Haemorrhagic nasal polyp mimicking melanoma in an 83-year-old on rivaroxaban

Abstract

An 83-year-old woman presented with rapid onset unilateral nasal obstruction after sneezing. She had a history of hypertension and atrial fibrillation, and was on rivaroxaban. Examination revealed a dark red polypoidal lesion completely obstructing the left nostril. She underwent CT and MRI, and proceeded to urgent excision biopsy of the lesion. Intraoperative appearance was in keeping with a haemorrhagic polyp arising from the nasal septum. Histology revealed haematoma within a layer of nasal mucosa. There was no evidence of haemangioma underlying the polyp. Our literature search has identified this case as the first described haemorrhagic polyp of the nasal septum. It is likely that rivaroxaban contributed to the formation of this haemorrhagic polyp, and it is important to differentiate benign haemorrhagic lesions from malignant conditions such as melanoma. Similar cases may become more common in the future as the proportion of the population on anticoagulants increases.

Background

This is the first described case of a haemorrhagic polyp arising from the nasal septum. Nasal polyps are a common cause of nasal obstruction, but unilateral symptoms in the presence of recurrent epistaxis requires careful investigation to rule out a malignant lesion.

Haemorrhagic polyps of the vocal cords are well described. They are caused by bleeding from a small vessel which may form a ‘blood blister’ under the vocal cord epithelium. However clots in the nose are usually evacuated and bleeding occurs through the nasal mucosa rather than become trapped underneath it. On review of the literature there is only one other report of a haemorrhagic nasal polyp, which arose from the maxillary sinus.¹

Haemorrhagic lesions of the nose can mimic the appearance of malignant lesions such as melanoma, or vascular lesions such as angiofibroma. It is important to differentiate these lesions, as simple resection is usually adequate to manage these haemorrhagic lesions.

Case presentation

An 83-year-old woman was referred to a 2-week wait ENT (Ear, Nose and Throat) outpatient clinic with a history of complete left-sided nasal obstruction and recurrent epistaxis after a sneezing episode a few weeks prior. She had no history of previous sinonasal symptoms or red-flag symptoms of head and neck malignancy such as otalgia, dysphagia or odynophagia. Her medical history included hypertension, atrial fibrillation, type 2 diabetes mellitus and chronic kidney disease for which she was on lisinopril, rivaroxaban and Lantus. She was a non-smoker, rarely drank alcohol and lived independently at home with her husband.

On examination; a large, heavily pigmented polyp was seen filling the left nostril. Flexible nasendoscopy showed no further lesions of the right nasal cavity and a normal larynx. She had no skin lesions, no lymphadenopathy and otoscopy was unremarkable.

Investigations

She initially underwent CT and MRI of her sinuses. She was unable to tolerate CT sinus with contrast due to her chronic kidney disease. The non-contrast CT scan showed a soft tissue mass filling the left nasal cavity, with patent maxillary ostia and sinuses bilaterally, and no evidence of other sinonasal disease (figure 1).

Figure 1.

CT sinuses without contrast, coronal 0.5 mm slice, showing soft tissue mass filling left nasal cavity (red arrow). Maxillary sinus appears clear, with no mucosal inflammation (white arrow).

MRI showed a homogeneous soft tissue mass originating from the left nasal septum anterior to the superior turbinates. There was no obvious bony destruction, although there was slight expansion and thinning of the medial maxillary wall (figure 2).

Figure 2.

MRI sinuses, T2 coronal 3 mm slice, showing soft tissue lesion originating from left nasal septum anterior to the superior turbinate (red arrow).

Differential diagnosis

Although the initial pigmented appearance of the polyp was suspicious for melanoma, other soft tissue lesions such as inverted papilloma and nasal carcinoma could not be ruled out. Imaging showed no evidence of other sinonasal disease, and the maxillary sinuses were clear.

Rare haemorrhagic lesions of the sinonasal cavity include haemangioma and organising haematoma. Haemangiomas of the nasal mucosa are benign vascular lesions that commonly present with symptoms of nasal obstruction and epistaxis.² They most frequently originate from the inferior turbinate, but also can be found on the nasal septum. They can grow in size and lead to significant bleeding, and surgical resection is indicated to treat symptoms and to confirm diagnosis.³

Rarely, bleeding into the paranasal sinuses can trigger the formation of organising haematomas. These are blood clots that are replaced with proliferating fibrous tissue and develop a tough outer capsule. They typically originate in the maxillary cavity,⁴ and progressive expansion can lead to bone erosion. Protrusion of these haematomas into the nasal cavity gives rise to an atypical polypoidal appearance that can mimic that of malignant lesions.¹

Treatment

The patient proceeded to excision biopsy of the lesion. Intraoperatively the polyp appeared to be haemorrhagic in nature arising from a small base on the nasal septum. The polyp did not transilluminate, was firm to palpation and did not bleed on examination. The polyp was completely excised in one piece including its attachment to the septal mucosa. The underlying nasal septum appeared normal, with no vascular blush or evidence of haemangioma (figure 3).

Figure 3.

Intraoperative endoscopy images. (A) shows the appearance of the dark red polypoidal lesion in situ. (B) shows the appearance of the lesion after removal. The lesion was firm to palpation with minimal bleeding, and was pulled off nasal septum by a narrow attachment. (C) shows the nasal septal mucosa after removing the polyp, and (D) shows the appearance at the end of the operation. There was minimal bleeding, with no obvious underlying haemangioma or vascular abnormality.

Histological examination of the polyp showed haemorrhagic material covered by partly ulcerated respiratory and squamous mucosa. There was evidence of bleeding from hyperplastic endothelial spaces, with reactive fibrosis, exudates and chronic inflammation, but no atypical features or evidence of malignancy. The conclusion was a haemorrhagic polyp of the left nasal septum.

Outcome and follow-up

The patient was reviewed 3 weeks after her operation, and flexible nasendoscopy revealed well-healed nasal septal mucosa. She was prescribed saline nasal douches, and remained well and asymptomatic during telephone review 4 months after her operation. She awaits formal outpatient review and repeat endoscopic nasal examination.

Discussion

A literature review was performed of PubMed and Embase using the search terms: ((Sinonasal OR Sino nasal OR intranasal OR intra nasal)) AND ((Haemorrhagic polyp OR bleeding polyp OR (Haemorrhage AND nasal polyp) OR (Bleeding AND nasal polyp)). MeSH (Medical Subject Headings) terms and alternative spellings such as hemorrhagic and sinunasal were also used, and results filtered by case reports to give 171 results.

Titles and abstracts were reviewed and identified only one other case report of a haemorrhagic polyp.¹ There was also a case series reporting on haemorrhagic nasal polyps of the horse,⁴ three articles describing nasal organising haematomas and a small number of reports of intranasal haemangiomas.

Haemorrhagic polyp

Algudkar et al (2013) describes a unilateral sinonasal haemorrhagic polyp arising from the maxillary sinus in a 32 year-old boxer.¹ He presented with similar symptoms of nasal obstruction and epistaxis, with a haemorrhagic pigmented lesion filling the right nasal cavity. It is likely that this polyp was formed as the result of traumatic bleeding into the maxillary sinus associated with this patient’s boxing career. He underwent CT imaging and excision biopsy, and histology revealed inflamed nasal mucosa and organising blood clot without any evidence of malignancy. Histology in this case suggests that the lesion was not a haemorrhagic polyp, but rather an organising haematoma.

Organising haematoma

Literature review identified three other articles on organising haematomas, describing the clinical and radiological features of 32 patients in total.^5–7 These patients presented with unilateral epistaxis, sometimes associated with obstructive symptoms, and most had no history of trauma. CT and MRI imaging showed mixed density lesions typically originating in the maxillary sinus, and leading to smooth erosion of bone and expansion of the maxillary sinus. Histology confirmed organising haematoma with neovascularisation, fibrin deposits, foamy macrophages and fibrosis.

The haemorrhagic polyp in our case differs from organising haematomas as it was comprised primarily of blood clot encased in nasal mucosa with no evidence of organisation, fibrin deposition or expansion. There was also no evidence of haemangioma on the underlying nasal mucosa, and no active bleeding during the operation.

Haemangioma: pyogenic granuloma

There were also multiple articles describing pyogenic granulomas of the nasal cavity.^{2 3} These are rare benign vascular tumours that can occur in the nasal cavity, and are also known as lobular capillary haemangiomas based on their histological appearance.

They often present with recurrent epistaxis and nasal obstruction, but typically form fleshy, friable polyps that bleed easily on examination. Histologically they have a characteristic appearance of capillary sized vessels arranged in lobules around central feeding vessels, within an inflammatory fibromyxoid stroma.² These lesions differ both macroscopically and histologically from the haemorrhagic polyp described in our case report.

Guidelines for investigating nasal lesions

NICE (National Institute for Health and Care Excellence) guidelines state that recurrent epistaxis in the presence of unilateral nasal obstruction, facial pain, hearing loss or change to vision warrants referral to ENT for further investigation. High-risk populations include those aged over 50 years, exposure to wood dust and chemicals and south Asian ethnicity.⁸

UK National multidisciplinary guidelines for the management of nasal and paranasal sinus tumours recommend comprehensive imaging and biopsy prior to definitive surgery, and early discussion as part of a specialist multidisciplinary team.⁹

This patient underwent appropriate imaging with both CT and MRI prior to urgent excision biopsy on the cancer wait pathway. Had the lesion proven malignant, further surgery to ensure oncological resection margins and adjuvant treatment with chemotherapy or radiotherapy may have been offered. However in this case surgical excision was sufficient to remove the lesion, and there has been no recurrence on routine review.

Anticoagulation

Rivaroxaban is a direct clotting factor Xa inhibitor. It is the most commonly prescribed anticoagulant in the UK and over 200 new patients were started on rivaroxaban per 100 000 population per year in 2015. The total number of patients on anticoagulation increased by 58% between 2009 and 2015.¹⁰

In this patient, rivaroxaban likely contributed to the initial haemorrhage causing this nasal lesion. Anticoagulants are already recognised to be problematic in patients presenting to A&E (the Emergency Department) with epistaxis, but as the proportion of the population on anticoagulants continues to increase, haemorrhagic lesions of the nasopharynx may become more common.

Conclusions

This case was unusual due to the nature of the lesion. Haemorrhagic polyps of the vocal cords have been well described, but this is the first described haemorrhagic lesion of the nasal septum. Haemorrhagic lesions may be mistaken for malignant sinonasal tumours due to their appearance and typically unilateral presentation. Other rare haemorrhagic lesions include organising haematomas and haemangioma.

Patient’s perspective.

I had a sneezing fit after doing some gardening and my left nose became very blocked. I was glad I was able to see someone so quickly and the ENT consultant was most reassuring. I am really happy this lump was nothing to worry about. I have been on rivaroxaban for more than 10 years and have never had problems like this before.

Learning points.

• Unilateral nasal obstruction and epistaxis requires investigation to rule out malignancy.

• Imaging and biopsy is indicated to establish diagnosis and ensure correct management.

• Haemorrhagic polyps of the nose may occur subsequent to trauma, and should be differentiated from vascular and malignant lesions.

• Haemorrhagic polyps may become more common as more patients are prescribed anticoagulants.

• These lesions can be managed with simple surgical excision.