|Year : 2015 | Volume
| Issue : 4 | Page : 468-473
Histopathological study of nasal masses in patients coming to a tertiary care hospital: A study of 70 cases
Alpesh M Maru1, Umang V Patel2, Atul Shrivastav1, Nayna R Lakum1, Tejas S Choksi1, AS Agnihotri1
1 Department of Pathology, C. U. Shah Medical College, Surendranagar, Gujarat, India
2 Department of Histopathology, Green Cross Pathology and Molecular Laboratory, Ahmedabad, Gujarat, India
|Date of Web Publication||14-Jul-2015|
Department of Pathology, C. U. Shah Medical College, Dudhrej Road, Surendranagar - 363 001, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Nasal polyps are defined as prolapsed lining of the nasal sinuses. They may be present as simple inflammatory polyps or neoplastic tumors and neoplastic tumors further divided in benign or malignant types. Objectives: This study was undertaken to note the various histopathological patterns of nasal masses, their classification and relative distribution of various lesions with regard to age and sex in our setting. Materials and Methods: in this study, 70 patients are selected who presented in our hospital with nasal masses and having multiple types of clinical presentations. Time period of study is 2 years. Results: Nonneoplastic nasal masses formed the largest group of lesions; 50 cases (71.43%), followed by 20 cases (28.57%) of neoplastic nasal masses, in neoplastic masses we found 14 benign and 6 malignant cases. Conclusion: Nasal obstruction and rhinorrhea are the most common symptoms of presentation, simple inflammatory nasal polyps are the most common histological pattern seen in our environment, and surgery is the best modality of treatment.
Keywords: Histopathology, nasal mass, neoplastic and nonneoplastic
|How to cite this article:|
Maru AM, Patel UV, Shrivastav A, Lakum NR, Choksi TS, Agnihotri A S. Histopathological study of nasal masses in patients coming to a tertiary care hospital: A study of 70 cases. Med J DY Patil Univ 2015;8:468-73
|How to cite this URL:|
Maru AM, Patel UV, Shrivastav A, Lakum NR, Choksi TS, Agnihotri A S. Histopathological study of nasal masses in patients coming to a tertiary care hospital: A study of 70 cases. Med J DY Patil Univ [serial online] 2015 [cited 2019 Dec 5];8:468-73. Available from: http://www.mjdrdypu.org/text.asp?2015/8/4/468/160787
| Introduction|| |
Since the days of Hippocrates; the father of medicine, nasal masses have been known as a common affliction of man. They are essentially rounded projections of edematous membrane above a mucosal surface and projects into lumen.  They are often bilateral and multiple which lead to visible broadening of nose.  Simple nasal polyps are round, smooth, soft, translucent, yellow or pale glistening structures attached to the nasal or sinus mucosa by a relatively narrow stalk or pedicle. They are nontender and displaced backwards on probing. The most common site of origin is in the ethmoidal labyrinths, particularly from the mucosa of the middle turbinate. 
Nasal polyps most frequently occur in middle-aged males.  Lesions of the nasal cavity, nasopharynx, and paranasal sinuses provide problem in their diagnosis, prognosis, and management because of certain unusual clinic pathological features. 
| Materials and Methods|| |
This study is conducted in Pathology Department of C. U. Shah Medical College and Hospital, Surendranagar. Patients attending outpatient department (OPD) with complaint of mass in nose, nasal blockage, and/or nasal discharge were selected for this study. Seventy patients of all ages and both sexes were included in this observational study of 2 years (February 2011 and February 2013). We had taken prior permission from our Institutional Ethical Committee to perform this study. When patient comes to OPD each and every patient is thoroughly examined, and after that routine hematological investigations relevant radiological investigations (ultrasonography, X-ray, and computerized tomography scan) are performed according to individual patient's need. After obtaining informed consent from the patients' incision or excision biopsies were performed and tissues are submitted for histopathological examination. All the tissues were fixed in 10% formalin and processed as routine. Sections of 4-5 μm thick were cut and stained with hematoxylin and eosin (H and E). Special stains like periodic acid Schiff and giemsa were done wherever necessary.
Histologically the nasal masses were classified into nonneoplastic masses and neoplastic masses. nonneoplastic masses were further subdivided as allergic and nonallergic types, and neoplastic masses were divided as benign and malignant lesions.
| Results|| |
In our study, a total of 70 patients are studied, and nonneoplastic nasal masses formed the largest group of lesions 50 cases (71.43%), followed by neoplastic nasal masses 20 cases (28.57%).
Nonneoplastic nasal masses were more common in the age group of fourth and fifth decades, while neoplastic masses were more in fifth and sixth decades. The age of the patients having nonallergic polyps, ranged from 11 to 70 years with peak incidence between second and fourth decades of life.
Radiological findings and their probable diagnosis is also taken in consideration, like in case of nasopharyngeal angiofibroma [Figure 1]a and b].
Statistical analyses are done on SPSS 16 software. [Table 1]a and b are showing gender wise distribution of various nasal mass lesions. [Table 2]a and b are showing age wise distribution of various nasal mass lesions. In our study, we have reported six cases of malignant nasal mass. Distribution of malignant lesions is shown in [Figure 2]. The clinical presentations of patients with various nasal masses are shown in [Table 3].
| Discussion|| |
Nasal masses are not true neoplasm, their formation is associated with inflammation, allergy, infection, and/or mucoviscidosis.  Nonneoplastic nasal masses were more common in the age group of fourth and fifth decades, while neoplastic masses were more in fifth and sixth decades. , Main presenting symptoms were nasal blockage in 66 cases (94.28%); followed by nasal discharge in 61 cases (87.14%). Epistaxis occurred in 5 cases (83.3%) of malignant masses.
Clinically nasal masses appear as soft exophytic masses that extend laterally from the mucosa into the anterior part of the middle meatus.  Microscopically, the epithelial lining of nasal masses is of the respiratory type unless squamous metaplasia has occurred. The interphase between them is sharp in some areas, whereas in other areas there is an intervening zone of transitional (intermediate) epithelium.  Majority of inflammatory nasal masses presents as pale gray to pink, soft shiny masses and usually bilateral and multiple.
Allergic masses are associated with increased numbers of eosinophils, whereas nonallergic masses contain more plasma cells, lymphocytes, and neutrophils. The basement membrane is thickened, sometimes greatly, especially in the case of allergic polyps. The stroma is edematous with an admixture of acute and chronic inflammatory cells and few fibroblasts and small vessels are present; sometimes, it appears much more substantial with more of a granulation tissue appearance. Vascularity is variable, and blood vessels often contain smooth muscle. 
Rhinosporidiosis is an inflammatory disease endemic in India, but it had also been reported in other parts of the world. Causative organism is Rhinosporidium seeberi. It is characterized by hyper plastic polypoid lesions of the nasal cavity and rarely of other mucous membranes. The diagnosis is readily made by the identification of numerous globular cysts measuring up to 200 nm in diameter.  Each of these cysts represents a thick-walled sporangium containing numerous spores [Figure 3]. In our study, three cases have been reported in the age group of 20-30 years.
|Figure 3: Numerous sporangium containing spores in rhinosporidiosis (H and E stain, ×200)|
Click here to view
Scleroma (rhinoscleroma) is an inflammatory disease of the nose, pharynx, and larynx caused by an organism of the Klebsiella group. Microscopically, the predominant cells are foamy macrophages (Mikulicz cells) and plasma cells. Vasculitis, ulceration, and pseudoepitheliomatous hyperplasia may be present.
Sinonasal papillomas are benign neoplasms of the respiratory mucosa most commonly presenting with nasal stuffiness, nasal obstruction, or epistaxis. Most cases are seen in adult men, but they can also occur in children. Many adjectives have been attached to them, such as inverted, cylindrical cell, everted, squamous, and schneiderian. In contrast to inflammatory polyps, sinonasal papillomas are unilateral in the large majority of cases. The papillomas arising in the nasal septum are usually exophytic and mushroom shaped ("fungiform" or "everted"), with a thin central core of connective tissue. Those located in the lateral wall (middle meatus or middle or inferior turbinate) are of the inverted type, with inward growth of the epithelium into the stroma. In our study, four cases of inverted papilloma are reported, and all the lesions showed endophytic pattern of growth, Most cases are seen in adult men usually in sixth decade, but they can also occur in children. 
Microscopically, sinonasal papillomas are composed of proliferating columnar and/or squamous epithelial cells, with an admixture of mucin-containing cells and numerous microcysts [Figure 4]. Some tumors are partially or entirely composed of swollen, granular, eosinophilic cells with features of oncocytes. Occasional mitoses are present in the basal layer. We had two cases of sinonasal papilloma with oncocytic epithelium; here, tumors are partially or entirely composed of swollen, granular, eosinophilic cells with features of oncocytes [Figure 5].
|Figure 4: Lining epithelium projecting inwards in a case of inverted nasal papilloma (H and E stain, ×200)|
Click here to view
|Figure 5: Oncocytic epithelium in inverted nasal polyp (H and E stain, ×200)|
Click here to view
Peripheral nerve tumors of the sinonasal region are extremely rare. They presumably arise from the ophthalmic and maxillary branches of the trigeminal nerve and from branches of the autonomic nervous system. The most common type is the neurilemmoma, which may cause diagnostic problems because of hypercellularity and the fact that - in contrast to its more common counterpart in the soft tissue - it is often unencapsulated.  We encountered one case of neurilemmoma. Histology revealed uniform spindle cells arranged in loose stroma. Nuclei were arranged in a palisade pattern (antony A and B) [Figure 6].
|Figure 6: Hyper cellular area in case of schwannoma in nasal mass (H and E stain, ×200)|
Click here to view
Extracranial meningioma may occur in relation to the base of the skull, the scalp, the orbit, the nasal cavity, the paranasal sinuses, and the middle ear.  They probably originate from arachnoid cells trapped within or around the bone as the cranial bone develop and fuse. We had one case of meningothelial meningioma in female aged 23 years. Histology reveals meningeal epithelium and cells forming whorled pattern of clusters and few psammoma bodies  [Figure 7].
|Figure 7: Meningothelial cells forming whorled pattern in meningioma presenting as nasal mass (H and E stain, ×200)|
Click here to view
Rhabdomyosarcoma (RMS) is a skeletal muscle sarcoma they commonly found in the head and neck region, and nasopharynx is second most common site next to orbit. We encountered two cases of embryonal RMS, with histology reveals, tumor cells are small and spindle shaped. Some have a deeply acidophilic cytoplasm. There is the presence of highly cellular areas usually surrounding blood vessels, alternating with paucicellular regions that have abundant myxoid intercellular material. 
Sinonasal lymphoma is more common in Asian than western populations, where it represents second most common group of extra nodal lymphomas next to gastrointestinal lymphomas. We found one case of lymphoma in our study, on histopathology there is small round blue cells are found.
Nasopharyngial carcinoma (NPC) is a clinicopathological entity different from other squamous cell carcinoma of head and neck region. It is distinguished by its particular histology, geographical distribution and its relation to Ebstien-Barr virus, and there is no association with tobacco smoking.  It has the peak incidence in the fourth and fifth decades, and a striking male predominance. We found two cases of NPC; both are males of sixth decade, they presented as moderately differentiated keratinizing squamous cell carcinoma.
Olfactory neuroblastoma is a rare tumor occurs in the upper nasal cavity and may cause nasal obstruction. It may also present as secondaries in neck.  We encountered one case of olfactory neuroblastoma in male aged 64 years. Histology reveals polypoid structure lined by pseudo-stratified tall columnar epithelium having fibrocollagenous stroma with the presence of small round cells, cells forming rossette, and arranged perivascularly  [Figure 8]. Nucleus pleomorphism is minimal, few mitotic figures are seen.
|Figure 8: Round blue tumor cells with fi brillary background in case of neuroblastoma (H and E stain, ×200)|
Click here to view
In our study, whenever there is doubt in diagnosis on the basis of histopathology, we sent the tissue blocks for immunohistochemistry (IHC) confirmation at a higher center; the diagnosis of meningioma, lymphoma, RMS and neuroblastoma are given after IHC confirmation.
| Conclusion|| |
Although the majority of nasal masses sent for histopathology are inflammatory, secondary to infection or allergy, a variety of benign and malignant lesions of the nose may present as nasal masses and hence all nasal masses must need thorough histopathological examination.
| References|| |
Mark WL, Kumar V. In: Kumar V, Abbas AK, Fausto N, editors. Robbins and Cotran Pathologic Basis of Disease. 7 th
ed. Pennsylvania: Elsevier; 2004. p. 773-96.
Dafale SR, Yenni VV, Bannur HB, Malur PR. Histopathological study of polypoidal lesions of the nasal cavity. Al Ameen J Med Sci 2012;4:403.
Das A, Bal A, Chakrabarti A, Panda N, Joshi K. Spectrum of fungal rhinosinusitis; histopathologist's perspective. Histopathology 2009;54:854-9.
Balogh K, Pantanowitz L. Mouth, nose, and paranasal sinuses. In: Mills SE, editor. Histology for Pathologists. 3 rd
ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 403-30.
Kirtsreesakul V. Nasal polyps: The relationship to allergy, sinonasal infection and histopathological type. J Med Assoc Thai 2004;87:277-82.
Kitapçi F, Muluk NB, Atasoy P, Koç C. Role of mast and goblet cells in the pathogenesis of nasal polyps. J Otolaryngol 2006;35:122-32.
Sakaki M, Shek TW, Hirokawa M, Kashima K, Daa T, Gamachi A, et al
. Melanotic oncocytic metaplasia of the nasopharynx: A report of seven cases and review of the literature. Virchows Arch 2004;444:345-9.
Ahluwalia KB. New interpretations in rhinosporidiosis, enigmatic disease of the last nine decades. J Submicrosc Cytol Pathol 1992;24:109-14.
D'Angelo AJ Jr, Marlowe A, Marlowe FI, McFarland M. Inverted papilloma of the nose and paranasal sinuses in children. Ear Nose Throat J 1992;71:264-6.
Buob D, Wacrenier A, Chevalier D, Aubert S, Quinchon JF, Gosselin B, et al
. Schwannoma of the sinonasal tract: A clinicopathologic and immunohistochemical study of 5 cases. Arch Pathol Lab Med 2003;127:1196-9.
Tan LH. Meningioma presenting as a parapharyngeal tumor: Report of a case with fine needle aspiration cytology. Acta Cytol 2001;45:1053-9.
Rosenblum MK. Central nervous system. In: Rosai J, editor. Rosai and Ackerman's Surgical Pathology. 10 th
ed. St. Louis: Elsevier; 2011. p. 2389-93.
Gensler MB. Sinonasal and nasopharyngeal surgical pathology. In: Silverberg SG, editor. Silverberg's Principles and Practice of Surgical Pathology and Cytopathology. 4 th
ed. Philadelphia: Churchill Livingstone Elsevier; 2006. p. 793-811.
Kollur SM, El Hag IA. Fine-needle aspiration cytology of metastatic nasopharyngeal carcinoma in cervical lymph nodes: Comparison with metastatic squamous-cell carcinoma, and Hodgkin's and non-Hodgkin's lymphoma. Diagn Cytopathol 2003;28:18-22.
Bellizzi AM, Bourne TD, Mills SE, Stelow EB. The cytologic features of sinonasal undifferentiated carcinoma and olfactory neuroblastoma. Am J Clin Pathol 2008;129:367-76.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]