Benign sinonasal masses presentation & management-1

DR Kamlesh Dubey
AIIMS NEW DELHI

 Epithelial:
 Sinonasal gland tumors
 Pleomorphic adenoma
 Myoepithelioma
 Oncocytoma
 Schneiderian papilloma
 Warts
 Neuroectodermal tumors:
 Paraganglioma
 Schwannoma
 Neurofibroma

 Bone & Cartilage tumors:
 Osteoma
 Osteoid osteoma
 Fibrous dysplasia
 Ossifying fibroma
 Osteoblastoma
 Ameloblastoma
 nasal chondromesenchymal hamartoma
 giant cell lesion
 giant cell tumor
 Chondroblastoma
 chondroma

 Displaced neural lesions(ectopic site):
 Nasal glioma
 Pituitary adenoma
 Soft tissue tumors:
 Vascular tumors:
 Juvenile nasopharyngeal angiofibroma(JNA)
 Hemangioma
 Hemangiopericytoma
 Fibrous :
 Nasal fibroma
 Muscle tumors:
 Leiomyoma
 Rhabdomyoma

 In 1600s C. Victor Schneider demonstrated nasal
mucosa :
 Produces catarrh not csf
 Ectodermal origin
 1854 Ward first described Schneiderian papillomas
(SPs) of the nose (i.e., sinonasal papilloma)
 Kramer and Som classified SPs as true nasal
neoplasms and described them as true papillomas
 Ringertz was the first to identify the tendency of
SPs to invert into the underlying connective tissue
stroma, which differs from other types of
papillomas

 Fungiform: 50% , nasal septum
 Cylindrical: 3%, lateral wall/sinuses
 Inverted: 47%, lateral wall

 arise in the nasal septum
 „ exophytic growth pattern
 „ do not grow down into the underlying normal
stroma
 „ associated with human papillomavirus
 „ do not have a tendency to recur
 >57% HPV DNA positivity

 ragged, beefy appearance and
 „ histologically : composed of columnar cells
 „ pink cytoplasm
 „ nuclei are oval or round
 „ many areas of mucin cysts
 „ actually act very similar to inverted papillomas
 More chances of malignancy

 The US National Cancer Institute has defined inverted
papilloma as a type of tumor in which surface
epithelial cells grow downward into the underlying
supportive tissue
 Inverted papillomas arise from the Schneiderian
membrane, which is an invagination of the olfactory
ectoderm that occurs during the fourth week of
embryonic development. The mucosa creates a
transitional zone between the endo-dermally derived
respiratory epithelium of the nasopharynx and
keratinizing squamous epithelium with the nasal
vestibule

 Locally aggressive sinonasal tumor
 „ Arises from nasal respiratory epithelium,,
 which undergoes metaplastic change and
 proliferation
 „ characterized best by its local invasion,
 tendency for recurrence, and association with
malignancy

 Schneiderian papilloma
 Schneider papilloma
 Inverting papilloma, Inverted papilloma
 Ringertz tumor
 epithelial papilloma
 Transitional cell papilloma

 Benign/intermediate
 0.5% to 4% of sinonasal tumor
 Site of origin
 Age/Sex: male, 5-6th decades

Exophytic (tree) Inverted (nodule)

 appearance of the epithelium inverting into the
stroma
 with a distinct and intact basement membrane
 that separates and defines the epithelial component
from the underlying connective tissue
 May be associated with:
 Atypia
 Ca in situ
 Carcinoma:
 Scc, transitional cell carcinoma, adenocarcinoma
 Mucoepidermoid ca, verrucous ca

 Etiology : association between common
papillomas and the human papillomavirus (HPV)
 „ HPV types 6 and 11
 Kusiak and Hudson described the presence of
intracytoplasmic and intranuclear inclusion bodies
in SPs
 air pollution and industrial carcinogens
 „ male: female ratio of 3:1. .
 „ average age was 54.3 years
 „ most common in the fifth and sixth decades
Respler DS, Jahn A, Pater A, Pater MM.
Isolation and characterization of papillomavirus
DNA from nasal inverting (schneiderian)
papillomas. Ann Otol Rhinol Laryngol. Mar-
Apr 1987;96(2 Pt 1):170-3
Weber RS, Shillitoe EJ, Robbins KT, Luna
MA, Batsakis JG, Donovan DT, et al.
Prevalence of human papillomavirus in
inverted nasal papillomas. Arch Otolaryngol
Head Neck Surg. Jan 1988;114(1):23-6

 Grossly :: exophytic and polypoid
 „ more vascular than an inflammatory polyp
 „ gray to pink
 „ frond--like projections that extend from the
 main bulk of the specimen
 „ Epithelium inverts into underlying stroma

epithelium distinct from the respiratory
(pseudostratified
ciliated columnar)
mucosa of the sinonasal cavity
-- may be squamous, transitional
or respiratory
-- epithelium proliferative and
thickened
-- lacks mucus--secreting cells
and eosinophils

 Tendency to recur
 Destructive capacity to surrounding structures
 Propensity to be associated with malignancy

 They are associated with malignancy, 5%
to 15% malignancy rates are most
generally accepted. Inverted papillomas are
more commonly associated with squamous
cell carcinomas.
 There are four types of association:
 Metachronous squamous cell carcinoma.
 Carcinoma in situ within the IP
 Synchronous lesions
 Malignant transformation

 unilateral nasal obstruction (58%)
 „ epistaxis (17%)
 „ nasal drainage (14%)
 „ bilateral nasal obstruction (12%)
 „ nasal mass (9%)
 „ sinusitis (9%)
 „ headache
 „ diplopia
 „ facial numbness
 „ facial swelling
 „ anosmia

 Krouse summarized from 1967 to 1997
 primary sites of IP
 „ lateral nasal wall (82%)
 „ maxillary sinus (53.9%)
 „ ethmoid sinus (31.6%)
 „ septum (9.9%)
 „ frontal sinus (6.5%)
 „ sphenoid sinus (3.9%)

 KrouseType 1: Tumour totally confined to the nasal cavity. The tumour
can be localized to one wall or region of the nasal cavity, or
 can be bulky and extensive within the nasal cavity, but must not extend
into the sinuses or into any extranasal compartment.
 There must be no concurrent malignancy.
 Type 2: Tumour involving the ostiomeatal complex, and ethmoid sinuses,
and / or the medial portion of the maxillary sinus,
 with or without involvement of the nasal cavity. There must be no
concurrent malignancy.
 Type 3: Tumour involving the lateral, inferior, superior, anterior, or
posterior walls of the maxillary sinus, the sphenoid sinus,
 and / or the frontal sinus, with or without involvement of the medial
portion of the maxillary sinus, the ethmoid sinuses, or
 the nasal cavity. There must be no concurrent malignancy.
 Type 4: All Tumours with any extranasal / extrasinus extension to involve
adjacent, contiguous structures such as the orbit,
 the intracranial compartment, or the pterygomaxillary space. All tumours
associated with malignancy

 Han et al. Group 1: Tumour involvement limited
to the nasal cavity, lateral nasal wall, medial
maxillary sinus, ethmoid sinus, and
 sphenoid sinus.
 Group 2: Same as group 1 except that tumour
extends lateral to the medial maxillary wall.
 Group 3: Tumour extends to involve the frontal
sinus.
 Group 4: Tumour extends outside the sinonasal
cavities (i.e., orbital or intracranial extension).

 Kamel et al. Type 1: Tumour originating from the
nasal septum or lateral nasal wall.
 Type 2: Tumour originating from the maxillary
sinus.
 [This classification focuses on origin and not size /
extent of tumour-does not analyze frontal sinus
separately]

 Oikawa et al. T1: Tumour limited to nasal cavity.
 T2: Tumour limited to ethmoid sinus and / or medial
and superior portions of maxillary sinus.
 T3: Tumour involves lateral, inferior, anterior, or
posterior walls of maxillary sinus, sphenoid sinus, or
frontal sinus.
 T3-A: without extension to frontal sinus or supraorbital
recess.
 T3-B: involving frontal sinus or supraorbital recess.
 T4: Tumour extends outside sinonasal cavities (orbital
or intracranial extension) or associated with
malignancy

 cannady et al. Group A: Inverted papilloma
confined to the nasal cavity, ethmoid sinuses, or
medial maxillary wall.
 Group B: Inverted papilloma with involvement of
any maxillary wall (other than the medial wall), or
frontal sinus, or
 sphenoid sinus.
 Group C: Inverted papilloma with extension
beyond the paranasal sinuses

 Typical presentation : unilat.polyps
 „ antral choanal polyp
 „ allergic fungal sinusitis
 „ squamous cell carcinoma
 „ adenocarcinoma
 „ esthesioblastoma

 „ CT and MRI are the common modalities
 „ CT is the most widely performed study
 „ bony changes
 „ bowing of the bones near the soft tissue
 mass

 convoluted cerebriform pattern on T2- or
enhanced T1-weighted images suggests inverted
papilloma as a histologic diagnosis
 Necrosis in a mass with such an appearance
strongly suggests coexistent carcinoma
 columnar pattern is a reliable MRI indicator of IP
and reflects its histological architecture (positive
predictive value of 95.8%)
 combination of this finding with the absence of
extended bone erosion allows for the confident
discrimination of IPs from malignant tumors

 Surgery
 „ Radiation therapy

 Surgical approaches:
 • Headlight intranasal polpectomy
 • Caldwell Luc procedure
 • Medial maxillectomy
 • Lateral rhinotomy
 • External procedures of the frontal sinus
 • Endoscopic intranasal polypectomy
 • Endoscopic maxillary antrostomy/ethmoidectomy,
Sphenoidotomy
 • Endoscopic medial maxillectomy
 • Median drainage procedure to gain access to the
frontal sinus

 Stammberger reported the first purely endoscopic
approach for treatment of SP, which was
performed in 15 patients in 1981
 Most reported endoscopic resections have involved
piecemeal resection of the inverting papilloma
followed by piecemeal resection of the lateral
nasal wall

 Contraindicated in:
 massive involvement of the mucosa of the frontal
sinus
 and/or of a supraorbital cells
 intradural extension or transorbital extension
 concomitant presence of a malignancy
 presence of abundant scar tissue from previous
surgery

 Key point:
 to dissect the involved mucosa along the
subperiosteal plane
 to drill the underlying bone whenever required by
imaging and/or intraoperative finding
 Extent surgery:
 site of the lesion
 area of mucosa involved by the lesion

 Initially via transnasal resection:
 50-80% recurrence
 Medial Maxillectomy via lateral rhinotomy:
 Gold Standard
 10-20%
 Endoscopic medial maxillectomy:
 Key concepts:
 Identify the origin of the papilloma
 Bony removal of this region
 Recurrent lesions:
 Via medial maxillectomy vs. Endoscopic resection
 22%

 Predisposing factors:
 Tumor location
 Histology
 Multicentricity
 Method of removal
 Length of follow up
 Main factor: thoroughness of removal

 Bielamowicz et al:
 found a statistically significant difference between
the recurrence rates in patients treated with medial
maxillectomy (20%) versus those treated with a
conservative resection (47%).
 Mirza et al:
 found that recurrence rates in 63 case series was
 12.8% for endoscopic procedures (n = 484), 17.0%
for lateral rhinotomy with medial maxillectomy (n
= 1025)
 34.2% forlimited resections such as nasal
polypectomy (n = 600)

Surgical approach Recurrence/case
series
Percentage Mean –follow up
Endoscopic
resection
173/1190 14.5% 3 years 1month
Lateral rhinotomy
with medial
maxillectomy
207/1239 16.7% 5 years 2 month
Limited resection
such as nasal
polypectomy
208/606 34.4% Inadequate

Classic entities:
 Osteoma
 Fibrous dysplasia
 Ossifying fibroma

 Definition :
Benign condition in which normal bone is replaced
by fibrous connective tissue due to a defect in
osteoblast differentiation and maturation

 Pensler et al:
 investigated cultures derived from the involved
bone in two children with MFD and in one child
with Albright’s syndrome
 showed a two- to threefold increased level of
estrogen and progesterone receptors by
radioimmunoassay and immunocytochemical
assay
 concluded that estrogen may play a major role in
the bony metabolism of FD

 Actual cause:
 set of mutations in the GNAS1 gene
 located on chromosome 20q13.2
 that normally codes for the alpha subunit of the G-
protein

 Genetically based developmental anomaly
 Defect in osteoblastic differentiation and
maturation
 replacement of normal bony tissue by fibrous
tissue of variable cellularity and immature woven
bone
 Histology:
slow replacement of medullary bone by abnormal
fibrous tissue with different stages of bone
metaplasia

 Incidence not known
 Females > males
 No race predilection
 Initial symptoms manifest age 3-15
 Not heritable
 Questionable genetic transformation
 Malignant transformation in < 1%

 Cystic (21%)
- Radiolucency surrounded by solid rim
 Sclerotic (23%)
- Dense and homogenous
 Mixed (56%)
- “Ground glass appearance”

 Monostotic
- Most common
- 25% involve head and neck
 Polyostotic
- 15% of cases
- 50% involve head and neck

 Eosinophilic granuloma
 Nonossifying fibroma
 Bone hemangioma
 Hyperparathyroidism
 Paget’s disease
 Brown’s tumor
 Aneurysmal bone cyst

 Polyostotic fibrous dysplasia
 Café-au-lait spots
 Endocrinopathology:
- Hyperthyroidism
- Precocious puberty in females

„ fibrous dysplasia characteristically has a
ground glass appearance on CT images. . It
generally presents in younger patients
(children and adolescents), and its growth
rate may decrease or stop after puberty

 Surgery:
 intended to relieve symptoms :
 visual impairment due to compression of the optic
nerve
 to correct aesthetic deformities
 but not to remove the entire lesion
 Radiotherapy is contraindicated
 Medical treatment :
 bisphosphonates (i.e., pamidronate)
 with success in patients with extensive lesions
associated with significant disfigurement and pain
 Octreotide, anti hyperthyroid agents, antiandrogens

 a true benign neoplasm
 occurs in the third and fourth decades of life
 preferentially in black women
 Manifestation:
 space-occupying lesion in the nasal cavity
 evident at endoscopic examination

Aetiology:
 so far not been clarified.
 Trauma has been reported to play a major role in
the development of OF,
 especially of the cemento-ossifying fibroma
Histology:
demarcated margins consisting of fibrous tissue with
varying amounts of mineralized or calcified
psammomatoid
bodies

 present between the second and fourth decades of life
 female incidence is more frequent than male incidence
a male to female ratio of 1:5
 Ossifying fibroma of the mandible is usually
asymptomatic
 Depending on its extent:
 facial pain
 Swelling
 nasal obstruction
 Rhinosinusitis
 ocular symptoms

 Differs from common OF by age (younger), location
(maxilla) & biologic behavior (sometime aggressive and/or
recurrent).
 Two microscopic types; trabecular & psammomatoid; age at
diagnosis 11 and 22 respectively.
 Maxilla often with impingement on sinuses, orbit, nose and
cranium.

 Treatment of choice is dependent on the site of tumour
location
 Tumours invading the midfacial portion and the
sinonasal tract:
 more aggressive behavior
 need surgical resection
 surgical treatment :
 requires radical resection/when possible a total removal
of the tumour:
 high rate of relapses
 aggressive behavior of recurring tumors :with local
destruction and potential invasion of adjacent vital
structures

 Since OF is very rare, larger series on pure
endonasal resection are not reported
 In case reports, some authors have achieved
tumour resection via an endoscopic approach
 Draf et al. (480) reported on endonasal
microendoscopic resection of four OF without any
complications
 OF with a large extension, most authors
recommend a combined approach including
craniofacial resection

 Introduction:
Sinonasal osteomas are common entity seen in
patients. Rhinosinus osteomas are commonly asymptomatic and
are incidental findings on imaging studies.
 History:
Viega was the first to document sinus osteoma in 1506.
In 1733, Vallisnieri described frontal sinus osteoma that
protruded into the brain.
 Epidemiology:
Ostomas are the most common benign tumors of paranasal
sinuses.
This condition is more common in males.
It is common in patients between their second and third
decades of life.

 Three accepted theories of etiology of osteomas
are:
1. Developmental
2. Traumatic
3. Infectious
 Developmental :
 Adult tissue contains embryonic remnants usually
remaining dormant
 Could be the reason for occurrence near
frontoethmoidal suture lines

 Traumatic :
 Inflammatory process as the initiating force
 Bony trauma could be the root cause
 Could account for male preponderance
 Infectious :
 This theory suggests that ostietis resulting from
chronic infections could lead to osteoma formation
in paranasal sinuses.

 possible aetio-pathogenetic role of traumatic and
inflammatory factors:
 Moretti A, Croce A, Leone O, D'Agostino L. Osteoma
of maxillary sinus: case report. Acta
Otorhinolaryngologica Italica2004;24(4):219-22
 Naraghi M, Kashfi A. Endonasal endoscopic resection
of ethmoido-orbital osteoma compressing the optic
nerve. American Journal of Otolaryngology
2003;24(6):408-12.
 Sayan NB, Ucok C, Karasu HA, Gunhan O. Peripheral
osteoma of the oral and maxillofacial region: a study of
35 new cases. Journal of Oral & Maxillofacial Surgery
2002;60(11):1299-301.

 Fu and Perzin classification:
 1. Ivory / compact osteoma:
 Otherwise also known as eburnated osteoma.
 In this type of osteoma the bone is very dense and lacks
haversian canals.
 These osteomas develop from membranous elements.
 2. Osteoma spongiosum:
 Also known as mature osteoma is composed of softer bone.
 This type of osteomas are known to arise from cartilaginous
elements.
 These osteomas have little medullary component containing
fibrofatty tissue.
 3.Mixed

 Behavior: Osteomas are very slow growing and are mostly
asymptomatic. They always stay benign and don't recur
after excision.
 The growth rate of osteomas of the paranasal sinuses
Koivunen P et.al. Clin. Otolaryng Allied Sci
1997Apr;22(2):111-4
 mean growth rate: 1.61mm/yr range 0.44 to 6.0 mm/yr
 Common sites:
 95% osteomas in the sinonasal region arise from the
frontoethmoidal region.
 80% of osteomas in the sinus region arise from the floor of
frontal sinus

 Plain sinus radiographs are adequate for detecting
osteomas of paranasal sinuses.

 most commonly localized to the frontal
 sinus
 „ slow growing and well circumscribed
 „ symptoms attributable obstruction of the
 drainage pathway of nearby sinuses
 „ On endoscopy : firm masses with a smooth
mucosal covering

 Wait ,watch n scan
 Surgery:
 Indications:
 Rapid growth of tumor
 Symptomatic patients with chronic rhinosinusitis due to
tumor obstruction
 Massive headache
 Facial deformity
 Smith & Calcaterra et al:
Surgery if tumor occupies more than 50% of frontal sinus
 Approaches :
 Endonasal
 External
 Combined approach

 Frontoethmoidal and intraorbital osteomas: exploring
the limits of the endoscopic approach
(Turri-Zannoni et. al Arch. Otolar Head Neck Surg.2012
May)
 Conclusion:
The size of the osteoma, far lateral extension of the tumor
in the frontal sinus beyond the lamina papyracea, and
intraorbital involvement are no longer absolute
contraindications for purely transnasal endoscopic
resection. What is important is that the surgeon should
not be dogmatic but rather be ready to change his or her
mind during surgery, shifting to an external approach
when required.

 Exceptions:
 scarring of the frontal recess
 Distortion from previous surgery,
 very advanced disease and associated malignancy

 made of neuroglial elements consisting of
 glial cells in a connective tissue matrix
 with or without a fibrous connection to the dura
 „ no fluid filled space connected to the
 subarachnoid space

 „ present as a red or bluish lump at or along the
 nasomaxillary suture, or as an intranasal mass.
 „ firm, noncompressible
 „ not increase in size with crying, and do not
 transilluminate
 „ not enlarge with bilateral compression of the
internal jugular veins (Furstenberg test)
 „ associated with a widened nose or with
 hypertelorism secondary to growth of the mass

 arise from the lateral wall of the nose or less
 often from the nasal septum.
 „ 60%extranasal
 „ 30% intranasal
 „ 10% are both
 „ 15% are connected to the dura
 „ intranasal type associated with dural
 attachment (35%) > extranasal type (9%).

 development similar to nasal dermoids.
 „ Abnormal closure of the fonticulus
 Develop from extracranial rests of glial tissue
 Abnormal closure of fonticulus nasofrontalis, possibly
encephaloceles which have lost CSF connection
 tissue being left extracranially.
 „ not always an intracranial connection to a
glioma

 Bluish, soft, compressible, transilluminate,
pulsatile
 Enlarge with crying
 Positive Furstenberg test (bilateral compression
of internal jugular veins)
 Originate medially in the nose
 May have associated CSF leak

 4% are found within the paranasal sinuses
 Schwannoma
 Neurofibroma
 Treatment via surgical resection
 When associated with Von Recklinghausen’s
syndrome: more aggressive (30% 5yr survival).

 Shrinivas SC, Deshmukh S, Pawar V, et al. Case
Study of Clinicopathological correlation of benign
sinonasal masses. World Articles in Ear, Nose and
Throat 2012;5(1)
:showed nasal schwannoma accounting for 2.4% of
benign nasal masses
 Vaideeswar P et al :
schwannoma formed 2.5% (three cases) of all
Sinonasal tumors

 slowly growing mass
 arise more frequently from the ophthalmic and
maxillary divisions of the trigeminal nerves
 also originate from sympathetic fibers of the
carotid plexus or parasympathetic fibers of the
pterygopalatine ganglion
 Symptoms depend on the location :
 progressive nasal obstruction ± epistaxis
 anosmia / hyposmia
 headache
 facial swelling and proptosis

 Macroscopically:
 well-delineated but nonencapsulated globular
 firm to rubbery yellow-tan mass
 Histologically:
 cellular Antoni A areas with Verocay bodies
 hypocellular myxoid Antoni B areas
 Immunocytohistochemistry:
 strongly and diffusely immunoreactive for S-100
protein

 Mey KH et al in a case series of five nasal
schwannoma
 Buob et al in a series of nasal schwannoma cases
 Unlike other areas nasal schwannoma is usually
not encapsulated
 According to these authors this peculiarity could
be explained by the development of these tumours
from Sinonasal mucosal autonomic nervous
system fibres
 which are devoid of perineural cells similar to the
case of gastric Schwannoma

 Immunohistochemistry :
 Positive stains: S100
 Negative stains: EMA, CD34, Ki-67/MIB1 (1-
5%)
 Treatment: radical surgical resection; no
recurrence or metastases

 Rare, frequently misclassified
 Mean age 48 years, range 13-88 years; no gender
preference
 Usually primary intranasal or paranasal mass; may
also be an intracranial tumor invading sphenoid or
frontal sinuses
 Primary extracranial tumors have a good
prognosis; intracranial lesions invading into upper
respiratory tract are difficult to excise
 Positive stains: EMA, vimentin
 Negative stains: S100 (usually)

 The term hemangioma has traditionally been used
to describe a variety of developmental vascular
anomalies.
 Currently, hemangiomas are considered to be
benign tumors of infancy that are characterized by
a rapid growth phase with endothelial cell
proliferation, followed by a gradual involution.
Most cannot be recognized at birth but make their
appearance in most instances during the first 8
weeks of life.
 Vascular malformations are structural anomalies of
blood vessels without endothelial proliferation and
are present at birth and persist throughout life.

 These lesions are present from birth and persist
throughout life.
 As with hemangiomas, these lesions tend to
darken with age.
 Low-flow venous malformations typically have
a blue color and are easily compressible.
 Arteriovenous malformations are high-flow
lesions that result from persistent direct arterial
and venous communications. A palpable thrill
or bruit is often noticeable and the overlying
skin typically feels warmer to the touch.

 Hemangiomas are the most common tumors of
infancy.
 They have a female gender predilection (3:1)
and are most common in the White population.
 60% of the hemangiomas occur in the head and
neck region with 80% of them occurring as
single lesions. Multiple lesions may be part of
a syndrome.
 About 50 % of all hemangiomas will show
complete resolution by 5 years of age.

 Types : depending on size of vessels
 Capillary
 Cavernous
 Mixed
 Multifocal angiomatosis:
when multiple or affecting a large segment of the
body

 frequently occur in the head and neck region,
 • uncommon in the nasal cavity and paranasal sinuses,
 • cavernous and capillary types have been reported in the
sinonasal region,
 • represent less than 20% of all benign nasal cavity tumors,
 • 80% arise from the nasal septum (Kiesselbach area), 15%
arise from the lateral wall of the nasal cavity.
 • originate from the soft tissues of the nasal cavity
 • also occur in bones of the inferior or middle turbinate (>
1% bone tumors).
 • cavernous hemangiomas usually do not present until
adulthood (adults)
 • in both sex with equal frequency,
 • incidence peaks in the 4th decade of life.

 Trauma, viral oncogenes, inflammatory conditions and
the production of
 angiogenic growth factors may play a role in the
development
 hyperplastic, neovascular response to an angiogenic
stimulus with imbalance of promoters and inhibitors
 The occurrence and growth of these lesions during
pregnancy may be
 related to increased blood volume or hormonal
influences.
 Cavernous hemangioma in adults not undergo
spontaneous involution
 such as head and neck hemangioma in the paediatric
population

 Clinical presentation and symptoms:
• epistaxis and/or hemoptysis
• enlarging lesion in the nasal cavity
 Macroscopy:
Red-blue, soft, spongy mass or nodule

 Differential Diagnosis
 • Antrochoanal polyp
 •Inverted papilloma
 • Hemangiopericytoma
 • Esthesioneuroblastoma
 Treatment and prognosis:
 • surgical resection via transnasal endoscopic approach,
 • for extensive lesions: preoperative selective
embolization,
 • radiation therapy: for unresectable or inaccessible
lesions,
 • no recurrences after surgical removal have been
reported.

 misnamed; they are neither infectious nor
granulomatous
 usually occurs in children and young adults
 solitary, glistening red papule or nodule that is
prone to bleeding and ulceration

 precise mechanism for the development of
pyogenic granuloma is unknown
 Postulated: Trauma, hormonal influences, viral
oncogenes, underlying microscopic arteriovenous
malformations, the production of angiogenic
growth factors, and cytogenetic
 Trauma: Nose picking, nasal packing,
cauterization, shaving/hair removal, and
nonspecific microtrauma
 Isolated cases: Sturge-Weber or von Hippel-
Lindau syndrome

 Curettage
 Cryotherapy
 Excision: with preop ± embolization
 EES
 LASER
 Sclerotherapy

 Cumming’s 5th edition
 Scott-Brown’s 7th edition
 Rhinology journal(Official Journal of the
International and European Rhinologic Societies)
 European Position Paper on Endoscopic
Management of Tumours of the Nose, Paranasal
Sinuses and Skull Base(Professor Stammberger,
Professor Lund)
 Pubmed
 medscap

Benign sinonasal masses presentation & management-1

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