determining the extensions of sinonasal mass lesions is limited due to the potential misinterpretation of retained or inspissated secretions and thicker mucosa within the PNS as expansions of malignancy, resulting in false-positive results. An MRI assessment is necessary even after a CT scan of the PNS to distinguish between actual disease infiltration and blockage caused by infiltration of the draining Ostia.⁵ Magnetic resonance imaging is crucial for determining the extent of soft tissue infiltration surrounding the tumor, which is essential for assessing its resectability. An important benefit of MRI is its ability to differentiate between tumors and accumulated secretions in the various sinus cavities.⁶ For a more thorough examination when there is suspicion of an intranasal tumor, CT of the PNS should be the preferable imaging method.⁷ Computer tomography PNS can assist in determining the stage of the disease and help with the process of surgical planning. Computer tomography PNS were performed in all cases in our study.

CONCLUSION

It is important to carry out an in-depth assessment of patients reporting symptoms in the unilateral nasal cavity. The clinical manifestation of unilateral sinonasal lesions may be identical, and represent diagnostic and therapeutic dilemmas. The early presentation of non-neoplastic and neoplastic lesions may exhibit identical characteristics, which can cause a considerable delay in making a diagnosis. Accurate diagnosis requires the correlation of clinical, radiological, and pathological modalities. All of these modalities are mutually complementary. In situations where there is a discrepancy between the clinical, radiological, and histological findings, it may be necessary to consider an alternative pathological explanation. An extensive histopathological assessment, supported by immunohistochemistry, is crucial and forms an integral element of the diagnostic process for patients with sinonasal masses.

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