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Locally Aggresive Nasal Polyp Masquerading As A Malignant Mass – A Case

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Article · August 2015

DOI: 10.18535/jmscr/v3i8.17

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DOI: http://dx.doi.org/10.18535/jmscr/v3i8.17

Locally Aggressive Nasal Polyp Masquerading As A Malignant Mass –

A Case Report
Authors
Dr Divyashree , Dr Rajesh Kumar Saket2, Dr Pallovie Singh3, Dr Surabhi Mehrotra4,
1

Dr Arjun Raju P5
1
Associ.Prof. Deptt Of Radiodiagnosis GMC Haldwani
2,3,4,5
Resident Deptt Of Radiodiagnosis GMC Haldwani
Corresponding Author
Dr Rajesh Kumar Saket
P.G.Student, Deptt. Of Radiodiagnosis, Dr Shusheela Tiwari Hospital, Rampur Road Haldwani, Nainital
(UK) 263139, Mob No 09627098684
Email: rajeshsaketssmc@gmail.com
ABSTRACT
Angiomatous nasal polyp (ANP) is a rare entity of inflammatory sinonasal polyp, constituting 4 to 5% of all
nasal polyps1,2. Without knowledge of the typical clinical presentation and the complete study of imaging
findings, the entity tends to be clinically and radiologically confused with neoplastic processes and even
malignancy.5 Their diagnosis and management requires more detailed evaluation in respect to classical
antrochoanal polyps. In both antrochoanal polyps and angiomatous nasal polyps, bone destruction is seen
as a rare exceptional finding. We present an interesting case of angiomatous nasal polyp. CT finding also
supported the clinical impression of neoplastic mass but biopsy was negative for malignancy. The biopsy
confirmed the final impression of angiomatous nasal polyp.
Angiomatous antrochoanal polyps are rare variants that require special attention both at diagnosis and
during surgery. The signs of bone destruction and epistaxis suggest additional pathologies including
inverted papilloma, lobular capillary haemangioma and carcinoma as differential diagnoses.
Keywords: Antrochoanal polyp, Angiomatous nasal polyp, Bone destruction

INTRODUCTION polyp can grow rapidly and exhibit an aggressive

Nasal polyps are chronic edematous mucosa clinical behavior that can simulate malignancy
attached by a pedicle, arising from nose or preoperatively1. The clinical and radiological
paranasal sinus, having a characteristic appeara- characteristics of these lesions have considerable
nce and a common occurrence2.The most common potential for confusion with neoplastic processes,
subgroup of nasal polyps are antrochoanal polyps. including juvenile nasopharyngeal angiofibroma,
Angiomatous nasal polyps, on the other hand, are inverted papilloma, and hemangioma. We report a
a rare variant of antrochoanal nasal polyps3. case of angiomatous antrochoanal polyp which
Angiomatous nasal polyps (ANPs) are also known presented with nasal obstruction, swelling over
as angiectatic nasal polyps. Angiomatous nasal cheek and occasional nasal bleeding.
Dr Divyashree et al JMSCR Volume 03 Issue 08 August Page 7005
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CASE HISTORY CECT nose and PNS (Fig. 3- A and B) showed a
A 45-year-old male, presented in ENT OPD, with heterogeneously enhancing large expansile
chief complaints of nasal obstruction and swelling polypoidal soft tissue density mass filling the
over left cheek since 3 yrs, change in voice and whole of left maxillary antrum, extending into the
history of occasional bleeding from left side of left nasal cavity, eroding the walls of maxillary
nose for one year. antrum with opacification of left ethmoid air cells
On local examination (Fig 1), there was a visible and left frontal sinus. The lesion was noted to
swelling over the left cheek and widening of left show focal areas of contrast enhancement more at
nasal cavity. Tenderness could be appreciated the periphery of lesion.The lesion was causing
over the dorsum of nose and left maxillary marked deviation of the nasal septum to the right
antrum. side. On CT, the first possibility of a malignant
mass was kept and second dfferential of a
malignant change in a preexisting antro-choanal
polyp of maxillary sinus was maintained.
MRI of the PNS (Fig.4-A and B) showed a large
expansile polypoidal mass lesion in left maxillary
antrum causing erosion of its walls extending
medially into left middle and inferior meatus via
Fig. (1) its medial wall, into the ipsilateral posterior
On anterior rhinoscopy, there was discharge and a choana and nasopharynx and was seen indenting
reddish polypoidal mass was visible, which was the soft palate with consequent opacification of
insensitive to touch, did not bleed on touch, could left ethmoid and frontal air cells. The lesion was
be probed medially but not laterally. The septum causing deviation of the nasal septum to right side.
was pushed to the right side. On examination of Superolaterally the lesion was noted to erode the
the throat, there was bulging of soft palate on left infero-medial wall of the left orbit and was
side. extending into the extra-conal space. The changes
The routine investigations were normal. on MRI were seen to corroborate the CT findings
X-ray PNS (fig.2) showed opacification in the and the same imaging differentials as the previous
region of the left maxillary antrum, left ethmoidal CT scan was maintained.
air cells and left nasal cavity with erosion of A subsequent punch biopsy was performed which
lateral wall of left maxillary antrum. revealed an angiomatous nasal polyp with the
extent as specified above.

Fig-2: X-ray PNS showing opacification in the region of the

left maxillary antrum, bilateral ethmoidal air cells and left Fig-3(A) Fig-3(B)
nasal cavity with erosion of lateral wall of left maxillary CECT nose and PNS axial-A and coronal-B showing a
antrum. heterogeneously enhancing large expansile polypoidal soft
tissue mass filling the whole of left maxillary antrum,
Then patient was sent to the radiology department extending into left nasal cavity and eroding the walls of
maxillary antrum.
of STGH for CT scan nose & PNS.

Dr Divyashree et al JMSCR Volume 03 Issue 08 August Page 7006

JMSCR Vol.||03||Issue||08||Page 7005-7009||August 2015
confused with other benign vascular lesions, such
as nasopharyngeal angiofibromas.
The angiomatous nasal polyp though rare can pose
a difficult diagnostic problem. These are benign,
pseudoneoplastic lesions, managed on the same
lines as the choanal polyps. Due to the presence of
pseudosarcomatous changes, they need to be
differentiated from a soft tissue sarcoma (e.g. a
malignant fibrous histiocytoma).
On CT scan, the angiomatous nasal polyp usually
shows a heterogeneous density filling the nasal
Fig-4 (A) cavity and/or maxillary sinus and the mass shows
minimal enhancement at the edge of the lesions.
These findings on CT were correlated with the
mixture of the extensive areas of hemorrhage,
organized thrombi, necrosis, and inflammatory
cells in this part of the polyp. The inflammatory,
necrotic, and cystic tissues were responsible for
the low density of the mass on CT, and the high
density of the mass was due to hemorrhagic
centres. The central part of the polyp showed no
enhancement and only minimally peripheral
enhancement, as observed in our case. Although
all cases were filled with clusters of irregularly
(B) shaped, thin-walled blood vessels and extensive
T2W MR image, (A-axial, B-coronal) of the PNS showed a vascular proliferation and ectasia, the dilated
large expansile polypoidal mass lesion in left maxillary vessels in the center were slow due to thrombus
antrum causing erosion of its walls extending medially into formation and the substantial infarction
left middle and inferior meatus via its medial wall, into the
responsible for the lack of enhancement. Fibrous
ipsilateral posterior choana and nasopharynx.
collagenous tissues in the lesions occasionally
caused enhancement on CT; however, this event
DISCUSSION
usually occurred in the delayed phase of contrast-
Angiomatous nasal polyp is a rare entity of
enhanced CT. Therefore, if the scan period is
inflammatory sinonasal polyp, constituting 4 to
inappropriate, CT would not indicate such
5% of all nasal polyps1,2.
enhancement. Because the peripheral area of the
Most common clinical presentation of
mass showed inflammation and vascular
angiomatous nasal polyp is nasal obstruction.
proliferation, the blood supply was more abundant
Other symptoms are loss of smell sensation,
than at the center of the mass, leading to
epistaxis,11 exophthalmoses, proptosis and visual
enhancement in the peripheral area. Calcium salt
disturbances6.On anterior rhinoscopy, they appear
deposition was observed in organized thrombi and
as a smooth, bluish gray/reddish polypoidal mass
necrotic areas, leading to punctuate calcification
with shiny surface. Angiomatous nasal polyp may
on CT.
exceptionally cause extensive bone erosion and
On MR imaging, there is typical appearance of an
remodeling. This erosive feature when present
antrochoanal polyp, hypointense on T1-weighted
raises the suspicion of a malignant process as in
and hyperintense on T2weighted images. On
our case. Being vascular, they may also be
gadolinium-enhanced MR images, the sinus part
Dr Divyashree et al JMSCR Volume 03 Issue 08 August Page 7007
JMSCR Vol.||03||Issue||08||Page 7005-7009||August 2015
shows little or no peripheral enhancement; The degree of necrosis and calcification on CT of
however, the nasochoanal part, corresponding to angiomatous nasal polyps raised suspicion
the angiomatous polyp, shows a strong regarding fungal infection. The information
enhancement. An angiomatous polyp mimics a obtained from the CT scan and MRI, together with
hypervascular mass lesion on enhanced MR the clinical findings, may provide the best
studies.9 guidelines for clinical management. Chronic
The angiomatous nasal polyps can be confused inflammatory disease is often associated with
with juvenile nasopharyngeal angiofibromas.13 mucosal thickening and sclerosis of the bone,
The angiomatous nasal polyps are located particularly within the sinuses17.The presence of
primarily in the nasal fossa and not in the diffuse increased attenuation within the paranasal
nasopharynx, it does not extend into the sinuses and nasal cavity should be considered as
pterygopalatine fossa, the sphenoid sinus and chronic allergic hypersensitivity aspergillosis 17.
intracranially. On angiography, angiomatous nasal However, bony destruction associated with fungal
polyps have only a few demonstrable feeding infection is rare, and angiomatous nasal polyps are
vessels compared with the rich vascular supply of negative on fungal staining.
angiofibromas. On CT, angiomatous nasal polyps In a relatively uncommon presentation,
do not enhance as well as the angiofibromas do, angiomatous nasal polyps may cause extensive
vascular flow voids, as seen in angiofibroma are bone erosion and remodelling or epistaxis. The
usually not seen on MRI imaging, in case of presence of any of the latter features can raise the
polyps. clinical suspicion of a malignant process 2. In
Vascular tumors are the most common type of general, angiomatous nasal polyps have a long
nonepithelial tumor of the nasal cavity and disease history. In our patient as well as in the
nasopharynx 2, and the prominent vascular previous reports, angiomatous nasal polyps
component in angiomatous nasal polyps can pose showed heterogeneous density, filling the nasal
problems with regard to differential diagnosis. cavity and/or maxillary sinus. The mass showed
The angiomatous nasal polyps should be mainly minimal enhancement on the edge of the lesions.
differentiated from capillary or cavernous The edge of angiomatous nasal polyps on CT is
hemangiomas. They are usually found in the clear and does not invade the peripheral fat layer.
anterior nasal septum, the turbinates and the However, malignant tumors occur in the elderly
vestibule.6 Most nasal hemangiomas arise from and are associated with a relatively short disease
the nasal septum or vestibule and are of the history 17. The bony erosion of malignant tumors
capillary type. Only a few arise from the lateral is destructive and the edges are indistinct;
wall of the nose, and these are usually cavernous. moreover, the peripheral fat layer is invaded and
In the paranasal sinuses, hemangiomas are even disappears 18.
rarer 15. On a CT scan, sinonasal angiomas show
greater enhancement on contrast-CT than CONCLUSION
angiomatous nasal polyps. Angiomatous antrochoanal polyps are rare
As clinical symptoms are nonspecific, the variants that require special attention both at
diagnosis of an inverted papilloma can be difficult diagnosis and during surgery. Angiomatous nasal
to establish and is sometimes missed. Excluding polyp can grow rapidly and exhibit an aggressive
inverted papilloma as a diagnosis not possible clinical behavior that can simulate malignancy
based on clinical or radiological grounds alone 5. preoperatively1. The clinical and radiological
On CT, an inverted papilloma is homogeneous; it characteristics of these lesions have considerable
has a density like that of soft tissue and may potential for confusion with neoplastic
contain calcium. The mass shows heterogeneous processes.The clinical, radiological and
enhancement after injection of contrast material. pathological data are usually complementary to
Dr Divyashree et al JMSCR Volume 03 Issue 08 August Page 7008
JMSCR Vol.||03||Issue||08||Page 7005-7009||August 2015
each other and provide a definite diagnosis angiomatous nasal polyps. Eur Arch
together. Detailed surgical planning, including Otolaryngol 2005;262:225-30.
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intense perioperative bleeding. angiomatous polyps of sinonasal tract.
Ann Otol Rhinol Laryngol 92;101:623-25.
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