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Clinicopathological Profile of Sinonasal Masses in
a Tertiary Care Center in Central India: A
Retrospective Study
Anjan K. Sahoo , Shaila Sidam , Aparna Chavan
1. Otolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, Bhopal, IND
Corresponding author: Anjan K. Sahoo, anjan.ent@aiimsbhopal.edu.in
Abstract
Introduction: Diseases of the nose and paranasal sinuses have a significant impact on the patient's
functional and structural aspects. They affect all age groups and both sexes. Due to its proximity to vital
structures, diseases of the nose and paranasal sinuses sometimes lead to very grave prognoses.
Materials and methods: This was a retrospective study done in one of central India's largest tertiary care
centers. We studied 227 cases of sinonasal masses in both the non-neoplastic and neoplastic categories.
Clinicopathological characteristics of masses were analyzed with the help of clinical and imaging findings
and subsequently confirmed by tissue diagnosis.
Results: The mean age of presentation was 45.5 years, with a male-to-female ratio of 1.25:1. Most of our
patients were from lower-middle socioeconomic groups with educational qualifications below the 10th
standard. Nasal obstruction was the most common symptom. A computed tomography scan was the
preferred radiological investigation. Sinonasal undifferentiated carcinoma was the most common variant of
malignancy, with a total number of six out of 22 (27%).
Conclusion: The evaluation of sinonasal masses should be carried out systematically and meticulously. Since
the initial presentation of most of the diseases of the nose and paranasal sinuses is the same, a proper
clinical, radiological, and tissue diagnosis should be carried out to avoid causing malignant lesions.
Categories: Otolaryngology, Allergy/Immunology
Keywords: proptosis, inverted papilloma, angiofibroma, neoplastic, sinonasal
Introduction
Nasal and nasopharyngeal masses significantly impact the patient's functional and structural aspects.
Diseases of the nose and paranasal sinuses are rising all over the world because of an increase in air
pollution [1]. They affect all age groups and both sexes. Both benign and malignant conditions are commonly
encountered during clinical practice. Because of its proximity to vital structures like the brain, orbit, and
critical neurovascular structures, diseases of the nose and paranasal sinuses sometimes lead to very grave
prognoses. Sinonasal masses like simple nasal polyps and their removal by Hippocrates were well mentioned
in literature centuries ago [2].
All the sinonasal masses have typical signs and symptoms like nasal obstruction, nasal discharge, bleeding
from the nose, facial swelling, decreased sense of smell, hearing loss, change in voice, etc. A detailed history
of clinical examinations like nasal endoscopy, imaging, and histopathology collectively may lead to a
conclusive diagnosis. Congenital midline nasal anomalies are rare and comprise gliomas, encephaloceles,
dermoids, etc. Around 60% of nasal gliomas are extranasal, and 40% are intranasal [3]. Nasal polyposis, one
of the most common inflammatory mass lesions of the nose, affecting up to 4% of the population, is smooth,
semi-transparent, and pale in color and primarily arises from the mucosa of the osteomeatal complex [4].
Sinonasal malignancies comprise less than 5% of all head and neck malignancies, with somehow increasing
trends presented with varied masked clinical presentation as that of benign disease poses a significant
challenge to both patients and surgeons [5]. The purpose of this retrospective study in one of the largest
tertiary care centers in central India is to provide a clinicopathological profile of various sinonasal masses.
Materials And Methods
This is a retrospective study of all the sinonasal masses presented to the Department of
Otorhinolaryngology, All India Institute of Medical Sciences, Bhopal, India. This study included all patients
diagnosed with sinonasal masses from July 2021 to August 2023. We retrieved all the data, such as age, sex,
occupation, socioeconomic status, signs and symptoms, and endoscopic, imaging, and histopathological
findings, from the medical record department. A total of 227 patients met our inclusion criteria. Patients
with complete data on clinical and pathological findings were included. All the lesions were classified as
1 1 1
Open Access Original
Article DOI: 10.7759/cureus.50700
How to cite this article
Sahoo A K, Sidam S, Chavan A (December 17, 2023) Clinicopathological Profile of Sinonasal Masses in a Tertiary Care Center in Central India: A
Retrospective Study. Cureus 15(12): e50700. DOI 10.7759/cureus.50700
non-neoplastic and neoplastic lesions, and again, the neoplastic lesions were divided into benign and
malignant lesions. Institutional human ethics committee approval was obtained before commencing the
study (approval number: IHEC-LOP/2023/IL0102). All the relevant history, including age, sex, personal,
occupational, and socioeconomic history, and detailed clinical examinations, were retrieved. Patients were
categorized as below 30 years, 30-50, 50-70, and above 70 years. Patients were also categorized as per their
occupation, like farmers, businessmen, housemakers, students, etc. Details of symptoms and signs like nasal
obstruction, nasal discharge, proptosis, periorbital swelling, vision loss, involvement of cranial nerves,
bleeding from the nose, etc. were also collected and compiled. The anterior nasal endoscopy findings of all
patients were compiled. The characteristics of mass, such as polypoidal, fleshy, or bleeding, during the
procedures were also noted. The probing of all sinonasal masses and their findings were also collected.
Significant findings like tumor site origin and tenderness on palpation were also reported. The imaging
findings from both the CT scan and MRI were included in the study. The histopathology of 198 patients was
retrieved and included in this study. All the patients were categorized as per the final histopathology into
neoplastic and non-neoplastic categories. The neoplastic categories were again subdivided into benign and
malignant categories. Three to four patients had immunohistochemistry for confirmation of the diagnosis.
All the patients underwent surgery, radiotherapy, and medication per the standard treatment guidelines.
Data was analyzed using Microsoft Office Excel 2010 (Microsoft Corporation, Washington, USA).
Results
The age ranges from 3 to 82 years, with the maximum number of patients (32%, n=72) in the range of 50 to
70 years with a mean age of 45.5 years. There were 126 males and 101 females, with a male-to-female ratio
of 1.25:1 (Figure 1). Most of our patients were housemakers (43%, n=98), followed by farmers (19%, n=44)
(Table 1). Around 142 (63%) patients belong to the lower middle socioeconomic group, followed by 52 (23%)
in the upper middle group (Figure 2). Nasal obstruction was the most common symptom (90%, n=204),
followed by nasal discharge (74%, n=169). Abnormalities in extraocular movement and decreased vision
were seen in 31 (14%) of cases, and total loss of vision in four (2%) of patients (Table 2). Proptosis was
present in 15 (7%) patients (Figure 3). In 22 (10%) patients, a mass or bulging was present inside the oral
cavity. On anterior rhinoscopy, 143 (63%) patients had septal deviations and spurs. The mass was polypoidal
in 89 (39%) cases and fleshy in 31 (14%). Purulent secretions were present in 80 (35%) patients, and in 21
(9%) cases, there was bleeding during the process of anterior rhinoscopy. Probing of the nasal mass suggests
that in 106 (47%) cases, the mass arose from the lateral nasal wall, and in 12 (5%) cases, it originated from
the septum and floor. In 79 (35%) patients, there was bleeding on probing, and in 60 (26%) cases, it was
tender to palpate. Almost all the patients except those with septal hematoma and inflammatory nasal polyps
had a CT scan, MRI, or both as part of their radiological investigations. A CT scan was the preferred
radiological investigation (85%, n=194). Noncontrast tomography was performed in 136 patients (60%),
whereas contrast CT scans were done in 58 patients (25%). An MRI was performed on 69 patients (30%).
Both CT and MRI were performed on 43 patients (19%). Histopathological examination was traced from 198
patients (87%) records. Of them, 139 patients were nonneoplastic, and 59 were neoplastic (22 were
malignant, and 27 were benign) (Table 3). In the nonneoplastic category, 93 were fungal sinusitis, including
mucormycosis, allergic fungal rhinosinusitis, and aspergillosis. Four patients (2%) had rhinosporidiosis.
Diseases confined only to the frontal sinus were seen in six patients (3%). Out of 22 patients with sinonasal
malignancy, six were of poorly differentiated carcinoma (27%), and four were of squamous cell carcinoma
(18%). Sinonasal sarcoma was found in three patients (14%). Of the 27 benign neoplastic lesions, 10 were of
juvenile nasopharyngeal angiofibroma (37%), and seven were of inverted papilloma (25%).
2023 Sahoo et al. Cureus 15(12): e50700. DOI 10.7759/cureus.50700 2 of 9
FIGURE 2: Socioeconomic status of patients
Symtoms Number of patients (%)
Nasal obstruction 204 (90%)
Nasal discharge 169 (74%)
Sneezing 92 (40%)
Nasal bleed 63 (28%)
Facial swelling 54 (24%)
Facial pain 44 (19%)
Protrusion of eyeball 15 (7%)
Decrease sense of smell 28 (12%)
Change in voice 45 (19%)
Decrease vision 31 (14%)
Absent vision 4 (2%)
Hearing loss 6 (3%)
Restricted eye movement 31 (14%)
Mass/swelling in the oral cavity 22 (10%)
TABLE 2: Signs and symptoms
2023 Sahoo et al. Cureus 15(12): e50700. DOI 10.7759/cureus.50700 4 of 9
FIGURE 3: Clinical picture of unilateral nasal mass with proptosis
Diagnosis No. of patients (%) Total
CRS with sinonasal polyposis 33 (14%)
227 (100%)
AC polyp 27 (12%)
Fungal sinusitis 93 (40%)
Rhinosporiodosis 4 (2%)
Juvenile nasopharyngeal angiofibroma 10 (4%)
Inverted papilloma 7 (3%)
Nasolabial cyst 5 (2%)
Rhinolith 1 (1%)
Dentigerous cyst 2 (1%)
Inflammatory polyp 3 (1%)
Fibrous dysplasia 2 (1%)
Frontal sinus disease 6 (3%)
Nasal schwannoma 2 (1%)
Hemangioma/hemangiopericytoma 2 (1%)
Meningoencephalocele 1 (1%)
Sphenochoanal polyp 1 (1%)
Sinonasal malignancy 22 (10%)
Septal hematoma/abscess 6 (3%)
TABLE 3: Sinonasal masses included in the study
CRS: chronic rhino sinusitis, AC: antrochoanal
Discussion
In our study, most sinonasal masses were in the age group of 50 to 70 years, whereas in other studies, the
typical age group for sinonasal masses was in the range of the second to fifth decades [6]. Our study had a
maximum elderly population, which may be because of the more significant number of invasive fungal
sinusitis and malignancy patients in our study. Another study suggests that the peak age for benign,
intermediate, and malignant lesions was in the second, fifth, and sixth decades, which also fits our study
[7,8]. Contrary to the above, one study in Nigeria [2] suggested that the peak age for sinonasal malignancy is
around 33 years. Sinonasal masses had a predilection for males, demonstrating a male (n=126) to female
(n=101) ratio of 1.25:1. In the Indian study by Zafar et al. [9], it was greater (male-to-female ratio: 1.7:1),
while in the Nigerian study [2], the ratio showed a preponderance of women (male-to-female ratio: 1:1.2).
2023 Sahoo et al. Cureus 15(12): e50700. DOI 10.7759/cureus.50700 5 of 9
According to a British review [10], the male-to-female ratio for nasal polyposis was 2:1.
Fungal sinusitis was our study's most common sinonasal pathology because of a sudden spike in
mucormycosis after COVID-19. Otherwise, chronic rhinosinusitis and antrochoanal polyps were the most
common nasal masses, comprising 14% (n=33) and 12% (n=27), respectively. Nasal polyposis was the
predominant sinonasal mass, as per the study by Tondon et al. (64%) and Dasgupta et al. (62.5%) [11,12]. The
most common nasal symptoms in our study were nasal obstruction (90%, n=204) followed by nasal discharge
(74%, n=169), which is similar to other studies [6,7]. Similar to other studies [7], facial swelling and pain
were noticed in 24% (n=54) and 19% (n=44), respectively. Swelling in the oral cavity was present in 10%
(n=22) of our cases, which was rarely mentioned in similar literature; this may be due to the maximum
number of cases of mucormycosis and advanced angiofibroma in our study. Ocular involvement, like
restricted extraocular movement, decreased vision, and proptosis, was seen in 14% (n=31), 14% (n=31), and
7% (n=15), respectively. Other studies also had similar incidences of 10% and 10.7% [6,7], but in some
studies, the orbital involvement went up to 21% [11]. In our analysis, the sinonasal undifferentiated tumor
was the most common variant (27%, n=6), followed by squamous cell carcinoma (18%, n=4). Most studies
conclude that squamous cell carcinoma is the most common variety. Tandon et al. [11] found that squamous
cell carcinoma is India's most common histology of sinonasal malignancy, accounting for approximately half
of all cases. Another study by Dasgupta et al. [12] also examined sinonasal masses in the Indian population
and reported that adenocarcinoma is the third most common mucosal malignancy in the sinonasal region,
after squamous cell carcinoma and adenoid cystic carcinoma. This may be due to the small sample size and
getting the maximum number of referrals to our center. Almost all our patients had had either a CT scan or
an MRI as part of their radiological investigations. For most neoplastic lesions and invasive fungal sinusitis,
we prefer MRI over CT because of its ability to differentiate between inflammation and tumor and its greater
sensitivity to intracranial extension. However, CT is the selected investigation for chronic rhinosinusitis,
inverted papilloma, and other benign diseases [13]. Bony erosion, an extension of the mass into the orbit
and beyond the bony confines, can be readily identified through a CT scan (Figure 4). In Figure 5, there is an
isodense lesion in the nasal cavity which is suggestive of an inverted papilloma. Other studies also believed
that MRI was complementary to a CT scan to evaluate the tumor's soft tissue components and the extent of
tumor invasion beyond the bony sinus wall [14-16]. A CT scan is essential for planning surgery and providing
a roadmap for endoscopic sinus surgery, and it is also readily available, cheaper, and faster. MRI quickly
identifies the invasion and encasement of the cavernous sinus and internal carotid artery [15]. MRI is also
helpful in detecting recurrence following surgery.
2023 Sahoo et al. Cureus 15(12): e50700. DOI 10.7759/cureus.50700 6 of 9
FIGURE 4: CT scan displaying a sizable, well-defined, smooth-walled
lobulated soft tissue lesion centered in the right nasal cavity (solid
arrow), measuring 5.6 x 4 x 4.8 cm, resulting in its expansion and
protruding into the remaining right maxillary sinus. Erosion of the nasal
septum with extension into the left nasal cavity is observed, reaching
up to the osteomeatal complex. Superior extension encompasses both
the anterior and posterior ethmoid sinuses and the floor of the bilateral
olfactory fossa, with the cribriform plate not visualized. Moreover, a
superolateral extension infiltrates the medial extraconal compartment of
the right orbit, abutting the right medial rectus and superior oblique
muscles
2023 Sahoo et al. Cureus 15(12): e50700. DOI 10.7759/cureus.50700 7 of 9
FIGURE 5: CT scan suggestive of unilateral isodense lesion suggestive
of inverted papilloma (solid arrow)
Limitations of the study
Our study is a retrospective study with a limited sample size, and the duration of the study is shorter. A
prospective multicenter study may provide more clear data regarding the clinicopathological variant of
sinonasal masses.
Conclusions
In the present retrospective study, we analyze the various sinonasal masses and their varied clinical
presentations. Nasal obstruction followed by nasal discharge were the most common symptoms. The mean
age of presentation was 44.5 years. Benign diseases are primarily seen in younger age groups, and
malignancy is in the elder group. Sinonasal undifferentiated carcinoma was the most common variant of
malignancy in our study, followed by squamous cell carcinoma. CT scans and MRIs were necessary for the
proper planning and surgical management of the patients. Histopathology is the gold standard for the
appropriate diagnosis of all sinonasal masses.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Anjan K. Sahoo, Shaila Sidam, Aparna Chavan
2023 Sahoo et al. Cureus 15(12): e50700. DOI 10.7759/cureus.50700 8 of 9
Acquisition, analysis, or interpretation of data: Anjan K. Sahoo, Shaila Sidam, Aparna Chavan
Drafting of the manuscript: Anjan K. Sahoo, Shaila Sidam, Aparna Chavan
Critical review of the manuscript for important intellectual content: Anjan K. Sahoo, Shaila Sidam,
Aparna Chavan
Supervision: Anjan K. Sahoo, Shaila Sidam, Aparna Chavan
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Institutional Human
Ethics Committee of All India Institute of Medical Sciences issued approval IHEC-LOP/2023/IL0102. Animal
subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conf licts of
interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any
organization for the submitted work. Financial relationships: All authors have declared that they have no
financial relationships at present or within the previous three years with any organizations that might have
an interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
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