Masses of nasal cavity, paranasal sinuses and nasopharynx: A ...

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MASSES OF NASAL CAVITY, PARANASAL SINUSES AND NASOPHARYNX: A CLINICOPATHOLOGICAL STUDY N. Khan,* U. Zafar, ** N. Afroz, *** S.S. Ahmad,* *** S. A. Hasan *****

Key words: Histopathology, Nasal cavity, Paranasal sinuses, Nasopharynx.

INTRODUCTION:

OBSERVATIONS:

The swellings of nasal cavity (NC), paranasal sinuses (PNS) and nasopharynx (NP) have inflicted man from time immemorial. The presenting symptomatology of all tumors is similar and using advanced imaging and CT and/or MRI, a presumptive diagnosis is often made. However, a careful histopathological examination is necessary to decide the nature of any particular lesion. A variety of non-neoplastic and neoplastic conditions involve the sinonasal sinuses and nasopharynx and these are very common lesions encountered in clinical practice. The large number of diseases affecting these structures is due, in major part, to the many specialized tissues, each with its own aberrations that exist in the region'. A detailed history, clinical examination and most importantly, thorough histopathological evaluation are essential part of workup of patients, so that a correct and timely intervention is done. The study aimed at analyzing the clinicopathological features of cases presenting as mass in NC, PNS and NP; to find out the relative incidence and to classify the lesions as nonneoplastic and neoplastic.

Histopathological Examination of total 240 cases presenting as mass in NC, PNS and NP revealed that tumor-like lesions constituted 144 cases (60%) and tumors constituted 96 cases (40%). Amongst the neoplastic cases, 56 cases (23.33%) were benign and 40 cases (16.67%) were malignant.

MATERIAL AND METHODS:

The study was conducted in the histopathology section of the Department of Pathology in Jawaharlal Nehru Medical College, Aligarh. The total duration of study was 5 years comprising of 240 cases presenting as mass in the nasal cavity, paranasal sinuses and nasopharynx. For each case a complete clinical history and detailed radiological findings were obtained and thorough histopathological examination was done. The tissues were routinely processed for histopathological examination and were stained by Hematoxylin and Eosin (H&E); and using Periodic acid Schiff's (PAS) and reticulin stains wherever necessary and applicable. The lesions were classified as non neoplastic and neoplastic lesions; the neoplastic lesions were further classified as benign and malignant.

NON - NEOPLASTIC LESIONS:

Non-neoplastic lesions/ tumor-like lesions formed 60% of the total cases of NC, PNS and NP. Nasal polyps were the commonest type of lesion encountered in this group with 120 cases (83.33%), followed by rhinoscleroma- 8 cases (5.55%). Other lesions, in the descending order of frequency, seen were tuberculosis, fungal infection, fibrous dysplasia and ossifying fibroma of bone and nasal glioma. The lesions have a vast range of age of presentation. The mean age of presentation of tumor-like lesions was 22.5 years .It was seen that males were more prone to affiliations of NC, PNS and NP by non-neoplastic lesions, with male to female ratio (M:F) being 1.7:1 .Of all the non-neoplastic lesions, 110 cases (76.39%) presented as mass in nasal cavity and 34 cases (23.61 %) presented as mass in paranasal sinuses. No case was reported from. nasopharynx (Table II) NEOPLASTIC LESIONS:

A total of 96 cases which constituted 40% of all lesions were studied; 23.33% were benign and 16.67% were malignant. Of 56 cases of benign tumors the commonest was of angiofibroma, constituting 24 cases (42.85%); followed by inverted papilloma (15 cases, 26.78%). Capillary hemangioma, lobular capillary hemangioma, pleomorphic adenoma and solitary nasal fibroma were the other benign lesions The age of presentation of individual tumors was variable and the mean age of presentation in our study was 26.8 years. The M:F ratio was found to be 3:1.

*Prof. ** Senior Resident, ***Lecturer, ****Reader, Dept. of Pathology, ***** Prof. Dept. of Otorhinolaryngology, JN Medical College, Aligarh Muslim University, Aligarh Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006

Masses of Nasal Cavity, Paranasal Sinuses and Nasopharynx

Fig. 1:Rhinoscleroma (nasal cavity): Stratified squamous lining. Underlying tissue shows plasma cells, foamy macrophages and lymphocytes.H&E x 200.

Fig. II:Nasopharyngeal angiofibroma: Collagenised fibrous stroma and vessels lined by endothelial cells. H&E x 400

The lesions involved NC, PNS and NP with variable frequency. Amongst the 56 benign case; we studied 28 cases (50%) involved nasal cavity, 4 cases (7.14%) involved paranasal sinuses and 24 cases (42.86%) involved nasopharynx (Table II).

study by Anjali et al 3 .The patients had a long history of allergic rhinitis and the presenting features were blocking of nose and sinusitis. Nasal polyps were bilateral in 60% of the cases in this study, whereas Batsakis et al 4 described that bilateralism is a rule in cases of nasal polyp.

The study included 40 malignant cases and the most common lesion was squamous cell carcinoma- 15 cases (37.5%), followed by nasopharyngeal carcinoma -10 cases (25%). The other malignant lesions that involved the region were malignant melanoma, sinonasal undifferentiated carcinoma, neuroblastoma, adenoid cystic carcinoma, Non -Hodgkin's lymphoma and adenocarcinoma. The age range varied from first to seventh decade of life but the mean age of presentation was 35.3 years which was a decade older than the mean age of the benign lesions. Males showed stronger predilection than females with male to female ratio being 2.3:1. Out of the total 40 cases the nasal cavity, paranasal sinuses and nasopharynx were the site of presentation in 18 (45%), 10 (25%) and 12 (30%) cases respectively (Table II). DISCUSSION:

The relative incidence of the lesions of NC, PNS and NP was 34.3 cases per year. The term relative incidence' shows hospital incidence rather than the incidence in general population. The incidence reported by Tondon et al 2 and Anjali et al 3 was 13.7 and 34.5 per year respectively. In the study 60% lesions were nonneoplastic, which is more or less similar to those of Tondon et all who did a similar study and according to their observations 74.61 % were non-neoplastic and 25.41 % were neoplastic. NON-NEOPLASTIC LESIONS:

Nasal polyp was the most common lesion observed in this present study, constituting 83.33 % (120 cases) of all non-neoplastic lesions. The majority (74.19%) of polyps were present in nasal cavity and only 25.81 % involved sinuses. According to Tondon et al e and Anjali et al 3 47% and 31.98%, respectively, of all lesions of nasal cavity were polyps. The difference might be due to higher incidence of allergic rhinitis in this region. The age of presentation ranged from the very young to adults but the peak was seen in second and third decade of life which is similar to the findings of Tondon et al 2 .The sex ratio in our study was 1.7:1; very close to

The study included 8 cases of rhinoscleroma, which was 5.55% of all the non-neoplastic lesions of NC, PNS, and NP. The peak age of presentation was 40 years with no sex predilection. The patients presented with profuse foul smelling nasal discharge, in accordance with William et al 5 . Microscopically the predominant cells were foamy histiocytes (mikulicz cells) and plasma cells (Fig. I) There were 6 cases of tuberculosis which presented as mass in the NC and constituted 4.17% of all the non-neoplastic lesions in this region. However tuberculosis was described as a rare entity by other authors 6 ''. This difference might be due to higher prevalence of tuberculosis in this part of the world. Five cases presented with foul smelling mucinous nasal discharge which on microscopy showed inflammation ranging from negligible to large numbers of neutrophils and histiocytes within granulation tissue'. It turned out positive after culture on sabouraud's dextrose agar medium proving the infection to be of fungal origin. BENIGN LESIONS:

The commonest benign tumor in our study was angiofibroma and it accounted for 42.85% (24 cases) of all the benign lesions in this region. All the cases were located in NP with profuse and recurrent epistaxis from the polypoidal mass as the chief complaints. Similar features were reported by other authors $. Microscopic features were similar to that described by Stiller et al I which showed an intricate mixture of blood and stroma. The stroma varied from loose edematous to dense. The vessels ranged from capillary sized to venous size (Fig. 2). Inverted papilloma was the second most common benign lesion studied. It constituted 26.78 % (15 cases) of all the benign lesions of NC, PNS and NP. The peak age of presentation was fifth decade of life and the male to female ratio was 3:1, similar to findings of Synder and Perzin'° and Anjali et al 3 . Microscopy revealed

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September


Fig III: Nasopharyngeal carcinoma- schmincke type: Diffuse growth pattern- inflammatory cells are intermingled with neoplastic cells. H&E x 400

Fig IV: Malignant melanoma: oval or spindle malignant cells with melanophages, containing pigments. H&E x 200.

proliferating columnar or squamous epithelium with an admixture of mucin secreting cells ". The presenting features of capillary hemangioma, lobular capillary hemangioma, pleomorphic adenoma and solitary nasal fibroma were almost similar and a provisional diagnosis was made after clinical examination and radiological investigations but final diagnosis was made after histopathological examination

one of the most common non-epithelial malignancies involving sino-nasal region. There were 2 cases of NHL in late second decade of life. Ferry et al'S stated that sino-nasal lymphomas are of diffuse large cell type but this is in contrast to small lymphocytic lymphoma seen in this study.

MALIGNANT LESIONS:

Squamous cell carcinoma was the most common malignancy observed in the study and it constituted 37.5% (15 cases) of all the malignant and 6.25% of all the lesions of NC, PNS and NP. Majority of the patients were in sixth or seventh decade of life and M:F ratio was 2:1, almost similar to the finding of Barnes et al'?. The presenting complaints were similar to those described by Lewis 13 , with nasal obstruction, rhinorrhoea, epistaxis and pain as chief complaints in malignancy of nasal cavity while additional symptoms of chronic sinusitis were seen in antral malignancy. Out of 15 cases, 10 cases originated from paranasal sinuses and 5 cases from the nasal cavity. There were 10 cases of nasopharyngeal carcinoma which constituted 25 % of all the malignant lesions of NC, PNS and NP. As the name suggests the primary site of lesions in all the cases was NP. Majority of the cases were seen in fourth or sixth decade but 2 cases were seen in second decade of life. The older age group had squamous cell carcinoma. Two young boys, aged 13 years and 16 years, presented with undifferentiated nasopharyngeal carcinoma - lymphoepithelioma, schminke pattern (Fig.3). Easton et al stated that there are two peaks of age incidence and that undifferentiated nasopharyngeal carcinoma had more affinity for younger age group. Other rare lesions that were seen in this region were neuroblastoma, Non-Hodgkin's lymphoma, malignant melanoma, adenoid cystic carcinoma and adenocarcinoma. There were 3 cases which could not be categorized after histopathological examination and were placed under lino-nasal undifferentiated carcinoma. There were 2 cases of neuroblastoma, an 8 year old and 6 year old male and female respectively. Non-Hodgkin's lymphoma (NHL) is

There were 4 cases of malignant melanoma presenting as mass in NC, 2 of which showed extension to NP. Histopathological features were very similar to a typical malignant melanoma consisting of malignant epithelioid and spindle cells with bizarre pleomorphic nuclei and small eosinophilic nucleoli with evidence of melanin deposition (Fig.4). Adenoid cystic carcinoma of nasal cavity is uncommon 16 but commonest amongst the salivary type adenocarcinoma found in the region of sino-nasal and nasopharynx ". In this study, adenoid cystic carcinoma was the only malignant salivary gland adenocarcinoma. 2 cases which constituted 5% of all the malignant lesions of this region. The microscopic features were similar to adenoid cystic carcinoma of salivary gland. There were also 2 cases of adenocarcinoma both presented in the 4 1 decade of life with microscopic features of a well-differentiated adenocarcinoma. To conclude, the clinical and radiological features of masses of NC, PNS and NP are overlapping and often, only a provisional diagnosis is possible. Definitive diagnosis requires histopathological examination, and as most of the lesions are either inaccessible for fine needle aspiration cytology (FNAC) or FNAC is not recommended because of fear of brisk hemorrhage. Histopathology, therefore becomes the ultimate diagnostic technique for correct and timely intervention. REFERENCES: Stacey E. Mills and Robert E. Fechner. (1999): Diagnostic Surgical Pathology. Ed. Stephen S. Sternberg., Philadelphia; 885-992. 2. Tondon PL and Gulati J, Mehta N. (1971): Histological study of polypoidal lesions in the nasal cavity. Indian Journal Otolaryngology and head & neck surgeryl3; 3-11. 0

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Table -I Distribution of cases of Nasal Cavity, Paranasal Sinuses and Nasopharynx according to the incidence, sex ratio and age of presentation of different lesions Diagnosis

Number of cases

Percentage

M:F

Peak age of presentation (decade)

120 8 6 5 2 2 1

83.33 5.55 4.17 3.47 1.38 1.38 0.69

2:1 1:1 2:1 1.5:1 2:1 2:1 F only

2-3 4 4 3 1 1 1

24 15 7 4

42.85 26.78 12.5 7.14

M only 3:1 1:2:5 1:1

2 5 1&6 4

4 2

7.14 3.57

1:1 F only

5 4

15 10 4 3

37.5 25 10 75

2:1 3:2 1:1 2:1

6&7 4&6 4 4

2 2 2 2

5 5 5 5

1:1 !:1 1:1 1:1

1 7 1 4

Non-neoplastic:(144 cases) Nasal Polyp Rhinoscleroma Tuberculosis Fungal infection Fiibrous Dysplasia Ossifying Fibroma Nasal Glioma

Benign lesions:(56 cases) Angiofibroma Inverted papilloma Capillary hemangioma Lobular capillary hemangioma Pleomorphic adenoma Solitary nasal fibroma Malignant lesions: (40 cases) Squamous cell carcinoma Nasopharyngeat carcinoma Malignant melanoma Sino-nasal undifferentiated carcinoma Neuroblastoma Adenoid cystic carcinoma Non- Hodgkins lymphoma Adenocarcinoma

Table -II Distribution of tumour-like lesions according to the site of presentation Nasal Cavity Number Percentage

Paranasal Sinuses Number Percentage

Nasopharynx Number Percentage

Total Cases

156

65.00

48

20.00

36

15.00

'ILmours

46

19.17

14

5.80

36

15.00

Benign

28

11.67

4

1.67

24

10.00

Malignant

18

7.50

10

4.17

8

5.00

'Humour-like lesions

110

45.83

34

14.17

0

0

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006

Ylasses of Nasal Cavity, Paranasal Sinuses and Nasopharynx

3. Anjali Das Gupta, Ghosh RN and Mukherjee Chhanda. (1997): Nasal Polyps- Histopathologic spectrum. Indian Journal Otolaryngology and head and neck surgery 49; 32-36. 4. Batsakis JG. (1980): The pathology of head and neck tumors. Nasal cavity and paranasal sinuses. Part 5. Head Neck surgery 2; 410-419. 5. William HL. (1973): Head and neck Otolaryngology. Edited by Paprella MM, Shumrick DA, Saunders WB, 27-28. 6. Waldman SR, Levine HL, Sebek BA. (1981): Nasal tuberculosis: a forgotten entity. Laryngoscope 91:11-16. 7. Nayar RC, Al Kabi J, Ghorpade K. (2004): Primary nasal tuberculosis: a case report. Ear Nose Throat Journal 83; 188-191. 8. Witt JR, Shan JP, Sternberg SS. (1983): Juvenile nasopharygeal angiofibroma: A 30 year clinical review. American Journal of Surgery 146; 521-15. 9. Stiller D and Kuttna K. (1988): Growth pattern of juvenile nasopharyngeal fibromas: A histological analysis on the basis of 40 cases. Allg Pathol 134; 409- 422. 10. Synder RN and Perzin KH. (1972) Papillomatosis of nasal cavity and paranasal sinuses (inverted papilloma, squamous papilloma): A clinicopathologic study. Cancer 30; 668-690.

11. Oberman HA. (1964): Papillomas of the nose and paranasal sinuses. American Journal of Clinical Pathology 42; 245258. 12.Barnes L and Bedetti C. (1984): Oncocytic schneiderian papilloma. A reappraisal of cylindrical cell papilloma of sinonasal tract. Human Pathology 15; 344-351. 13.Lewis JS and Castro EB. (1972): Cancer of the nasal cavity and paranasal sinuses. J Laryngol otol 86; 255-262. 14.Easton JM, Levine PH and Hyams VJ. (1980): Nasopharyngeal carcinoma in the United States: A pathologic study of 177 US and 30 foreign cases. Archives of Otolarygology 106; 88-91. 15.Ferry JA, Sklar J, Zukerberg LR et al.(1991): Nasal lymphoma: a clinicopathologic study with immunophenotypic and genotypic analysis. American Journal of Surgical Pathology 15; 268-279. 16.Sivaji N, Basavaraj S, Stewart Wet al.(2003): Adenoid cystic carcinoma of the nasal septum. Rhinology 41 (4); 253-254. 17.Heffner DK, Hyams VJ, Hauck KW et al.(1982): Low grade adenocarcinoma of the nasal cavity and paranasal sinuses. Cancer 50; 312-322. Address for correspondence

Prof. Nazoora Khan A-11, Medical Enclave Aligarh Muslim University Aligarh - 202002 (UP) INDIA

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