Differential diagnosis of nasal mass

Differential diagnosis of nasal mass

Dr. Sharath Chandra,JR ENT,AIIMS RISHIKESH.

Reason for detecting various nasal mass

Symptoms and its frequency

3

In extreme cases

Physical examination

Nasal examination

Oral cavity examination

Face and orbit examination

Facial swelling , cheek and nose skin thickening indicates tumor involved soft tissue through anterior wall.Proptosis indicates lamina papyracea involvement.Diplopia present along with proptosis in most cases.Vision loss indicates to involvement of O.N.

Can be divided as..

Normal anatomical variants appearing as nasal mass

Concha bullosaDNS & SPUR

Congenital / developmental

Congenital / developmental

Glioma Ectopic rests of glial tissue.Some visible out side the nasal vault.some completely present in nasal cavity.No expansion on crying.

Meningocele and Encephalocele.

Meninges out side cranial vault .Located in area of foramen caecum.Expand on crying.Brain tissue along with meninges protrude out the cranial vault.

Inflammatory and infectious Nasal polypsSarcoidosisWegner's granulomatosisRhinoscleroma

Nasal polyp Non neoplastic masses .Edematous nasal or sinus mucosa.chronic inflammation leading to stromal edema and variable cellular infiltrate.watery rhinorrhea , postnasal drip, hyposmia.A/R reveals single or multiple pale, grey polypoid masses arising most middle meatus and prolapsing into the nasal cavity.

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X ray wont help, except for opacification.CT scan will show the extent of NP and anatomical variations and is essential if surgical treatment is to be implemented.

Sarcoidosis Classic non caseating granuloma .Ext. nose and face lupus pernioThickened nasal septum due to granulomatous infiltrationYellowish , nodular appearing lesion.DNE: classic sarcoid submucosal nodules.HPE: classic, non caseating pattern asteroid bodies.

Rhinoscleroma Chronic granulomatous conditionInvolves URTBegins in mucocutaneous junction(vestibule)Females > males; 10-30 yrs. age group.Presents as nasal obstruction, rhinorrhea , deformity, anosmia.

Initial nodule small sizeCT: homogenous and non enhancingInclude calcification.

Wegner's granulomatosis Sino nasal involvement in 80% cases nasal obst, rhinorrhea , ulceration, crusting epistaxis .Osseocartilaginous frame work damage (saddle nose).Kidney and joint involvement ANCA C associated .

Who classification of benign nasal massEpithelial Soft tissue tumorBone and cartilage Miscellaneous Papilloma Myxoma Giant cell tumor Juvenile angio fibroma Salivary gland adenomas LeiomyomaChondroma Hemangioma osteoma SchwannomaOsteoid osteomaMeningioma neurofibroma

Incidence of various massData from a series of 931 patients treated at the University Hospitals of Brescia and Varese (Italy) from 1994 to 2013.

Inverted papilloma(Schneiderian papilloma)

0.5 to 7 % of all nasal tumorsa/c HPVFrom lateral nasal wall (middle meatus mostly + any one sinus)Some times involve septum and involve C/L cavity

Inverted papilloma

Cerebriform appearance

Juvenile angiofibroma

Vascular endothelium lined spaces embedded in fibrous stromaExclusively male adolescent Pterygoid palatine fossa epicenter

Lobular capillary hemangioma vascular tumor involving nasal vestibule and nasal septum.m/c seen pregnant females , 20 30yrRecurrent nasal trauma.Presents as red to purple mass.Spontaneous epistaxis and nasal obstruction.On CT U/L mass with soft tissue density.

Schwannoma

25-55yr of ageArise from Schwann cellsTrigeminal nerve ,Carotid plexus and parasympathetic fibers of pterygopalatine ganglion

Well delineated , unencapuslatedGlobularFirm to rubbery yellow tumorAntoni A and B bodiesEndoscopy shows network of fine capillaries giving image of vascular tumor.

Schwannoma

lesions with a prevalent Antoni A component have an intermediate signal on both T1- and T2-weighted images, whereas in those with a predominant Antoni B pattern, which is related to a loose myxoid stroma, hyper intensity is observed on T2-weighted images.MRI showing ..A large hyper intense mass obliterates the nasal fossa and protrudes into the sphenoid and frontal sinus. The ethmoid roof is eroded, and the crista galli cannot be recognized.

Hamartomas Hamartomas are defined as benign masses of disorganized mature cells of any tissue type.

Malignant nasal massCarcioma Squamous cell Ca Adenocarcinoma Malignant melanomaOlfactory neuroblastomaHaemangiopericytomaLymphomaSolitary plasmacytomaVarious types of sarcoma

Squamous cell CAm/c malignant tumorArise from lateral nasal wall and septum Grow insidiously with little symptoms.Pain in maxillary teethPalatal erosion.Proptosis .Cheek paresthesia's

Adenocarcinoma / adenocystic carcinoma4-8 % of Sino nasal tumorsNasal cavity and ethmoid sinus.a/c with hardwood workers3 types- papillary, sessile, alveolarAdenocystic CA m/c minor salivary gland tumor in Sino nasal tractm/c in women3 types cribriform ,tubular , solidSwiss cheese app, Perineural invasion .

Mucosal melanoma Rapidly lethal neoplasm.m/c nasal septum , inf turbinate.Spread submucosally with little erosion of bone and cart.Varies from normal to heavy pigmentation.IHC s-100 and HMB 45.

Esthesioneuroblastoma From olfactory epith. in superior nasal vault.Sup to middle turbinate.Tumor made of round cells arranged in to rosettes , pseudo rosettes and sheets.Express NSE , chromogranin ,synaptophysin. Snow man appearance on CT scan.

Miscellaneous Rhinolith: Forms when an intranasal foreign body acts as a nidus uponwhich salts from inspissated mucus precipitate; symptoms include purulent secretions, recurrent infections, fetid odor, and nasal obstruction;can appear as bone-density on CT.

Meningocele/encephaloceleExpands with cryingDermoidFistulous tractRhinoscleromaKlebsiella rhinosderomatisMikulicz cellsSarcoidosisNoncaseating granulomasWegener diseasePulmonary and renal diseaseUnilatera I nasal polyposisAllergic fungal sinusitisAntrochoanal polypInverting papillomaMalignancyInverting papillomaHPV infectionJuvenile nasopharyngeal angiofibromaAdolescent males

Thank you