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CORRESPONDENCE
Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 733-736

Rare case of an angiectatic sinonasal polyp feigning malignancy


1 Department of ENT and Head and Neck Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
2 Department of Pathology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India

Date of Web Publication29-May-2019

Correspondence Address:
Dr. Vijendra S Shenoy
Department of Otolaryngology, Kasturba Medical College Hospital, Attavar, Mangalore - 575 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1236_16

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 > Abstract 


Angiectatic sinonasal polyps are uncommon. However, riveting nature of this polyp lies in its clinical presentation mimicking a neoplasm. It is radiologically very challenging to pick up this lesion in spite of its characteristic findings on imaging. Histopathology is paramount for asserting diagnosis. We report a rare case of a patient who presented to our outpatient department with chief complaints of nasal block, nasal discharge, and epiphora for 6 months. On examination, a mass was found filling the left nasal cavity. Computed tomography scan and diagnostic nasal endoscopy were suggestive of fungal sinusitis or sinonasal malignancy as a differential diagnosis. Biopsy was reported as benign sinonasal polyp. The patient underwent endoscopic resection of the mass, which on histopathology revealed the diagnosis of an angiectatic sinonasal polyp.

Keywords: Angiectatic, malignancy, sinonasal polyp


How to cite this article:
Guntur S, Shenoy VS, Kshithi K, Domah HA, Chaithra G V. Rare case of an angiectatic sinonasal polyp feigning malignancy. J Can Res Ther 2019;15:733-6

How to cite this URL:
Guntur S, Shenoy VS, Kshithi K, Domah HA, Chaithra G V. Rare case of an angiectatic sinonasal polyp feigning malignancy. J Can Res Ther [serial online] 2019 [cited 2019 Jun 17];15:733-6. Available from: http://www.cancerjournal.net/text.asp?2019/15/3/733/244200




 > Introduction Top


Sinonasal polyps can be classified on the basis of histopathology into five types – edematous, fibrous, glandular, cystic, and angiectatic.[1] Angiectatic polyps are also known as angiomatous polyps. They are rare constituting approximately 5% of total inflammatory or allergic polyps which grow rapidly exhibiting an aggressive clinical behavior simulating malignancy.[2] Hence, an accurate preoperative diagnosis is essential for planning a simplified surgical resection avoiding extensive surgical approaches. Radiologically, magnetic resonance imaging (MRI) is superior to computed tomography (CT) for describing the internal structures and the involved extent of the polyp.[3] In our case, clinically the mass raised suspicion of inverted papilloma or malignancy. CT scan was suggestive of fungal sinusitis, sinonasal malignancy, or mucocele. Hence, the histopathological diagnosis of benign sinonasal polyp took us by surprise.


 > Case Report Top


A 22-year-old female presented to us with chief complaints of nasal block and nasal discharge since 6 months. Nasal block was insidious, presents only on the left side and gradually progressive. It was present throughout the day and associated with intermittent episodes of a headache. Nasal discharge was copious, nonfoul smelling, and occasionally blood tinged. She also had 2–3 episodes of frank nasal bleed from the left nostril. Each episode was sudden, unprovoked, and associated with scanty bleeding which resolved spontaneously. The patient had also noticed a mass in her left nasal cavity, which was small initially but rapidly, progressed to fill the entire cavity over a period of 1 month. Reduced perception of smell and frequent watering of the left eye was her other complaints. There was no history suggestive of any allergy.

The general and systemic examination was normal. Except for decreased perception of smell on the left, there was no other cranial nerve deficit. Nasal examination showed a bulge over the dorsum of the nose extending from root to the left ala. Anterior rhinoscopic examination revealed a pinkish irregular mass filling the entire left nasal cavity, anteriorly reaching one cm short of vestibule. The mass extended till the septum medially and inferior turbinate laterally. Inferiorly, it extended till the nasal floor. Mass was obscuring the view of middle turbinate and meatus. The right nasal cavity showed hypertrophied inferior turbinate. Postnatally, mass was covering choana and posterior end of septum. Fossa of Rosenmuller on both sides could not be visualized due to the mass. Oral cavity examination was normal.

CT scan showed homogenous opacity in the left nasal cavity extending filling maxillary sinus and posteriorly reaching nasopharynx. It was seen breaching the medial wall of the orbit. There was evidence of mass effect with deviation of nasal septum to opposite side. There were areas of fine calcifications and hemorrhagic foci within the mass. Differential diagnoses were of allergic fungal sinusitis, sinonasal malignancy, and mucocele [Figure 1]. Although MRI would have probably provided additional information, it was not available at our facility, and the patient was not able to afford the cost of this investigation from outside, and hence, was not done. The patient was started on intravenous antibiotics and antihistamines. Ophthalomologic examination was normal.
Figure 1: Computed tomography scan pictures showing mass filling the left nasal cavity and eroding medial wall of orbit

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She underwent diagnostic nasal endoscopy and biopsy which was reported as “necrotic tissue with fibrinohemorrhagic material and adjacent nasal tissue.” In view of a confirmative diagnosis, repeat diagnostic nasal endoscopy was performed which was reported as “benign sinonasal polyp.” After giving a short course of intravenous steroids, endoscopic excision of the mass was carried out.

Excision of the mass was carried out under general anesthesia. The observed mass was pinkish, polypoidal, firm in consistency with extent involving left maxillary sinus, and anterior and posterior ethmoidal cells. Posteriorly, it extended till nasopharynx [Figure 2]. With the aid of Blakesley set of nasal forceps, curved suction, backbiting forceps, and ball probe, mass was freed from the maxillary sinus mucosa and gently pulled out. Then, with the help of 45°; 90° upturned Blakesley forceps and through cutting forceps, the remaining mass was excised from anterior and posterior ethmoidal air cells. The entire specimen was delivered in toto with ease [Figure 3]. Very minimal bleeding was observed during the entire procedure. Septum was pushed to the right by the mass. There was no evidence of septal erosion. The right nasal cavity was examined for any evidence of mass or mucosal changes but found to be normal. Bilateral nasal cavity was packed with merocel which was removed after 24 h.
Figure 2: Intraoperative endoscopic picture of the mass

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Figure 3: Excised specimen of nasal mass showing variable consistency

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Postoperatively, steroids were continued and tapered and eventually stopped. She was taught nasal douching which she followed regularly. Postoperative period was uneventful and her symptoms completely resolved. Diagnostic endoscopy on the 3rd and 10th day showed nasal cavity completely free of mass [Figure 4]. Histopathological evaluation of the mass showed polypoidal tissue bits lined by pseudostratified ciliated columnar epithelium and edematous stroma. Dilated ectatic blood vessels along with fibroblasts and hemosiderin-laden macrophages were seen in the stroma. In few sections, squamous metaplasia was noted in the lining epithelium. Mixed inflammatory infiltrate composed of eosinophils, plasma cells, lymphocytes, and neutrophils was present in almost all the sections. Areas of extensive ulceration and infarction were also observed. All the above features were in favor of “angiectatic sinonasal polyp” [Figure 5].
Figure 4: Intraoperative endoscopic picture showing left nasal cavity free of mass

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Figure 5: Histopathological sections. (a) Polypoidal tissue bits lined by pseudostratified ciliated columnar epithelium with edematous stroma. (b) Squamous metaplasia noted in the lining epithelium. (c) Section showing areas of necrosis. (d) Section showing dilated and ecstatic vessels

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 > Discussion Top


Angiomatous nasal polyps are a rare subtype of inflammatory sinonasal polyps. These often develop secondary to changes in a choanal polyp, in specific sites, most vulnerable to vascular compromise which are the ostium, posterior end of the inferior turbinate, choana, and nasopharynx.[2],[4],[5] They are characterized by extensive vascular proliferation and ectasia with deposition of pseudo amyloid.[2],[6] Patients most commonly present with nasal obstruction. Other symptoms are decrease or loss of smell perception, epistaxis,[7] exophthalmos, proptosis, and visual disturbances.[2] In our case, the patient had epiphora probably caused by obstruction of nasolacrimal duct due to the mass. Differential diagnoses include inflammatory polyp, fungus ball, mucocele, inverted papilloma, juvenile nasopharyngeal angiofibroma,[8] and malignant tumors (such as squamous cell carcinoma, adenoid cystic carcinoma, and melanoma).[8],[9]

Among investigations, MRI is better than CT scan for diagnosis. On MRI, T2-weighted images show internal heterogeneous hyperintensity with a peripheral hypointense rim and postcontrast images show a strong nodular and patchy enhancement.[3] Vessel-like marked enhancement, and progressive enhancement are important features on 2-phase helical CT. These invariably highlight the pathological and hemodynamic characteristics of the lesion preoperatively.[10]

Histologically, on light microscopy, we find racemose aggregates of irregularly shaped blood vessels resembling dilated capillaries without elastic or muscular layers. These are seen embedded in pools of Congo red-negative eosinophilic material associated with patchy necrosis and atypical stromal spindle cells. Electron microscopy and immunohistochemistry (CD34, factor VIII) show endothelial cells lining the spaces and myofibroblasts in stroma.[2]

Surgically, endoscopic excision is preferred instead of other extensive approaches. Excision is associated with minimal bleeding both intraoperatively and in postoperative period. The patient was completely relieved of nasal obstruction, epistaxis, and even epiphora postsurgery.


 > Conclusion Top


Among sinonasal polyps, ethmoidal, and antrochoanal polyps are commonly encountered in any otorhinolaryngology outpatient department. However, angiectatic sinonasal polyps are rare. These polyps clinically and radiologically simulate a neoplastic process – even malignancy. Thus, histopathological examination remains a must to reach a definitive diagnosis. Surgical endoscopic resection is preferred mainstay of treatment with beneficial postoperative results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Nimbkar SA, Sane SY. Histology and histochemistry of nasal polyps. J Postgrad Med 1978;24:231-4.  Back to cited text no. 1
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2.
Yfantis HG, Drachenberg CB, Gray W, Papadimitriou JC. Angiectatic nasal polyps that clinically simulate a malignant process: Report of 2 cases and review of the literature. Arch Pathol Lab Med 2000;124:406-10.  Back to cited text no. 2
    
3.
Wang YZ, Yang BT, Wang ZC, Song L, Xian JF. MR evaluation of sinonasal angiomatous polyp. AJNR Am J Neuroradiol 2012;33:767-72.  Back to cited text no. 3
    
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Batsakis JG, Sneige N. Choanal and angiomatous polyps of the sinonasal tract. Ann Otol Rhinol Laryngol 1992;101:623-5.  Back to cited text no. 4
    
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Ceylan A, Asal K, Celenk F, Uslu S. An angiomatous nasal polyp: A very rare variant of sinochoanal nasal polyps. B-ENT 2007;3:145-7.  Back to cited text no. 5
    
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Sheahan P, Crotty PL, Hamilton S, Colreavy M, McShane D. Infarcted angiomatous nasal polyps. Eur Arch Otorhinolaryngol 2005;262:225-30.  Back to cited text no. 6
    
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Sayed RH, Abu-Dief EE. Does antrochoanal polyp present with epistaxis? J Laryngol Otol 2010;124:505-9.  Back to cited text no. 7
    
8.
Ewing JA, Shively EH. Angiofibroma: A rare case in an elderly female. Otolaryngol Head Neck Surg 1981;89:602-3.  Back to cited text no. 8
    
9.
De Vuysere S, Hermans R, Marchal G. Sinochoanal polyp and its variant, the angiomatous polyp: MRI findings. Eur Radiol 2001;11:55-8.  Back to cited text no. 9
    
10.
Ding C, Wang Q, Guo Q, Wang Z, Lu X, Zhang J, et al. Sinonasal angiomatous polyp: Evaluation with 2-phase helical computed tomography. Medicine (Baltimore) 2015;94:e1196.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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