Clinicopathological study of sinonasal masses

Objective: To observe the incidence, clinical presentation and to perform comparative study of different sinonasal masses. Study design: Prospective study. Setting: Department of otolaryngology and Head-Neck Surgery & ENT OPD of Chittagong Medical College Hospital. Patients & methods: 50 patients are included in this study (39 male & 11 female) between the ages of 3 years and 80 years who were treated between August 2006 to January 2007. Study based on history, clinical, radiological, laboratory and histopathological examination. Results: Mean age for male was 35.12 years and for female was 22.63 years. Male to female ratio was 3.5:1. Highest frequency was noted in second decade. Most of patient (78%) were from poor class. Frequency of inflammatory nasal masses were more in second decade, benign tumour in fourth and fifth decade, malignant tumour in second decade (OAN & NHL) and fifth and second decades (others). Rhinosporidiosis were most frequent inflammatory nasal masses. Nasal obstruction was the commonest and orbitus symptoms were less frequent symptoms. But orbital symptoms were more prevalent in malignant lesion. Conclusion: sinonasal masses are found in all age group. Rhinosporidiosis are appearing to be the commonest nasal masses. The prevalence of nasal polyp is also high. Among the malignant sinonasal masses the percentage of squamous cell carcinoma is high. 1. OSD, DGHS, Deputed to Dept. of Otolaryngology & Head-Neck Surgery, BSMMU, Dhaka, Bangladesh 2. Assistant Professor, Dept. of Otolaryngology & Head-Neck Surgery, BSMMU, Dhaka, Bangladesh 3. Registrar, Chittagong Medical College Hospital (CMCH), Chittagong, Bangladesh 4. Junior Consultant (CC), ENT, UHC, Chatkhil, Noakhali, Bangladesh 5. Professor (Rtd.), Dept. of Otolaryngology & Head-Neck Surgery, CMCH, Chittagong, Bangladesh Address of Correspondence: Dr. Abu Hena Mohammad Parvez Humayun, OSD, DGHS, Deputed to Dept. of Otolaryngology & HeadNeck Surgery, BSMMU, Dhaka, Bangladesh Introduction: Sinonasal mass is a common finding in the ENT Department. It is found in almost all age groups of people. These masses may be inflammatory including allergic, traumatic, granulomas or may be neoplastic2. The commonest nasal mass seen is polyp3. Rhinosporidiosis is also one of the most common nasal mass in our country4. Angiofibroma is a benign but biologically aggressive tumour in adolescent males.8 Haemangioma may be found any where in the nasal cavity. But commonly found on the anterior part of the septum, where they are called bleeding polypus of the septum7. A wide variety of tumours of different histological types are found in the nasal cavity6. Benign tumours are not uncommon but malignant tumours are rare, . Bangladesh J Otorhinolaryngol 2010; 16(1): 15-22


Introduction:
Sinonasal mass is a common finding in the ENT Department.It is found in almost all age groups of people.These masses may be inflammatory including allergic, traumatic, granulomas or may be neoplastic 2 .The commonest nasal mass seen is polyp 3 .Rhinosporidiosis is also one of the most common nasal mass in our country 4 .Angiofibroma is a benign but biologically aggressive tumour in adolescent males. 8aemangioma may be found any where in the nasal cavity.But commonly found on the anterior part of the septum, where they are called bleeding polypus of the septum 7 .A wide variety of tumours of different histological types are found in the nasal cavity 6 .Benign tumours are not uncommon but malignant tumours are rare, .constituting less than I percent, of all malignancies (3% of head and neck tumours) 9 .Primary neurogenic tumour that involve the nose and paranasal sinuses are comparatively rare 10 .Tumours of schwan cell origin, neurofibroma and neurilemoma occurs in nasal fossa very rarely 10 .The neoplasm deserving most attention is the olfactory neuroblastoma 9 .The sinonasal malignancy may be found to be arising from the tissues & structures of the nasal cavity & paranasal sinuses 2 .Even pathologies, which are arising from cranial cavity, may also appear as mass in the nasal cavity or paranasal sinuses 8 .The presentation of sinonasal malignancy depends on the primary site, the direction and extent of spread.The most common initial symptoms are nasal obstruction, epistaxis, proptosis, epiphora, diplopia, loose teeth, facial pain & swelling, buccal or palatal swelling.The presence of nodal involvement drastically reduces the prognosis and 5 years survival rate come down from 27.2% to 6.8% 25 .Although there is marked limitation of scope and many shortcomings of this study, yet attempt has been made to find out the actual facts and figures related to the subject prevailing in our country.

Aims and Objectives:
• To observe the incidence of different sinonasal masses on the basis of age, sex and socio-economic condition.Maximum numbers of patients were from poor class.

Financial categorization: (Poverty Alleviation and Empowerment Through Microfinance: Tow
Decades of experience Bangladesh) 26 .
Non poor class: Working capital-Taka >3,338.00per month per earner.
From the above Table-III it can be observed that inflammatory nasal masses were more frequent in the second decade, benign tumours were more frequent in fourth and fifth decades.Malignant tumours were more frequent in second and fifth to seventh decades.From the above Table-IV it is noted that males outnumbered the females with a ratio of 3.5:1.Here it reveals that among the malignant tumours of nasal cavity squamous cell carcinoma was most frequent (41.67%) with average age 51 years.

Symptoms
Average The prevalent symptoms in inflammatory nasal mass were nasal obstruction, nasal discharge and loss of smell etc. Fifty patients with different age, sex and socioeconomic condition studied in this series.The maximum number of patients were presented during second decade.The increased number of patients in the second decade may be due to the increased incidence of inflammatory disease in that group.

Benign
In this study, among the patient the male and female ratio was 3.5:1.
This may be due to the increased prevalence of such disorder among the male or it may be simple reflection of overall higher male attendance in the hospital.
From socio-economic background most of the patient was poor (78%).This was probably rich patients not came to government hospital, rather they took their health service at private clinic or hospital.Otherwise the overall incidence of sinonasal diseases among rich was less.
In this study, the sinonasal diseases include inflammatory disease 35 cases (70%).Benign tumours 3 cases (6%) and malignant tumours 12 cases (24%).So it assumes that the overwhelming majority of the nasal lesion in this series were inflammatory.
.The second most frequent symptom was nasal discharge (82.85%) for long duration.This findings were well supported by Lumsden and Wilson 22 .
Sinonasal tumours are rare, comprising less than 3% of all aerodigestive tract tumour.In this study benign sinonasal tumours were 3 cases (6%) of all sinonasal diseases.Among the benign tumours, one was inverted papilloma (33.33%) and one was meningioma (33.33%) and another one was haemangioma (33.33%).The main clinical presentation was nasal obstruction and epistaxis.The case haemangioma was presented with alarming epistaxis.
In this study prevalence of malignant tumour was 12 cases (24%) of all sinonasal masses.Though the percentage was very high for malignant tumour, we think the reason behind this was, as the management of sinonasal malignancy was destructive with obvious morbidity, usually these cases was not managed at private clinic or hospital.So the almost all the sinonasal malignancy was attend to the government hospital (which was not happed in other sinonasal diseases).For that reason the percentage become high in this study.
This study also reveals that malignant tumour was more frequent in second (OAN & NHL) and fifth to seventh decade (others) (Table-III) which was consistent with reference books.
Among the 12 cases of malignant tumour, 5 cases (41.67%) were squamous cell carcinoma, 3 cases (25%) were lymphoma, 1 case was adenoid cystic carcinoma, 1 case was embryonal rhabdomyosarcoma 1 case was olfactory neuroblastoma and one case was secondary metastatic squamous cell carcinoma.
From clinical presentation it was found that embryonal rhabdomyosarcoma, olfactory neuroblastoma were more aggressive than the other sinonasal malignancy.In this study, it was also observed that neck node metastasis was rare or it occurs in very advanced disease.

Table - III
Age incidence and relationship with nasal massMajority of the patients presented with more than one symptom and nasal obstruction was the commonest symptom noted in 47 cases.Orbital symptoms were less frequent.From Table-VI average age for benign nasal tumours was 39 years.From table, it was observed that meningioma occur in early age and inverted papilloma occurs in late age.