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Main Article
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 sino-
nasal 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 non-
neoplastic and neoplastic.
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.
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.
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.
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).
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, sino-
nasal 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 non-
neoplastic, 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
Fig.
II:Nasopharyngeal
angiofibroma: Collagenised fibrous stroma and
vessels lined by endothelial cells. H&E x 400
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 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
Masses
of
Nasal Cavity, Paranasal Sinuses and Nasopharynx
Fig III: Nasopharyngeal carcinoma- schmincke type: Diffuse growth
pattern- inflammatory cells are intermingled with neoplastic cells. H&E
x 400
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
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
Fig IV: Malignant melanoma: oval or spindle malignant cells with
melanophages, containing pigments. H&E x 200.
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.
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.
Indian Journal
of
Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006
0
Masses
of
Nasal Cavity, Paranasal Sinuses and Nasopharynx
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)
Non-neoplastic:(144
cases)
Nasal Polyp
120
83.33
2:1
2-3
Rhinoscleroma
8
5.55
1:1
4
Tuberculosis
6
4.17
2:1
4
Fungal infection
5
3.47
1.5:1
3
Fiibrous Dysplasia
2
1.38
2:1
1
Ossifying Fibroma
2
1.38
2:1
1
Nasal Glioma
1
0.69
F only
1
Benign lesions:(56
cases)
Angiofibroma
24
42.85
M only
2
Inverted papilloma
15
26.78
3:1
5
Capillary hemangioma
7
12.5
1:2:5
1&6
Lobular capillary
hemangioma
4
7.14
1:1
4
Pleomorphic adenoma
4
7.14
1:1
5
Solitary nasal fibroma
2
3.57
F only
4
Malignant lesions:
(40 cases)
Squamous cell carcinoma
15
37.5
2:1
6&7
Nasopharyngeat carcinoma
10
25
3:2
4 & 6
Malignant melanoma
4
10
1:1
4
Sino-nasal undifferentiated
carcinoma
3
75
2:1
4
Neuroblastoma
2
5
1:1
1
Adenoid cystic carcinoma
2
5
!:1
7
Non- Hodgkins lymphoma
2
5
1:1
1
Adenocarcinoma
2
5
1:1
4
Table -II
Distribution of tumour-like lesions according to the site of presentation
Nasal Cavity
Paranasal Sinuses
Nasopharynx
Number
Percentage
Number
Percentage
Number
Percentage
Total Cases
156
65.00
48
20.00
36 15.00
'ILmours
Benign
46
19.17
14
5.80
36
15.00
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
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of
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William HL. (1973): Head and neck Otolaryngology. Edited
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WB,
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Waldman SR, Levine HL, Sebek BA. (1981): Nasal
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Nayar RC, Al Kabi J, Ghorpade K. (2004): Primary nasal
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Witt JR, Shan JP, Sternberg SS. (1983): Juvenile
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Stiller D and Kuttna K. (1988): Growth pattern
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Synder RN and Perzin KH. (1972) Papillomatosis
of
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of
the nose and paranasal
sinuses. American Journal
of
Clinical Pathology 42; 245-
258.
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.
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lymphoma: a clinicopathologic study with
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carcinoma
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the nasal septum. Rhinology 41 (4); 253-254.
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Address for correspondence
Prof. Nazoora Khan
A-11, Medical Enclave
Aligarh Muslim University
Aligarh - 202002
(UP)
INDIA
Indian Journal
of
Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006
