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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 12
| Issue : 1 | Page : 109-111 |
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Transnasal endoscopic resection of vascular leiomyomas of the nasal septum
Hai-Hong Chen, Qin-Ying Wang, Shui-Hong Zhou
Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhe Jiang University, Hangzhou, Zhejiang, China
| Date of Web Publication | 13-Apr-2016 |
Correspondence Address:
Qin-Ying Wang
Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhe Jiang University, Hangzhou - 310 003, Zhejiang
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0973-1482.150417
Objective: Our experience with endoscopic surgery for vascular leiomyomas of the nasal septum was reviewed.
Patients and Methods: All patients with vascular leiomyomas of the nasal septum who were treated with endoscopic surgery from May 1995 to June 2007 were reviewed retrospectively.
Results: Twelve patients had vascular leiomyomas of the nasal septum removed successfully; there were no recurrences or endocrine complications during the 15–62-month follow-up postoperatively.
Conclusion: The endoscope technique offers simple, rapid access to the nasal septum, and excellent visualization; it is a safe, minimally invasive, efficient procedure for removing benign nasal septum tumors that leaves no scar on the face. Keywords: Endoscopy, leiomyoma, nasal septum
How to cite this article:
Chen HH, Wang QY, Zhou SH. Transnasal endoscopic resection of vascular leiomyomas of the nasal septum. J Can Res Ther 2016;12:109-11 |
| > Introduction | |  |
Leiomyomas are common tumors that usually originate from the uterus and alimentary tract, but rarely from the soft tissues of the head and neck. Leiomyomas in the nasal septum are rare, with only two cases reported in the English-language literature.[1],[2] The most common presenting symptoms are nasal obstruction, pain, and epistaxis. The traditional surgery removes the mass via a nose-side incision, causing much damage and affecting the patient's appearance. We achieved total excision with a small cuff of adjacent normal tissue via endoscopic surgery, and the treatment outcome was satisfactory.
| > Patients and Methods | | |
Twelve patients (7 females, 5 males; mean age 48 ± 9.52 (range 12–73) years were referred to our hospital from 1995 to 2007. Six complained of left-sided nasal obstruction and left-sided headache without pain in the larynx, rhinorrhea, orepistaxis; four complained of right-sided nasal obstruction, local pain, and epistaxis, with no pain in the larynx, rhinorrhea, or headache; one complained of right-side nasal obstruction and rhinorrhea with no pain in the larynx, epistaxis, or headache; and one complained of left-side nasal obstruction, pain in the larynx, rhinorrhea, and epistaxis, with no headache. No patient had a history of nasal trauma. On the initial examination, all 12 cases had a reddish polypoid mass in the region of the left or right middle meatus. Computed tomography (CT) revealed a mass in the left/right nasal cavity that appeared to arise in the region of the nasal septum, filling the nasal cavity and not extending into the nasopharynx [Figure 1]. | Figure 1: Coronal computed tomography shows a lesion on the left side of the nasal septum
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After inducing general anesthesia, the mass was extirpated by Weber-Ferguson incisions. Additional nasal decongestion was obtained by applying a solution of 1% lidocaine hydrochloride and 0.25% phenylephrine hydrochloride to neurosurgical cotton pledgets that were carefully placed in the nasal cavity three times. The findings at the time of surgery revealed a smooth-appearing, reddish polypoid mass arising from the nasal septum, filling the nasal cavity, and not extending into the nasopharynx. Under endoscopic guidance, a “[”-type incision was made in the pedicel of the mass, the periosteum or perichondrium of the nasal septum was separated, and the mass was excised completely with a small cuff of adjacent normal tissue.
Pathology
The pathological diagnoses were vascular leiomyomas with numerous blood vessels without malignant change [Figure 2]. There was less than one mitosis on average per five high-power fields. Immunohistochemically, the tumor cells stained strongly for actin [Figure 3], but were negative for CD34, CK, and S-100 protein. These results support the diagnosis of vascular leiomyoma, compared with other soft-tissue tumors, such as schwannoma or neurofibroma. | Figure 2: A vascular leiomyoma with rich vascular channels with thick muscular vessel walls and intervascular smooth muscle bundles (H and E stain, original magnification ×50)
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 | Figure 3: A vascular leiomyoma with intense smooth muscle actin staining in the smooth muscle bundles (ABC method, original magnification ×50)
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| > Result | | |
Twelve patients had vascular leiomyomas of the nasal septum removed successfully. All patients are currently doing well, with no evidence of recurrent disease or endocrine complications during follow-up for 15–62 months postoperatively. The characteristics of these cases are summarized in [Table 1].
| > Discussion | | |
Vascular leiomyomas are an uncommon type of leiomyoma that rarely occur in the head and neck area. Of all of the leiomyomas in the human body, less than 1% occur in the head and neck area.[3] In a review of 562 cases of vascular leiomyoma by Hachisugaover a 17-year period, 48 were in the head and neck area and only 5 of these were in the nasal cavity.[4] Nasal septum vascular leiomyomas are rare. To date, only two other cases of nasal septum leiomyoma have been published in the English language literature.[1],[2] Both of these patients were female. In comparison, our series includeds even females and five males. The sex predilection of nasal septum leiomyomas is similar to that of common vascular leiomyomas originating from the uterus, alimentary tract, or skin at other sites.[5]
The most common presenting symptoms are nasal obstruction, pain, and epistaxis. A relationship between leiomyomas and trauma has been reported.[6] In our series, however, there was no history of trauma before the nasal septum leiomyoma. In addition, the case presentations were similar. The pathology demonstrated vascular leiomyomas in all 12 cases. The nuclear atypia should not be taken as evidence of malignancy.[7] A nasal septum tumor requires a precise pathological diagnosis, even if it is believed benign before surgery. If a tumor has an average of one or more mitoses per five high-power fields, it is probably malignant, and if mitoses are seen in every high-power field, it is certainly malignant.[8] All of our cases had less than one mitosis per five high-power fields, so benign leiomyoma was the diagnosis.
Computed tomography (CT) revealed a mass in the left nasal cavity that appeared to arise in the region of the nasal septum, filling the nasal cavity, but not extending into the nasopharynx. Unfortunately, the CT and magnetic resonance imaging (MRI) findings do not indicate the preoperative diagnosis.[9] The diagnosis of vascular leiomyoma is difficult, and vascular leiomyomas are seldom included in the differential diagnosis of a head and neck mass before surgical excision.[4] Surgical excision with a histological study is the only way to make the diagnosis. Most vascular leiomyomas can be diagnosed correctly under microscopy with conventional H and E staining. Several stains have been used to identify vascular leiomyomas, including desmin, vimentin, Masson's trichrome, actin, and myosin.[10] In our patients, the tumor cells stained strongly for actin, but were negative for CD34, CK, and S-100 protein. These results support the diagnosis of vascular leiomyoma.
For cutaneous vascular leiomyomas at other sites, the treatment is complete excision,[5] and there are rare reports of recurrence [11] In the two reported cases of nasal septum leiomyoma, complete excision was the treatment of choice. Those masses were removed through nose-side incisions, which caused much damage and affected the patients' appearance. We achieved total excision with a small cuff of adjacent normal tissue via endoscope surgery. The endoscope technique has the following advantages: (1) It offers simple and rapid access to the nasal septum, (2) with excellent visualization, (3) minimal invasiveness, (4) and no scar on the face; (5) it is a safe, efficient procedure for removing benign nasal septum tumors. Carrau also considered endoscopic and endoscopic-assisted surgery feasible alternatives or adjuncts to traditional techniques for treating juvenile angiofibroma.[12]
In summary, vascular leiomyomas of the nasal septum are rare. Surgical excision of these benign tumors yields high cure rates. The endoscope technique is a simple, rapid, safe, esthetic, and efficient procedure for removing benign nasal septum tumors, improving the surgeon's ability to remove nasal cavity tumors. Surgeons should understand its feasibility, limits, and indications.
| > References | | |
| 1. | Timiryaleev MKh. Angioleiomyoma of the nasal septum. Vestn Otorinolaringol 1973;35:106.  |
| 2. | Ardekian L, Samet N, Talmi YP, Roth Y, Bendet E, Kronenberg J. Vascular leiomyoma of the nasal septum. Otolaryngol Head Neck Surg 1996;114:798-800. |
| 3. | Barnes L. Surgical pathology of head and neck. Leon Barnes, Editor. Vol. 1. New York: Marcel Dekkar, Inc; 1985. p. 442-5. |
| 4. | Hachisuga T, Hashimoto H, Enjoji M. Angioleiomyoma: A clinicopathologic reappraisal of 562 cases. Cancer 1984;54:126-30. |
| 5. | Duhig JT, Ayer JP. Vascular leiomyoma. A study of 61 cases. Arch Pathol 1959;68:424-30. |
| 6. | Haedicke G, Kaban LB. Smooth-muscle tumors of the oral cavity. Plast Reconstr Surg 1988;81:264-9. |
| 7. | Fu YS, Perzin KH. Nonepithelial tumors of the nasal cavity, paranasal sinuses and nasopharynx: A clinicopathological study. IV. Smooth muscle tumors (leiomyoma, leiomyosarcoma). Cancer 1975;35:1300-8. |
| 8. | Stout AP, Hill WT. Leiomyosarcoma of the superficial soft tissues. Cancer 1958;11:844-54. |
| 9. | Wang CP, Chang LY, Sheen TS. Vascular leiomyoma of the head and neck. Laryngoscope 2004;114:661-5. |
| 10. | Maeda Y, Osaki T. Angiomyoma of the cheek: A case report. J Oral Maxillofac Surg 1989;47:1090-3. |
| 11. | Khan MH, Jones AS, Haqqani MT. Angioleiomyoma of the nasal cavity - report of a case and review of the literature. J Laryngol Otol 1994;108:244-6. |
| 12. | Carrau RL, Snyderman CH, Kassam AB, Jungreis CA. Endoscopic and endoscopic-assisted surgery for juvenile angiofibroma. Laryngoscope 2001;111:483-7. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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