대한비과학회

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KISEP Original Article J Rhinol 11(1,2), 2004

Clinical Consideration of Benign Nasal Neoplasm

Jin-Woo Lim, M.D., Dong-Hyuk Han, M.D., Il-Suk Park, M.D., Yong-Bok Kim, M.D., Young-Soo Rho, M.D. and Hyo-Jin Park, M.D.

ABSTRACT

There are many different kinds of histological types of nasal masses. But there were few studies based on the clinical consideration of benign nasal neoplasms in comparison with its histologic types. In this study we compare and analyze the benign nasal neoplasm in wish to guide for a diagnosis and management. Twenty- seven patients with benign nasal neoplasms excluding inverted papilloma, antrochoanal polyp and dentigenous cyst from March 1996 and June 2003 were selected for this study. Their clinicopathologic records were reviewed retrospectively. The male-female ratio was 1：1.25 and the right to left ratio was 1：

1.7. Bening nasal neoplasms were frequently found in the fifth decade. Hemangioma was the most common benign nasal neoplasm. Nasal obstruction was the most common symptom. Benign nasal masses were frequently found at the inferior turbinate and vestibule. When the masses were found, they were smaller than 1 cm in most cases. An endoscopic and transnasal approach was the most commonly utilized approach method during surgery. There were no recurrent cases during the average 41 months follow up. In conclusion, there is no statistical significance between benign nasal neoplasm and the patient’s sex and age. But, they were frequently found in left side rather than the right side. Surgical treatment seemed to be extremely useful in the case of benign nasal neoplasms.

KEY WORDS：Neoplasm・Nose・Paranasal sinuses.

INTRODUCTION

Benign neoplasm of the nasal cavity and paranasal sinus shows numerous types of histologically different masses. Its clinical characters are also diverse. Benign nasal neoplasm is classified according its origin into epithelial tumor, mesenchymal tumor and osseous tumor.

There is papilloma, adenoma and mixed tumor in the epithelial tumor group and hemangioma, lymphangioma, neurogenic tumor, fiborma, lipoma and chondroma in the mesenchymal tumor group. Osteoma, giant cell tumor, ossifying fibroma, fibrous dysplasia are included in the osseous tumor group. Nasal obstruction is known to be the chief complaint. Other symptoms include epistaxis or pain while a diverse set of symptoms may also

be observed depending on the site affected. There are numerous studies from the past based on commonly found tumors such as inverted papilloma, antrochoanal polyp or dentigenous cysts, however, there are only few cases reports followed by histological classification with not much dealing with its generalized clinical conside- rations. Through this study we wish to assist for a more definite diagnosis and treatment modality by analyzing the clinical characters of benign nasal neoplasm such as sex, age, site and size of lesion at the time of diagnosis, treatment and recurrence rate.

MATERIAL AND METHODS

This study was based on 172 patients who underwent biopsy and surgery for benign nasal neoplasm from March 1996 through June 2003 at the department of Otorhinolaryngology Hallym University. Among them 52 patients diagnosed with inverted papilloma, 63 with antrochoanal poly and 30 with dentigenous cyst were excluded from the experiment which left 27 patients appropriate for the experiment. A retrograde analysis was executed through a chart analysis based on the group’s sex, age, location and size of mass, treatment, Department of Otolaryngology-Head and Neck Surgery, College

of Medicine, Hallym University, Seoul, Korea

Address correspondences and reprint requests to Hyo-Jin Park, M.D., Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hallym University, Kangdong Sacred He- art Hospital, 445 Gil-dong, Gangdong-gu, Seoul 134-701, Korea Tel：82-2-2224-2279, Fax：82-2-482-2279

E-mail：[email protected]

Accepted for publication on May 14, 2004

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72 / J Rhinol 11(1,2), 2004

follow up period and recurrence rate. The average age was 35.33 years and the youngest patient was 6 years old and the oldest 66 years old. There were 12 male (44%) and 15 (56%) female patients. There were 2 (7%) patients between the ages 0-9 years old, 4 (15%) between the ages 10-19, 5 (19%) between the ages 20-29, 4 (15%) between the ages 30-39, 4 (15%) between the ages 40-49, 6 (22%) between the ages 50-59 and 2 (7%) over the age of 60 according to an analysis based on age group.

RESULT

Classification of the disorders based on histological diagnosis are 10 cases of hemangioma, 3 cases of angiofibroma, 2 cases of hemangioendothelioma, fibroma, pyogenic granuloma and trichofolliculoma each and 1 case of angiomyofibroma, organized hematoma, osteoma, juvenile xanthogranuloma, fibroepithelial polyp and verruca vulgaris each (Table 1). The chief complaint was nasal obstruction in 19 patients (70%) followed by epistaxis in 5 (19%), and nasal pain in 3 (11%) patients (Table 2). The location was in the left in 17 patients (63%), right in 10 (37%), inferior turbinate in 9 (34%), nasal vestibule in 7 (26%), ethmoid

sinus in 5 (19%), maxillary sinus in 2 (7%), middle turbinate in 2 (7%), and nasal septum in 2 patients (Table 3). Size of the neoplasm at the time of diagnosis was smaller than 1cm in 15 patients (55%), between 1-2 cm in 4 (15%), between 2-3 cm in 4 (15%), between 3-4 cm in 3 (11%) and larger than 4 cm in 1 patient (4%) (Table 4). The average size was 1.75 cm and the largest size was 7 cm. As for treatment, 24 (89%) patients underwent an endoscopic and transnasal operation and 2 patients with hemangioma and 1 patient with organized hematoma which complete neoplasm excision was difficult, a Caldwell-Luc operation was carried out (11%). The average follow up period was 3 years and 5 months and there were no cases of recurrence.

DISCUSSION

Benign nasal neoplasm is relatively rare.¹⁾ Most patients visit with chief complaints of unilateral nasal obstruction or nasal pain, epistaxis and so forth. Benign nasal neoplasm is mostly observed as a nasal mass and therefore, differential diagnosis with malignant tumor is necessary.²⁾³⁾ Fu et al., reported that the frequency of benign nasal neoplasm was the highest with angiofibroma in 24.4% cases, followed by osteoma and hemangioma in 19.9% and 19.2% cases, relatively.¹⁾ Kim et al., reported that papilloma (38.9%), hemangioma (18.6%), and angiofibroma (13.6%) excluding polyps was com-

Table 1. Diagnosis of benign nasal neoplasm

Diagnosis Number of patient (%)

Hemangioma 010 (037)

Angiofibroma 003 (011)

Hemangioendothelioma 002 (007)

Pyogenic granuloma 002 (007)

Fibroma 002 (007)

Trichofolliculoma 002 (007)

Osteoma 001 (004)

Angiomyofibroma 001 (004)

Juvenile xanthogranuloma 001 (004) Fibroepithelial polyp 001 (004)

Organized hematoma 001 (004)

Verruca vulgaris 001 (004)

Total 27 (100)

Table 2. Chief complaints of the patients with benign nasal neo- plasm

Chief complaint Number of patient (%)

Nasal obstruction 019 (070)

Epistaxis 005 (019)

Pain 003 (011)

Total 27 (100)

Table 3. Location of benign nasal neoplasm

Location Number of patient (%)

Inferior turbinate 09 (034)

Vestibule 07 (026)

Ethmoid sinus 05 (019)

Maxillary sinus 02 (007)

Middle turbinate 02 (007)

Septum 02 (007)

Total 27 (100)

Table 4. Comparison of the size of benign nasal neoplasm Size (cm) Number of patient (%)

0-0.9 15 (055)

1-1.9 04 (015)

2-2.9 04 (015)

3-3.9 03 (011)

4-0.0 01 (004)

Total 27 (100)

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Lim et al：Benign Nasal Neoplasm / 73

monly observed²⁾ Sohn et al., reported that papilloma (31.3%), fibroma (12.5%), hemangioma (12.5%) and so forth were commonly observed.³⁾ In this study, hemangioma was the most common in 10 cases and other neoplasms were angiofibroma, hemangioendothelioma, pyogenic granuloma, trichofolliculoma, fibroma, angiomyofibroma, organized hematoma, osteoma, juvenile xanthogranuloma, fibroepithelial polyp, verruca vulgaris and so forth.

Imaging studies such as magnetic resonance imaging and computed tomography of benign nasal neoplasm decides the location and extent of the disease and in case of a vascular neoplasm enhancement is distinct and differential diagnosis is made possible.⁴⁾ It also adjudges whether or not there has been intracranial extension and aids in deciding the extent to be operated.⁵⁾ Due to nasal endoscopy, observation of the posterior part of the nasal cavity or nasopharynx has been made easier, therefore, grasping the definite location has been made possible and being able to simultaneously carry out a biopsy has increased the diagnostic rate.⁶⁾

Treatment for benign nasal neoplasm is mostly possible through surgery. Nasal speculum and a transnasal approach using a headlight or Caldwell-Luc surgery has been used in the past, however, recently an endoscopic approach is mostly being carried out. Transnasal approach carries the demerit of having limitations in judging the exact boundary of a benign nasal neoplasm and therefore has a high recurrence rate.⁷⁾ Extranasal approac- hes such as lateral rhinotomy that was carried out often in the past to obtain a wide visual field carries the danger of bleeding, requires long term hospitalization and is cosmetically unfavorable. Due to these facts, this method is limited to cases of high recurrence rate and neoplasms extended to the extranasal cavity or masses that carry the possibility of being malignant tumors.⁸⁾ An endoscopic approach is necessary when the mass has been confirmed by a biopsy before surgery or when differential diagnosis is necessary for malignancy.⁹⁾ It pro- vides a good operative field and postoperative follow up is made convenient and as a result, recurrence can be rapidly found which makes this approach commonly used as a surgical method for treatment.¹⁰⁾¹¹⁾ For most of the cases we experienced in this study were smaller than 1 cm, we believe that an endoscopic approach will be useful for operational treatment and follow-up.

Hemangioma, the most common neoplasm we expe-

rienced in this study, along with hemangioendoehtlioma, angiofibroma, angiomyofbrom, pyogenic granuloma and so forth are all neoplasms that possess an abundant vascular component and bleeding can occur during resection in many cases. Therefore, we were able to mini- mize bleeding by injecting a sufficient amount of vasoconstrictors in the area surrounding the tumor and carrying out an en bloc resection. Bleeding and recurrence was also minimized by diathermy of the resection site.⁵⁾¹²⁾ Recently, resection of vascular tumors such as pyogeic granuloma has been carried out using laser which showed a 91% success rate and we believe that its utilization will gradually be increased in the near future.¹³⁾¹⁴⁾

There were no recurrences during a 3 year and 5 month follow up period in this study. We believe that this was possible by recognizing the exact location, extent and type of benign nasal neoplasm using imaging studies such as computed tomography and magnetic resonance imaging and choosing the appropriate surgical method and removing the tumor by obtaining an appropriate resection margin and lastly executing diathermy of the resection site.

CONCLUSION

Benign nasal neoplasm occurs irrelevant to sex and age and usually invades the left side and mostly origina- tes from the inferior turbinate. Hemangioma had the highest occurrence rate. Since benign nasal neoplasms are usually smaller than 1cm at the time of diagnosis, nasal obstruction is the chief complaint when visiting the hospital. Therefore, we believe that an endoscopic approach carried out at the first visit, irrelevant to age, will have an important affect in the early detection, diagnosis and prognosis of the disease. Dissimilarly from inverted papilloma, antrochoanal polyp and dentigrnous cysts, the recurrence rate of benign neoplasm in this study were 0%. However, since the follow up period was relatively short with a 3 year and 5 month, we believe that a continuous follow up will be necessary.

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