Rare Case of Nasal Tip Schwannoma - A Case Report

Abstract

Schwannoma is a benign neurogenic neoplasm which is arising from schwann cells of peripheral nerve sheath. It can occur in anywhere in the body. Schwannoma of sinonasal tract is extremely rare. Here we report a rare case of schwannoma of nasal tip. A 45 year old male presented with a swelling of tip of the nose, causing cosmetic deformity with no other associated symptoms. Surgical excision of the mass done by using external rhinoplasty approach. Histolopathology report of specimen showed a well circumscribed schwannoma with Antoni A and Antoni B areas.

Introduction

Schwannomas of the head and neck region are uncommon tumours, that arise from any peripheral, cranial or autonomic nerve. 25–45% of extracranial schwannomas occur in the head and neck region [1], approximately 4% schwannomas arise from sinonasal tract and schwannomas of nose and nose tip are particularly unusual [2]. In our knowledge only few cases of nasal tip schwannomas are reported till date. A sinonasal schwannoma can be found in different sites, including the nasal septum, paranasal sinuses, tip of the nose, turbinates and nasopharynx. I The presenting symptoms of the tumour are nonspecific, depending on the site of the mass [3]. Radiological examination can assist in its diagnosis. Treatment of these tumours are surgical excision and histologic examination of the specimen [4].

Case Report

A 45 year old male presented to our out patient department with complaints of swelling over the tip of nose since past two years, which was gradually increasing in size and causing cosmetic deformity to the nose. It was not associated with pain, epistaxis, nasal obstruction. He denied history of facial trauma also. On examination, a well defined spherical swelling was present at the tip of nose, approximately measuring 2 × 2 cm, firm in consistency and was non tender. Skin over the swelling was smooth and normal. Anterior rhinoscopy was within normal limits. CT scan of paranasal sinuses showed a well defined soft tissue swelling of size 2.5 cm x 2 cm at nasal tip which was free from bonycartilaginous frame of the nose. Fine needle aspiration of swelling was inconclusive and showed paucicellular smear. Clinically we suspected it to be a benign soft tissue tumour like dermoid cyst as preoperative diagnosis and decision for excision of lesion by using exo-rhinoplasty approach had taken.

Patient was taken under general anaesthasia. First Rethi’s incision was made on the columella and which is then connected to marginal incisions on the caudal borders of the alar cartilages on both sides. Skin with subcutaneous tissue elevated. A well encapsulated spherical mass of size 2.5 × 2 cm visualised, which was free from underlying cartilaginous framework of nose. Skin of the nasal tip was expanded by the effect of the mass. Mass removed in toto and sent for Histopathological examination. To attain a good cosmetic result, we reshaped the skin flap and placed small pieces of gel foams in the defect before closing the wound for tip correction .

Grossly tumour was spherical in shape and grey white in colour with smooth surface. Cut surface of tumour showed onion peel like appearance which ruled out our provisional diagnosis of dermoid cyst.

Histopathological report of specimen turned out to be a schwannoma with typical Antoni A and Antoni B areas .

Post operative follow up at 2 weeks, 3 months and 6 months showed good cosmetic outcome and no evidence of recurrence (Figs. 1 and 2).

Fig. 1.

Preoparative image of patient showing nasal tip swelling

Fig. 2.

Image of specimen showing cells arranged in layers (onion skin appearance)

Discussion

Schwannomas are benign, slow growing nerve sheath tumours. They can develop anywhere in the body and arise from the myelin sheaths of peripheral motor, sensory, sympathetic and cranial nerves [2].

Although head and neck schwannomas are common, Nasal tip schwannomas are rare entity. The exact neural origin of nasal tip schwannoma has not been determined; speculation includes terminal somatosensory branches of trigeminal nerve [5].

Incidence of schwannomas are equal in both men and women and they are more common in the age groups of thirty to sixty ⁶. Our patient is 45 year old male and fits in this age group.

Schwannomas usually cause no symptoms, however epistaxis, pain and rhinorrhagia can occur. Differential diagnosis of nasal tip schwannoma includes a bulbous nasal tip, dermoid cyst ,organized hematoma or hemangiomas, lipoma, tumours of cartilage (chordoma) or muscular tissue (leiomyoma, Leiomyosarcoma) and tumors arising from the nerves (von Recklinghausen disease) [4]. Our patient has no symptoms other than swelling at the tip of nose.

As per Khodaei et al., Computed tomography (CT ) is indicated in the initial investigation of schwannomas in order to define the tumour’s anatomical position and relationship to surrounding structures, in addition to size and presence of bony erosion [6]. Our patient’s CT scan showed soft tissue swelling measuring 2.5 × 2 cm at the tip of nose without the involvement of bonycartilaginous framework.

Magnetic Resonance Imaging ( MRI ) is usually useful for obtaining information about intracranial or skull base involvement in sinonasal schwannomas [7]. Since our patient presented with nasal tip swelling with no involvement of surrounding structure in CT, we did not do MRI for our patient.

Macroscopically, schwannoma is usually an encapsulated mass with a smooth surface. Microscopically Antoni A and Antoni B arrangements are diagnostic for schwannomas [3].

Surgical excision is the treatment for these types of tumors and surgical approach may vary depending on the site and size of the tumour [8]. As open rhinoplasty approach is the option of treatment for nasal tip tumors, we opted exo- rhinoplasty approach for tumour removal in our patient. Ferraz et al. removed nasal tip plexiform schwannoma by similar approach [9].

Conclusion

Schwannoma of the nasal tip is rare clinical entity. This case is a reminder to include schwannoma in the differential diagnosis of the nasal tip swellings.

Patients may present with gradually growing mass at the tip of nose, often complaints of pain and epistaxis. Treatment is surgical excision of tumour with Histopathological examination of the specimen .

Declarations

The authors did not receive support from any organizations for the submitted work. This work was granted permission approval from Ethics committee of the concerned Institute. Informed consent for publishing in Springer Nature was taken from the patient.

Conflict of interest

The authors declare that they have no conflicts of interest to disclose.