Aetiopathological Spectrum of Unilateral Nasal Mass: A Hospital-based Cross-sectional Study
Correspondence Address :
Dr. Ajay Kumar Neeli,
Senior Consultant, Department of Otorhinolaryngology, KIMS Hospital, Secunderabad-500003, Telangana, India.
E-mail: drajayneeli@gmail.com, doc_amarnath@yahoo.co.in
Introduction: The presence of unilateral symptoms or pathology should be regarded with extreme caution as sinonasal neoplasms in their early stages with subtle symptoms may mimic inflammatory pathology. It is always the otolaryngologist’s endeavour to diagnose a neoplastic pathology in the early stage to prevent further complications.
Aim: To study the aetiopathological profile, age, and sex distribution of unilateral nasal masses presented at a tertiary care centre, Telangana, India.
Materials and Methods: The present study was a hospital-based cross-sectional study consisting of 53 patients of all age groups, of both sexes, with unilateral nasal mass presenting to the Ear, Nose and Throat (ENT) Outpatient Department (OPD) at Krishna Institute of Medical Sciences, Secunderabad, Telangana, India from December 2020 to June 2021. A detailed history was recorded and the patient underwent a complete ENT check-up, and head-neck examination followed by Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and biopsy.
Results: The mean age of the study population was 44 years and there were 47 males and six females. Nose block was the most common presenting symptom in 43 (81.1%). Middle meatus was the common site seen in 12 patients (22.6%). Inflammatory lesions was the most common observed in 24 (45.3%), followed by fungal sinusitis in 6 (11.3%), granulomatous lesions in 2 (3.8%), benign lesions in 15 (28.3%), and malignant lesions in 6 (11.3%).
Conclusion: Unilateral nasal masses were found common in males than females, with a peak incidence in the 5th to 6th decades of life. Histopathologically inflammatory lesions are the most common followed by benign and then malignant lesions.Any unilateral nasal mass should be viewed with a high index of suspicion for malignant lesions and should be subjected to diagnostic nasal endoscopy, imaging, and histopathological examination after surgical excision of the mass.
Inflammatory lesions, Malignancy, Nasal obstruction
Patients with nasal masses may present with rhinorrhoea and nasal obstruction. Unilateral persistent nasal obstruction may indicate the presence of an inflammatory or neoplastic lesion (1),(2). It is always the otolaryngologist’s endeavour to diagnose a neoplastic pathology in the early stage to prevent further complications. Most of the time, sinonasal neoplasms are present in an advanced stage because they do not cause early symptoms (3),(4). Most of the sinonasal masses have similar presenting features and symptomatology including nasal obstruction, rhinorrhoea, blood-stained nasal discharge, epistaxis, oral symptoms, facial swelling, orbital and ear symptoms (5),(6),(7).
Sinonasal masses have been instituted principally in the second to fourth decades of life (8),(9), however, malignant tumours have been mostly reported after the fourth decade (10),(11). Nasal polyps were the most common lesions with benign sinonasal masses observed (12),(13). Simple nasal polyps are round, smooth, soft, translucent, yellow, or pale glistening structures attached to the nasal or sinus mucosa by a relatively narrow stalk or pedicle. These are non tender and displaced backward on probing. These features clinically distinguish them from the turbinates, which are sometimes assumed to be nasal polyps by the less experienced (14). Various studies confirmed the predominance of squamous cell carcinoma in adult sinonasal cancers (15),(16),(17).
Clinical diagnosis of these unilateral nasal masses condition is based on the symptoms and clinical examination of the nose but often uses diagnostic tests like nasal endoscopy, imaging studies, and allergy tests. Histopathological examination plays a significant role in the diagnosis to rule out different types of malignancies (18). The present study mainly focuses on the aetiopathological profile, age, and sex distribution of unilateral nasal masses presented to the tertiary care centre.
The hospital-based cross-sectional study was conducted at the ENT OPD at Krishna Institute of Medical Sciences, Secunderabad, Telangana, India, from December 2020 to June 2021. The study was conducted after obtaining approval from the Institutional Ethical Committee (IEC). (KIMS/IEC/2020/07-02).
Inclusion criteria: A total of 53 patients of all age groups and both sexes presented with unilateral nasal masses were included in this study.
Exclusion criteria: Patients with bilateral nasal mass, hypertrophied inferior turbinate and concha bullosa were excluded from the study.
Study Procedure
After obtaining consent from the patients, all patients were evaluated thoroughly after a detailed history and complete ENT, head and neck, and systemic examination. Patients underwent nasal endoscopic and radiological examination {Computed tomography-paranasal sinuses (CT-PNS)}, to make an aetiological diagnosis of unilateral nasal mass. Cases with orbital and intracranial complications were further evaluated with {Magnetic Resonance Imaging (MRI)} and other relevant investigations. All cases of unilateral nasal mass were subjected to biopsy and sent for histopathological examination.
Statistical Analysis
Data entry was done using MS Excel and was statistically analysed using Statistical Package for Social Sciences (SPSS Version 16.0) for MS Windows. Descriptive statistical analysis was carried out to explore the distribution of several categorical and quantitative variables. Categorical variables were summarised with n (%), while quantitative variables were summarised by mean±Standard Deviation (SD). All results were also presented in tabular form and were also shown graphically. The difference in the two groups was tested for statistical significance using parametric tests such as t-test, and categorical variables were tested by Chi-square test.
Out of these 53 patients who had unilateral nasal masses, the age range of patients was from 15-75 years with a mean age of 44 years. These masses were more commonly seen in males 47 (88.7%) than in females 6 (11.3), and the symptoms were also seen more on the right side, 35 (66%) than on the left side, 18 (34%). Nose block was the most common presenting symptom seen in 43 (81.1%) (Table/Fig 1).
Middle meatus was the most common site of the location of seen in 12 (22.6%) (Table/Fig 2).
The most common clinical findings on nasal endoscopy were observed to be polyp 46 (86.8%) (Table/Fig 3). Based on the histopathological analysis, the most common diagnosis was an inflammatory lesion in 24 (45.3%) (Table/Fig 4). Among inflammatory lesions, ethmoidal polyps were the most common histopathological diagnosis 14 (26.4%) (Table/Fig 5).
Final diagnosis vs clinical finding: All the inflammatory lesions presented as polyps. Even in malignant lesions, polyps were the most common. Mass was common in all benign lesions including the bleeding tumor like juvenile nasopharyngeal angiofibroma and other lesions like Wegener’s granulomatosis, inverted papilloma, and squamous cell carcinoma. Proliferative lesions were found in malignant lesions and locally aggressive benign tumours like ameloblastoma (Table/Fig 6),(Table/Fig 7),(Table/Fig 8),(Table/Fig 9),(Table/Fig 10),(Table/Fig 11).
Unilateral nasal masses can be broadly classified into non neoplastic and neoplastic lesions. Non neoplastic lesions could be inflammatory or granulomatous. Neoplastic lesions could be benign or malignant. Unilateral nasal masses always need special attention, as they have varied clinical symptoms and presentations. Early diagnosis with a high index of suspicion for malignancy helps prevent grave complications. The present study throws light on age and sex distribution, varied clinical presentations, aetiology, and pathology of unilateral nasal masses in all ranges of age groups.
In the present study, most of the unilateral nasal masses presented with nose block (81.1%). This was probably because any inflammation in the nasal mucosa, irrespective of its cause will lead to nasal obstruction. But, the severity of nasal obstruction may vary from person to person, what one person feels may be of less importance to another patient with the same level of obstruction (5). Other symptoms were epistaxis, headache, nasal discharge etc. These were consistent with the study by Nair S et al., stated nasal obstruction as the commonest symptom followed by rhinorrhoea, headache, epistaxis, facial pain, hyposmia, and less frequently orbital symptoms (19).
The middle meatus 12 (22.64%) was the most common site of origin of unilateral nasal mass on endoscopy. In the middle meatus common site was ethmoid. Other sites were choana, septum, turbinate, frontal recess, nasopharynx, and sphenoid. These findings were similar to the study by Sridhar Rao M et al., which reports the most common site of unilateral nasal mass being the middle meatus followed by the lateral wall, roof of the nasal cavity and the nasopharynx (20). The study by Bakari A et al., conducted illustrates ethmoidal sinus, maxillary sinus, and osteomeatal complex as the commonest site followed by frontal sinus, sphenopalatine foramen, septum, skull base, and middle turbinate (14).
On endoscopy, the most common findings were polyps followed by mass and proliferative lesions. These findings were also consistent with the study by Sridhar Rao M et al., where polypoidal lesions were seen in 70%, fleshy in 18.45%, and ulceroproliferative in 2.92% (Table/Fig 12) (14),(18),(19),(20),(21),(22),(23).
Limitation(s)
The sample size is relatively too small, to make population-based conclusions.
Incidence of unilateral nasal mass was more common in the 5th to 6th decades of life and seen more commonly in males than females. Histopathologically inflammatory lesions are the most common, followed by benign and malignant lesions. The clinical presentation of unilateral nasal lesions may be indistinguishable, therefore, thorough evaluation of patients with nasal endoscopy, relevant imaging, and histopathological examination are extremely important for accurate diagnosis and early intervention.
DOI: 10.7860/JCDR/2022/60743.17217
Date of Submission: Oct 12, 2022
Date of Peer Review: Nov 01, 2022
Date of Acceptance: Nov 26, 2022
Date of Publishing: Dec 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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