Abstract

Background and objectives: Computerized tomography (CT) scan with contrast can delineate soft tissue pathologies and is now the first choice in diagnosing sinonasal malignancy and inflammatory lesions. The present study compared the diagnostic nasal endoscopy (DNE) and CT scan to diagnose cases presented with sinonasal mass.

Materials and methods: This was a descriptive study conducted on patients with sinonasal masses attending at Government TD Medical College, Alappuzha, Kerala from 1/1/2014 to 30/6/2015. Each patient was examined by diagnostic nasal endoscopy and had undergone preoperative CT scan. Histopathological examination of the specimens was carried out and compared with the findings of DNE and CT scan.

Results: A total of 72 cases were enrolled in the study. Age group was from 13-85 years with a male to female ratio of 1.3:1. Nasal obstruction was the commonest symptom. Among the 72 cases, 59 belonged to the non-neoplastic group and 13 to the neoplastic group. Sinonasal polyps (65.3%) formed the majority of the non-neoplastic lesions. Vascular lesions (6.9%) were the commonest benign neoplastic mass and malignancy was seen in 6.9% of cases. Diagnosis by DNE and CT scan was same except in 3 cases. Histopathology and radiological scan result correlated well except in 3 cases.

Conclusion: Histopathology still remains the gold standard in the diagnosis of sinonasal masses. Clinical, CT scan and histopathology diagnoses were complementary with each other. However, CT scan is indispensible in studying the anatomical variants and providing the route map prior to and during endoscopic sinus surgeries.

IMC J Med Sci 2022; 16(1): 008. DOI: https://doi.org/10.55010/imcjms.16.006

*Correspondence: Santhi Thankappan Pillai, Department of Otorhinolaryngology, Government TD Medical College, Vandanam, Alappuzha, Kerala 688005, India. Email: [email protected]

Introduction

Sinonasal masses are often diagnosed as nasal polyp which is a pedunculated prolapsed mucosa that projects from the normal mucosal surface [1,2]. These originate from the epithelial mucosa, mucous gland, bony structures, minor salivary glands, neural tissue and lymphatics [3].

Diagnostic nasal endoscopy (DNE) is used to understand the gross nature of nasal masses, nasal discharge, structures on the lateral nasal wall and the various anatomic variations [4]. Computerized tomography (CT) scan with contrast can delineate soft tissue pathologies and is now the first choice in diagnosing sinonasal malignancy and inflammatory lesions [5,6]. Patients with significant pathology are planned for surgery.

CT scan with fine coronal sections at the level of osteomeatal complex is an excellent technique in assessing bony detail, extent of the disease, hyperdensities and anatomical variations of sinonasal diseases [7]. CT scan can also reveal mucosal thickening and secretions in the sinuses, but the mucosal thickening cannot be interpreted specifically for sinusitis [8]. So at least 4-6 weeks of aggressive medical therapy should be given prior to CT scan so that the extent of the disease can be delineated amidst irreversible mucosal or bony changes, as around 40% of the asymptomatic population has mucosal changes in the CT [9].

However, for patients being considered for endoscopic sinus surgery, the CT should be carefully interpreted before beginning surgery and should be available for review during the procedure. But, if CT findings are not interpreted in the light of the clinical findings, many people who have incidental changes may be labeled as having sinus disease and would undergo unnecessary surgery [10]. The combination of DNE with conventional CT scan has proven to be the ideal method for the examination of inflammatory disease of the paranasal sinuses. Also, histopathology of the surgical specimen is necessary as neoplasms of the sinuses and nasal cavity account for 0.2–0.8 % of all carcinomas [11].

Objective of this study was to compare the DNE features of the sinonasal masses with the findings of preoperative CT scans for an accurate diagnosis and proper management of the condition.

Materials and methods

Study population and design: This descriptive study was conducted on patients with sinonasal masses who attended the ENT (ear, nose and throat) outpatient department (OPD) at Government TD Medical College, Alappuzha, Kerala during 1^st January, 2014 to 30^th June 2015. Ethical clearance and approval of the protocol from the Institutional Review Committee (approval number No.B3/1573/2010/TDMCA/EC 9/2013) was obtained prior to initiation of the study.

With informed consent, patients were clinically evaluated. The study variables were age, sex, symptomatology, duration, laterality, findings of DNE, CT scan and histopathology. DNE was performed and the patients with sinonasal masses were sent for preoperative CT scan. Coronal and axial cuts of CT of nose and paranasal sinuses with contrast were done. Nature and extent of the lesion, involvement of the osteomeatal complex and paranasal sinuses, mucosal thickening, bone involvement and anatomical variants were studied radiologically. Patients were operated and histopathological examination of the specimens was carried out. All details were systematically recorded in predesigned data sheet.

Inclusion criteria: Both males and females patients above 12 years of age with clinically diagnosed sinonasal masses and willing to do CT scan of the nose and paranasal sinuses were included in the study.

Exclusion criteria: Cases excluded from the study were: (i) patients below 12 years of age to avoid radiation exposure during CT scan and above 85 years due to associated comorbidities where CT scan with contrast is contraindicated, (ii) patients with congenital nasal masses, (iii) patients with lesions arising from the nasopharynx and (iv) patients who have been previously operated for sinonasal masses.

Study procedure: DNE was performed using a 0 degree adult nasal endoscope under local anesthesia followed by CT scans with contrast of the nose and paranasal sinuses. A provisional diagnosis was made after correlating clinical assessment with radiological investigation findings. Endoscopic sinus surgery was performed and surgical specimens were sent for histopathology. Clinical and radiological findings were compared with the histopathological findings and the results were analyzed.

Data obtained was analyzed with SPSS 16.0. Percentages and proportions were used for qualitative variables and appropriate statistical tests were employed to determine significant difference of findings by the different methods.

Results

A total of 72 patients with sinonasal masses were enrolled in this study. The age distribution of the patients ranged from 13-85 years and majority (51.7%) belonged to 41-60 years age group (Table-1). Male to female ratio was 1.3:1. The commonest symptoms were nasal obstruction (81.9%), nasal discharge (61.1%) and headache (58.3%). Frequency of the symptoms is shown in Figure-1.

Table-1: Age distribution of the study population (n=72)

Figure-1: Symptoms of study population (n=72)

On clinical examination by DNE, 48 patients (66.7%) had bilateral and 24 (33.3%) had unilateral nasal masses (Table-2). Among the 48 patients with bilateral nasal masses, clinically 46 (95.8%) had non-neoplastic and 2 (4.2%) had neoplastic masses. Among the unilateral masses, 11 (45.8%) and 13 (54.2%) had neoplastic and non-neoplastic type lesions respectively. Among the 72 patients, 59 patients (81.9%) were clinically diagnosed as non-neoplastic while 13 patients (18.1%) were diagnosed as having neoplastic lesions. Among the 13 neoplastic cases, 8 were diagnosed clinically as benign and 5 as malignant lesions.

Table-2: Relation between laterality and type of sinonasal mass (n=72)

Comparative diagnosis by DNE and CT scan is shown in Table-3. Clinically sinonasal polyposis was the commonest diagnosis in 47 patients (65.3%), others being fungal sinusitis in 10 patients (13.9%), malignancy and vascular lesions in 5 patients each (6.9% each), inverted papilloma in 3 patients (4.2%) and frontoethmoid mucocele in 2 patients (2.8%). According to the CT scan, 49 patients (68.1%) had sinonasal polyps, 8 patients (11.1%) had malignancy, fungal disease in 7 patients (9.7%), vascular lesion in 4 patients (5.6%), mucocele and inverted papilloma in 2 patients (2.8%) each. No significant (p>0.05) difference in diagnosis of sinonasal masses was observed between DNE and CT scan.

Table-3: Diagnosis of sinonasal masses by diagnostic nasal endoscopy (DNE) and CT scan (n=72)

Detail histopathological diagnosis of sinonasal masses is shown in Table-4. Histopathology examination revealed that 31 (43.1%) cases of the polyps as inflammatory, while 16 (22.2 %) cases were allergic in nature making a total of 47 cases of sinonasal polyps. Other non-neoplastic lesions were aspergillosis (8 cases, 11.1%), mucormycosis (3 cases, 4.2%) and mucocele (2 cases, 2.8%). Among the benign neoplastic lesions, hemangiomatous lesions were the commonest (5 cases, 6.9) followed by inverted papilloma (3 cases, 4.2%). Histopathologically, squamous cell carcinoma and angiosarcoma were detected in 3 (4.2%) and 1 cases (1.4%) respectively. Histopathology report correlated well with clinical diagnosis by DNE and CT scan in 71 patients with the exception of one patient.

Table-4: Diagnosis of sinonasal masses by histopathology

Discussion

Sinonasal masses constitute a heterogeneous group of lesions with a broad spectrum of histopathological features [12]. Commonly presenting as nasal polyps, at times it is difficult to differentiate neoplastic lesions from non-neoplastic lesions and benign from malignant lesions clinically [13].Hence, this study was conducted to determine the correlation of the clinical and radiological diagnosis with the histopathology of the sinonasal masses.

In our study, the mean age of presentation was 42.75 years and the male to female ratio was 1.3:1. The most common presenting symptoms in patients with sinonasal masses were nasal obstruction, nasal discharge and headache while the presence of polyp was the predominant nasal endoscopic feature which were comparable to the findings by similar studies [1,14,15]. Eye symptoms were seen in 10 (13.9%) cases.Eye symptoms were more in non-neoplastic lesions (11.1%) which were similar to the study by Rawat et al. [14]. According to this study, 33.3% of sinonasal masses were unilateral and 66.7% were bilateral. Bone erosion was seen in 25% of the cases on CT. This was either due to malignancy or invasive fungal sinusitis and was similar to another study [16]. Though CT scan helps in diagnosis and tumour staging, it is not totally reliable in assessing the extent of the sinonasal mass lesions as retained/inspissated secretions and thickened mucosa within the paranasal sinuses can be misinterpreted as extension of the malignancy [15]. In such cases, investigation like MRI may be needed to differentiate true disease infiltration from obstruction of the draining ostia [17].

Majority (81.9%) of our cases with sinonasal masses had non-neoplastic lesions. Similar preponderance of non-neoplastic sinonasal masses were reported by others [1,14,15]. Lobular capillary hemangioma was the commonest benign lesion diagnosed in 6.9% of patients (5 cases) which was similar to the study by Lathi et al. [1] while inverted papilloma formed 4.2% of the benign neoplasms in our study but 36.8% in the study by Lathi et al. [1]. In the study by Bist et al. [15], 56.4% cases were non-neoplastic lesions, 19.8% were benign and 23.7% were of malignant nature. Angiofibroma formed 35% of the benign cases and carcinoma of the nasal cavity was present in 45.83% out of which squamous cell carcinoma was the commonest histopathological diagnosis in 33.3% cases.

Among the malignant lesions, malignancy of maxilla was the commonest lesion seen in 4.2% of patients in our study. Squamous cell carcinoma (SCC) was diagnosed in 3 out of the total 4 patients with neoplastic malignant lesions. The results were partly in accordance with the study by Bist et al. [15] where nasal polyps, angiofibroma, and SCC were the commonest non-neoplastic, benign, and malignant lesions respectively.

The variation noted between CT diagnosis and histopathology was 4.16% in the current study (3 patients). This was in accordance with a similar study of sinonasal masses, which showed variation in 3.63% of the cases [15] and 3.62% in another study by Somani et al. [17]. One of the limitations was that other radiological investigation like MRI was not done in this study of sinonasal pathologies.

In our study histopathology and clinical diagnosis did not correlate in only one case (1.38%). Diamantopoulos et al. reported different histopathological findings from the clinical diagnosis in 1.1% of patients who presented with sinonasal masses [18]. Two other studies also reported that only 0.3% of their patients had histopathological findings different from clinical diagnosis [16,19].

It appears that histopathology remains the gold standard for the accurate diagnosis and further management of cases with sinonasal mass. Though histopathology is considered as the gold standard in diagnosis of sinonasal lesions, CT scan as an imaging modality should be done following diagnostic nasal endoscopy to understand the nature and extent of the disease and planning surgical management. It is essential to correlate clinical, radiological and pathological findings in the management of sinonasal masses, as these modalities are complementary to each other.

Authors’ contributions

NS, ABMP and STP designed the study protocol. NS and ABMP collected the data; NS, ABMP and STP did the statistical analysis; NS, ABMP and STP prepared the manuscript. ABMP and STP supervised and coordinated the study and edited the manuscript.

Competing interests

None of the authors have any conflict of interest to declare.

Ethics approval and consent to participate and publish

Prior to commencement, the research protocol was approved by the Institutional Review (IRC) of Govt TD Medical college (No.B3/1573/2010/TDMCA/EC 9/2013). Informed written consent was taken from all participants to participate in the study and publish the study findings.

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