Diagnosis and management of benign tumors of nasal and paranasal cavities: 31 cases

Aim To precise the clinical, paraclinical and therapeutic features of the benign tumors of nasal and paranasal cavities. Methods We report a retrospective study carried out in the ENT Department of the Military Hospital of Tunis, Tunisia over a period of 10 years (2003-2012). Results we report 31 patients operated for benign tumors of the nasal and paranasal cavities. The mean age was 38 years (2 months to 73 years), and the sex ratio was 2.4 (22 male and nine female). The diagnosis was assessed through endoscopic and radiological findings. Surgery was underwent by an endonasal approach in 84% and an external approach in 16% of the cases. The evolution after surgery was different according to the histological type of the tumor. Discussion Benign tumors of the nasal and paranasal cavities are characterized by their histological diversity. Thus, clinical presentation is variable and nonspecific. Their diagnosis has been improved by modern imaging techniques and is definitely confirmed after histological examinations. Actually, endoscopic surgery of the paranasal sinuses has become the procedure of choice for treatment.


Introduction
Sinonasal diseases are mainly dominated by infl ammatory lesions. Benign and malignant tumors are uncommon. Th e benign tumors are characterized by their histological diversity [1]. Th eir clinical presentation is nonspecifi c, including facial pain, purulent nasal discharge, epistaxis, and nasal obstruction [2]. Imaging plays a critical role in establishing the diagnosis and may occasionally illustrate characteristic features of specifi c histological types. Th e treatment is based on surgery. External and endonasal endoscopic approach are two complementary methods, both of them having their indications [1].

Materials and methods
We report a retrospective study carried out in the ENT Department of the Military Hospital of Tunis, Tunisia: 31 patients operated for benign tumors of the paranasal cavities over a period of 10 years (2003-2012). Th e study was approved by the medical committee of the military hospital of Tunis, Tunisia. Th e mean age was 38 years (2 months to 73 years), and the sex ratio was 2.4 (22 male and nine female). Th e diagnosis was suspected in all the cases after nasal endoscopy and radiological examinations. All the patients benefi ted from a computed tomographic (CT) scan of the sinuses in the coronal and axial planes before surgery. Scans were carried out using the Siemens Somatom Plus 4 (Global Business Unit Siemens AG Medical Solutions Computed Tomography & Radiation Oncology, Siemensstr. 1 DE-91301 Forchheim Germany). Parameters applied included 512 matrix, 200 fi eld of view, 1-mm section thickness (contiguous slices), fast scan mode, beam hardening correction, 140 kV and 94 mA exposure. Surgery was performed through endonasal approach in 26 cases and external approach in fi ve patients. Th e confi rmation of the diagnosis and the type of tumor was histological in all the cases.

Results
A total of 31 patients were included in our study. No medical past history was reported, and, especially, neither rhinologic nor any neoplastic disease was previously diagnosed in all the patients. Epistaxis was the most frequent complaint symptom (51.6%)

Aim
To precise the clinical, paraclinical and therapeutic features of the benign tumors of nasal and paranasal cavities.

Methods
We report a retrospective study carried out in the ENT Department of the Military Hospital of Tunis, Tunisia over a period of 10 years (2003-2012).
followed by unilateral chronic nasal obstruction (41.9%). Nasal discharge was reported in only 19% of the cases. Extrarhinologic symptoms were noted in fi ve cases: proptosis in two cases, facial swelling in two cases, and headache in one case. Th e interval between the fi rst symptom and the diagnosis varied between 1 and 36 months (mean 10 months). Endoscopic examination of the nasal cavities revealed a mass in 87% of the cases. Moreover, the physical examination found a proptosis in two cases and a facial swelling in two cases. Neither cranial nerve palsy nor cervical node was noted in all the patients. Radiological examinations were conducted preoperatively in 18 patients: CT scan alone was conducted in 18 cases and CT scan with MRI in three cases. Surgery was indicated in all the patients using an endonasal approach in 84% and an external approach in 16% of the cases. Th e histological types of the tumors are shown in Table 1. Treatmentrelated complications varied according to the surgical approach. After endonasal surgery, three patients had a severe bleeding requiring blood transfusion. After external approach, one patient complained of an inesthetic lateronasal scar with paroxysmal facial pain. Th e postoperative complications and the long-term outcomes are resumed in Table 2.
A detailed description of the clinical and paraclinical features is presented according to the histological type of the tumor.

Epithelial tumors Inverted papilloma
Th ere were nine cases of inverted papilloma (IP) diagnosed in our study. Th e mean age was 48 years. Male to female ratio was 8 (eight male to one female). All cases presented with unilateral nasal obstruction. Of them, fi ve had nasal discharge, and two had proptosis. Endoscopic examination revealed a polypoid mass in the nasal cavities in all the cases. CT scan showed an enlargement of the middle meatus in all the cases and an extension to the frontal and ethmoid sinus in six cases. Bony lysis of the maxillary sinus walls was found in fi ve cases and bony condensations in two cases (Figs. 1-3). We have classifi ed our patients according to the Krouse staging system: seven patients were under stage T3, and two under T2. For the treatment, an endonasal endoscopic approach was carried out for eight patients. A tumor resection associated with a wide antrostomy was performed in all the cases, associated in two cases with ethmoidectomy. An external approach with lateral rhinotomy was achieved for one patient. During the follow-up, a recurrence of the tumor was diagnosed in three cases. For the fi rst case, the recurrence was noted 2 years postoperatively and treated surgically successfully. For the other two cases, we had observed multiple recurrences: at 5 months and 4 years for the second case; and at 3, 6, and 8 years for the third one. No case of degeneration was observed.

Vascular tumors
In our study, 14 cases of vascular tumors were diagnosed. Th e two main types observed were.

Cavernous hemangioma
It was found in two men aged 73 and 55 years, respectively, who presented with recurrent epistaxis. Th e tumor arose from the inferior turbinate in one case and from the superior turbinate in the second case. Its size was 1 and 2 cm, respectively. An endoscopic surgery   [3] Endonasal [4] Severe bleeding: 2 (22) 3 cases (33) -External [1] shetic lateronasal scar, paroxysmal facial pain Cavernous hemangioma [2] Endonasal Severe bleeding: 1 (50) --Capillary hemangioma [5] Endonasal ---Osteoma [6] External -1 case (33) -Ossifying broma [1] External Endonasal Persistent facial pain --sinus with an extension to the orbit in two cases and was confi ned to the ethmoid and the orbit in the last case (Fig. 4). External surgery approach was indicated for these cases. A lateral rhinotomy was performed in two cases and an external frontoethmoidectomy in the third case. Recurrence was observed in one case, 1 year postoperatively in the case treated initially by lateral rhinotomy. A revision surgery was performed through a bicoronal approach and the tumor was extirpated in toto.

Ossifying broma
It was diagnosed in a woman aged 47 years who presented with a facial swelling aff ecting the frontal region. CT scan showed a calcifi ed mass of the frontal sinus with an extension to the ethmoid (Fig. 5). Th e patient had an excision of the tumor through an external frontoethmoidectomy.

Mesenchymatous tumors Glioma
It was diagnosed in a 2-month-old baby who suff ered from dyspnea owing to a mass bulking the right nasal fossa. CT scan and MRI showed a 2 cm formation was performed in both cases with no recurrence during follow-up.

Capillary hemangioma
Th is tumor was diagnosed in 12 cases. Th e mean age was 34 years with no sex preponderance. Epistaxis was the main complaint. It involved the nasal septum in 11 cases and the vestibule in one case. All patients underwent endonasal surgery with a good outcome.

Bony tumors Osteoma
Th ere were three men with an average age of 22 years who presented with osteomas. Extrarhinologic symptoms led to the diagnosis. It was mainly a face swelling in two cases associated in the fi rst case with frontal headache and with a proptosis in the other case; the third case presented with an isolated proptosis. Th e CT scan performed in all the cases showed that the tumor involved the frontal and the ethmoidal Coronal and axial computed tomographic (CT) scan: inverted papilloma (IP) involving the maxillary sinus and the left nasal cavity.

Figurs 1
Coronal and axial computed tomographic (CT) view of an inverted papilloma (IP) involving the maxillary sinus and the right nasal cavity.

Figurs 3
Coronal and axial computed tomographic (CT) scan: large ossi ed mass arising from the left ethmoid sinus and extending into the orbit and the nasal cavity (ethmoid osteoma).

Figurs 4
at the level of the right inferior turbinate. Endonasal surgery was performed with an excellent outcome.

Myxoma
A 10-year-old child presented with unilateral nasal obstruction. Nasal endoscopy revealed a translucent mass in the left nasal cavity coming from the middle meatus. CT scan showed a mass involving the left maxillary sinus with an extension to the nasal cavity and the nasopharynx. Endoscopic excision was successfully performed with no recurrence noted during follow-up.

Leiomyoma
A 68-year-old man presented with chronic nasal obstruction. On endoscopic examination, we found a friable mass fulfi lling completely the right nasal cavity. CT scan showed an expansive mass coming from the sphenoethmoidal recess (Fig. 6). Th e patient underwent surgery by endoscopic approach. No recurrence of the disease was noted after 3 years of follow-up.

Schwannoma
It was diagnosed in a 54-year-old woman who presented with recurrent epistaxis and nasal obstruction. CT scan showed an expansive mass of the left maxillary sinus with an extension to the ethmoid (Fig. 7). Schwannoma was excised by the endonasal approach. After 4 years of follow-up, no recurrence has been noted, but the patient still experienced facial pain.

Epithelial tumors Sinonasal papillomas
Sinonasal papilloma is a benign tumor deriving from the mucosa of the nose and paranasal sinuses. Th ree types are individualized: IP, cylindrical cell, and exophytic papilloma [6]. Th is classifi cation is based on histological fi nding. In IP, the epithelium grows inwardly toward a stroma leading into the IP formations. Th e exophytic fungiform papilloma has exophytic papillary formations. However, the cylindrical cell sinonasal papilloma has an epithelium made of several layers of the eosinophilic columnar cells. Furthermore, the cylindrical cell and IP generally arise from the lateral nasal wall and extend into the maxillary and/or ethmoidal sinuses [7]. IP is the commonest type. It is frequently revealed by unilateral nasal obstruction, but we can also note bleeding, or sinusitis. On clinical examination, the IP presents like a mulberry uneven surface and reddish grey-livid color and may bleed when touched [7]. Etiology is still not yet elicited; many causes have been reported such as allergy, chronic sinusitis, viral infections, and infl ammation [7]. Human papillomavirus infection appears to be implicated as one of the possible causative factors in the pathogenesis of IP [8]. Th e CT appearance of IP is variable and nonspecifi c. Calcifi cation is usually seen, but not constant. Bone changes including erosion, remodeling, and widening are usually present and do not presume any malignant transformation. In fact, in more than 75% of patients, Axial and coronal computed tomography showing ossifying broma involving the ethmoid sinus.

Figurs 5
Coronal and axial computed tomographic (CT) scan showing a leiomyoma of the right ethmoid sinus with an extension into the nasal cavity.

Figurs 6
Axial and coronal computed tomographic (CT) scans: expansive mass of the left maxillary sinus and the nasal cavity with bony remodeling of the septum (nasal schwannoma).

Figurs 7
various degrees of bone destruction are reported [7]. On MRI, a striated cerebriform pattern on T2-weighted and contrast enhanced T1-weighted images is supportive but not specifi c [2]. In our study, variable degrees of bony lysis and/or condensation have been noted in CT-scan images. Many staging classifi cations were proposed, especially Krouse, which is based on IP location and extension [9]. In our study and according to this classifi cation, seven patients were classifi ed under T3. Treatment is based on surgery. It must be early and curative. Th e whole mucosal disease should be excised by the endonasal route when complete resection is possible, or by external surgery [10]. Th e extent of the disease essentially, the individual patient factors, and the surgical expertise determine the choice of the surgical approach. Endoscopic approach should be abandoned in some cases such as: massive skull base erosion, intradural or intraorbital extension, brain invasion, extensive involvement of the frontal sinus or infratemporal fossa involvement, or the concomitant presence of squamous cell carcinoma [3,4]. A combined external and endonasal approach can also be used to a better control of lesions. Recurrence is directly proportional to the removal. It mainly occurs at an average of 24-40 months after the operation.
No signifi cant diff erences were observed between the recurrence rates on diff erent approaches, but they were higher with conservative resections [7]. In our study, we have noted three cases of recurrence of IP. Th ey were multiple occurrences after several years of surgery in two patients. Th e main stress for the surgeon is the coexistence of carcinoma with IP. In fact, it arises in about 10% of patients with IP [11]. Th e prevalence of carcinoma is higher in cases of: bilateral IP, predominance of mature squamous epithelium, severe hyperkeratosis, a mitotic index equal to or greater than 2, and the absence of infl ammatory polyps among the papillomas [12].

Nonepithelial tumors Vascular tumors
Hemangioma is a benign neoplasm of vascular origin with endothelial proliferation. Histologically, they are divided into two types, capillary and cavernous depending on the dominant vessel size at microscopy [5]. Th ey can arise from the osseous, mucosal, or submucosal tissues of the nasal cavity or sinuses [13]. Capillary hemangiomas are more frequent and usually arise in the nasal cavity from the nasal septum or the vestibule less frequently on the anterior side of the inferior turbinate. Th ey occur predominantly in children and male youth. Hormonal imbalance and excessive infl ammatory response after local trauma have been evocated in their involvement [14]. Th e main symptom is recurrent epistaxis. Conservative local excision is the recommended treatment. However, electrocoagulation, cryotherapy, and laser have also been reported as successful therapies of these lesions [14].
Cavernous hemangiomas are more common in adults, especially men after their fi fth decade of life. Th ey always arise from the lateral wall of the nasal cavity or from the medial wall of the maxillary sinus [13]. Th ese tumors tend to arise from the bony tissue of the paranasal cavities [15]. On imaging, they appear like an expansive soft tissue mass with bone changes including thinning and deviation to bone destruction. A heterogeneous enhancement is often seen due to areas of bleeding and necrosis [13,14]. Th e main treatment of cavernous hemangiomas is surgical. Radiation therapy is reserved for inaccessible lesions [15].

Bony tumors Osteoma
It is a benign slow growing tumor usually aff ecting men in their third and fourth decades of life [16]. Th e frontal sinus is the commonest site (50%) followed by the ethmoid (40%) [2]. In our study, the ethmoid was the most frequent site aff ected. Th ese tumors are, often, completely asymptomatic. If symptomatic, they present with headache, cosmetic deformity, proptosis, epiphora, and visual complaints [17]. Two histologic types are reported: the hard cortical osteoma and the soft cancellous osteoma [18]. On CT fi ndings, osteomas present as dense bony masses protruding into or from the sinus [2]. Th e treatment is based on surgery. Surgery is indicated for symptomatic osteomas and those threatening the noble structures. Th e approach depends on the size and the localization of the tumor [19].

Ossifying broma
Ossifying fi broma is presumed to originate from the mesenchymal blast cells that exist in the periodontium surrounding the teeth [20,21]. It is often seen in women in their third and fourth decades of life. Mainly observed in the mandible and the maxilla, they are rarely found in the nasal cavities. On these localizations, ossifying fi broma tends to display more aggressive behavior and rapid growth [21]. Although they can be asymptomatic, these lesions often expand, causing signifi cant facial asymmetry, pain, and local destruction [20]. On CT, they present as well-defi ned unilocular radiolucencies with scattered radiopaque foci [19]. Total removal must be performed to avoid recurrence. Endoscopic resection of sinonasal ossifying fi broma (OF) is an excellent therapeutic option if it is possible to do.

Rare benign tumors
Leiomyoma, meningioma, fi broma, myxoma, and schwannoma are rare tumors occurring in the paranasal cavities. No specifi c fi ndings are reported. Th e diagnosis is immunohistologic. Surgical approach allows the diagnosis and the treatment of these lesions.

Conclusion
Th e treatment of benign tumors of the nasal and paranasal cavities is mainly surgical. Endoscopic approaches have become the procedures of choice. Total resection is the guarantee of no recurrence. Th e follow-up is mandatory in all the cases.