Differential diagnosis of nasal mass

Dr. sharath chandra

1. Differential diagnosis of nasal mass Dr. Sharath Chandra, JR ENT, AIIMS RISHIKESH.

2. Reason for detecting various nasal mass

3. Symptoms and its frequency

4. In extreme cases

5. Physical examination Nasal examination

6. Oral cavity examination

7. 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.

8. Can be divided as..

9. Normal anatomical variants appearing as nasal mass Concha bullosa DNS & SPUR

10. Congenital / developmental

11. 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.

12. 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.

13. Inflammatory and infectious Nasal polyps Sarcoidosis Wegner's granulomatosis Rhinoscleroma

14. 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.

15. Continue… 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.

16. Sarcoidosis Classic non caseating granuloma . Ext. nose and face – lupus pernio Thickened nasal septum due to granulomatous infiltration Yellowish , nodular appearing lesion. DNE: classic sarcoid submucosal nodules. HPE: classic, non caseating pattern asteroid bodies.

17. Rhinoscleroma Chronic granulomatous condition Involves URT Begins in mucocutaneous junction(vestibule) Females > males; 10-30 yrs. age group. Presents as nasal obstruction, rhinorrhea , deformity, anosmia. Initial nodule small size CT: homogenous and non enhancing Include calcification.

18. 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 .

19. Who classification of benign nasal mass Epithelial Soft tissue tumor Bone and cartilage Miscellaneous Papilloma Myxoma Giant cell tumor Juvenile angio fibroma Salivary gland adenomas Leiomyoma Chondroma Hemangioma osteoma Schwannoma Osteoid osteoma Meningioma neurofibroma

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

21. Inverted papilloma(Schneiderian papilloma) 0.5 to 7 % of all nasal tumors a/c HPV From lateral nasal wall (middle meatus mostly + any one sinus) Some times involve septum and involve C/L cavity

22. Inverted papilloma Cerebriform appearance

23. Juvenile angiofibroma Vascular endothelium lined spaces embedded in fibrous stroma Exclusively male adolescent Pterygoid palatine fossa – epicenter

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

25. Schwannoma 25-55yr of age Arise from Schwann cells Trigeminal nerve ,Carotid plexus and parasympathetic fibers of pterygopalatine ganglion Well delineated , unencapuslated Globular Firm to rubbery yellow tumor Antoni A and B bodies Endoscopy shows network of fine capillaries giving image of vascular tumor.

26. 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.

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

28. Malignant nasal mass Carcioma Squamous cell Ca Adenocarcinoma Malignant melanoma Olfactory neuroblastoma Haemangiopericytoma Lymphoma Solitary plasmacytoma Various types of sarcoma

29. Squamous cell CA m/c malignant tumor Arise from lateral nasal wall and septum Grow insidiously with little symptoms. Pain in maxillary teeth Palatal erosion. Proptosis . Cheek paresthesia's

30. Adenocarcinoma / adenocystic carcinoma 4-8 % of Sino nasal tumors Nasal cavity and ethmoid sinus. a/c with hardwood workers 3 types- papillary, sessile, alveolar Adenocystic CA m/c minor salivary gland tumor in Sino nasal tract m/c in women 3 types – cribriform ,tubular , solid Swiss cheese app, Perineural invasion .

31. 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.

32. 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.

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

34. Meningocele/encephalocele Expands with crying Dermoid Fistulous tract Rhinoscleroma Klebsiella rhinosderomatis Mikulicz cells Sarcoidosis Noncaseating granulomas Wegener disease Pulmonary and renal disease Unilatera I nasal polyposis Allergic fungal sinusitis Antrochoanal polyp Inverting papilloma Malignancy Inverting papilloma HPV infection Juvenile nasopharyngeal angiofibroma Adolescent males

35. Thank you