Case Report:
A 38-years old female presented to Outpatient department of
otolaryngology and head and neck surgery, Benazir Bhutto Hospital,
Rawalpindi with complaints of bilateral complete severe nasal
obstruction from 3 months and intermittent epistaxis from 3 days.
Patient also has history right sided nasal obstruction 13 years back
with epistaxis for which intranasal polypectomy was done and symptoms of
nasal obstruction and epistaxis were resolved. But now patient again
presented with symptoms of B/L nasal obstruction and epistaxis. At
presentation patient was vitally stable and laboratory analysis was also
normal with no significant abnormalities except low hemoglobin (8.1
g/dl) for which 3 pints of transfusion was done with improvement in
hemoglobin levels.
On external nasal examination a deformity (expanded vestibule was
observed) with increased inter-canthal and inter-pupillary distance but
Normal eye movement and reflexes, on anterior rhinoscopy B/L completely
obstructing nasal mass was observed that was bleeding with probing. On
palpation, the mass was painful and tender sinuses were present. Nasal
patency was absent bilaterally with anosmia bilaterally. On probing mass
originating from lateral aspect of nasal cavity was observed. No
neurological dysfunction was present at the time of presentation.
Posterior rhinoscopy was insignificant and there were no significant
findings in throat and ear examination. Cervical level II lymph nodes on
left side of the neck were palpable.
On X ray (water’s view) of nose and paranasal sinuses, homogeneous haze
in B/L maxillary and frontal sinuses and nasal cavity was observed
suggesting polypoidal mass formation as shown in figure 1. On
CECT aggressive looking polypoidal heterogeneously enhancing soft tissue
density mass measuring 9x6.3x5.6cm involving nasal cavity and all
paranasal sinuses causing their expansion, obliteration, and bony
erosions with intracranial extension was observed as shown infigure 2 . MRI scan was suggesting a highly neoplastic mass with
bony erosions with intracranial extension and involving right cavernous
sinus as well. Tumour was also encircling the internal carotid artery
covering 90% of its circumstance validating the unresectable mass with
intracranial extension. On incisional biopsy, microscopy showed low
grade spindle cell proliferation in fascicular herring bone pattern
suggesting sinonasal sarcoma as shown in figure 3. On
immunohistochemistry analysis, S-100 was positive.
After all baseline and specific investigation and work up a final
diagnosis of sinonasal sarcoma was made and it was labelled as
unresectable mass due to intracranial extension and vascular invasions
and patient was referred for radiotherapy for reduction in mass volume.