The Nasal Hemangioma

Abstract

Hemangioma is a disease of head and neck commonly, but its presence in the nasal cavity or sinus is rare. It is a form of benign tumour of vascular origin consisting of predominantly blood vessels. It can be categorized into capillary, cavernous and mixed type in accordance to its histopathology features. Retrospectively, we reviewed five cases of nasal hemangioma presenting at University Kebangsaan Malaysia Medical Center (UKMMC) between September 2007 and May 2015. Information on the patients age, gender, ethnicity, clinical symptoms, imaging findings (if available), treatment modalities were collected retrospectively for analysis. Five patients were analysed. Females were more affected than male with ratio of 4:1. All patients presented with unilateral lobular capillary hemangioma of the nasal cavity with 60 % (3/5) of the lesions on the right side and 40 % (2/5) on the left side. The common symptoms at presentation were epitaxis and nasal obstruction (5/5, 100 %), followed by rhinorrhea (3/5, 60 %) and facial pain (1/5, 20 %). All the patients underwent a surgical excision of the hemangioma. The five patients had no recurrence on subsequent follow ups. Computed tomography of paranasal sinuses can be performed to exclude bony erosions. Endoscopic sinus haemangioma excision provide good visualisation and better outcomes. In conclusion, nasal hemangioma should always be differential diagnosis for nasal lesions and surgical excision is still the preferred first line treatment.

Introduction

Although hemangioma is a common disease of head and neck, however it is rarely found in the nasal cavity or sinus. It is a form of benign tumour of vascular in origin, comprising of blood vessels and connective tissue. It can be categorized into capillary, cavernous and mixed type according to its histopathological features [1]. The main complaints at presentation are of unilateral nasal obstruction and epitaxis [2, 3].

A retrospective study by Chi et al. [1], where there were only 15 cases of nasal hemangioma being diagnosed from the data collected from January to December 2003 in Kaohsiung, Taiwan, indicating its rarity. Prior literature reviews on nasal hemangioma disease were mostly derived from case series of western population; but rarer among the Asians.

Patient presented with nasal hemangioma, are frequently being mistakenly diagnosed for bleeding polyposis or an angiofibromatous polyp [2, 3]. We present five cases of hemangioma occurring in the nasal region. The clinical features, radiological findings and treatment and outcomes were analyzed. The objective of this case series is to demonstrate the clinical presentation of nasal hemangioma, the role of nasal endoscopy as a diagnostic and treatment modality and to highlight the possibility of a nasal hemangioma as a significant differential diagnosis of a bleeding mass occupying the nasal cavity, albeit its rarity.

Methods

A retrospective chart review of patients who were diagnosed with nasal hemangioma over a period of 92 months between September 2007 and May 2015 at UKMMC, Kuala Lumpur, Malaysia was performed. UKMMC is a tertiary referral hospital for ear, nose and throat disorders in Malaysia. Patient who had undergone biopsy procedures with or without surgical excision were included. Information on the patient age, gender, ethnicity, clinical symptoms, imaging findings (if available) and treatment modalities were collected for analysis via appraisal of their admissions notes and electronically stored investigation results.

All the patients were subjected to complete history, Ear, Nose and Throat examination inclusive of an endoscopic examination of the nasal cavity by a senior ENT consultant and rhinologist whom was involved in the management of the cases.

Results

There were five patients in this study, including one male (20 %) and four females (80 %) with a male:female ratio of 1:4. The mean age was 35 years, ranging from 20 to 62. The ethnicity consists of four Chinese and one Burmese patient. Three patients had no underlying disease, whereas the remaining two had hypertension and diabetes mellitus. None of the patients reported a history of nasal trauma or previous epitaxis. Table 1 shows the demographic presentation and characteristic features of nasal hemangioma among the five patients.

Table 1.

Characteristic features of nasal haemangioma ranging from simple to complicated disease

Case no.	Age	Gender	Ethnicity	Symptoms duration	Lesion site	Symptoms
1	38	Female	Chinese	3 weeks	Left, IT	Nasal obstruction, rhinorrhea, intermittent profuse epitaxis
2	20	Female	Chinese	8 weeks	Right, IT	Nasal obstruction, rhinorrhea, Epitaxis
3	15	Female	Chinese	1 week	Left, AS	Nasal obstruction, Epitaxis
4	62	Female	Chinese	5 months	Right, MT	Epistaxis, nasal obstruction, facial pain
5	46	Male	Burmese	3 months	Right, MT	Epistaxis, nasal obstruction, rhinorrhea

AS anterior septum, IT inferior turbinate, MT middle turbinate

All patients presented with unilateral lobular capillary hemangioma of the nasal cavity with 60 % (3/5) of the lesions on the right side and 40 % (2/5) on the left side. The mean duration of presentation to the Ear Nose and Throat Clinic is 8.8 week with the mean duration follow up of 3.4 years with no evidence of recurrences. The common presented symptoms were epitaxis and nasal obstruction (5/5, 100 %), followed by rhinorrhea (3/5, 60 %) and facial pain (1/5, 20 %). Table 2 shows the treatment modality for the five patients with the imaging findings.

Table 2.

Minimally invasive investigating procedure and imaging findings with their corresponding surgical treatment

Case no.	Diagnostic procedures prior to definitive surgical treatment	CT findings	Definitive surgical procedure
1	None	Not performed	Wide excision of mass from upper anterior part of septum. Silastic sheath inserted
2	None	Right inferior turbinate polypoidal mass	Left uncinectomy with wide medial maxillary antrostomy. Ethmoidectomy done. Bleeding secured with surgical
3	None	Mass over the left anterior part of nasal cavity	Wide excision of the mass behind the valve septum involving the upper anterior part of septum and extending to upper part of the inferior turbinate
4	None	Not performed	Mass arising from right ostiomeatal complex displacing middle turbinate medially. Mega medial maxillary antrostomy performed
5	Punch biopsy	Enhancing soft tissue mass from right lateral nasal wall involving medial wall of maxillary sinus	Endoscopic middle meatal antrostomy under G.A.

CT computed tomography, G.A. general anaesthesia

Discussion

Nasal hemangioma was first described by Poncet and Dor in 1897 as human botryomucomycosis [1, 2]. More than half of the hemangioma affects the head and neck region; rarely the nasopharynx [1, 4]. Therefore it is safe to presume that hemangioma in the nasal region is a rare disease. Unlike infantile hemangiomas, adult hemangiomas have a tendency to progressively enlarge and do not spontaneously regress [5]. Thus given its nature, a suspected nasal hemangioma in an adult warrants the need for further investigation and treatment.

Because of its rarity, to the best of our knowledge, there were only a handful of reported cases in Malaysia prior. According to the literature review, adult nasal hemangioma showed a female predominance, and commonly seen in the third decade of life [6, 1]. In our series, although 80 % of the patients were females, a peak incidence was found in the third decade. The patients in this study were between 15 and 65 years of age with a mean age of 35 years. This variation could be a result of a small sample size.

Epistaxis and unilateral nasal obstruction were the most common presenting symptoms in this series, followed by other nasal symptoms such as rhinorrhoea. This is consistent with previous published studies [7]. However, extranasal symptoms such as facial pain and headache were less common.

In view of the similar clinical features of the epistaxis with unilateral nasal obstruction, the differential diagnosis should include inflammatomy lesions, i.e. Wegener granulomatosis, angiofibromas, other neoplasms such as; sinonasal papilloma, hemangiopericytoma, esthesioneuroblastoma and angiosarcomas [1].

Although nasal haemangiomas commonly affect the anterior septum as described in prior literature, nasal hemangioma has also been reported in other nasal sites such as middle turbinates, inferior turbinates, posterior part of the septum and vestibule [7, 8]. The commonest site shown in our case series is the nasal turbinates.

Radiological imaging such as Computed tomography (CT) of paranasal sinuses can be performed to exclude bony erosions or possible malignant transformations. In this review, three out of five patients underwent CT paranasal sinuses in which all the lesions presented as soft tissue mass with no evidence of bony erosions (Figs. 1, 2).

Fig. 1.

Left an endoscopic image of Patient 3 showing a left hemangiomatic lesion at the anterior septum (arrow). Right an endoscopic image of Patient 4 with a right expansile sinonasal friable mass at the right ostiomeatal complex displacing the middle turbinate medially and occupying a large proportion of the antrum

Fig. 2.

Left endoscopic finding of a soft tissue mass shown arising from the right lateral nasal wall of patient 5. Right excised haemangioma from the right lateral nasal wall measuring 3.5 × 3 cm

Surgical excision is the preferred treatment for nasal hemangioma in adults [5]. Various surgical methods can be employed for this lesion; including excisional surgery, laser ablation, cryotherapy and electrocoagulation [8]. Total excision of the lesion is best done via endoscopic guided sinus surgery techniques which have shown to have good outcomes [2]. Such a method provides better visualization of the mass and surrounding anatomy, enabling the surgeon to perform a complete excision of the lesion. Nasal haemangioma recurrence is uncommon and no malignant transformation has been reported [8].

Histopathological examination often shows haemorrhargic fibrocollagenous tissue lined by squamous epithelial lining (Fig. 3). There is a collection of thinned wall vascular channels in which some are dilated lined by flat and bland epithelium, reported in other studies [1, 8].

Fig. 3.

Left Coronal view of the CT Paranasal Sinus of patient 5 showing an enhancing soft tissue mass arising from right lateral nasal wall with associated fluid in the right maxillary sinus. Right Histology slide of nasal hemangioma showing proliferation of small capillary channels in a loose fibromyxoid stroma infiltrated by chronic inflammatory cells (H&E ×400)

All the patients were successfully treated with adequate endoscopic surgical excision from the site of origin and no complications. No recurrence of disease was seen in all the outpatient follow ups with a mean duration of follow-up of 3.4 years.

Although, nasal hemangioma is uncommon in adult, it should be considered as a differential diagnosis of enlarging vascular lesion within nasal cavity. Surgical excision is a key for confirmation via histological examination, should be and remains the mode of choice of treatment for nasal haemangiomas.