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International Journal of Otorhinolaryngology and Head and Neck Surgery | July 2020 | Vol 6 | Issue 7 Page 1226
International Journal of Otorhinolaryngology and Head and Neck Surgery
Aljafar HM et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Jul;6(7):1226-1231
http://www.ijorl.com
pISSN 2454-5929 | eISSN 2454-5937
Original Research Article
The clinicopathological and radiological features of unilateral nasal
mass in adults, a tertiary hospital experience
Hadeel M. Aljafar1*, Eman R. Alenazi2, Abdulrahman M. Alkhatib3,
Ghaleb M. Alazzeh3, Ali A. Almomen3
INTRODUCTION
Nasal polyps or nasal masses are benign lesions on the
epithelial linings of nasal mucosa and the paranasal
sinuses with unidentified etiology, which leads to
inflammation of its vicinities. The clinical conditions of
these polyps are chronic inflammation, infections,
recurrent allergies and if the polyps are grown larger it
can obstruct the passage which may even interfere with
normal breathing. The Otolaryngologists very frequently
come across cases presented with conditions like
unilateral sinonasal symptoms, nasal polyps or sinus
opacity. However, a study indicates that the prevalence of
nasal polyps was reported to be 4% by a study.1 A review
indicates that nasal polyps are commonly seen in non-
allergic asthma patients (13%) than allergic asthma (5%)
ABSTRACT
Background: Aim and objectives of the study were to analyze and study the diverse presentations of unilateral nasal
mass and to identify the suggestive features of neoplastic pathology in adult’s population at a tertiary referral hospital.
Methods: A retrospective analysis of 90 patients presented with unilateral sinonasal mass, reported to the Rhinology
and Skull Base Clinic at the department of ENT in King Fahad Specialist Hospital, Dammam. The parameters include
patient history, clinical assessments and histopathological examinations, which were supplemented with radiological
investigations.In addition, demographic information and histopathological examinations for patients, who underwent
surgical excision was analyzed for correlation with clinical diagnosis.
Results: The reported cases are 55 males and 35 females with a median follow-up period of 12 months, ranging from
2-72 months. Nasal obstruction is the major symptom 34 (38%), 25 (27.8%) cases were reported with nasal mass and
clinical diagnosis indicates 18 (20%) cases of malignancy. Type of disease and gender demonstrates low significance
(p=0.023), whereas the diagnosis with age is highly significant (p=0.005).
Conclusions: Carcinoma, inflammatory polyposis, inverted papilloma and allergic fungal sinusitis were the highest
histological diagnosis. The clinical diagnosis and the suggestive features of radiological findings mostly resembled
the histological findings. In contrary to the resemblance, the histological finding reveals the general diagnosis of nasal
mass to the precise diagnosis, especially the fatal conditions like carcinoma. The high rate of malignancy and its
suggestive radiological findings indicates that the specialists should consider the cases with caution to carryout
histological analysis to rule out the probability of neoplasm.
Keywords: Clinicopathological, Unilateral nasal mass, Neoplastic pathology
1Department of Otorhinolaryngology, Imam Abdulrahman Bin Faisal University, College of Medicine, Khobar,
Eastern Province, KSA
2Department of Otorhinolaryngology, King Abdulaziz Hospital, Alhasa, Eastern Province, Saudi arabia
3Department of Otorhinolaryngology, King Fahad Specialist Hospital, Dammam, Eastern Province, Saudi Arabia
Received: 12 February 2020
Revised: 13 June 2020
Accepted: 15 June 2020
*Correspondence:
Dr. Hadeel M. Aljafar,
E-mail: ja_hadeel@hotmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20202772
Aljafar HM et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Jul;6(7):1226-1231
International Journal of Otorhinolaryngology and Head and Neck Surgery | July 2020 | Vol 6 | Issue 7 Page 1227
cases.2 The symptoms of nasal polyps include watery
anterior rhinorrhea with or without mucous dripping.
Hyposmia and or anosmia are yet another complication of
sinonasal polyps. Pain is quite unusual, but may
precipitate along dorsum of the nose, at the forehead and
may spread the cheeks. The symptoms may become
further complicated based on the size and location of the
polyp and it aggravates if the blockage become prominent
and the sinuses gets infected.3 The condition is
uncommon in children and is observed commonly in
adults, but its etiology is not known, but usually with
allergic conditions.4 The polyps are usually noticed on the
middle meatus, which may have the influence of the
anatomic factors. Further, chronic inflammations in the
nasal cavity may also be a reason for the development of
such polyps.
These nasal masses are edematous tissues, usually formed
in the middle meatus, which then prolapses into the nasal
cavity. The cell structure of these polyps is characterized
by ciliated columnar epithelium with thickened basement
membrane, which will be infiltrated with plasma cells.
Clinical diagnosis of the condition is based on the
symptoms and clinical examination of nose, but often
uses diagnostic tests like, nasal endoscopy, imaging
studies and allergy tests. Histopathological investigations
are uncommon if these tissues are bilateral in nature, but
it requires histopathological examinations if it is
presented unilaterally to rule out different types of
malignancies.5 A retrospective review of histological
findings of nasal polyp illustrates that 1.1% of the cases
were with malignancy and concluded that all such
specimens should undergo histological examination to
confirm whether the growth is malignant.6 A study
describing the histopathological findings of a series of
cases observed neoplasm of sinonasal polyps was 2.3%,
which is higher than reported in literature and the
observation was that the cases were inverted papilloma,
whereas others were considered as incidental in bilateral
nasal polyps. Despite the low incidence, the study
recommends to conduct histopathologic examinations in
all cases not to skip the fatal pathologies. 7
The literature thus points out the need of attention, even
though unilateral sinonasal symptoms are usually treated
without risk, in some cases it may be a signal to sinonasal
neoplasms with subtle symptoms, mimicking
inflammatory pathology. Moreover, unattended benign
lesions in the sinonasal vicinity may often lead to
frequent recurrence and radical surgeries. Irrespective of
its significant morbidity and commonality, research on
unilateral sinonasal conditions is sparse, which
emphasizes the need of research in this area.
METHODS
A retrospective analysis of 90 patients presented with
unilateral sinonasal mass, reported to the Rhinology and
Skull Base Clinic at the department of ENT in King
Fahad Specialist Hospital, Dammam. The cases reported
from January 2009 till December 2018 were analyzed.
The parameters include patient history, clinical
assessments and histopathological examinations,
radiological investigations (computed tomography and
magnet resonance imaging). In addition, demographic
information was obtained and the histopathological
examinations of tissues for patients, who underwent
surgical excision was analyzed for correlation with
clinical diagnosis.
Ethical approval
The study secured ethical clearance from the Institute for
Research and Medical Consultations (IRMC) at the
organization. A proposal letter explaining the purpose,
methods, and anticipated benefits and risks of the study
was reviewed along with the questionnaire to obtain an
approval from the IRMC. Furthermore, the data collector
informed the respondents of the benefits and risks of the
study prior to their participation.
RESULTS
A total of 90 patients reported to the rhinology clinic with
unilateral sinonasal polyps consist of 55 (61.1%) males
and 35 (38.9%) females with mean age of 46.1 (SD 16.9),
ranging from 19 to 88 years, of them 30 (33.3%) were
smokers. The median follow-up period of patients was 12
months with minimum period of 2 months to a maximum
period of 72 months (Table 1). The common presenting
symptoms (Figure 1) were nasal obstruction 34 (38%),
nasal discharge 15 (17%), epistaxis 12 (14%), headache 9
(10%) and hyposmia 7 (8%).
Table 1: Demography (n=90).
Variables
N (%)
Gender (%)
Male
55 (61.1)
Female
35 (38.9)
Age in years
Mean (SD)
46.10 (16.9)
Minimum - Maximum
19-88
Follow-up in months
Median
12.0
Minimum-maximum
2.0-72.0
Smoking
Yes
30 (33.3)
No
60 (66.7)
Figure 1: Presenting symptoms.
Aljafar HM et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Jul;6(7):1226-1231
International Journal of Otorhinolaryngology and Head and Neck Surgery | July 2020 | Vol 6 | Issue 7 Page 1228
Figure 2: Clinical diagnosis.
Table 2: Histopathological findings.
Histopathological findings
Frequency
Allergic fungal sinusitis
10
Invasive fungal sinusitis
4
Granulomatous sinusitis
2 (1 fungal
granulomatous and 1
rhinoscleroma)
Inflammatory polyposis
12
Mucocele
7
Meningocele/
meningoencephalocele
7
Inverted papilloma
10
Fibrous dysplasia
3
Antrochoanal polyp
4
Carcinoma
13 (7 SCC, 4 adenoid
cystic carcinoma and 2
adenocarcinoma)
Sarcoma
4 (2 pleomorphic
sarcoma, 1 Ewings
sarcoma and 1 kaposi
sarcoma)
Multiple myeloma
1
Juvenile angiofibroma
2
Osteoma
3
Capillary hemangioma
1
Schwanoma
2
Craniopharyngoma
2
Giant cell tumor
1
Infratemporal Papilloma
1
Pyogenic granuloma
1
The clinical diagnosis (Figure 2) illustrates that nasal
mass was the leading clinical diagnosis 25 (27.8%),
followed by nasal polyposis 18 (20%), fungal sinusitis 13
(14.44%), neoplastic nasal mass 11 (12.22%), inverted
papilloma 7 (7.8%) and antrochoanal polyp 5 (5.56%).
All surgical specimens were sent for histopathological
examinations to confirm the final diagnosis (Table 2) and
carcinoma (n=13) is the most common condition, (7
squamous cell carcinoma (SCC), 4 adenoid cystic
carcinoma and 2 adenocarcinoma). This was followed by
inflammatory polyposis (n=12), allergic fungal sinusitis
(n=10), inverted papilloma (n=10), 7 mucoceles and 7
meningoceles and 3 cases of osteoma. Malignant soft
tissue tumors sarcoma (n=4) and multiple myeloma (1)
were observed. 11 other cases of different benign tumors
were identified.
Figure 3: Type of disease.
The disease conditions were classified into different types
(Figure 3) and it is observed that 33 (36.7%) were
inflammatory in nature, followed by benign tumors 26
(28.9%), 18 (20%) malignant cases, non-inflammatory 12
(13.3%) and mixed type 1 (1.1%)
Table 3: Other characteristics.
Characteristics
Number
Disease free duration
Yes
73
No
16
No f/u
1
Residual disease
Yes
14
No
75
No f/u
1
Recurrence
Yes
8
No
78
Expired
1
Lost f/u
3
The Table 3 illustrates the other characteristics like the
disease free duration, residual disease and its recurrence.
Most of the patients (n=73) were having a disease-free
duration and the majority (n=75) doesn’t have residual
diseases, whereas one patient expired during the study
period and disease recurrence was observed in 8 patients.
It is observed that there is a statistically significant
relation between the gender (p=0.023) and the different
types of diseases diagnosed (Table 4). The diagnosed
malignant growth was high among males (n=11) when
compared to females (n=7). Statistical significance was
observed between the disease and the reported age, but
with high statistical significance of 0.005 (Table 5). 18
malignant cases observed at the mean age of 59, whereas
benign growth was high (n=26) at the mean age of 44.3.
non-Inflammatory
12, 13.3%
Mixed
1, 1.1%
Malignant
18, 20.0%
inflammatory
33, 36.7%
Benign
26, 28.9%
Aljafar HM et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Jul;6(7):1226-1231
International Journal of Otorhinolaryngology and Head and Neck Surgery | July 2020 | Vol 6 | Issue 7 Page 1229
However, inflammatory conditions were the highest
among the diseases which accounted for 33 cases at a
mean age of 42.5
Table 4: Type of disease and gender.
Type of the disease
Gender
P value
Male
Female
inflammatory
19
14
0.023
Non- inflammatory
9
3
Mixed
0
1
Benign
16
10
Malignant
11
7
Table 5: Disease and its relation with age.
Type of the
disease
N
Mean
age
SD
P value
inflammatory
33
42.5
16.6
0.005
Non-
inflammatory
12
39.8
19.6
Mixed
1
56.0
-
Benign
26
44.3
13.5
Malignant
18
59.0
14.8
The most common type of diseases was inflammatory
(n=33), non inflammatory (n=12), benign (n=26) and
malignant (n=18), which are further correlated with the
histological findings (Table 6). Among the inflammatory
type, histological findings demonstrate that 6 (18.2%) as
allergic fungal sinusitis and 4 (12.1%) as antrochoanal
polyp. The non-inflammatroy types were histologically
classified into two namely, meningocele-menin-
goencephalocele 6 (50.0%), and frontal mucocele 3
(25.0%). In the tumor group, the benign and malignant
tumors of which, inverted papilloma 10 (38.5%) and
fibrous dysplasia 3 (11.5%) were the commonest benign
type and adenoid cystic carcinoma 2 (11.1%), non
keratinizing poorly differentiated squamous cell
carcinoma 2 (11.1%) were related with malignancy.
Table 6: Most common type of diseases.
Type of
disease
Histology findings
N (%)
Inflammatory
(n=33)
Allergic fungal sinusitis
6 (18.2)
Antrochoanal polyp
4 (12.1)
Non-
inflammatory
(n=12)
Meningocele-
meningoencephalocele
6 (50.0)
Frontal mucocele
3 (25.0)
Benign
(n=26)
Inverted papilloma
10 (38.5)
Fibrous dysplasia
3 (11.5)
Malignant
(n=18)
Adenoid cystic
carcinoma
2 (11.1)
Non keratinizing poorly
differentiated squamous
cell carcinoma
2 (11.1)
Table 7: Correlation of clinical, radiological and histopathological diagnosis.
Clinical diagnosis
N
Radiological findings
N
Histopathology findings
N
Angiofibroma
2
Suggestive
2
Juvenile angiofibroma
2
Antrochoanal polyp
5
Suggestive
5
Antrochoanal polyp
4
Inflammatory polyposis
1
Frontal mucocele
3
Suggestive
3
mucocele
3
Fungal sinusitis
11
Suggestive
11
Fungal sinusitis
11
Granuloma
1
Suggestive
1
Granuloma
1
Hemangioma
1
Suggestive
1
Capiliary hemangioma
1
Inverted papilloma
7
Suggestive
7
Inverted papilloma
7
Nasal mass
25
Meningocele
Meningoencephalocele
Suggestive of other
pathology
4
2
19
Meningocele
4
Meningoencephalocele
1
Meningocele
1
Infra temporal papilloma
1
Meningocele
1
Mucocele
1
Multiple myeloma
1
Carcinoma
5
Craniopharyngioma
2
Fibrous dysplasia
3
Fungal sinusitis
1
Gland cell tumor
1
Rhinoscleroma
1
Schwannoma
2
Continued.
Aljafar HM et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Jul;6(7):1226-1231
International Journal of Otorhinolaryngology and Head and Neck Surgery | July 2020 | Vol 6 | Issue 7 Page 1230
Clinical diagnosis
N
Radiological findings
N
Histopathology findings
N
Nasal polyposis
18
Suggestive of other
pathology
18
Fungal sinusitis
3
Granulomatous sinusitis
1
Inflammatory polyposis
10
Inverted papilloma
3
Meningocele
1
Neoplastic nasal mass
11
Suggestive
11
Carcinoma
7
Sarcoma
4
Septal mass
1
Suggestive
1
Carcinoma
1
Correlation of clinical, radiological and histopathological
diagnosis was analyzed (Table 7) which illustrates that
for the first seven clinical diagnoses the radiological
finding were suggestive of clinical findings, which means
it is pointing out towards the clinical diagnosis, but not
completely affirming the diagnosis. However, the
histopathological findings almost completely agree with
the clinical diagnosis. This was followed by clinical
diagnosis of 25 nasal masses, of which 6 cases were
radiologically identified as meningocele, but 19 cases
were suggestive of other pathology. The histological
investigation too agrees with the six radiological findings
as meningocele. From the remaining 19 radiological
findings ‘indicating suggestive for other findings’, the
histopathological findings provided with more specific
findings than the clinical diagnosis as nasal mass. Out of
which, the majority was identified as carcinoma (n=5)
followed by a case of multiple myeloma, gland cell tumor
(n=1), schwannoma (n=2). The clinical diagnosis as nasal
polyposis (m=18) was provided with findings suggestive
of other pathology by the radiological investigation. But
the histological findings were more specific, provided
with 5 categories, of which, inflammatory polyposis
consists of 10 cases and 3 cases each for inverted
papilloma and fungal sinusitis. Eleven cases were
clinically diagnosed as characteristic of cancer or
neoplastic nasal mass, which was provided with
radiological findings as suggestive. Among them the
histological findings was more specific which indicates 7
cases of cancer and 4 cases of sarcoma. Furthermore, the
clinical diagnosis of septal mass was radiologically
suggestive, but identified histologically as carcinoma.
DISCUSSION
Nasal polyps are common diagnosis for the cases
reported to the Ear Nose Throat (ENT) clinics, which are
treated without much complication, but the unilateral
sinonasal symptoms may be often a signal to sinonasal
neoplasms with understated indications, mimicking
inflammatory pathology. The prevalence of nasal
polyposis in Saudi Arabia is not known well, however, a
cross-sectional case control study in France indicates the
prevalence as 2.11%.8 Further, studies are sparse on the
diverse presentations of unilateral nasal mass, if not
diagnosed properly it may go unnoticed with probability
of becoming a benign or malignant nasal mass. Hence,
this study intended to identify the suggestive features of
neoplastic pathology verifying the different diagnosis
with radiological and histopathological findings.
The presented symptoms of this study illustrate nasal
obstruction as the predominant symptom, which is quiet
common among cases with nasal mass and polyps. This
may be because any sort of inflammation in the nasal
mucosa, irrespective of its cause will lead to nasal
obstruction. But, the feeling of nasal obstruction may
vary from person to person, what one person feel may be
of less importance to another patient with same level of
obstruction.9 It is reported that nasal mass and nasal
polyps were the most common clinical diagnosis, which
are the common diagnoses in the ENT clinics presented
with nasal inflammations. Studies also indicate that
chronic sinusitis with or without polyposis always prompt
the clinicians to suspect potential presentation of cystic
fibrosis.10 However, radiological and histopathological
investigations are necessary to rule out possible
malignancies of the nasal mass and polyps.11
The histopathological investigations demonstrated
carcinoma, inflammatory polyposis and allergic sinusitis
as the leading findings. Histological investigations
provide with specific findings, which help to rule out the
unclear diagnosis and unveil the hidden carcinomas as
illustrated by a case study.12 Surprisingly, the percentage
of malignancy (20%) and benign tumors (29%) were
observed to be similar among both the genders. Literature
is not sufficient to explore the difference in sinonasal
malignancies between the two genders. But, a study on
olfactory neuroblastoma indicated that the survival rate of
male higher than that of female with treatment. Benign
tumors were also the same between the genders with 29%
cases in both the genders. As expected we also observed
the number of malignancy at a higher median age. We
also noticed the higher rate of inverted papilloma, a
benign tumor, which can undergo aggressive malignant
transformation into squamous cell carcinoma. This is
clarified by a retrospective cohort study, which stated that
it has the most severe degree of abnormal cells prior to
neoplasmic transformation and with higher recurrence
rate and multifocal involvement, but with low rate of
conversion to invasive carcinoma.13
Even though most of the clinical diagnosis correlates with
radiological findings and histopathological findings, the
diagnosis of nasal mass and nasal polyposis was not
Aljafar HM et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Jul;6(7):1226-1231
International Journal of Otorhinolaryngology and Head and Neck Surgery | July 2020 | Vol 6 | Issue 7 Page 1231
#exactly matching with the histological findings. This
was in particular for the diagnosis of nasal mass and
polyposis, when the radiological investigations provided
are suggestive of the condition, but the histopathological
findings clarified specific conditions. Currently, there is
no relevant literature available for comparing the clinical
with radiological and histopathological findings in
patients with nasal mass or nasal polyposis. The only
study which titles the comparison between the
investigations stated a positive correlation of radiological
findings and concluded that there is no histopathological
difference between polypoind infiltrations of sinuses.14
Hence, this study could not explore the literature to
contrast with findings of this study with similar studies.
However, the neoplastic pathology of the unilateral nasal
masses was well clarified and confirmed by the
histological investigations, which correlates with clinical
diagnosis to a major extent.
CONCLUSION
Nasal obstruction is the major symptom of sinonasal
mass with a high rate of malignancy. Carcinoma,
inflammatory polyposis, inverted papilloma and allergic
fungal sinusitis were among the highest histological
diagnosis. The clinical diagnosis and the suggestive
features of radiological findings mostly resemble the
histological findings. However, in contrary to the
resemblance, the histological finding reveals the general
diagnosis of nasal mass to the precise diagnosis,
especially the fatal conditions like carcinoma. The high
rate of malignancy and suggestive radiological findings
warrants histological analysis to rule out the probability
of neoplasm.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Aljafar HM, Alenazi ER,
Alkhatib AM, Alazzeh GM, Almomen AA. The
clinicopathological and radiological features of
unilateral nasal mass in adults, a tertiary hospital
experience. Int J Otorhinolaryngol Head Neck Surg
2020;6:1226-31.