Content uploaded by Olushola Afolabi
Author content
All content in this area was uploaded by Olushola Afolabi
Content may be subject to copyright.
DATA NOTE Open Access
Clinico-pathological profile of sinonasal masses:
an experience in national ear care center Kaduna,
Nigeria
Aminu Bakari, Olushola A Afolabi
*
, Adeyi A Adoga, Aliyu M Kodiya, Babagana M Ahmad
Abstract
Background: The presence of a mass in the nose and paranasal sinuses may seem to be a simple problem;
however it raises many questions about the differential diagnosis. The aim of this study is to evaluate the clinico-
pathological profile of sinonasal masses in our environment
This is a retrospective analytical review of all the patients with sinonasal masses that presented to the national ear
care center, Kaduna over a six year (2003-2008) period. Their biodata, clinical profile and histological diagnoses
were analyzed.
Findings: A total of 76 patients were analyzed, age range 5 to 64 yrs with a mean age of 33.3 yr median and
modal age of 35.00 (SD = 13.1 ± 1.5). Majority of the patients were in the age groups 21-50 yrs. There were
34 male and 42 female with M: F ratio of 1:1.2. The main presenting symptoms are nasal blockage 97.4% and
rhinorrhea 94.7%. It was bilateral in 34 (44.7%), left side in 24(31.6%) and right side in 18(23.7%) patients. The
commonest clinical diagnoses were simple nasal polyp 47(61.8%) and antrochoanal polyp 10(13.2%). About 59
(77.6%) were benign, 2 (2.6%) were malignant and 15 (19.7%) were lost to follow up. The commonest histological
diagnosis is simple inflammatory nasal polyp in 28 (36.8%) patients and the least was nasal capillary hemangioma
2 (2.6%). About 55(72.4%) patients had surgical treatment.
Conclusions: Nasal obstruction and rhinorrhea are the commonest symptoms of presentation, simple inflammatory
nasal polyp is still the commonest histological pattern seen in our environment, and surgery is still the best
modality of treatment for benign tumor thus the need for advocacy for early recognition and referral to the ENT
surgeon.
Introduction
The presence of a mass in the nose and paranasal sinuses
may seem to be a simple problem; however it raises
many questions about the differential diagnosis. Nasal
polyps (NPs) as part of sinonasal masses (SNM) have
been a medically recognized condition since the time of
the ancient Egyptians and their removal with a snare was
described by Hippocrates, a method which persisted well
into the second half of the 20th century [1].
Simple nasal polyps are round, smooth, soft, translu-
cent, yellow or pale glistening structures attached to the
nasal or sinus mucosa by a relatively narrow stalk or
pedicle. They are non-tender and displaced backwards
on probing. These features clinically distinguish them
from the turbinates, which are sometimes assumed to
be nasal polyps by the less experienced [2]. Classically
they are caused by a combination of allergy and infec-
tion [3]. Turbinates will shrink on application of
vasoconstrictors but polyps will not shrink [2].
Polyps are a common cause of nasal obstruction in the
adult, while the diagnosis in children is so rare (0.1%) as
to be questionable [1]. In the general population, the
prevalence of NP is considered to be around 4% [3]. In
cadaveric studies, this prevalence has been shown to be
as high as 40% [4]. It predominantly affects adults
usually those older than 20.
Benign neoplasia of the nose and paranasal sinuses is
relatively not uncommon [4]. Cancers of the nose and
paranasal sinuses account for less than 1% of all
* Correspondence: droaafolabi@yahoo.com
National Ear Care Center, PMB 2438, No 3 Golf/Independence Way, Kaduna,
Nigeria
Bakari et al.BMC Research Notes 2010, 3:186
http://www.biomedcentral.com/1756-0500/3/186
© 2010 Afolabi et al ; licensee BioMed Central Ltd. This is an Open Access arti cle distributed under the terms of the Creative Commons
Attribution L icense (http://creati vecommons.org/licens es/by/2.0), which permits unrestricted use, di stribution, and reproduction in
any medium, provided the original work is properly cited.
malignancies and about 3% of all head and neck cancers
[5]. It has a geographic tendency to affect the African,
the Japanese, and the Arab [5]. It is rarer in Western
Europe and America [5].
Theaimofthisstudyistoevaluatetheclinico-
pathological profile of sinonasal masses (SNM) seen
during the study period and to draw attention to the
fact that not all cases of nasal obstruction/discharge are
due to chronic infective/allergic sinusitis.
Method
This is a retrospective analytical review of all the
patients with sinonasal masses that presented to the
national ear care center, Kaduna over a six year period
(2003-2008).
The data retrieved included biodata such as age, sex,
occupation, aetio-pathological profile which includes
presenting complaint, duration of complaints, associated
history of allergy, number of episode(s), associated con-
dition(s), nasal obstruction, epistaxis, nasal discharge,
loss of smell, site, bilateral or unilateral, clinical diagno-
sis, histological diagnosis and outcome.
Patients with clinical diagnosis of benign lesion like
inflammatory polyps had intranasal polypectomy with
intranasal antrostomy while others had examination
under anaesthesia (EUA) with incisional and excisional
biopsy. Patients with clinical diagnosis of malignant
nasal masses had examination under anaesthesia and
tumour biopsy and some had nasal clearance in
advanced disease to reduce tumour bulk and provide
biopsy specimen.
All masses excised were subjected to histological
examination. All the data were entered into the SPSS
version 11.0 computer soft ware for analysis and results
presented in tables and figures.
Results
A total of 84 patients had SNM in the study period
however only 76 patients had complete data for analysis
which form the basis for this report. The age range
from 5-64 yrs with a mean age of 33.3 yr median and
modalageof35.00(SD=13.1±1.5).Majorityofthe
patients were in the age groups 21-50 yrs (Figure 1).
There were 34 males and 42 females with M: F ratio of
1:1.2.
About 31% of the patients that presented were either
pupils or students, 30.1% were self employed, 21.5%
were civil servants and 17.4% were housewives.
The main presenting symptoms are nasal blockage
97.4%, rhinorrhea 94.7%, allergic symptoms 52.6%, anos-
mia 34.6% others are as in Table 1. Duration before pre-
sentation was within 1 to 360 months with a mean
duration of 40 months.
Sinonasal masses were found to be bilateral in 34
(44.7%), left sided in 24(31.6%) and right sided in 18
(23.7%) patients.
The clinical diagnosis in most of the cases correlates
with the post operative histological diagnosis. The clini-
cal diagnosis were simple nasal polyp in 47(61.8%) Out
of the 47 with ethmoidal polyp 31 were male and 16
were females with M: F ratio of 2:1.
Antrochoanal polyp occurred in 10(13.2%) of the total
sinonasal masses and common among those less than
20 yrs (60%), inverted papilloma 5(6.6% of the total
sinonasal masses) with M: F ratio of 1:1.5, recurrent
nasal polyp in pregnancy 4(5.3%) others as in table 2
Histological diagnosis showed that 59 (77.6%) were
benign, 2 (2.6%) were malignant. 15 (19.7%) patients did
not have a histological diagnosis as they were either
treated medically or lost to follow up.
Histopathological diagnosis of the various sinonasal
masses showed simple inflammatory nasal polyp in 28
(36.8%), inverted papilloma in 11 (14.5%), allergic nasal
polyp 8 (13.1%), fibroepithelia polyp in 8 (10.6%), plas-
macytoma 4 (6.6%) nasal capillary hemangioma 2 (2.6%),
See Table 3. An Histopathological micrograph of the
nasal polyposis showing an edematous mass with loose
stroma, infiltrated by inflammatory cells. H&E stain ×
100 as seen in figure 2.
Discussion
Thenoseandparanasalsinusesareinvolvedinawide
variety of pathological conditions. Macroscopically sim-
ple nasal polyps are pale bags of non specific eosinophi-
lic, oedematous, hyperplastic, sinonasal masses, they are
most often bilateral, and indeed any unilateral lesion
should be considered as a neoplasia, benign or malig-
nant. The frequency of SNM increases with age similar
to findings in our study, peaking in individuals aged 50
years or more [6], however our study showed a peak
incidence of 33years which is relatively lower than find-
ings by other previous workers [6].
There is a high incidence of benign non-neoplastic
lesions in our study, constituting about 77.6% of cases
while 2.6% were malignant and 19.7% had no pathologic
diagnosis. Simple nasal polyps and antrochoanal polyps
were the most common non-neoplastic sinonasal masses
in this study forming up to 57(75%). Simple nasal polyps
are uncommon in children under 10years of age in con-
trast to antrachoanal polyps and are similar to findings
in our study, while another study reported it to be a
presenting feature of cystic fibrosis [2]; however the
least finding was among the elderly from our study.
Nasal polyp seems to occur more often in men, and
their prevalence increases in both sexes with age from
previous reports [6,7], our study showed higher
Bakari et al.BMC Research Notes 2010, 3:186
http://www.biomedcentral.com/1756-0500/3/186
Page 2 of 5
preponderance among the females than males which is
at variance with previous reports [2,5,7], this may prob-
ably be related to hormonal differences [8] but this was
not classically established by our study. Antrochoanal
polyps and inverted papilloma were found to be com-
moner in females than males which are similar to find-
ings from previous reports [2,5,7]. Recurrence were
observed in simple nasal polyps in 4 pregnant patients
and in 3 other patients within 6 to 10 months of nasal
polypectomy while some studies have recorded a recur-
rence rate as high as 29-53% [9].
A familial history has been reported in 14% of patients
with NPs in an uncontrolled study [3] however this is at
variance with our study with a higher value of 28.9% of
patients with a family history of NPs. The hospital pre-
valence of sinonasal masses was estimated to be 1.2% as
the total number of patients seen over this period is
estimated to be 6333. This is still within the range
found by other workers on this subject [4].
Occupation has been observed not to be a risk factor
from our study as majority of the patients reviewed
were students of different levels, then the self employed,
Figure 1 Age - Frequency bar chart distribution.
Table 1 Symptoms of presentation
Symptoms Frequency (%)
Allergy 40 (52.6)
Epistaxis 23 (30.3)
Nasal blockage 74 (97.4)
Rhinorrhea 72 (94.7)
Anosmia 24 (34.6)
Asthma 6 (7.9)
Facial pain 7 (9.2)
Ophthalmic symptoms 12 (15.8)
Otological symptoms 26 (34.2)
Oropharyngeal symptoms 21 (27.6)
Recurrence of nasal masses 11 (14.5)
Table 2 Clinical Diagnosis
Clinical diagnosis Frequency (%)
Bilateral Left Right
Simple nasal polyp 30 (39.6) 11 (14.5) 6 (7.9)
Antrochoanal polyp 4 (5.3) 2 (2.6) 4 (5.3)
Inverted papilloma 1 (1.3) 4 (5.3)
Recurrent Nasal polyp in pregnancy 4 (5.3)
Recurrent Simple nasal polyp 3 (4.0)
Allergic nasal polyp 2 (2.6)
Ethmoidal polyp 1 (1.3)
Fungal sinusitis with polyp 1 (1.3)
Nasal papilloma 1 (1.3)
Nasal granuloma 1 (1.3)
Simple Nasal polyp in bronchial asthma 1 (1.3)
Table 3 Histological diagnosis
Histological types Frequency (%)
Simple inflammatory nasal polyp 35 (45.9%)
Simple allergic nasal polyp 10 (13.1%)
Inverted papilloma 14 (18%)
Capillary hemangioma 1 (1.3%)
Missing 21 (27.6%)
Bakari et al.BMC Research Notes 2010, 3:186
http://www.biomedcentral.com/1756-0500/3/186
Page 3 of 5
civil servants and the least was unemployed full time
housewives.
Earliest presentation was within one month with an
average of 40months duration before presentation this
may be due to patient’s visit to non-specialists who have
been offering palliative conservative treatment and are
only referred after treatment failure.
The common symptoms and signs of sinonasal masses
found in our study were nasal obstruction [2,10-12], rhi-
norrhea, feeling of nasal mass, epistaxis [7], loss of smell
and voice changes [10] however majority of our patients
presented with nasal obstruction and rhinorrhea which
compares favourably with findings from other studies
[2,6,7,10,11]. Epistaxis was noticed in 30.3% of the
patients most of whom were 41years and above which
should give a suspicion of neoplastic changes [2,6-8,11].
Symptoms of allergy such as rhinorrhea, itchy nostrils,
excessive sneezing were noticed in more than 50% of the
patients which support the fact that allergy still plays a
major role in nasal polyp in our environment, however
no demonstrable allergic confirmation were found from
the records which is one of the deficiency of this study.
Only 18% of the records had documentation relating
to voice changes which is one of the major complaints
or observation in patients with sinonasal mass and this
is usually more of a hyponasal speech which is in sup-
port of previous reports [2,6,10]. In addition 31.6% of
the patients had anosmia based on symptoms which
may be associated with taste changes which are charac-
teristic of the symptoms [7] which was not volunteered
from records due to the retrospective nature of our
study. History of asthma was the least among our
patients, this was at variance with a study by settipane
et al [5] which reported that one third of patients with
nasal polyp have asthma and only 7% of patients with
asthma have nasal polyp which is comparable with our
report of 7.9%.
Examination revealed bilateral sinonasal masses in
44.7% and unilateral in 55.3% out of which 31.6% were
found on the right side and 23.6% on the left nasal cav-
ity no reason could be deduced for this in our study.
Nasal polyposis are invariably bilateral as noted in less
than half of our patients similar to a previous report
[13] and when unilateral as noted above requires histo-
logical examination to exclude malignancy or other
pathology such as inverted papilloma [13] which was
the commonest intermediate tumor recorded in our
study. It was found to be commoner in females and this
is similar to previous reports, even though it is a benign
tumor the tendency towards malignant transformation is
high and treatment is usually surgical excision and stu-
dies have found a recurrence rate as high as 50% after
treatment. They are insensitive to palpation and rarely
bleed [14,7,15].
About 5.3% of our patients had antrochoanal polyp.
This was found more among the younger age group and
its treatment is also via surgical excision and delivery
via the nasopharynx. Pathological assessment of the
nasal polyp showed that more than three-quarters of the
nasal masses were benign in nature and this may be due
to reduced risk of exposure to carcinogenic agents from
wood work, boot and shoe work, furniture making and
reduce exposure to environmental hydrocarbons in our
series as documented in other reports [16] as majority
of our patients were civil servants, students and those
that are self employed trade in provisions, cloths and
other materials non carcinogenic. About 2.6% of the
patients had malignant nasal polyp and in almost one
fifth of the population studied, some responded to medi-
cal treatment with steroid spray but were lost to follow
Figure 2 Photomicrograph of nasal polyposis showing an edematous mass with loose stroma, infiltrated by inflammatory cells. H&E
stain × 100.
Bakari et al.BMC Research Notes 2010, 3:186
http://www.biomedcentral.com/1756-0500/3/186
Page 4 of 5
up while some did not return their histological results
after per-nasal biopsy was taken.
Out of the histological result available 45.9% were
simple inflammatory polyp which is a benign lesion and
most responded to surgical excision and follow up while
13.1% had allergic nasal polyp which showed evidence
of high eosinophils in contrast to a previous study that
reported allergic nasal polyp to be the commonest [6].
Eighteen percent had inverted papilloma, although it is
a rare tumor occurring in approximately 0.5% of the
nasal tumors thus representing about 4% of all nasal
polyps but our study revealed a higher value of 18%
[17], most of whom also had surgical excision (nasal
polypectomy) and follow up. Out of the patients with
inverted papilloma who were operated recurrence of
polyp was noticed in 36% lower than that recorded by
Buchwald et al [18], these patients were offered re- exci-
sion with referral for post operative chemo-radiotherapy.
Other histological variants are as noted in Table 3
below.
On the treatment offered the patient a good number,
72.4% had surgical excision while 9.2% had medical
treatment with nasal topical steroid spray with remission
of the sinonasal masses which previous literature have
found to be of value and safe in both allergic and non-
specific rhinitis [9,19,20]. In this study, 1.3% of the
patients had nasal steroid spray with minimal relieve of
nasal obstruction but without remission of the sinonasal
mass. These patients however declined surgery but were
subsequently lost to follow up. A total of 17.1% patients
were lost to follow up.
Conclusion
Sinonasal masses are still thought to be a simple pro-
blem in our environment. The need for early recogni-
tion and referral to the ENT surgeon needs to be
advocated among the primary care physicians as well as
continuing medical education for the primary care phy-
sician on the care of sinonasal masses.
Nasal obstruction and rhinorrhea are the commonest
symptom of presentation, bilateral is likely to be benign
and commoner on the left side than the right side and
simple inflammatory nasal polyp is still the commonest
histological pattern seen in our environment.
For benign tumor surgery is still the best modality of
treatment and in case of recurrence in unilateral nasal
masses a suspicion of malignant transformation should
be envisaged.
Acknowledgements
We are grateful to Mr Abiagam and the staff of the Health information
Department of the National Ear Care Center, Kaduna.
Authors’contributions
AB: Conceived of this work, performed literature search, collected and
analyzed data and reviewed the manuscript. OAA: Performed literature
search, collected and analyzed data and prepared the manuscript. AAA:
Collected and analyzed data and reviewed the manuscript critically for
important intellectual content. AMK: Collected and analyzed data and
reviewed the manuscript. BMA: Reviewed the manuscript and have given
final approval of the version to be published.
All authors have read and approved the final manuscript for publication.
Competing interests
The authors declare that they have no competing interests.
Received: 31 December 2009 Accepted: 9 July 2010
Published: 9 July 2010
References
1. Wright J: History of laryngology and rhinology. St Louis: Lea and Febiger
1893, 57-9.
2. Newton RJ, Ah-See WK: A review of nasal polyposis, Therapeutics and
Clinical Risk Management. 2008, 4(2):507-512.
3. Hedman J, Kaprio J, Poussa T, et al:Prevalence of asthma, aspirin
intolerance, nasal polyposis and chronic obstructive pulmonary disease
in a population-based study. Int J Epidemiol 1999, 28:717-22.
4. Laren PL, Tos M: Anatomic site of origin of nasal polyps: endoscopic
nasal and paranasal sinus surgery as a screening method for nasal
polyps in autopsy material. Rhinology 1994, 33:185-8.
5. Settipane GA: Epidemiology of nasal polyps. Allergy Asthma Proc 1996,
17:231-6.
6. Lund VJ: Diagnosis and treatment of nasal polyps. BMJ 1995,
311:1411-1414.
7. Drake-Lee AB: Nasal polyps. Scott-Brown’s Otolaryngology Rhinology, Oxford:
Butterworth-HeinnemanKerr AG, Mackay AS, Bull TR , 7 1997, 4, 4/10/1-16..
8. Hillman JE: Otolaryngologic manifestations of pregnancy - The Baylor
College of Medicine in Houston, Texas Grand Rounds Archive. 1995.
9. Larsen K, Tos M: Clinical course of patients with primary nasal polyps.
Acta Otolaryngol (Stockh) 1994, 114:556-9.
10. Martin GF: Lessening the Misery of Nasal Polyps Can. Fam Physian 1991,
37:1441-1444.
11. Mgbor N, Onuigbo WLB: Inverted papilloma of the nose and paranasal
sinuses. J Coll Med 2003, 8(1):33-35.
12. Fasunla AJ, Lasisi AO: Sinonasal malignancies: a 10-year review in a
tertiary health institution. J Natl Med Assoc 2007, 99(12):1407-10.
13. Drake-Lee AB: Nasal polyps. Hospital Med 2004, 65:264-7.
14. Fokkens W, Lund V, Mullol J, European Position Paper on Rhinosinusitis and
Nasal Polyps Group.: European position paper on rhinosinusitis and nasal
polyps. a summary for otorhinolaryngologists. Rhinology 2007, 45:97-101,
EP3OS.
15. Becker SS: Surgical management of polyps in the treatment of nasal
airway obstruction. Otolaryngol Clin North Am 2009, 42(2):377-85.
16. Cody DT II, DeSanto LW: Neoplasms of the Nasal Cavity in
Otolaryngology. Head and Neck Surgery Charles Cummings CW,
Frederickson JM, Harker LA, Krause CJ, Richardson M, Schuller DE , 3 1999,
47(2):885.
17. Mishra D, Singh R, Saxena R: A Study On The Clinical Profile And
Management Of Inverted Papilloma. The Internet Journal of
Otorhinolaryngology 2009, 10(2).
18. Buchwald C, Fransman MB, Tos M: sinonasal papilloma. Laryngoscope 1995,
105(10):72-79.
19. Pedersen CB, Mygind N, Sorensen H, Prytz S: Long-term treatment of nasal
polyps with beclomethasone dipropionate aerosol. Acta Otolarygol 1976,
82:256-9.
20. Martin GF: Pharmacology of nasal medication:an update. Can Fam
Physician 1988, 34:2706-9.
doi:10.1186/1756-0500-3-186
Cite this article as: Bakari et al.: Clinico-pathological profile of sinonasal
masses: an experience in national ear care center Kaduna, Nigeria. BMC
Research Notes 2010 3:186.
Bakari et al.BMC Research Notes 2010, 3:186
http://www.biomedcentral.com/1756-0500/3/186
Page 5 of 5
