HISTOPATHOLOGY SECTION - ORIGINAL ARTICLE
Year : 2008 | Volume
: 51 | Issue : 1 | Page : 26--29
Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses
U Zafar1, N Khan1, N Afroz1, SA Hasan2,
1 Department of Pathology, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
2 Department of Otorhinolaryngology, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
4/1121, Sir Syed Nagar, Aligarh - 202 002, Uttar Pradesh
An analysis of cases presenting as mass in nasal cavity (NC), paranasal sinuses (PNS), and nasopharynx (NP) was done over a period of 7 years in Jawaharlal Nehru Medical College, Aligarh. A provisional diagnosis was made after clinical assessment and radiological investigations, but final diagnosis was made after histopathological examination. The incidence of masses in NC, PNS, and NP was 34.3 cases per year, non-neoplastic lesions constituted 60% of these cases and their incidence was 20.7 cases per year. All the cases were carefully examined histopathologically and it was found that the region was affected by a variety of non-neoplastic lesions. Among 240 cases, 145 were non-neoplastic and 95 were neoplastic The lesions in the decreasing order of frequency were - nasal polyp, rhinoscleroma, tuberculosis, fungal infection, fibrous dysplasia, ossifying fibroma, cysts, nasal glioma, and cemento-ossifying fibroma. NP was involved by a range of neoplastic lesions; however, no non-neoplastic lesion was seen in this region.
|How to cite this article:|
Zafar U, Khan N, Afroz N, Hasan S A. Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses.Indian J Pathol Microbiol 2008;51:26-29
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Zafar U, Khan N, Afroz N, Hasan S A. Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses. Indian J Pathol Microbiol [serial online] 2008 [cited 2022 Sep 29 ];51:26-29
Available from: https://www.ijpmonline.org/text.asp?2008/51/1/26/40386
A variety of non-neoplastic and neoplastic conditions involve the nasal cavity (NC), paranasal sinuses (PNS), and nasopharynx (NP), and these are very common lesions encountered in clinical practice. A large number of diseases affecting these structures are due, in major part, to many of the specialized tissues, each with its own aberrations that exist in the region.  The presenting features and symptomatology and advanced imaging technique help to reach a presumptive diagnosis but histopathological examination remains the mainstay of final definitive diagnosis. Thus, careful histological workup is essential for a correct diagnosis and timely intervention. The aim of this clinicopathological study was to find out the incidence of non-neoplastic and neoplastic polypoidal lesions of NC, PNS, and NP and to find out the great variety of non-neoplastic lesions in this region.
Materials and Methods
The study was conducted in the Departments of Pathology and Otolaryngology at Jawaharlal Nehru Medical College, Aligarh, over a period a period of 7 years both retrospectively and prospectively. The formalin-fixed specimens were received with complete clinical and radiological features. Routine gross examination and required number of sections were taken and stained with hematoxylin and eosin. Periodic acid schiff's and reticulin stains were used wherever necessary.
A total 240 cases presented as mass in NC, PNS, and NP over a period of 7 years. Histological examination revealed that the non-neoplastic lesions (144 cases) outnumbered the neoplastic cases (96 cases) in the ratio of 1.5:1.
Incidence: The incidence of lesions presenting as masses in NC, PNS, and NP was 20.7 cases per year. A general overview is presented in [Table 1].
Age: The age of presentation ranged from 1 st to 6 th decade of life. The mean age of presentation was 22.5 years. Thus, indicating that the majority of the patients were young adults .
Sex: The lesions of NC, PNS, and NP had a stronger predilection for males as compared to females with the male-to-female ratio being 1.7:1.
Site: NC was the predominant site of involvement with 108 cases (74.48%) and PNS with 37 cases (25.5%). No non-neoplastic lesion was found in NP. However, a variety of benign and malignant tumors involved this region.
Nasal polyp was the commonest lesion observed in this region. It constituted 82.06% (119 cases) of all non-neoplastic cases. The other non-neoplastic lesions in the decreasing order of frequency were - rhinoscleroma (seven cases, 4.83%), tuberculosis (six cases, 4.14%), fungal infections (five cases, 3.45%), fibrous dysplasia, ossifying fibroma and cysts with two cases (1.38%) each, one case (0.63%) each of nasal glioma and cemento-ossifying fibroma was seen.
Nasal polyp: It was the most common lesion involving this region. The age range was wide - the youngest patient was a 9-year-old and the oldest was a 58-year-old male, but peak was seen in 2 nd and 3 rd decade of life. These polyps were typically bilateral in 60% cases and presented as mass in single nostril in the rest.
The patients presented with symptoms of nasal stuffiness and obstruction and mass protruding from the nostril. Other symptoms were total and partial loss of smell, headache due to sinusitis, sneezing, and mucoid or watery discharge. On examination, the mass was glistening grape-like, insensitive to probing and did not bleed on touch. Microscopically, the polyps were composed of loose mucoid stroma and mucus glands, covered by respiratory epithelium. The epithelium in some cases showed areas of squamous metaplasia. The stroma was infiltrated by lymphocytes, plasma cells, neutrophils, and eosinophils. Sometimes necrosis was seen indicating infarction. The basement membrane underlying the surface mucosa was markedly thickened in most, but not in all inflammatory polyps
Rhinoscleroma: It was the second most common non-neoplastic lesion in this region. The peak age of presentation was 40 years with slight male predominance. The presenting features were obstruction of NC, foul-smelling nasal discharge, and crusting. Microscopically, the predominant cells were foamy histiocytes (Mikulicz cells) and plasma cells [Figure 1]. Vasculitis, ulceration, and pseudoepitheliomatous hyperplasia were also present.
Tuberculosis: The patients presented in 4 th and 5 th decade of life with 2:1 male-to-female ratio. The presenting features were loss of appetite, low-grade fever, weight loss, and cervical lymphadenopathy. Cough and rhinorrhea were present in two patients. Microscopically, the granulomas were well to poorly formed and non-necrotic. They were composed of Langhan's giant cells, epithelioid cells, and lymphocytes arranged in follicular pattern.
Fungal infections: The patients were in 3 rd and 4 th decade of life with male-to-female ratio of 1.5:1. They presented with foul-smelling nasal discharge, which on microscopy, showed inflammation ranging from negligible to large number of neutrophils and histiocytes within granulation tissue. The culture was positive on Sabouraud's dextrose agar medium, confirming the infection to be of fungal origin.
Cysts: Two patients presented with cystic swellings in maxilla, which on microscopy, showed features of dentigerous cyst (one case) and epidermal inclusion cyst (one case). Dentigerous cyst was found in a 20-year-old male, and on histopathological examination, showed a stratified squamous epithelium lining without keratinization. Focal thickening was seen at several places. The peripheral portion of dentigerous cyst wall consisted of mature collagenous tissue infiltrated by chronic inflammatory cells, increased vascularity, and areas of hemorrhage.
The other cystic swelling was found in a 3-year-old male, the microscopy of which showed cyst lined by keratinizing squamous epithelium devoid of cutaneous adnexal structures and filled by lamellated keratinous debris.
Lesions with fibrous and osseous components include fibrous dysplasia, ossifying fibroma, and cemento-ossifying fibroma. We found two cases each of fibrous dysplasia and ossifying fibroma and one case of cemento-ossifying fibroma. Fibrous dysplasia and ossifying fibroma showed no sex predilection and all the cases were in early 1 st decade of life and cemento-ossifying fibroma was seen in a 12-year-old female.
A case of nasal glioma in a 3-month-old female clinically presented as grey polypoidal mass, which was firm non-compressible and non-pulsatile. It was present in NC, resulting in nasal obstruction. Microscopically, the tumor was made up of astrocytic neuroglial cells interlaced with fibrous and vascular connective tissue that was covered with nasal mucosa [Figure 2].
The incidence of non-neoplastic masses of NC, PNS, and NP was 20.7 cases per year. This is consistent with the finding of Anjali et al .  who reported an incidence of 17.4 per year. However, the incidence reported by Tondon et al.  was 10 cases per year.
It is important to recognize the range of non-neoplastic lesions in this region and to differentiate them from neoplastic lesions because of different treatment modality and emotional burden on the patient. Among the polypoidal lesions, nasal polyp was the commonest. The incidence of nasal polyp was slightly higher in this study (82.06%) as compared to the observations by Tondon et al.  (64%) and Anjali et al.  (62.85%). The peak age of presentation, sex ratio, and clinical presentation were similar to that observed by these authors. Nasal polyps were bilateral in 60% of cases in our study, while according to Batsakis  bilateralism was the rule.
The incidence of rhinoscleroma in our study (4.83%) was lower than that observed by Tondon et al.  (9% of all inflammatory lesions). In their study, a younger peak age of presentation was noted (20-29 years) as compared to our observation where the peak age was 40 years; however, the sex ratio was almost the same (1:25).
We observed six cases of tuberculosis but according to Waldman  and Nayar et al. ,  sino-nasal tuberculosis is a rare entity. This difference might be due to higher prevalence of tuberculosis in many parts of the world. Acid fast bacilli stain and culture were positive.
We did not classify the fungus, the overall incidence based on growth on Sabouraud's dextrose agar was 3.45%. Tondon et al.  did not mention fungal infection as such, but the incidence of rhinosporidiosis was 24% in his study.
According to Tsai et al. ,  fibrous dysplasia in NC is rare. However, we found two cases (1.37%) involving maxilla. Microscopic features were similar to fibrous dysplasia at other sites and consistent with Ruggieri et al.  and Tsai et al.  showing narrow, curved misshaped discontinuous woven bone trabeculae having a characteristic fishhook configuration, interspersed with fibrous tissue of variable cellularity. The woven bone trabeculae were not surrounded by osteoblasts.
There were two cases of ossifying fibroma, which on microscopy, showed irregular lamellar bone with osteoblastic rimming. The trabeculae were continuous with one another. These features helped to distinguish it from fibrous dysplasia of bone. Both the patients were in 1 st decade of life with no sex predilection. The rarity of this lesion is documented by Lawton et al.  and Choi et al.  . Lawton et al.  studied four cases of ossifying fibroma, in which males predominated the picture and the mean age of presentation was 28 years. The histological characteristics matched with those of other authors. ,
According to Jayachandran and Meenakshi,  cemento-ossifying fibroma is a rare benign, non-odontogenic tumour-like lesion of jaw, a subdivision of fibro-osseous lesions. The age of occurrence is between 20 and 40 years with female-to-male predilection of 2:1. In our study, the lesion was seen in maxilla of a 12-year-old girl. The most striking feature if this lesion on microscopy was the presence of large, sharply defined, irregularly shaped, calcified spherules set in a densely fibrotic stroma.
Nasal glioma is an unfortunate term given to heterotopic central nervous system tissue. Nasal glioma (glial heterotopias) are variants of encephalocele and not true neoplasms. Nasal glioma is a rare lesion and was seen in a 3-month-old female in our study. According to Wischneiwski et al. ,  glioma most commonly presents in newborn infants and children. Rahbor et al.  studied nine cases of nasal glioma with the mean age of presentation as 9 months. The clinical and histological features in this case correlated with the study by Chang et al. 
|1||Mills SE, Fechner RE. The nose, paranasal sinuses, and nasopharynx. In : Sternberg SS, editor. Diagnostic Surgical Pathology. 3 rd ed. Lippincott Williams & Wilkins: Philadelphia; 1999. p. 885-92.|
|2||Dasgupta A, Ghosh RN, Mukherjee C. Nasal polyps - Histopathologic spectrum. Indian J Otolaryngol & Head Neck Surg 1997;49:32-6.|
|3||Tondon PL, Gulati J, Mehta N. Histological study of polypoidal lesions in the nasal cavity. Indian J Otolaryngol 1971;13:3-11.|
|4||Batsakis JG. The pathology of head and neck tumors: Nasal cavity and paranasal sinuses. Head Neck Surg 1980;2:410-9.|
|5||Waldman SR, Levine HL, Sebek BA. Nasal tuberculosis: A forgotten entity. Laryngoscope 1981;91:11-6.|
|6||Nayar RC, Al Kabi J, Ghorpade K. Primary nasal tuberculosis: A case report. Ear Nose Throat J 2004;83:188-91.|
|7||Tsai TL, Ho CY, Guo YC, et al . Fibrous dysplasia of the ethmoid sinus. J Chin Med Assoc 2003;66:192.|
|8||Ruggieri P, Sim FH, Bond JR, Unni KK. Malignancies in fibrous dysplasia. Cancer 1994;73:1411-24.|
|9||Lawton MT, Heiserman JE, Coons SW, et al . Juvenile active ossifying fibroma: Report of four cases. J Neurosurg 1997;86:279-85.|
|10||Choi YC, Jeon EJ, Park YS. Ossifying fibroma arising in the right ethmoid sinus and nasal cavity. Int J Pediatr Otorhinolaryngol 2000;54:159-69.|
|11||Jayachandran S, Meenakshi R. Cemento-ossifying fibroma. Indian J Dent Res 2004;15:35-9.|
|12||Wischneiwski E, Klaber HG, Oppermann J. Nasal glioma as a rare cause of obstructed nasal breathing in a newborn infant. Klim padiatr 2001;213:139-41.|
|13||Rahbor R, Resto UA, Robson CD, et al . Nasal glioma and encephalocele: Diagnosis and management. Laryngoscope 2003;113:2069-77.|
|14||Chang KC, Leu YS. Nasal glioma: A case report. Ear Nose Throat J 2001;80:410-1.|