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Cavernous hemangioma of the middle turbinate: a case report.

Abstract

Most cavernous hemangiomas present at birth or soon after. Cavernous hemangiomas of the nasal cavity, which are rare, usually do not present until adulthood; their incidence peaks in the fourth decade of life. Most affected patients experience epistaxis or hemoptysis and an enlarging lesion in the nose. Histologically, cavernous hemangiomas appear as closely packed, dilated vascular channels lined with a layer of flattened endothelial cells. We describe the case of a 32-year-old man who was admitted to our clinic with the complaint of a nasal obstruction. On anterior rhinoscopy, he was found to have a hypervascularized and hypertrophied left middle turbinate and septal deviation. Computed tomography and magnetic resonance imaging of the paranasal sinuses demonstrated a well-defined cystic lesion that had arisen with in the bony left middle turbinate and caused deviation of the septum to the right. The lesion was excised via endoscopic surgery with general anesthesia. No complications occurred during the postoperative period. Histologic examination identified the tumor as a cavernous hemangioma. To the best of our knowledge, this is the first case reported in the English-language literature of a cavernous hemangioma appearing as a cystic mass in the middle turbinate.

Introduction

Hemangiomas are common lesions of the head and neck, but they are rare in the nasal cavity and paranasal sinuses. (1,2) When nasal hemangiomas have been seen, most patients have presented with epistaxis or hemoptysis, signs that might suggest malignancy. (1-3) Computed tomography (CT) and magnetic resonance imaging (MRI) are helpful in making the diagnosis. Surgical excision of the lesion with ligation or cautery of the feeding vessels is the treatment of choice. (1-5)

In this article, we describe a case of cavernous hemangioma that appeared as a cystic mass in the middle turbinate. To the best of our knowledge, this is the first such case to be reported in the English-language literature. A similar case in French is being published almost simultaneously with our report. (6)

Case report

A 32-year-old man was admitted to our clinic with nasal obstruction of 6 months' duration. His history was significant for a septoplasty 10 years earlier and epistaxis 1 year earlier that did not require nasal packing.

Anterior rhinoscopy revealed a septal deviation to the right and a hypertrophied left middle turbinate with hypervascularized overlying mucosa that obstructed the left nasal cavity. The results of coagulation studies were normal, and findings on the remainder of the head and neck examination were unremarkable. CT and MRI of the paranasal sinuses demonstrated the presence of a cystic mass that had originated in the left middle turbinate; the mass had obstructed the nasal passage and expanded the antral wall (figure). The differential diagnosis for this lesion included a mucocele of the left middle turbinate.

The lesion was excised via endoscopic surgery with general anesthesia. Nasal packing was removed after 48 hours. No complications occurred during the postoperative period.

Macroscopic examination of the lesion identified a hemorrhagic mass that measured 2 x 2 x 0.5 cm. Histologic examination revealed closely packed, dilated, and congested cavernous vascular channels lined with a layer of flattened endothelial cells. The mass was diagnosed as a cavernous hemangioma.

[FIGURE OMITTED]

Discussion

Hemangiomas are benign endothelial lesions that are usually seen in the skin, mucosa, and skeletal system. Although they frequently occur in the head and neck region, hemangiomas of the nasal cavity are rare. When they are seen in the nasal cavity, approximately 80% arise from the nasal septum in the Kiesselbach triangle and 15% arise from the lateral wall of the nasal cavity. (1,3)

Hemangiomas are classified histologically according to the predominant type of vascular channel as capillary, cavernous, or mixed:

* Capillary hemangiomas present early in life, and they tend to involute spontaneously. They usually affect the vertebrae. Histologically, capillary hemangiomas are made up of capillary-sized vessels that are lined with flattened epithelium separated by a collagen stroma. (1,3) Capillaryhemangiomas are more common than cavernous hemangiomas.

* Cavernous hemangiomas usually present in adults; they are seen in both sexes with equal frequency. Trauma may play a role in the development of these lesions, and they do not undergo spontaneous involution. Cavernous hemangiomas most commonly affect the calvaria. Histologically, these lesions are composed of dilated vascular channels lined with a layer of flattened endothelial cells. (1,3)

* Mixed hemangiomas demonstrate a proliferation of thin-walled blood vessels of several sizes lined with endothelium. (1-3)

As a nasal hemangioma grows, it obstructs the nasal cavity and eventually compresses the surrounding structures. Most patients present with a sessile or polypoid lesion that bleeds easily when traumatized. The mass is frequently red or purple. (1,3,4)

Radiographic examination is useful in defining the location and extension of a hemangiomatous lesion. Both CT and MRI can identify the typical features of hemangiomas, which differ according to their anatomic location. Soft-tissue cavernous hemangiomas are hyperintense on both T1- and T2-weighted MRIs, owing to their fatty content. However, in some cases the classic diagnostic appearance of a hemangioma of the nasal bone has been found to actually represent spiculation and "soap bubble osteoporosis."

A cystic appearance of a hemangioma may be attributable to chronic hemorrhagic degeneration. Slowly enlarging nasal masses must be considered in the differential diagnosis. Nasal dermoids cause dimpling of the overlying skin, and they have no characteristic radiologic features. Sebaceous cysts are located intradermally, and they do not involve the underlying bone. Fibrous dysplasias and ossifying fibromas demonstrate replacement of normal medullary bone with fibrous tissue; radiographically, they have a ground-glass appearance. Osteomas are radiodense b onylesions that are characterized by replacement of bone with fibrovascular fatty tissue. Aneurysmal cysts feature blood-filled cavernous spaces lined with fibroblasts and 0 steoclast-like giant cells; they are rarely seen in nasal bone. Osteosarcomas are important in the differential diagnosis; unlike hemangiomas, osteosarcomas exhibit a characteristic sunburst pattern radiographically, with disruption of the periosteum and the presence ofa sarcomatous stroma with osteoid formation histologically. (1,3)

Appropriate management of a nasal hemangioma involves wide resection of the lesion and the underlying mucosa and perichondrium with ligation or cautery of the feeding vessels. For extensive lesions, selective embolization preoperatively may be useful. In a case similar to ours, Bakhos et al performed arteriography with selective embolization of a cavernous hemangioma of the nasal cavity that was in close contact with the middle turbinate. (6) They completely removed the lesion via endonasal endoscopic surgery. No recurrences after surgical removal have been reported. Radiation therapy is reserved for arresting the progression of unresectable or inaccessible lesions. (1-6)

References

(1.) Iwata N, Hattori K, Nakagawa T, Tsujimura T. Hemangioma of the nasal cavity: A clinicopathologic study. Auris Nasus Larynx 2002; 29(4):335-9.

(2.) Webb CJ, Porter G, Spencer MG, Sissons GR. Cavernous haemangioma of the nasal bones: An alternative management option. J Laryngol Otol 2000;114(4):287-9.

(3.) Gourin CG, Millay DJ. Pathology forum: Quiz case 3. Diagnosis: Caverno us hemangioma of the nasal bones. Arch Otolaryngol Head Neck Surg 2000;126(7):902, 906-7.

(4.) Fahmy FE Back G, Smith CE, Hosni A. Osseous haemangioma of inferior turbinate. J Laryngol Otol 2001;115(5):417-18.

(5.) Adanali G, Ayhan M, Gorgu M, Erdogan B. Nasal bone destruction by a cavernous hemangioma in an elderly patient. Ann Plast Surg 2001;47(2):216-17.

(6.) Bakhos D, Lescanne E, Legeais M, et al. Cavernous hemangioma of the nasal cavity [in French]. Ann Otolaryngol Chir Cervicofac 2008 Feb. 14 [E pub ahead of print].

Fatma Caylakli, MD; Alper Can Cagici, MD; Cem Hurcan, MD; Nebil Bal, MD; Osman Kizilkilic, MD; Fikret Kiroglu, MD

From the Department of Otorhinolaryngology-Head and Neck Surgery (Dr. Caylakli, Dr. Cagici, and Dr. Kiroglu), the Department of Radiology (Dr. Htircan and Dr. Kizilkilic), and the Department of Pathology (Dr. Bal), Baskent University Faculty of Medicine, Ankara, Turkey.

Corresponding author: Fatma Caylakli, MD, Department of Otorhinolaryngology--Head and Neck Surgery, Baskent University Faculty of Medicine, Adana Teaching and Research Medical Center, Baraj Yolu 1. Durak 01110, Seyhan, Adana, Turkey. Phone: 90-322-458-6868; fax: 90-322-459-2622; e-mail: fcaylakli@yahoo.com
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Title Annotation:ORIGINAL ARTICLE
Author:Caylakli, Fatma; Cagici, Alper Can; Hurcan, Cem; Bal, Nebil; Kizilkilic, Osman; Kiroglu, Fikret
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:7TURK
Date:Jul 1, 2008
Words:1335
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