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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 11-14

Computed tomography evaluation of sinonasal masses with histopathological correlation


1 Department of Radiodiagnosis, GMC, Srinagar, Jammu and Kashmir, India
2 Department of Pathology, GMC, Srinagar, Jammu and Kashmir, India

Date of Submission11-Mar-2020
Date of Decision02-Apr-2020
Date of Acceptance07-Apr-2020
Date of Web Publication20-Jun-2020

Correspondence Address:
Dr. Suhail Rafiq
Department of Radiodiagnosis, GMC, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_34_20

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  Abstract 


Background and Aim: A variety of nonneoplastic and neoplastic conditions involving the nasal cavity (NC), paranasal sinuses (PNSs), and nasopharynx are commonly encountered in clinical practice. Etiological factors for the development of sinonasal masses are human papillomavirus 6 and 11, allergens, air pollution, and industrial carcinogens, tobacco, alcohol, and occupational exposure to heavy metal particles. The aim was to explicate and corroborate the CT radiological features of sinonasal masses of benign versus sinister differential diagnosis. Materials and Methods: A total of 50 cases of sinonasal masses were included in this study. Written informed consent from the patients was obtained. Detailed clinical history and local and general examinations were done according to the pro forma attached with a special reference to the nose, PNSs, and oral cavity. These cases were subjected to after routine hematological and biochemical evaluation, nasal endoscopy, X-ray PNSs/computed tomography scan, fine-needle aspiration cytology, and, whenever required, biopsy. Results: On radiological assessment, of 50 patients, 45 patients were declared benign, while as 5 patients were diagnosed as having primary or secondary malignancy involving sino-NCs. Based on bone erosions along with internal hyperdense contents and enhancement pattern, there was some amount of discordance among radiological and histopathological diagnosis. One case which was diagnosed as malignancy (likely metastasis) was found to have invasive fungal sinusitis. Among the three radiologically diagnosed inverted papillomas (based on focal hyperostosis, subtle calcification, and cerebriform enhancement on postcontrast study), only 1 case correlated histopathologically. The rest were hemangioma and schwannoma (very rare). Radiological esthesioneuroblastoma, hemangioma, angiofibroma, and rhinolith correlated well with histopathology. Conclusion: Imaging plays an important role in the evaluation of sinonasal masses. Benign lesions are diagnosed very accurately. The distinction between sinonasal and invasive fungal sinusitis is still debatable, and hence, histopathological correlation is necessary. The presence of significant cervical lymphadenopathy can serve as a surrogate marker of malignancy.

Keywords: Adenocarcinoma, fungal sinusitis, lymphoma


How to cite this article:
Dar MA, Rafiq S, Manzoor F, Mohideen I. Computed tomography evaluation of sinonasal masses with histopathological correlation. Arch Med Health Sci 2020;8:11-4

How to cite this URL:
Dar MA, Rafiq S, Manzoor F, Mohideen I. Computed tomography evaluation of sinonasal masses with histopathological correlation. Arch Med Health Sci [serial online] 2020 [cited 2020 Nov 25];8:11-4. Available from: https://www.amhsjournal.org/text.asp?2020/8/1/11/287359




  Introduction Top


A variety of nonneoplastic and neoplastic conditions involving the nasal cavity (NC), paranasal sinuses (PNSs), and nasopharynx are commonly encountered in clinical practice.[1] Various etiological factors for the development of sinonasal masses are human papillomavirus 6 and 11, allergens, air pollution, and industrial carcinogens, tobacco, alcohol, and occupational exposure to heavy metal particles (such as nickel and chromium), particularly for workers in the leather, textile, furniture, and wood industries.[2] Patients with sinonasal masses present with multitude of symptoms such as nasal obstruction, nasal congestion and discharge, headache and/or swelling and facial pain, orbital symptoms, and ear symptoms. Evaluation begins with proper clinical history, examination, and subsequently, may need sinonasal endoscopy, radiological evaluation, and finally, histopathological correlation. As for as imaging is concerned, X-ray, computed tomography (CT), and magnetic resonance imaging are frequently used in the evaluation of the sinonasal masses. Fluorodeoxyglucose positron-emission tomography/CT imaging is not recommended for routine diagnosis and staging of head-and-neck cancer in most guidelines;[3] however, it has been shown to be useful for imaging of residual and recurrent tumor [3] in monitoring treatment response [3] to measure tumor volume [4] and to select patients who may benefit from oxygenation-modifying treatments.[5] Sinonasal masses can be grossly divided into two main categories: non-neoplastic and neoplastic, which in turn, are further divided into benign and malignant. The various benign masses include inflammatory polyp, angiofibroma, invasive fungal sinusitis, inverted papilloma, capillary hemangioma, osteogenic keratocyst, and rhinoscleroma and malignant masses include squamous cell carcinoma adenocarcinoma, esthesioneuroblastoma, extramedullary plasmacytoma, and hemangiopericytoma.


  Materials and Methods Top


This prospective study was conducted at the Department of Radiodiagnosis and Imaging, Government Medical College, over a period of 12 months. All the patients were referred by the Otorhinolaryngology Department with complaints of sinonasal masses, and patients with mass arising from the nose or PNS during the study period were included in the study. A total of 50 cases of sinonasal masses were included in this study. Written informed consent from the patients was obtained.

Detailed clinical history was taken with reference to age, sex, residence, occupation, family history, past history, any allergic disorder, and any addictive habits. Detailed clinical local and general examinations were done according to the pro forma attached with special reference to the nose, PNSs, and oral cavity. These cases were subjected to after routine hematological and biochemical evaluation, nasal endoscopy, X-ray PNSs/CT scan, and fine-needle aspiration cytology/biopsy whenever required. Tissues were routinely processed for histopathological sections of 5μ thickness and were stained by hematoxylin and eosin stain. Special staining by reticulin, Van Gieson, PAS, and Masson's trichrome was undertaken whenever applicable. The data so obtained were compiled and analyzed and a valid conclusion was drawn.


  Results Top


In our study, all 50 patients underwent CT scan. Various CT findings in our study include bilateral sinonasal masses, expanded sino-NCs, hyperdense contents within sinuses, bone erosions, and neck nodes [Table 1].
Table 1: Computed tomography findings in cases of our study

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On radiological assessment, of 50 patients, 45 patients were declared benign, while as 5 patients were diagnosed as having primary or secondary malignancy involving sino-NCs. The various benign causes in our study were polyposis, fungal sinusitis, odontogenic keratocyst, inverted papilloma, rhinolith, angiofibroma, and hemangioma. Among the five malignancy diagnoses, only one case was characterized as having esthesioneuroblastoma. Other four cases were reported as malignancies not otherwise specific.

Histopathological examination was done in 43 cases. Good consistency with radiological diagnosis was seen. Of all the 30 patients with radiological diagnosis of polyposis, who underwent histopathology, inflammatory polyps were documented histopathologically. Based on bone erosions [Figure 1] along with internal hyperdense contents and enhancement pattern, there was some amount of discordance among radiological and histopathological diagnosis. One case which was diagnosed as malignancy (likely metastasis) was found to have invasive fungal sinusitis. Among the three radiologically diagnosed inverted papillomas (based on focal hyperostosis, subtle calcification, and cerebriform enhancement on postcontrast study) [Figure 2], only 1 case correlated histopathologically. The rest were hemangioma and schawanoma (very rare). Radiological esthesioneuroblastoma, hemangioma, angiofibroma, and rhinolith correlated well with histopathology.
Figure 1: Computed tomography bone reconstructed window showing ulcerated lesion involving posterior wall of maxillary antrum with adjacent soft tissue along with bony erosion

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Figure 2: Postcontrast coronal computed tomography image showing heterogeneously cerebriform like enhancement of the right maxillary sinus mass with adjacent bone remodeling

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  Discussion Top


A variety of nonneoplastic and neoplastic conditions involve the NC and PNSs, and these are very common lesions encountered in clinical practice. Although masses in the anterior NC or involving the nasal ala can be readily apparent at clinical examination, those in the posterior NC and nasopharynx are often difficult to visualize at physical examination. In addition, the signs and symptoms of these lesions tend to be nonspecific, mimicking common upper respiratory processes that may result in a delayed diagnosis. Furthermore, these masses occasionally may be found incidentally at imaging.[6] The presenting features and symptomatology and advanced imaging technique help to draw a provisional diagnosis, but histopathological examination remains the gold standard to illustrate definitive diagnosis.[7] Based on the incorrect radiological diagnosis, most of the benign lesions undergo radical surgeries, and the same time, many of the malignancies are encountered in advanced stage with poor prognostic outcome.[8],[9] The various radiological factors that predict malignancy in sinonasal masses include bony erosions, site, pattern of enhancement, and invasion into the surrounding structures. Various sinonasal masses are Aunt Minnie for a radiologist to comment.

Angiofibroma typically presents in young males with vascular mass with typical imaging characteristics on contrast CT like lobulated nonencapsulated soft-tissue mass centered on the sphenopalatine foramen (which is often widened) and usually bowing the posterior wall of the maxillary antrum anteriorly with marked contrast enhancement following administration of contrast, reflecting the prominent vascularity.

Odontogenic keratocyst on CT presents an expansile, cystic lesion with scalloped, well-corticated borders with a variable density of cystic contents.

Sinonasal schwannoma usually has nonspecific features on CT like hypo-enhancing mass on contrast CT with bone remodeling.

In our study, polyposis was diagnosed correctly in 100% of cases [Figure 3] and [Figure 4]. Malignant masses often confuse radiologically with invasive fungal sinusitis. Bone erosions with secondary bony fragments often confuse with primary internal hyperdense contents. Enhancement pattern is also not diagnostic of malignancy as compared to invasive fungal sinusitis. In our study, the only radiological factor that shows some specificity regarding malignant mass as compared to invasive sinusitis was cervical lymphadenopathy (3 Vs1) [Table 2]. The other cases which show discordance in our study were inverted papilloma [Figure 5] with hemangioma and schwannoma. Of the three radiologically diagnosed inverted papillomas, two were schwannoma and hemangioma. However, on close retrospection, previously diagnosed papillomas (HPE schwannoma) show some homogeneous enhancement as compared to typical cerebriform enhancement of inverted papilloma. Esthesioneuroblastoma, angiofibroma, and odontogenic keratocyst had 100% radiological specificity for diagnosis.
Figure 3: Axial bone reconstructed computed tomography showing sinonasal polyposis with expansion of the nasal cavity

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Figure 4: Histopathological slide showing inflammatory polyp

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Table 2: Radiopathological correlation in our study cases

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Figure 5: Histopathological slide showing inverted papilloma

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Angiofibroma typically presents in young males with vascular mass with typical imaging characteristics on contrast CT like lobulated nonencapsulated soft-tissue mass centered on the sphenopalatine foramen (which is often widened) and usually bowing the posterior wall of the maxillary antrum anteriorly with marked contrast enhancement following administration of contrast, reflecting the prominent vascularity.

Odontogenic keratocyst on CT presents an expansile, cystic lesion with scalloped, well-corticated borders with a variable density of cystic contents.


  Summary and Conclusion Top


  1. Imaging plays an important role in the evaluation of sinonasal masses. Benign lesions are diagnosed very accurately
  2. However, the distinction between sinonasal malignancies (squamous, adenocarcinoma, and metastasis) and invasive fungal sinusitis is still debatable, and hence, histopathological correlation is necessary
  3. Presence of significant cervical lymphadenopathy can serve as a surrogate marker of malignancy.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zafar U, Khan N, Afroz N, Hasan SA. Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses. Indian J Pathol Microbiol 2008;51:26-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Shirazi N, Bist SS, Selvi TN, Harsh M. Spectrum of sinonasal tumors: A 10-year Experience at a tertiary care hospital in North India Oman. Med J 2015;30:435-40.  Back to cited text no. 2
    
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Bussink J, van Herpen CM, Kaanders JH, Oyen WJ. PET-CT for response assessment and treatment adaptation in head and neck cancer. Lancet Oncol 2010;11:661-9.  Back to cited text no. 3
    
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Daisne JF, Duprez T, Weynand B, Lonneux M, Hamoir M, Reychler H, et al. Tumor volume in pharyngolaryngeal squamous cell carcinoma: Comparison at CT, MR imaging, and FDG PET and validation with surgical specimen. Radiology 2004;233:93-100.  Back to cited text no. 4
    
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Kaanders JH, Wijffels KI, Marres HA, Ljungkvist AS, Pop LA, van den Hoogen FJ, et al. Pimonidazole binding and tumor vascularity predict for treatment outcome in head and neck cancer. Cancer Res 2002;62:7066-74.  Back to cited text no. 5
    
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Rodriguez DP, Orscheln ES, Koch BL. Masses of the nose, nasal cavity and nasopharynx in children. Radio Graphics 2017;37:1704-30.  Back to cited text no. 6
    
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M Kulkarni A, G Mudholkar V, S Acharya A, V Ramteke R. Histopathological study of lesions of nose and paranasal sinuses. Indian J Otolaryngol Head Neck Surg 2012;64:275-9.  Back to cited text no. 7
    
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Bhattacharyya N. Factors affecting survival in maxillary sinus cancer. J Oral Maxillofac Surg 2003;61:1016-21.  Back to cited text no. 8
    
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Thorup C, Sebbesen L, Danø H, Leetmaa M, Andersen M, Buchwald C, et al. Carcinoma of the nasal cavity and paranasal sinuses in Denmark 1995-2004. Acta Oncol 2010;49:389-94.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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