Download Nasosinus organizing hematoma at Chiang Mai University Hospital

Original article
Nasosinus organizing
University Hospital
hematoma
at
Chiang
Mai
Kannika Roongrotwattanasiri,1 Pailin Kongmebhol,2 Saisawat Chaiyasate,1 Supranee Fooanant1 and Pongsak Mahanupab3
1. Department of Otolaryngology, Faculty of Medicine, Chiang Mai University, Thailand
2. Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
3. Department of Pathology, Faculty of Medicine, Chiang Mai University, Thailand
Corresponding authors: Kannika Roongrotwattanasiri E-mail: [email protected]
Summary Organizing hematoma is a rare pathological lesion which usually presents with symptoms and signs which
mimic those of tumors of the nose and paranasal sinuses, so the diagnosis is usually done by pathological
study after biopsy or surgical removal. Most patients usually need multiple biopsies before getting the final
pathological diagnosis. In our hospital, if the clinical presentations and initial tissue biopsy is negative for
malignancy, only CT scan is enough for investigation preoperatively. The CT characteristics, which consistent
with organizing hematoma are encapsulated slowly expansile mass with scattered areas of well-demarcated
patchy and nodular contrast enhancement within the mass, with no surrounding soft tissue infiltration. This
lesion can be treated by endoscopic approach or combination with minimal open approach, with good results
and no serious complications.
Keywords: organizing hematoma, paranasal sinuses, nasal mass, epistaxis
Introduction Organizing hematoma is a rare pathological lesion,
usually presents with symptoms and signs which mimic
those of sinonasal tumors.1,2 The diagnosis is usually
done by pathological study after biopsy or surgical
removal. There are some delays in the diagnosis and
treatment of patients with organizing hematoma, and
also increases the unnecessary costs for investigations.
Moreover, some patients may have undergone extensive
surgery despite the possibility of minimal invasive
surgery by either endoscopic or combination with a
minimal open approach.4 From international database
searching, we have revealed that most reports cases of
nasosinus organizing hematoma were from Japan and
South Korea3-6, but none in Thailand. The aim of this
study is to review the clinical presentations, CT scan
characteristics and pathology of nasosinus organizing
hematoma, to remind the physicians to be on the alert
and enable for early diagnosis and appropriate
management of this lesion.
Methods From January 2005 to June 2013, patients with the
diagnosed of sinonasal organizing hematoma, who were
admitted and undergone surgical treatment at Chiang
Mai University Hospital, were included. The study was
approved by the Research Ethics Committees of Faculty
of Medicine, Chiang Mai University. Retrospective
review of the medical records were performed. The
demographic data, clinical presentations, CT scan
characteristics, surgical methods and histopathological
study were retrieved.
Results There were 4 patients (3 males and 1 females)
admitted and had undergone surgical treatment during
the study period. The common presenting symptoms
were progressive nasal obstruction and intermittent
epistaxis. Three of the 4 cases had multiple biopsies
before definite surgery because of the aggressive CT
scan findings that mimic the malignant lesions. (Table 1)
Case 1
A 66- year- old man presented with a 1- year history
of right intermittent epistaxis. Three months before his
hospital visit, the symptom progressed and he also had
right nasal obstruction and epiphora. He had ischemic
heart disease, hypertension and dyslipidemia and
22 Nasosinus organizing hematoma
Figure 2. A large amount of fibrin deposits with
extravasation of red blood cells and angiogenesis.
(hematoxylin & eosin, x100)
Figure 1. CT scan showed a large heterogenous
enhancing mass (figure 1a), with multiple areas of
serpigenous tubular enhancement within this mass,
suggestion of high vascularity (figure 1b), occupying
right maxillary sinus causing destruction of medial wall
of sinus.
received acetylsalicylic acid as part of his medications.
On nasal examination, a pale pinkish, smooth surface
mass was found at right middle meatus. CT scan
revealed large heterogeneous enhancing mass (figure
1a), with multiple areas of serpigenous tubular
enhancement within this mass, suggesting of high
vascularity (figure 1b). Mass occupied in the right
maxillary sinus (3.8 x 4 x 4.1cm in diameter), causing
destruction of the medial wall of the sinus.
Carcinoma of right maxillary sinus was the first
provisional diagnosis, with the possibility of highly
vascular tumor. Biopsy of the nasal mass was performed
3 times for pathological diagnosis. No malignancy was
seen, with no definite pathological diagnosis. An
endoscopic excisional biopsy with frozen section was
carried out as it was well-defined and no invasion to
surrounding tissues. Double set up for open surgical
approach was planned if the frozen section reported as
malignancy. The frozen section did not show any
malignant cells, the surgery was complete by only
endocopic approach. Final permanent section reported
as organized hematoma with chronic inflammation of
mucosa (figure 2). Intraoperative blood loss was about
200 ml. and no operative complications. The patient was
doing well with no recurrence during the 8 years follow
up period.
Case 2
A 68 year-old man had mild right intermittent
epistaxis, facial pain and right nasal obstruction for 1
year. His symptoms were progressively worse during the
past 2 months. Nasal examination revealed a red
irregular surface mass, originated from right middle
meatus. CT scan, from another hospital which was done
about 1 year ago, showed an enhancing lesion of 5 cm
in the whole right maxillary sinus with bulging of the
medial wall into right nasal cavity. This led to a possible
diagnosis of carcinoma or tumor of the right maxillary
sinus. A pathological study of the tissue revealed nasal
polyps with infarction. Because of the aggressive CT
findings, which was unusual for the nasal polyps case,
tissue biopsy was repeated another 3 times with
immunohistochemistry staining. Pathological studies
revealed no malignant cells in all three biopsies. CT
scan was repeated to re-evaluate the lesion. The scan
showed an expansile patchy heterogenous enhancing
soft tissue mass about 3.7x3.3x4.1 cm in size, which
23 ASIAN RHINOLOGY JOURNAL 2015;2:22-8
A.
B.
C.
Figure 3. A large expansile patchy heterogeneous
enhancing soft tissue mass containing few stipple
calcifications in the right maxillary sinus, which
caused cortical thinning and scalloping of medial
wall of the right maxillary sinus and mild nasal
septal deviation to the left side. (A-axial view: 1
plain CT , 2 with IV contrast; B-coronal view)
contained a few stripple calcifications, in the right
maxillary sinus, extending into the right nasal cavity and
the medial wall of the right orbit. This was when an
organized hematoma of the right maxillary sinus was the
first consideration (figure 3).
The patient was undergone endoscopic surgery
combined with Caldwell-Luc approach, under local
anesthesia, with no immediate complications.
Pathological study showed marked chronic inflammation
with an organized thrombus (figure 4). He was doing
well at the 2 week post-operative appointment, but he
had lost follow up since then.
Case 3
A 31year- old woman complained of a left nasal
obstruction for 3 years. Her nasal obstruction was
progressively worse for the last one year, and she also
had swelling of left cheek for one month. Examination
revealed swelling of the left cheek and a pinkish mass
occluding the left nasal cavity with necrotic tissue on the
surface. There was mucopurulent discharge from the left
punctum. CT from the referred hospital revealed a large
soft tissue mass in the left nasal cavity with a nodular
enhancing part, which extended into the left maxillary
sinus and anterior nares. Bony destruction of the medial
and lateral wall of the left maxillary sinus was also found.
Carcinoma of the left nasal cavity was the first
provisional diagnosis. An incisional biopsy was carried
out twice at the outpatient department, no malignant
lesion was found in the pathological study. Four days
before admission, she developed fever and complained
of decrease in visual acuity with diplopia. Physical
examination found a pinkish mass totally occluding the
left nasal cavity with necrotic tissue on top (figure 5).
Figure 4. Fibrin deposits with hemorrhage and
angiogenesis. (hematoxylin & eosin, 100)
24 Nasosinus organizing hematoma
A.
Figure 5. Left nasal mass with necrotic tissue on top
Swelling of lower and upper eyelids were found, with
no chemosis or subconjunctival hemorrhage. The
extraocular movement was normal. CT scan was
repeated because of preseptal cellulitis, as a
complication of rhinosinusitis, was considered. After
intravenous antibiotic administration, a multiple biopsy
was carried out and showed necrotic tissue, acute
inflammation exudate, but still no malignancy was seen.
CT scan sinus was carried out again, due to the
worsening of symptoms and revealed a large
encapsulated expansile heterogeneous hyperdense soft
tissue mass; about 5.4x5.3x4.8 cm in anteroposterior,
transverse and vertical dimensions respectively, which
primarily involved the left maxillary sinus and enhanced
the preseptal thickening of the left orbit, adjacent left
medial canthus and soft tissue thickening with clouding
subcutaneous fat at left cheek (figure 6 a, b).
The radiologic diagnosis of organized hematoma in
the left maxillary sinus was considered, with cellulitis of
face and abscess formation in left nasolacrimal sac and
duct. An organized hematoma was suspected which
was raised in the preexisting polyps. Endoscopic
surgery combined with the Caldwell-Luc approach was
performed to remove the mass. Intraoperative blood loss
was about 200 ml, there was no immediate
postoperative complication. Pathological study revealed
organized thrombus in the stroma of the polyps,
consistent with previous intra-polyps hemorrhage (figure
7). She was referred for follow up at the primary care
hospital due to the unavailable to come to our hospital.
Case 4
A 37 year-old man had progressive left nasal
obstruction, recurrent minor epistaxis and facial pain for
1 year. Physical examination showed bulging of left
lateral side of his nose and an exophytic mass with
necrotic tissue on the left lateral nasal wall. Biopsy of the
B.
Figure 6. A large encapsulated expansile heterogeneous
hyperdense soft tissue mass primarily involving the left
maxillary sinus with medial bulging and pushing medial
maxillary sinus wall and nasal septum contralaterally,
causing occlusion of the left nasal cavity. Note scattered
areas of well-demarcated patchy and nodular contrast
enhancement within this mass. (A- axial view, B- coronal
view)
nasal mass was carried out and the pathological study
revealed a fibrinoid exudate with focal organizing
vessels at the periphery. There was no evidence of
neoplastic lesion or malignancy. CT scan, which was
done 5 months earlier, from the referral hospital,
revealed an enhancing mass occupying the left nasal
cavity, with destruction of the medial and posterior wall
of the left maxillary sinus. Differential diagnosis included
inverted papilloma, squamous cell carcinoma, other
nasal malignancy, and an unlikely possibility of juvenile
25 ASIAN RHINOLOGY JOURNAL 2015;2:22-8
A.
B.
Figure 7.
angiofibroma. Repeated CT scan was performed, which
revealed a large enhancing soft tissue mass involving
left nasal cavity, left ethmoid and maxillary sinus. At
least T2 cancer was suspected (figure 8 A, B). As the
imaging and clinical pictures were similar to the second
and the third case, we consulted a radiologist to confirm
the diagnosis of organizing hematoma. The tumor was
removed with a combined endoscopic and Caldwell-Luc
approach with no immediate postoperative
complications.
Pathological
study
showed
characteristics of organized hematoma and nasal
polyps with no evidence of malignancy (figure 9).
Discussion Figure 8. CT scan shows enhancing mass occupying left
nasal cavity, left maxillary sinus with destruction of the
medial and posterior wall of the sinus (A- axial view, Bcoronal view)
Nasosinus organizing hematoma was once a rare
lesion, reported mostly from Japan3,4 and South Korea.5,6
This study has presented 4 cases of nasosinus
organizing hematoma in Chiang Mai University hospital,
Thailand. This lesion may not be as rare as previously
described, it is just unrecognized. The symptoms and
signs are similar to those of the tumors of the nose and
paranasal sinuses, i.e. nasal obstruction, epistaxis,
facial pain and swelling. It also has the locally invasive
and expansile in nature. Biopsies of the lesion need to
be done several times before getting the final
pathological diagnosis because of the lack of specific
tissue diagnosis, and the patients may be treated with
aggressive surgery as in malignant lesions. CT scan
characteristics of nasosinus organized hematoma can
be differentiated from malignant tumor by its
encapsulated expansile nature with scattered areas of
well-demarcated patchy and nodular contrast
enhancement within the mass as Lee et al.5 found
patchy heterogenous enhancement in all of their 7 cases
who receive IV contrast material. In contrast, the
Figure 9. Pathological section reveals fresh hemorrhage,
fibrin exudation, extravasation of red blood cells and
neovascularization. (hematoxylin& eosin, 100)
The details of patients’ demographic data, clinical
presentation, number of biopsy, CT scan, Type of surgery
are shown in Table 1.
26 Nasosinus organizing hematoma
Table 1. Demographic data, clinical presentation, number of biopsy, CT scan, Type of surgery
27 ASIAN RHINOLOGY JOURNAL 2015;2:22-8
malignant tumor infiltrates surrounding tissues or
destroys adjacent bony structures and shows contrast
enhancement in the periphery or the whole mass.
Omura et al.3 described three radiological
characteristics of nasosinus organizing hematoma as
follow: 1). CT scan shows an expansive, clearly
demarcated, heterogeneously enhanced mass, which is
never infiltrative, 2). It is a compressive lesion, and
diminishes the bone structure, 3). MRI shows thickening
of the sinus mucosa and its surroundings, which is well
enhanced on T1-weighted images with contrast, and
has a high intensity on the T2-weight image, suggesting
inflammatory change due to the obstruction by the
lesion.
In this study, only CT scan was performed. From the
authors’opinion, in cases which clinical presentations
are slow progressive and the tissue biopsy is negative
for malignancy, CT scan alone is sufficient for diagnosis
and preoperative evaluation. Treatment of choice for
nasosinus organizing hematoma is surgical treatment,
either by endoscopic approach alone or in
combinationwith the Caldwell-Luc approach. Three out
of four had intraoperative blood loss of about 200 ml.
(case 2; no record data) with no immediate
postoperative complications. Symptoms improved after
surgery, but recurrence data is limited as unfortunately
most of the patients did not attend the follow up
appointments. Only 1 case had follow up for 8 years with
no recurrence of disease.
Conclusion Organizing hematoma may not be rare, but an
unrecognized benign condition which may mimic a
malignant tumor. If clinical presentation and radiologic
study show an encapsulated slowly expansile mass with
scattered areas of well-demarcated patchy and nodular
contrast enhancement within the mass with no
surrounding soft tissue infiltration, and if tissue biopsy is
negative for malignancy; organizing hematoma should
be considered. This condition can be managed with
endoscopic surgery alone or combined with the
Caldwell-Luc approach and have excellent treatment
results.
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