|Year : 2023 | Volume
| Issue : 1 | Page : 79-85
Clinical and histopathological correlation of unilateral nasal mass – A retrospective observational study
Raghunath Shanbag1, JS Arunkumar1, Shraddha Pai1, Santosh S Garag1, GY Pooja1, Umesh R Dixit2
1 Department of Otorhinoloryngology and Head and Surgery, SDM College of Medical Sciences and Hospital, Dharwad, Affiliated to SDM University Dharwad, Karnataka, India
2 Department of Community Medicine, SDM College of Medical Sciences and Hospital, Dharwad, Affiliated to SDM University Dharwad, Karnataka, India
|Date of Submission||24-Jan-2022|
|Date of Acceptance||30-Apr-2022|
|Date of Web Publication||21-Jan-2023|
Dr. J S Arunkumar
Department of Otorhinoloryngology and Head and Surgery, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Nasal obstruction and nasal discharge are the most common symptoms in otorhinolaryngology practice; they may be unilateral or bilateral. Unilateral persistent nasal obstruction may indicate the presence of sinonasal lesion that could be inflammatory or neoplastic. Biopsy and histopathological examination of the nasal mass will give the definitive diagnosis, which was correlated with the clinical diagnosis.
MATERIALS AND METHODS: This study was conducted retrospectively in a tertiary health care center after collecting the data of patients who underwent biopsy or surgical excision of unilateral nasal mass during 6 years period from January 2015 to December 2020. A total of 208 patients who met the inclusion criteria were included in the present study. These cases were subjected to a detailed history, clinical examination, nasal endoscopy, computed tomography scan, biopsy or excision biopsy, and histopathological examination. The data collected from these cases were compiled, analyzed, and conclusions were drawn.
RESULTS: Of these 208 patients, majority (127; 61.1%) had non-neoplastic lesions while 81 (38.9%) had neoplastic lesions based on clinical diagnosis. Among patients with neoplastic lesions, 50 (61.7%) were benign and 31 (38.3%) were malignant.
CONCLUSION: Antrochoanal polyp is the most common type of unilateral nasal mass, followed by inflammatory polyp among nonneoplastic lesions and hemangioma and inverted papilloma among neoplastic lesions in this study. Majority of the patients were in the age group of 11‒20 years. Nasal obstruction and rhinorrhea were the most common symptoms in majority of patients.
Keywords: Biopsy, inverted papilloma, nasal polyp, unilateral nasal obstruction
|How to cite this article:|
Shanbag R, Arunkumar J S, Pai S, Garag SS, Pooja G Y, Dixit UR. Clinical and histopathological correlation of unilateral nasal mass – A retrospective observational study. Indian J Health Sci Biomed Res 2023;16:79-85
|How to cite this URL:|
Shanbag R, Arunkumar J S, Pai S, Garag SS, Pooja G Y, Dixit UR. Clinical and histopathological correlation of unilateral nasal mass – A retrospective observational study. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Jan 28];16:79-85. Available from: https://www.ijournalhs.org/text.asp?2023/16/1/79/368343
| Introduction|| |
Nasal obstruction and nasal discharge are the most common symptoms in otorhinolaryngology practice; they may be unilateral or bilateral. Unilateral persistent nasal obstruction may indicate the presence of sinonasal lesion that could be inflammatory or neoplastic. Although most sinonasal masses are inflammatory polyps, neoplastic lesions do occur, especially in unilateral pathologies. Unilateral sinonasal mass in adults is commonly assumed as either inverted papilloma or a malignant lesion. However, some workers have reported simple nasal polyp and squamous cell carcinoma as the most frequent sinonasal lesion. The etiology of nasal polyp is generally unknown; however, certain clinical conditions such as allergy, asthma, infection, aspirin hypersensitivity and cystic fibrosis are associated with it. Patients with unilateral sinonasal masses may present with the complaints of nasal obstruction, rhinorrhea, epistaxis, facial pain, facial swelling, hyposmia/cacosmia, proptosis, and diplopia. In the initial stages, it is very difficult to differentiate these symptoms from simple conditions such as a common cold or rhinosinusitis. Hence, it is imperative to fully evaluate patients presenting with unilateral nasal symptoms by taking a thorough history, complete head-and-neck examination, nasal endoscopy with biopsy, and radiological evaluation. The complex anatomy of the nose and paranasal sinuses permits the tumor to grow and fill a particular sinus or nasal cavity before invading the periosteum, perichondrium, or bone. Most of the patients have trivial symptoms and mimic some local infection in the initial stages; this may explain why a patient with sinonasal mass is present in the late stage of the disease. Very few studies have been available in the review of literature, prompting us to take this study on unilateral nasal mass with a wide range of clinical and histopathological patterns. This study was conducted retrospectively in a tertiary health care center after collecting the data of patients who underwent biopsy or surgical excision of unilateral nasal mass during 6 years period from January 2015 to December 2020, with an objective to estimate the correlation between clinical and histopathological findings.
| Materials and Methods|| |
A retrospective observational study was conducted by reviewing medical records of the patients who underwent biopsy or surgical excision of nasal mass in the department of otolaryngology, head-and-neck surgery in a tertiary health-care center. The data of these patients were collected over a 6-year period from January 2015 to December 2020. Those patients with the grossly deviated nasal septum, hypertrophied inferior turbinate, histopathological diagnosis of mucormycosis, and nasal mass extending to both the nasal cavities were excluded from the study. The parameters collected include patient history, clinical assessments, histopathological examinations, and radiological investigations (computed tomography [CT] and magnetic resonance imaging [MRI]). In addition, demographic information was obtained and the histopathological examinations of tissues for patients who underwent surgical excision were analyzed for correlation with clinical diagnosis. The collected data were entered into a Microsoft Excel sheet and analyzed. Ethical clearance was obtained from SDM College of Medical Sciences and Hospital institutional ethics committee with ref no SDMIEG /2021/75.
This study received approval from the Institutional Ethical Committee that reviewed a proposal letter explaining the purpose, methods, and anticipated benefits and risks of the study along with the questionnaire. Appropriate permissions were obtained from the Medical Records Department to use the hospital data for this research.
| Results|| |
During the period from January 2015 to December 2020, data belonging to a total of 208 patients met with the inclusion criteria of this study and was included in the analysis. Out of 208 patients, 123 (59%) were male and 85 (41%) were female. The age of the patients ranged from 9 days to 82 years, with most of the patients (47/208; 22.6%) belonging to the age group of 11–20 years, followed by 41/208 (19.7%) between 21 and 30 years of age. Other age distributions of the patients are shown in [Table 1].
|Table 1: Age and sex distribution of patients with unilateral nasal mass|
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The most common symptom was nasal obstruction (191/208; 91.8%), followed by rhinorrhea (169/208; 81.3%). Over three in four patients presented with complaints of nasal mass (159/208; 76.4%). Other prevalent symptoms were epistaxis and facial pain/headache. Majority of the cases had symptom duration ranging from 6 months to 18 months. Epistaxis was observed to be more common among patients with neoplastic lesions (24/31; 77.4%) than nonneoplastic lesions (20/127; 20.5%). Proptosis and cheek swelling were the least symptoms at presentation and were observed in patients with neoplastic lesions, as shown in [Table 2].
Of these 208 patients, majority (127; 61.1%) had non-neoplastic lesions while 81 (38.9%) had neoplastic lesions based on clinical diagnosis. Among patients with neoplastic lesions, 50 (61.7%) were benign and 31 (38.3%) were malignant. The most common lesion in this study was inflammatory lesion (89/208; 42.8%).
Out of 127 nonneoplastic lesions, clinically, the most common diagnosis was antrochoanal (AC) polyp (50/127; 39.4%), followed by cystic lesions (27/127; 21.3%) and inflammatory polyps (23/127; 18.1%).
There were four cases of pyogenic granulomas and two cases of rhinoscleroma, all of which presented as unilateral nasal mass. Rosai‒Dorfman disease, a rare lesion, was seen in one patient. Other less frequent lesions observed are shown in [Table 3].
|Table 3: Distribution of nonneoplastic and neoplastic nasal masses as diagnosed clinically|
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AC polyps were equally distributed among both sexes. Majority of the AC polyps were seen in patients in the age group of 11–20 years (18/50; 36%), followed by the age group of 21–30 years (10/50; 20%). Only five patients were aged below 10 years with the youngest being 6 years old. All these patients were treated with endoscopic sinus surgery.
Among the cystic lesions, mucocele was most common (13/27; 48.2%), followed by nasolabial cyst (8/27; 29.6%) and dental cysts (5/27; 18.5%). One case of the nasolacrimal cyst was also observed.
Among 13 mucocele patients, the majority of patients had involvement of the frontal sinus (7/13; 53.8%), followed by frontoethmoid (5/13; 38.5%). There was one case involving sphenoid sinus. Males were slightly more common (7/13; 53.8%) compared to females (6/13; 46.2%). The most common affected age group observed in this study was 41–50 years and 51–60 years, with three cases each (23.1%). All patients underwent endoscopic excision [Figure 1] and [Figure 2], and one case needed an additional external approach to completely excise the wall.
|Figure 2: Computed tomography scan of right side frontoethmoidal mucocele|
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Females outnumbered males (5 [62.5%] vs. 3 [37.5%]) in nasolabial cyst. The most common age group affected observed was 21–30 years (3/8; 37.5%).
Dental cysts were observed in five patients, with three being dentigerous cysts and two odontogenic keratocysts. Majority of these patients were males (4/5; 80%), whereas only one was female. Majority of dental cyst patients, 3/5 (60%), belonged to the age group of 11–20 years.
Among 23 patients diagnosed clinically with inflammatory nasal polyps, 12 (52%) were female and 11 (48%) were male. The most common age group with inflammatory polyps observed was 41–50 years and 51–60 years, with five cases (21.7%) each. All patients underwent endoscopic sinus surgery with complete clearance of the lesion.
Among 50 patients with benign lesions, hemangioma was most common (17/50; 34%), followed by inverted papilloma (15/50; 30%). Juvenile angiofibroma was seen in 14 cases (28%) and squamous papilloma in two patients (4%). One case each of rare benign tumors such as schwannoma and fibroma was also shown in [Table 3].
Hemangioma was observed more among males (11/17; 64.7%) compared to females (6/17; 35.3%). Majority of the hemangiomas patients (6/17; 70.6%) were in the 21–30 years age group. They all underwent endoscopic excision, and the site of attachment was cauterized with bipolar cautery and hemostasis was maintained.
Inverted papilloma [Figure 3] and [Figure 4] had a male preponderance (11/15; 73.3%). The most common age group affected was 51–60 years, with 5/15 cases (33.3%). One patient had recurrence after 6 months which was again taken for surgery for endoscopic excision. No evidence of any malignant change was seen in any of the cases.
Angiofibroma was observed only among male patients, youngest patient being 13 years of age. Majority of these patients belonged to the 11–20 years age group (9/14; 64.3%). In our series majority of angiofibromas were confined to the nasopharynx, nasal cavity with extension into the pterygopalatine fossa except in one case. In one patient, angiofibroma extended into the inferior orbital fissure with erosion of the greater wing of the sphenoid. All angiofibroma patients were managed with endoscopic endonasal excision. Immediate postoperative CT scan was done in all 14 patients after pack removal, and no remnant was seen.
Malignant lesions were observed more among males (19/31; 61.3%) compared to females (12/31; 38.7%). Majority of the patients belonged to the age group of 61–70 years (7/31; 22.6%), followed by 51–60 years (6/31; 19.4%).
The predominant type of malignant lesion was squamous cell carcinoma (9/31; 29%), followed by lymphoma (5/31, 16.1%). Other types of malignant lesions included adenoid cystic carcinoma, malignant melanoma, plasmacytoma, undifferentiated carcinoma, low-grade papillary adenocarcinoma, basal cell adenocarcinoma, neuroectodermal tumor, spindle cell carcinoma, hemangiopericytoma, and Ewing's sarcoma [Table 3].
Among nine cases of squamous cell carcinoma, four cases were nasopharyngeal carcinoma, in three cases, anterior ethmoid and nasal cavity were involved, and two cases involved maxillary sinus. Among five cases of lymphoma, two were NK-T-cell lymphoma and nonHodgkin's lymphoma each and one case of diffuse large B-cell lymphoma.
The diagnoses of unilateral nasal masses with clinical, radiological, and histopathological examinations are tabulated in [Table 4]. The agreement between clinical and histopathological diagnoses was analyzed with Cohen's kappa statistic.
|Table 4: Comparison of clinical, histopathological, and radiological diagnoses of unilateral nasal masses|
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The concordance between clinical and histopathological diagnoses matched predominantly except in eight cases of inflammatory polyps. Six cases that were clinically diagnosed with inflammatory polyps turned out to be AC polyps on histopathological examination. Two cases which were diagnosed as inflammatory polyps on histopathology turned out to be fungal sinusitis.
Based on Cohen's k calculations, there was almost perfect agreement for AC polyp (89.28%) and inflammatory polyp (88.24%), whereas there was the substantial agreement for fungal sinusitis (71.43%).
In 33 patients, nasal mass could not be definitively diagnosed clinically. However, using additional radiological imaging, two cases were diagnosed as fibrous dysplasia, one case as vascular malformation, and the other one as olfactory neuroblastoma. The remaining 29 patients were not diagnosed with any type of lesion with clinical and radiological imaging. The final diagnosis was obtained with histopathological examination, as mentioned in [Table 4].
| Discussion|| |
Patients presenting with unilateral nasal mass pose a diagnostic challenge for the clinician. Many of the symptoms of unilateral nasal mass resemble or mimic chronic rhinosinusitis. Diagnostic nasal endoscopy, CT scan, and MRI whenever used will give some additional information, particularly about skull base defects such as meningocele and vascular lesions that are contraindications for an ambulatory biopsy. Preoperative tissue diagnosis is recommended to plan the surgical intervention with the additional benefit of better patient–doctor acknowledgment of the nature of the disease. However, the definitive diagnosis will be by histopathological examination of the biopsy tissue or excision biopsy.
In the present study, unilateral nasal mass included both nonneoplastic and neoplastic lesions; males were more compared to females (1.44:1), which is similar to the findings reported by Humayun et al. (3.5:1) and by Erkul et al.(1.9:1).
Patients with unilateral nasal masses can present with nasal blockage, rhinorrhea, epistaxis, hyposmia, facial pain/headache, cheek swelling, proptosis, and diplopia. Nasal blockage was the most common symptom, followed by rhinorrhea in nonneoplastic lesions. However, epistaxis and facial pain/headache were the predominant symptoms among patients with neoplastic cases. Unilateral nasal obstruction was a predominant presenting symptom in our study (191/208; 91.8%). This finding is similar to the studies reported by Lathi et al. and Singh et al. Our finding also matches the observation made by Nair et al., in which nasal obstruction was the most common symptom in both the inflammatory and neoplastic groups.
In our study, nonneoplastic lesions were common (61%) compared to neoplastic lesions (39%). Similar findings were reported by Kahveci et al. (74.2% vs. 25.2%, respectively) and Gomes et al. (64.7% and 35.3%, respectively). This finding also matched with that by Satarkar and Srikanth, in which tumor-like lesions were predominant (116/206; 56.3%) compared to neoplastic lesions.
Our study results differed in the age group distribution of inflammatory polyps from Ghosh and Bhattacharya. Tondon et al. who reported the incidence of inflammatory lesions most in 20–29 years.
Among the nonneoplastic lesions, AC polyp was most common, accounting for 56 cases (44.09%), and inflammatory polyps in 15 cases (11.8%). These prevalent lesions observations were on par with other studies of unilateral nasal masses. Erkul et al. also reported that unilateral nasal lesions were most frequently AC polyp. Similarly, the study by Belli et al. observed that among nasal mass, nasal polyp (81.03%) was common, followed by inverted papilloma (13.33%). Our observations differed from those of Iseh and Kucur et al. who reported inflammatory polyp and mucocele as the most common lesion.
Among the benign tumors, hemangioma (17/50; 34%) was the most common in this study. This was different from Humayun et al., Kucur et al., and Shuaibu et al. in all of which inverted papilloma was most common.
In the present study, predominant type of malignant lesion was squamous cell carcinoma (9/31; 29%). Similar observations were made by Nair et al., Belli et al., and Shuaibu et al. In our study, all squamous cell carcinoma cases were aged above 40 years. This observation was similar to that made by Chung et al. and Sokmen et al. in both of which these cases were in the age group of fifth to seventh decades. In our study, squamous cell carcinoma was commonly seen among males compared to females, and this picture was similar to that observed by Belli et al. but differed from Chung et al. and Sokmen et al.
Frequently, it gives symptoms as a unilateral nasal mass, and at the early stages of the disease may appear like benign nasal polyps. In our study, the second-most common malignant lesion was lymphoma, whereas in all these studies, the second-most common was a different malignant lesion.
Satarkar and Srikanth have opined that it is difficult to determine the primary site of origin of the malignant tumors of the nose and paranasal sinuses. This is because these sites and surrounding structures are complexly related. Cancer in this region is inclined to overgrow its natural boundaries so that at the time of diagnosis, it is rarely confined to a single site making it difficult to identify the site of origin.
| Conclusion|| |
AC polyp is the most common type of unilateral nasal mass, followed by inflammatory polyp among nonneoplastic lesions and hemangioma and inverted papilloma among neoplastic lesions in this study. Majority of the patients were in the age group of 11-20 years. Nasal obstruction and rhinorrhea were the most common symptoms in majority of patients. However, epistaxis and facial pain/headache were observed in patients with neoplastic lesions. Although detailed clinical history, examination, diagnostic nasal endoscopy, and imaging studies, including CT and MRI scans will help in the early diagnosis of unilateral nasal masses, the definitive diagnosis, particularly in fungal sinusitis, will be better established with histopathological diagnosis. Some of the rare conditions are also diagnosed with histopathological examination of biopsy or excision biopsy specimen with the help of nasal endoscope, which plays an important role in diagnosis and consequently the management of nasal masses.
Declaration of patient consent
The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]