|Year : 2020 | Volume
| Issue : 3 | Page : 128-138
Spectrum of histopathological lesions of nose and paranasal sinuses: A 5-year study
Urmi Chakravarty Vartak, Aditi Girishrao Sarnaik, Shailesh Vartak, Farhat Pathan
Department of Pathology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
|Date of Submission||30-Sep-2020|
|Date of Acceptance||16-Feb-2021|
|Date of Web Publication||29-Apr-2021|
Department of Pathology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To study the spectrum of lesions of nose and paranasal sinuses over a period of 5 years in a tertiary care hospital. To find the incidence and age and sex distribution along with their clinical presentation and various histopathological patterns.
Materials and Methods: The study included biopsies and resection specimens. The clinical details such as age and sex of the patient, clinical presentation, and radiological findings were retrieved from the records. The tissue specimens were processed after fixing in 10% formalin and stained with hematoxylin and eosin stains. Various special stains were performed as per the need such as Gomori methenamine silver stain and periodic acid–Schiff for fungus. The neoplastic lesions were classified as per the World Health Organization 2017 classification.
Results: The incidence of nose and paranasal sinus lesions was 0.71% (310 cases). Nonneoplastic cases (156) constituted 50.32%, whereas neoplastic lesions (154) constituted 49.67%. Benign neoplasms (126) were 40.64% and malignant neoplasms (28) formed 9.03% of total neoplasms. A wide age ranging between the 1st and 9th decades was observed. Male predominance in neoplastic as well as nonneoplastic lesions was noted. Nasal obstruction (90.96%) was the most common symptom seen. Radiology was available in 30 cases and accurate diagnoses were made in 28 cases (93.33%). Among nonneoplastic lesions, inflammatory cases (128) formed the largest group (82.05%). Nasopharyngeal angiofibroma (NPA) was the dominant benign neoplasm (67.46%) exclusively seen in males of the second decade (76.47%). Among malignant lesions (9.03%), squamous cell carcinoma was the most common (28.57%) malignancy. Lesions with round cell morphology could not be typified on histopathology; hence, immunohistochemistry (IHC) was done for the exact diagnosis.
Conclusion: This study elaborates wide spectrum of lesions encountered in nose and paranasal sinuses with their relative frequencies in the population. Nonneoplastic lesions are more common than neoplastic lesions. Histopathological examination is essential for the diagnosis as clinical and radiological features may be overlapping. Round cell tumors could not be typified on the basis of histopathology; hence, use of ancillary techniques such as IHC plays a vital role in diagnosis.
Keywords: Histopathology, nasal mass, neoplastic, nonneoplastic, nose and paranasal sinus lesions
|How to cite this article:|
Vartak UC, Sarnaik AG, Vartak S, Pathan F. Spectrum of histopathological lesions of nose and paranasal sinuses: A 5-year study. J Med Soc 2020;34:128-38
|How to cite this URL:|
Vartak UC, Sarnaik AG, Vartak S, Pathan F. Spectrum of histopathological lesions of nose and paranasal sinuses: A 5-year study. J Med Soc [serial online] 2020 [cited 2021 Aug 1];34:128-38. Available from: https://www.jmedsoc.org/text.asp?2020/34/3/128/315097
| Introduction|| |
A variety of nonneoplastic and neoplastic conditions involve the nasal cavity and paranasal sinuses. Large number of diseases affecting these structures are due to many of the specialized tissues, each with its own aberrations that exist in the region. Lesions often present as nasal obstruction, nasal discharge, epistaxis, facial swelling, orbital and ear symptoms, or simply as nasal mass. Nonneoplastic lesions comprise bulk of these lesions, some of them clinically mimicking neoplasia. Among neoplastic lesions, benign lesions are common and lack of appreciation of these lesions can lead to radical surgeries. They have long clinical history with frequent local recurrence and thus relatively significant morbidity. Malignant lesions of the sinonasal tract accounts for not more than 3% of head-and-neck malignancies and <1% of all the malignant tumors. These lesions often have clinical and radiological features overlapping with certain inflammatory conditions such as fungal sinusitis. The presenting features and advanced imaging techniques help to reach a presumptive diagnosis, but histopathological examination remains the mainstay of definitive diagnosis. Thus, careful histological workup is essential for a correct diagnosis, timely clinical intervention, and therapy. Apart from establishing the final diagnosis in individual cases, study of biopsies can provide insights related to pathogenesis and prognosis of these lesions. Coupled with radiological techniques and thorough history with clinical examination, histopathology has become indispensable in the timely diagnosis and treatment of these lesions. This study aimed to analyze the clinicopathological features of cases presenting as a mass in NC (nasal cavity), PNS (paranasal sinus), and NP (nasopharynx); to find out the relative incidence; and to classify the lesions.
| Aims and objectives|| |
This was a retrospective and prospective study of spectrum of lesions of nose and paranasal sinuses over a period of 5 years (June 2013–June 2018) in a tertiary care hospital. The study aimed to find out the incidence of nonneoplastic and neoplastic lesions of NC and paranasal sinuses, the age and sex distribution of various lesions and their clinical presentation and study various histopathological patterns.
| Materials and Methods|| |
A total number of 310 cases of sinonasal mass lesions included in study are biopsies and resection specimens. The clinical details such as age and sex of the patient, clinical presentation, and radiological examination were retrieved from the departmental records. The tissue specimens were processed routinely after fixing in 10% formalin and stained with hematoxylin and eosin stains. Various special stains were performed as per the need such as Gomori methenamine silver (GMS) stain and periodic acid–Schiff (PAS) for fungus. Immunohistochemistry (IHC) was performed wherever required. The neoplastic lesions were classified as per the World Health Organization (2017) classification. The inadequate samples were not included in this study.
| Results|| |
A total number of 43,231 surgical cases were received over a period of 5 years (June 2013–June 2018), of which 310 cases (0.71%) were lesions of nose and paranasal sinuses. Out of these 310 cases, 156 (50.32%) were nonneoplastic cases and 154 (49.67%) were neoplastic. Among neoplastic lesions, 126 (40.64%) were benign neoplastic cases and 28 (9.03%) were malignant cases. Nonneoplastic lesions were the most predominant lesions followed by benign neoplasms.
Distribution of sinonasal neoplastic lesions
Among neoplastic lesions, benign lesions are more common (81.81%) than malignant lesions (18.18%). Majority of nonneoplastic lesions presented in the 4th and 5th decades and majority of neoplastic lesions presented in the 2nd decade. There were 235 males and 75 females in the study. Male preponderance was noted with M:F ratio of 3.13:1. Nasal obstruction was the most common presenting symptom seen in 282 (90.96%) cases, followed by breathing difficulty 275 (88.70%), nasal discharge 137 (44.19%), and epistaxis 123 (39.67%).
Importance of radiological imaging in the diagnosis of sinonasal lesions
Radiological findings were available in 30 cases, of which 28 gave a concordant diagnosis (93.33%). Out of the two discordant cases, one which was considered a malignant lesion on radiology turned out to be invasive fungal rhinosinusitis (FRS) and other case which was radiologically considered a nonneoplastic lesion was benign neoplastic case on histopathology.
Nonneoplastic cases of sinonasal lesions (n = 156)
Sinonasal polyps (n = 95)
Inflammatory polyp was the most predominant polyp accounting for 61 cases (64.21%) of all sinonasal polyps, followed by 30 cases of antrochoanal polyps and 4 cases of allergic polyps. Majority of sinonasal polyp cases presented between 2rd and 5th decades. There were 64 males and 31 females. Overall male:female ratio of sinonasal polyps was 2.06:1 (inflammatory polyp = M:F ratio, 1.69:1; antrochoanal polyp = M:F ratio, 3.14:1; and allergic polyp = M:F ratio, 3:1). Inflammatory polyp (n = 61): Histologically, it showed polypoidal structure lined by ciliated pseudostratified columnar epithelium. Underlying stroma was loose, edematous with dilated mucous glands and dense mixed inflammation composed of polymorphs, lymphocytes, and plasma cells. Antrochoanal polyp (n = 30): Histologically, it showed polyp lined by ciliated pseudostratified columnar epithelium. Underlying stroma was loose, edematous and showed mild mixed inflammation. Allergic polyp (n = 4): Histologically, it showed a polyp lined by respiratory epithelium with underlying stroma showing dense mixed inflammation predominantly comprising eosinophils.
Rhinosinusitis (n = 30)
Majority of patients presented between the 4nd and 5th decades. There was male preponderance with male:female ratio of 1.72:1. Maxillary sinus was the most common site seen in 17 (56.66%) cases. Nasal obstruction and nasal discharge were the most common presenting symptoms seen in 21 cases. Histologically, it showed tissue bit lined by ciliated pseudostratified columnar epithelium. Underlying stroma showed dense lymphoplasmacytic infiltrate and mucous glands. All the cases had duration of symptoms more than 12 weeks.
Infective sinusitis (n = 29)
Twenty-one cases (72.41%) were of fungal etiology, followed by 5 cases of rhinosporidiosis (17.24%) and 3 cases of bacterial sinusitis (10.34%). Majority of patients were in the 5th (24.13%) and 7th (20.68%) decades. There was male preponderance with male:female ratio of 2.22:1. NC was the most common site of involvement in all cases. Of all fungal lesions, mucormycosis (n = 18) was the most common etiology (62.06%) followed by aspergillosis (n=3)(10.34%). All the 3 cases of bacterial sinusitis were of Rhinoscleroma accounting to 10.34% cases of infective sinusitis. FRS (n = 21): Invasive FRS was seen in 3 cases (14.28%) and noninvasive FRS in 18 (85.71%) cases. Out of 18 cases of mucormycosis 15 cases were noninvasive and 3 were invasive FRS. Histologically, edematous stroma with congested blood vessels and mixed inflammatory infiltrate composed of lymphocytes, plasma cells, and polymorphs were seen. Furthermore, areas of necrosis with fungal elements having broad, aseptate, obtuse angled hyphae were seen. Few fungal hyphae invading blood vessels were seen suggestive of angioinvasion. Special stains such as GMS and PAS were positive for fungal hyphae. All aspergillosis (n = 3) cases were noninvasive FRS. Histologically it showed necrosed tissue bit with inflammation composed of lymphocytes, plasma cells and few polymorphs along with numerous fungal elements which were slender and septate with acute angled branching of hyphae. Special stains such as GMS and PAS were positive for fungus in all cases. Rhinosporidiosis (n = 5): In all cases, NC was involved and in one case along with NC maxillary sinus was involved; all cases were presented with nasal obstruction. No age predilection was observed. All five cases were male. Histologically, it showed fibrocollagenous tissue with dense mixed inflammation composed of lymphocytes, plasma cells, and occasional eosinophils along with congested and dilated blood vessels. Also seen were thick-walled globular cysts containing abundant spores of Rhinosporidium seeberi. Special stains such as PAS and GMS [Figure 1] were positive. Rhinoscleroma (n = 3): All cases presented with nasal obstruction with no age predilection. The most common presentation was nasal obstruction and NC involved in all cases. Histologically, it showed granulation tissue admixed with foamy histiocytes (Mikulicz cells) and mild inflammatory infiltrate composed of lymphocytes and plasma cells.
|Figure 1: Thick walled globular cyst containing abundant spores of rhinosporidium seeberi are seen (Gomori Methenamine Silver; ×400)|
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Cystic lesions (n = 2)
Both the cases presented as nasal mass with obstruction. No specific age predilection was observed. Histologically, the nasolabial cyst showed ciliated pseudostratified columnar epithelium lining with underlying stroma containing mild mixed inflammation, which was diagnosed as nasolabial cyst on histopathology.
Benign sinonasal lesions (n = 126)
Inverted papilloma/schneiderian papillomas (n = 12)
Majority of the cases presented in the 5th decade (33.33%). Male:female ratio was 1.4:1. Histologically, the lesions showed downward endophytic growth of hyperplastic squamous epithelial nests. Underlying stroma was edematous and showed dense chronic inflammation. The differential diagnosis for inverted papilloma includes nasal polyp with squamous metaplasia, respiratory epithelial adenomatoid hamartoma (REAH), and invasive carcinoma.
Respiratory epithelial adenomatoid hamartoma (n = 1)
A single case of a 62-year-old male with nasal mass presented with rhinitis, anosmia, and nasal obstruction. Histologically, the lesion showed proliferation of glandular spaces lined by ciliated columnar epithelium with stromal edema and chronic inflammatory cells.
Lobular capillary hemangioma (n = 11)
45.45% of the cases presented in the 4th decade. Among 11 cases, there were 7 males and 4 females. Male:female ratio was 1.75:1. Swelling over the nose was the most predominant symptom found in 63.63% of cases, followed by nasal obstruction (18.18%), epistaxis (9.09%), and nasal discharge (9.09%). Histologically, it showed lobules of vascular proliferation along with edema and mild inflammation separated by thin fibrous septae. Differentials for lobular capillary hemangioma include granulation tissue, angiosarcoma, and nasopharyngeal angiofibroma (NPA). Distinction from granulation tissue and angiosarcoma can be done by noting the lobular architecture seen on low power in lobular capillary hemangioma.
Nasopharyngeal angiofibroma (n = 85)
76.47% of the cases presented in the 2nd decade. NPA almost exclusively affected male population. Histologically [Figure 2], it showed stellate cells and staghorn blood vessels with variable wall thickness. Underlying stroma was loose, edematous, and fibrocollagenous with mild chronic inflammation. NPA needs to be differentiated from other vascular lesions such as lobular capillary hemangioma and hemangiopericytoma.
|Figure 2: Numerous capillary sized blood vessels are seen lined by endothelial cells (H and E; ×400)|
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Neurilemmoma/schwannoma (n = 9)
33.33% of the cases presented in the 4th decade. Male:female ratio was 2:1. Histologically, it showed biphasic pattern with hypercellular areas (Antony A) and hypocellular areas (Antony B). Nuclear palisading was seen in cellular areas (Verocay bodies). Cells were narrow, elongated, and wavy. Also seen were thick-walled hyalinized blood vessels.
Fibroma (n = 1)
There was a single case of a 30-year-old male with swelling over the tip of the nose. Histologically, it showed mature, hypocellular fibrous tissue. There was no evidence of invasion into underlying tissue seen.
Hemangioma (n = 3)
All cases presented with a mass in the NC with nasal obstruction and epistaxis but seen in varied age group. Histologically, it showed numerous cystically dilated and thin-walled blood vessels filled with blood and lined by endothelial cells.
Arteriovenous malformation (n = 2)
Both the cases presented with NC mass along with nasal obstruction and epistaxis. It showed admixture of malformed blood vessels with abrupt changes in thickness of medial and elastic layers of vessels with abnormal vascular dilation.
Dermal acrospiroma (n = 1)
A single case of a 60-year-old female presented with swelling over the nose. Histologically, the lesion showed nests of tumor cells with clear cytoplasm along with congested blood vessels. Small and large lumina were seen lined by cuboidal ductal cells. Few cystic spaces were also seen.
Apocrine hidrocystoma (n = 1)
A single case of a 70-year-old male presented with swelling over the nose. Histologically, it was a cystic lesion lined by double layer of columnar cells with apocrine features (snouts and decapitation secretion) forming papillary projections. These cells had eosinophilic cytoplasm and basally located round vesicular nuclei.
Malignant lesions of nose and paranasal sinuses (n = 28)
Squamous cell carcinoma (n = 8)
Among all the cases, there were 6 males and 2 females. Out of 8, 3 cases (37.5%) presented in the 7th decade, whereas 2 cases each (25%) presented in the 5th and 6th decades with an overall M:F ratio of 3:1. Nasal obstruction was the most common symptom (87.50%), followed by epistaxis (50%) and facial swelling in 12.50%. One case radiologically showed lobulated soft tissue density mass in maxillary sinus with osteolytic destruction with extension into retromaxillary fat pad and intraorbital extracanalicular compartment of the right orbit. Histologically, there were 6 cases of well-differentiated keratinizing squamous cell carcinoma (SCC), 1 case each of moderately differentiated keratinizing SCC and nonkeratinizing SCC. Non keratinizing SCC radiologically showed a large enhancing mass in the left maxillary sinus with destruction of the medial wall. Histologically [Figure 3], the lesions showed sheets, nests, and cords of tumor cells with squamous differentiation with mild to moderate pleomorphism. Furthermore, there was evidence of intracellular and extracellular keratin, keratin pearls, and few mitotic figures.
|Figure 3: Individual tumor cells are polygonal with moderate pleomorphism. Few cells show individual tumor cell keratinization (H and E; ×100)|
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Sinonasal undifferentiated carcinoma (n = 5)
Out of 5, 3 cases (60%) presented in the 6th decade. Three cases were male and 2 were female. Nasal obstruction and epistaxis were the most common symptoms with an overall male:female ratio of 1.5:1. Nasal obstruction was the most common symptom (80%), followed by epistaxis (80%) and anosmia in (20%). One case with anosmia radiologically showed a soft tissue density lesion in the right NC, right ethmoid, right orbit, and bilateral frontal sinuses. Histologically, the lesion showed tumor cells arranged in nests and lobules, with individual tumor cells being round to oval with vesicular nuclei and also hyperchromatic nuclei with prominent nucleoli. Many mitotic figures and necrosis was also seen.
Nasopharyngeal carcinoma (n = 6)
All 6 cases presented in the nasopharynx. 33.33% of the cases presented in the 2nd decade and 33.33% in the 6th decade with all involving the male population. The most common symptom encountered was nasal obstruction and epistaxis. Histologically, all our cases were undifferentiated variant of nonkeratinizing squamous cell carcinoma which showed syncytial arrangement of cells with indistinct cell borders, round to oval vesicular nuclei, and large central nucleoli.
Adenoid cystic carcinoma (n = 1)
A single case of a 30-year-old male with nasal mass presented with nasal obstruction. Histologically, it showed tubular growth pattern with individual tumor cells having bland nuclear appearance and high nuclear: cytoplasmic ratio mucin and deposition of basement membrane material was seen in between cells.
Mucoepidermoid carcinoma (MEC) (n = 1)
A single case of a 52-year-old male with a nasal mass presented with rhinitis headache and nasal obstruction. This case radiologically showed a lobulated enhancing soft tissue density mass along the left lateral wall of nasopharynx. Histologically, it showed cords, sheets, and clusters of mucous, squamous, and intermediate cells. Glands were seen lined by single layer of mucous secreting columnar cells with mild nuclear atypia. Features were suggestive of low-grade mucoepidermoid carcinoma (MEC).
Chondrosarcoma (n = 1)
A single case of a 60-year-old female presented with a nasal mass with epistaxis and nasal obstruction. Microscopically, it showed lobules of cartilaginous stroma with round to oval cells in lacunae with minor atypia and chondroid matrix.
Chordoma (n = 1)
A single case of a 50-year-old male presented with nasal obstruction and epistaxis. On radiology, it was a lobulated soft tissue polypoidal mass involving midline posterior nasal septum with erosion into adjacent sinuses and left pterygoid plate. Microscopically, it showed nests of bland eosinophilic cells in a loose myxoid matrix. At higher magnification, cells showed prominent cytoplasmic vacuoles (physaliphorous cells).
Malignant round cell tumors (n = 5)
| Lymphoma (n = 2)|| |
Two cases one male and one female with different age groups presented with a mass in NC along with nasal obstruction and rhinitis. One case presented with a soft tissue density mass in the right NC involving sinuses on the right side with erosion of floor of orbit and extending laterally to involve cheek on radiology, while the other presented as soft tissue opacification in the right frontal, maxillary, and ethmoid sinuses. Histologically, it showed diffusely arranged tumor cells and some cells arranged in large nests. Individual tumor cells were small, round having scant cytoplasm, hyperchromatic nuclei, and minimal pleomorphism with minimal necrosis. IHC was performed and immunoreactivity for CD45 was seen in tumor cells which confirmed the diagnosis of lymphoma.
| Olfactory neuroblastoma (n = 3)|| |
All 3 cases presented with NC mass along with nasal obstruction and epistaxis. All were in different age groups. Histologically, it showed nests and lobules of monotonous tumor cells with round nuclei, indistinct nucleoli, and scant cytoplasm in a fibrillary background with few mitotic figures. IHC showed negative immunostain for CD99 and desmin which ruled out diagnosis of primitive neuroectodermal tumor and alveolar rhabdomyosarcoma respectively.
| Discussion|| |
Nose and paranasal sinuses are sites of variety of tumors. Clinically, these tumors can be misdiagnosed as chronic inflammatory conditions quite often posing a difficulty to comment whether the lesion is neoplastic or nonneoplastic. Presenting features and imaging studies help in reaching a probable diagnosis, but histopathological examination leads to a definitive diagnosis.
In our study, we encountered 310 cases of lesions of nose and paranasal sinuses with an incidence of 62 cases/year (0.71%) over a period of 5 years. Age group of presentation was wide presenting from 1st to 8th decade with majority in the 2nd and 3rd decade [Table 1]. This is comparable to the study by Garg and Mathur where most of the patients presented in the second and third decade. In studies by Parajuli and Tuladhar and Kulkarni et al. also showed wide age group involvement that is 1st to 7th decade. Khan et al. observed the incidence of lesions to be 34.3 cases/year. Males were more predominantly affected with an overall male:female ratio of 3.13:1 [Table 1] which is comparable to the study conducted by Kulkarni et al. Our study pointed out that males were more prone to have neoplastic lesions as compared to females which is same as that projected by Garg and Mathur. Out of total 310 cases, nonneoplastic lesions comprised the largest group with 156 cases (50.32%). Neoplastic lesions comprised of 154 cases (49.68%) which included 126 (40.64%) benign neoplastic lesions and 28 (09.03%) malignant cases [Table 1]. In the studies by Khan et al. Kulkarni et al., and Garg and Mathur, they observed a comparatively higher number of nonneoplastic lesions. The most predominant symptom in our study was nasal obstruction (nasal stuffiness) with 90.96% followed by breathing difficulty (88.70%), nasal discharge (44.19%), rhinitis and epistaxis (39.67%). Other less common symptom included headache, swelling over nose, facial swelling, and anosmia. This is comparable to the study by Garg and Mathur where nasal obstruction was the most common symptom (87.07%) followed by nasal discharge (69.39%).
Radiology was available in 30 cases out of total 310 cases and gave an accurate diagnosis in 28 cases (93.33%). Of special mention are two cases. One case was radiologically considered a malignant lesion in which tissue invasion and bone destruction were seen which turned out to be invasive FRS on histology. The other case was radiologically considered a nonneoplastic lesion, but was diagnosed as benign neoplastic case on histopathology. Hence, radiography is important tool of diagnosis, but has to be supplemented with histopathology.
Nonneoplastic lesions (n = 156)
Sinonasal polyps (n = 95)
Accounting for 60.89% of nonneoplastic lesions. There was a wide age range from 1st to 7th decade with a peak in the 2nd to 5th decade having a male preponderance. In the studies by Kulkarni et al. and Zafar et al., peak was seen in the 2nd and 3rd decade with male preponderance [Table 2]. NC was the most predominantly involved site. All the above-mentioned studies did not classify types of polyp. In our study, the incidence of inflammatory polyps (64.25%) was greater than the allergic polyp (4.21%). These findings are consistent with the study by Jaison and Tekwani where the incidence of inflammatory polyps was highest that is 56% followed by allergic polyps 44%. We encountered 29 cases of antrochoanal polyp accounting for 30.52% of sinonasal polyps. Majority presented in the 3rd to 5th decade with a male predominance.
We encountered 30 cases (19.23%) of sinusitis out of total 156 nonneoplastic lesions. All cases were categorized as chronic sinusitis. A wide age range was noted with peak in 4th and 5th decade with a male preponderance (M:F = 1.72:1).
Infective sinonasal lesions
We got 29 cases of infective sinusitis (18.58%) of which 21 lesions were of fungal etiology (72.41%), followed by rhinosporidiosis (17.24%) and rhinoscleroma (10.34%). Bacterial sinusitis-rhinoscleroma – There were 3 cases of bacterial sinusitis all categorized as rhinoscleroma (1.92%). All the cases presented with the involvement of NC with obstruction. All the cases were male with variable age presentation between 3rd to 8th decade. Study by Zafar et al. showed male preponderance with male:female ratio of 1.3:1 [Table 2]. Fungal rhinosinusitis (FRS) [Table 3] – There were 18 cases (85.71%) which presented as noninvasive FRS whereas 3 cases (14.28%) presented as invasive FRS. Majority of these studies have reported a higher incidence of noninvasive lesions as compared to invasive lesions which was comparable to our study. Rhinosporidiosis: We encountered 5 cases of rhinosporidiosis (3.20%) presented between 2nd and 5th decade with majority in 4th and 5th decade and all the cases were males. Nasal obstruction was the predominant clinical presentation. Parajuli and Tuladhar showed an incidence of 3.36% which is comparable with our study [Table 2]. A study by Kulkarni et al. found age of presentation in the 2nd and 3rd decade with male preponderance (M:F = 3.6:1) [Table 2].
There were 2 cystic lesions in our study (1.28%). The patients presented in between age 5 and 47 years with equal sex predilection. Both the cases presented with nasal mass with obstruction with one case additionally showing cheek swelling. In the studies by Parajuli and Tuladhar and Zafar et al., the incidence was 2.52% and 1.37%, respectively. Incidence found by Zafar et al. is comparable with our study [Table 2]. In our study, age of presentation was 1st and 5th decade, whereas in a study by Zafar et al., it was 2nd decade involving only male population.
Benign neoplastic lesion (epithelial neoplasms)
There were 12 cases of inverted papilloma's (9.52%). The age distribution was between 3rd to 8th decade with peak incidence in 5th decade. It showed a male preponderance with M:F ratio of 1.4:1. Our study findings correlate with the study by Khan et al. which showed age peak in 5th decade with male preponderance [Table 4]. NC was involved in all the 12 cases in our study.
Respiratory epithelial adenomatoid hamartoma
There was one hamartomatous lesion in our study (0.79%). The patient was male presented at 62 years involving NC. Wenig and Heffner reported a case of a 65-year-old male with a hamartoma in the left NC.
Lobular capillary hemangioma
There were 11 cases (8.73%) which is comparable with study of Khan et al., where incidence of 7.14% was found. He showed peak age of presentation in 4th decade which is same as our study with equal sex predilection [Table 4].
We encountered 85 cases of NPA (67.46%). Khan et al. gave an incidence of 42.85% which is close to our study. The age distribution peak was seen in the age group of 2nd decade and 3rd decade in our study which is comparable with all above mentioned studies. Khan et al. found all male cases in their study which is comparable with our study [Table 4]. The site involved in all the cases was nasopharynx with nasal obstruction and epistaxis being the most common symptom.
There were 9 cases of neurilemmoma (7.14%). Kulkarni et al. found an incidence of 7.69% which is comparable with our study. Maximum peak was seen in 4th decade with male preponderance which is comparable with the studies by Garg and Mathur and Kulkarni et al [Table 4].
There was a single case of fibroma (0.79%), 30-year-old male presented with swelling over tip of nose. In a study of 256 nonepithelial neoplasms involving the NC, paranasal sinuses and nasopharynx by Fu and Perzin 23 lesions were classified as fibrous tissue tumors including 4 cases of fibroma.
There were three cases of hemangioma (2.38%) with peak age of presentation between 2nd and 5th decade which is comparable with study by Khan et al. which showed peak age of presentation between 1st and 6th decade [Table 4]. In our study we got M:F ratio as 2:1 contrary to 1:2.5 by study conducted by Khan et al., this difference could have probably occurred due to small number of hemangioma cases in our study.
There were two cases of arteriovenous malformation (AVM) (1.58%). One was 23 years male and other was 40 years female, presented with nasal obstruction and epistaxis. In a case report by Chaudhuri GR et al., a 28 years male presented with diffuse swelling over the nose associated with episodes of bleeding was diagnosed as AVM.
There was single case of dermal acrospiroma (0.79%). A 60-year-old female presented with swelling over nose.
There was single case of apocrine hidrocystoma (0.79%). A 70-year-old male presented with swelling over dorsum of nose. In the study of multiple eccrine hidrocystomas of the face by Alfadley et al. found that all cases were middle aged women with numerous asymptomatic skin colored to bluish papulonodular skin lesions.
Malignant epithelial tumors
Squamous cell carcinoma
It is the most predominant malignant lesion seen in our study, amounting to 28.57% of total malignant cases. Khan et al. stated an incidence of 37.5% while Garg and Mathur quoted an incidence of 46.15% [Table 5]. The slightly lower incidence reported in our study is a relative incidence as our study included a wide variety of lesions being a tertiary referral centre. The age distribution peak was between 5th and 7th decade. Majority of the studies show a peak incidence in the seventh decade. The sex distribution showed a male preponderance with M:F ratio of 3:1 which was comparable to studies by Khan et al. which showed M:F ratio of 2:1 [Table 5]. Nasal obstruction was the most common presenting symptom in 7 out of 8 cases (87.50%). Radiological findings available in one case showed soft tissue density mass in maxillary sinus with osteolytic destruction and extension into retromaxillary fat pad and intraorbital extracanalicular compartment of right orbit.
Sinonasal undifferentiated carcinoma
We encountered 5 cases of sinonasal undifferentiated carcinoma (17.85%). Khan et al. stated an incidence of 7.5% with presentation in 4th decade and M:F ratio of 2:1. The age range in our study was 4th to 7th decade with a male preponderance (M:F = 1.5:1) which is comparable with study by Khan et al [Table 5]. The most common presentation in our study was nasal obstruction and epistaxis. Radiology in one case showed soft tissue density lesion in right NC, right ethmoid, right orbit, and bilateral frontal sinuses.
We got 6 cases of nasopharyngeal carcinoma (21.42%). Khan et al. showed 25% incidence and age of presentation which is comparable with our study [Table 5]. Three of our cases were between 2nd and 3rd decade whereas remaining 3 cases were in the age range of 5th and 6th decade showing a bimodal age distribution but with slight variation. All cases were males in our study and had involvement of NP with nasal obstruction and epistaxis.
Adenoid cystic carcinoma
A single male diagnosed with adenoid cystic carcinoma (3.57%) presented in the 3rd decade came with nasal mass and obstruction. Khan et al. gave an incidence of 5% comparable with our study. Only male population seen in study by M.Kulkarni et al. comparable with our study [Table 5]. Peak age of presentation was 6th decade and 7th decade by M.Kulkarni et al. and Khan et al.
There was a single case of MEC (3.57%). A 52 years male presented with nasal obstruction, rhinitis and headache. Radiologically showed lobulated enhancing soft tissue density mass along left lateral wall of NP. A study by Wolfish et al. found that patients are in middle age without gender predilection and present with mass lesion.
Tumors of bone and cartilage
| Chondrosarcoma|| |
We reported a single case of chondrosarcoma (3.57%) in a 60 year old female who presented with nasal obstruction and epistaxis. Bahgat et al. reported a 62-year-old female patient.
| Chordoma|| |
We reported a single case of chordoma (3.57%) in a 50 year old male who presented with nasal obstruction. Radiologically it showed a lobulated soft tissue polypoidal mass involving midline posterior nasal septum with erosion into adjacent sinuses and left pterygoid plate. Lynn-Macrae et al. mentioned primary chordoma of the nasal cavities and paranasal sinuses present with symptoms related to mechanical obstruction related to tumor mass.
Malignant round cell tumors
There were 5 cases which showed round cell morphology and IHC was performed to reach final diagnosis. (a) Lymphoma – We got 2 cases of lymphoma (7.14%). Khan et al. mentioned an incidence of 5% with equal sex predilection comparable with our study. Age of presentation in our study was 2nd decade in one case and 4th decade in other case whereas Khan et al. showed in 1st decade [Table 5]. (b) Olfactory neuroblastoma (ONB) – There were 3 cases of ONB (10.71%) comparable with Parajuli and Tuladhar which showed an incidence of 10%. Our study showed 3 cases in 3rd, 5th and 6th decade whereas Khan et al. showed an age of presentation as 1st decade in their study. There was female preponderance in our study whereas Khan et al. mentioned equal sex predilection in their study [Table 5].
| Conclusion|| |
This study elaborates wide spectrum of lesions encountered in nose and paranasal sinuses with their relative frequencies in population. Nonneoplastic lesions are encountered more as compared to the neoplastic lesions. Histopathological examination is essential for the diagnosis of these lesions as clinical and radiological features may be overlapping. Correlation between radiological and histopathological findings is must for an accurate diagnosis. Round cell tumors could not be typified on the basis of histopathology hence use of ancillary techniques like IHC plays a vital role in diagnosing malignant neoplasm especially in cases with round cell morphology.
Histopathology, it is essential in lesions where clinical and radiological findings are overlapping. Appreciation of nonneoplastic lesions like invasive fungal rhinusinusitis which can mimic malignancy requires correct histopathological diagnosis to prevent radical surgeries.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]