Hemangiomas of the nasal septum and paranasal sinuses are rare; only 62 cases of septal hemangiomas and 32 cases of maxillary sinus/maxilla hemangiomas have been reported in the English literature. Hemangiomas should be considered in the differential diagnosis of any nasal mass lesion because biopsy may result in profuse bleeding and even death. We report the clinical presentation, differential diagnosis, etiology, and histologic appearance of paranasal sinus hemangiomas occurring in four of our patients

Mickelson, Samuel A.

Sheppard, Lisa Marie

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 38 Number 1 Article 7 3-1990 Hemangiomas of the Nasal Septum and Paranasal Sinuses Lisa Marie Sheppard Samuel A. Mickelson Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Sheppard, Lisa Marie and Mickelson, Samuel A. (1990) "Hemangiomas of the Nasal Septum and Paranasal Sinuses," Henry Ford Hospital Medical Journal : Vol. 38 : No. 1 , 25-27. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol38/iss1/7 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Hemangiomas of the Nasal Septum and Paranasal Sinuses Lisa Marie Sheppard, MD,* and Samuel A. Mickelson, MD* Hemangiomas of the nasal septum and paranasal sinuses are rare; only 62 cases of septal hemangiomas and 32 cases of maxillary sinuslmaxilla hemangiomas have been reported in the English literature. Hemangiomas should be considered in the differential diagnosis of any nasal mass lesion because biopsy may result in profuse bleeding and even death. We report the clinical presentation, differential diagnosis, etiology, and histologic appearance of paranasal sinus hemangiomas occurring in four of our patients. (Henry Ford Hosp MedJ 1990;38;25-7) Hemangiomas are common lesions of the head and neck and are the most prevalent benign tumor in infants and children (1). However, hemangiomas of the nose and paranasal sinuses are rare. A review of the English literature reveals only 62 re-ported cases of nasal septal hemangiomas (2-8) and 32 cases of maxillary sinus and maxilla hemangiomas (7,9-13). Although hemangiomas are rare in these sites, they must be considered in the differential diagnosis of nasal mass lesions because biopsy may resutt in profuse bleeding and even death (13-15). We pre-sent four cases of nasal and sinus hemangiomas recentty encountered. Case Reports Case 1 A 15-year-old girl presented with a four-week history of a right-sided nasal mass and intermittent epistaxis. Examination revealed a pink, pedunculated 1.5 cm lesion attached to the righl nasal septum by a thin stalk. Excisional biopsy was performed under local anesthesia with intravenous sedation, and histologic examination revealed a hem-angioma. Two months later a recurrent lesion was excised with margins of normal tissue. No further recurrence has been demonstrated. Case 2 A 49-year-old man complained of intermittent epistaxis with partial right nasal obstruction for about one and a half years. A septoplasty had been performed four years previously. Examination revealed a 1 cm erythematous, hemorrhagic, pedunculated mass attached to the right anterior nasal septum. Excisional biopsy was performed in the clinic with local anesthesia. A cuff of normal mucosa was also excised and the base cauterized with silver nitrate. Histologic examination revealed a hemangioma. The lesion has not recurred. Case 3 A 76-year-old woman had experienced intermittent epistaxis and right nasal obstruction for a period of nine weeks. A 2 cm peduncu-lated, hemorrhagic mass on a wide base was found attached to the right anterior septum. Surgical excision was performed with removal of a cuff of normal septal mucosa and electrocautery ofthe base. A polypoid hemangioma was identified by histologic examination (Fig 1), and no recurrence was noted four months later Case 4 A 56-year-old man had undergone in 1980 an intranasal ethmoidec-tomy and Caldwell-Luc procedure with nasal antral windows for exci-sion of a hemangioma of the right middle turbinate. At that time the maxillary and ethmoid sinuses were both observed to be free of the tu-mor However, in 1988 he retumed for evaluation of repeated profuse right-sided epistaxis. A 2 cm lobulated erythematous lesion associated with the anterior aspect of the right middle turbinate was found extend-ing into the middle meatus but not into the nasopharynx. Computed to-mography (CT) disclosed a tumor nearly filling the right maxillary and ethmoid sinuses, abutting the lamina papyracea (Fig 2). The mass, which was surrounded by a bony wall, enhanced radiographically after injection of contrast medium. In light of the history of a nasal hemangioma and the recurrent profuse epistaxis, angiography was per-formed. The mass was shown to be less vascular than expected and small feeding vessels off the inlemal maxillary artery could be embo-lized angiographically. Surgical excision was performed subsequentiy through a Weber-Fergusson incision with completion of a right medial maxillectomy and extemal ethmoidectomy. The bony wall which sur-rounded the mass appeared to be the expanded bone of the lateral nasal wall. Histologic examination revealed a cavernous hemangioma. The patient did well postoperatively and there has been no recurrence in one and a half years. Discussion Patients with a septal hemangioma will usually present with unilateral epistaxis and nasal obstmction of several months du-ration. Septal hemangiomas most commonly occur as polypoid or sessile masses and usuafiy can be diagnosed by clinical exam-ination. They range in size from several millimeters to two cen-timeters in diameter (3), arise most commonly from the anterior nasal septum in Little's area, and are bluish red in appearance. Submitted for publication: October 13, 1989. Accepled for publication: April 6, 1990. •Formerly Department of Otolaryngology, Henry Ford Hospital. Currendy Departmenl of Radiology. Beth Israel Hospital. Newark, NJ. tDepartment of Otolaryngology, Henry Ford Hospital. Address cortespondence to Dr Mickelson, Departmenl of Otolaryngology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit. MI 48202. Henry Ford Hosp Med J—Vol 38, No I . 1990 Hemangiomas of the Nasal Septum—Sheppard & Mickelson 25 Fig 1—Case 3; Surgical specimen ofa septal hemangioma. Patients with maxillary sinus/maxilla hemangiomas may pre-sent with a facial mass, anesthesia or paresthesia, rhinitis, sinusifis, proptosis, diplopia, oroantrat fistula, loose teeth, gingival bleeding, pain, epistaxis, or a pulsafile lesion (9). Occurrence of gingival bleeding and epistaxis should suggest the possibility of a hemangioma or other vascular lesion. How-ever, these are not always the presenting symptoms and cases of profuse bleeding and inadvertent fatal biopsy have been reported (14,15). In case 4, frequent and profuse epistaxis with the history of previous hemangioma made us suspect a recurrent vascular tumor of the right maxillary sinus. Histopathotogically, benign vascular tumors of the nasal cav-ity inctude capillary hemangioma, angiofibroma, cavernous hemangioma, venous hemangioma, hemangioendothelioma, and angiomatous glomus tumor. Malignant vascular tumors of the paranasal sinuses, which are extremely rare, inctude hemangiopericytoma and hemangiosarcoma (7). The diagnosis of maxillary sinus hemangiomas is aided by ra-diologic studies of the paranasal sinuses. Tomograms and plain films are helpful, but CT and magnetic resonance imaging (MRI) of the sinuses are more useful in delineafing the lesions and surrounding bone involvement. On CT with contrast admin-istration, hemangiomas may become enhanced inhomoge-neously or may demonstrate early peripheral enhancement with a border of opacification gradually advancing centripetally. Be-cause thrombosed and fibrosed portions ofthe mass will not en-hance, CT cannot exclude hemangioma. Occasional presence of phleboliths may suggest the diagnosis of hemangioma. With MRI, hemangiomas characteristically produce intense T2-weighted images. Areas of tow signat intensity may be second-ary to fibrosis or phleboliths within the lesion. Serpiginous areas of low signal intensity may represent a feeding or draining ves-sel (16). If the lesion is found within bone, ''"Tc-labeled phos-phate bone scans can be used to demonstrate the vascular supply (17). Carotid and vertebral angiograms can be used to determine whether the vascular supply is primarily from the extemal or in-temal carotid arteries and will demonstrate the presence of col-lateral vessels. Preoperative embolization of these lesions re-duces intraoperative blood loss and permits better exposure for complete resecrion with fewer complications (18-21). Angiogra-Fig 2—Case 4; Transaxial CT scan of a cavernous heman-gioma . A contrast-enhancing .soft tissue mass encased in bone is seen in the right maxillary sinus. phy in case 4 showed a vascular tumor with no large feeding ves-sels and several of the smaller afferent vessels were embotized. The best method of treatment for septal hemangiomas is re-section of the tumor along with a cuff of uninvotved mucosa and perichondrium. Failure to include the perichondrium is associ-ated with a high rate of recurrence. We believe that the tumor recurred in case 1 for this reason. The high rate of recurrence may be explained by the vascular proliferation extending down to cartilage or bone white maintaining an intact mucosal cover-ing (5,6). Nasal hemangiomas behave clinically as true neo-plasms and must be treated as such because of their propensity for locat recurrence when excised inadequately. Our review of the English literature did not reveal a consensus in the treatment of maxillary hemangiomas. As is the case of septal hemangiomas, we believe the treatment of choice of max-illary/maxilla hemangiomas is complete excision after an-giography and embolization (11,18,21). In case 4, the patient had a probable recurrence after incomplete excision. The role ofthe Nd-Yag laser in the treatment of these lesions is not yet estab-lished, although its use is an effective method for coagulation and ablation of capillary and small cavemous hemangiomas of the skin and tongue (22). Hemangiomas have a characteristic histology. Capillary hemangiomas are usually polypoid, pedunculated, nodular masses with smooth surfaces and a lobulated pattern. Micro-scopically, they consist of masses of dilated, thin-walled vessels that are lined by a single layer of flattened or plump endothelial cells and are surrounded by relatively little stroma (Fig 3). Larger cavemous vessels are often found, and when ulceration is present polymorphonuclear leukocytic infiltration is noted. Confusion may exist between this tumor and angiofibromas when a capillary hemangioma undergoes fibrosis, the prevalent diagnosric feature of angiofibromas, tn addition, a capillary 26 Henry Ford Hosp Med J—Vol 38. No I , 1990 Hemangiomas of thc Nasal Septum—Sheppard & Mickelson '̂•' Fig 3—Case 2; Histologic appearance of a capillary he-mangioma displaying large numbers of small blood vessels pre-dominantly of capillary size (hematoxylin-eosin stain, 24X). hemangioma is difficult to distinguish from a granuloma pyogenicum when inflammatory infiltration is evident. Accord-ing to current concepts, the pathogenesis of the lesions differs but the histologic pattem may be extremely simitar (7,12,23). Hemangiomas of the cavemous type may be multiple or sin-gle, discrete or diffuse, red to blue, soft masses that are spongy on sectioning. Microscopically, they are composed of tangles of thin-walled, cavernous blood vessels and spaces separated by scanty connective tissue stroma (Fig 4). An entire small lesion may be composed of one or two cyst-like spaces lined with en-dothelial cells and fil led with erythrocytes. Cavernous hemangiomas, which rarely involute spontaneously, arise most commonly from the lateral watt of the nasal cavity. Many hemangiomas are actualty mixtures of capillary and cavemous types. Small and targe vascular spaces may be interspersed or may appear in different areas of the same lesion. The cellular type of hemangioma presents a pattem of solid sheets and cords of endothelial cells with occasional vascular spaces (12,23). In summary, hemangiomas must be considered in the differ-enfial diagnosis of unilateral nasal mass lesions. They usually present with unilateral nasal obstmction and epistaxis and have a characteristic dutt, blue-red color. Surgical excision, the treat-ment of choice for maxillary and sinus hemangiomas, must be individualized based on the extent of the lesion in order to obtain normal tissue margins and avoid recurrent disease. Septal hemangiomas should be excised with the underlying perichon-drium in order to minimize recurrence. References 1. Handley GH. Hemangiomas of the head and neck. Ear Nose Throat J 1987:66:486-90. 2. Ash JE, Old JW. Hemangiomas of nasal septum. Trans Am Acad Ophth 1950;54:350-6. 3. Osbom DA. Haemangiomas of the nose. J Laryngol Otol 1959;73:174-9. 4. Levey M. Hemangioma of the nasal septum. Int Surg 1976;61:344-7. 5. Wenig BL, Sciubba JJ, Cohen A, Abramsom AL, Nasal septal hemangioma. Otolaryngol Head Neck Surg 1985:93:436-41. Fig 4—Case 4; High power view of a maxillary cavernous hemangioma showing cyst-tike spaces lined with endothelial cells (hematoxylin-eosin stain, 15.5X). 6. Myer CM I I I . Gluckman GL. Hemangioma ofthe nasal septum. Ear Nose Throat J 1983;62:536-7. 7. Fu YS, Perzin KH. Non-epithelial tumors of the nasal cavity, paranasal si-nuses, and nasopharynx: A clinicopathologic study. I . General features and vas-cular tumors. Cancer 1974;33:1275-88. 8. Shallit JB. Smith GA, Francis D, Canalis RF. Nasal hemangiomas of preg-nancy Ear Nose Throat J 1977;56:377-9. 9. Freeman JL, Shemen LJ, Alberti PW, Holgate R, Pritzker KP, Noyek AM. Ossifying capillary hemangioma of the maxillary and ethmoid sinuses—a case reporf. J Otolaryngol 1981;10:481-92. 10. Ghosh LM, Samanta A, Nandy T, Das S. Hemangioma of the maxilla. J Laryngol Otol 1988;102:725-6. 11. Tsutsumiuchi K, Hasegawa M, Okuno H, Watanabe I , Okayasu I , Suzuki S. Haemangioma of the maxillary sinus: Some comments on preoperative diag-nosis. ORL J Otorhinolaryngol Relat Spec 1982;44:43-50. 12. Shklar G, Meyer I . Vascular tumors of the mouth and jaws. Oral Surg 1965;19:335-8, 13. Fordham SD. Hemangioma of the maxillary sinus. Ear Nose Throat J 1978;57:333-5. 14. Broderick RA, Round H. Cavemous angioma of maxilla, fatal haemor-rhage after teeth extraction, with notes of similar non-fatal case. Lancet 1933;2:13-5. 15. Hayden RE, Luna M, Goepferl H. Hemangiomas ofthe sphenoid sinus. Otolaryngol Head Neck Surg 1980;88:136-8. 16. Computed body tomography with MRI cortelation. Lee JKT, Sagel SS, Stanley RJ, eds. 2nd ed. New York: Raven Press, 1989:612-6. 17. Greyson ND, Noyek AM. Nuclear medicine in otolaryngological diag-nosis. Otolaryngol Clin North Am 1978;11:541-60. 18. Persky MS, Berenstein A, Cohen NL. Combined trealmenl of head and neck vascular masses with preoperative embolization. Laryngoscope 1984;94:20-7. 19. Overholt SL, Gado M, Sessions DG, Ogura JH. Angiography in the diag-nosis and management of extracranial vascular lesions of the head and neck. Laryngoscope 1978;88:1769-83. 20. Frame JW, Pulnam G, Wake MJC, Rolfe EB. Therapeutic arterial embo-lisalion of vascular lesions in lhe maxillofacial region. BrJ Oral Maxillofac Surg 1987;25:181-94. 21. Biller HF, Krespi YP, Som PM. Combined therapy for vascular lesions of the head and neck with inlra-arterial embolization and surgical excision. Otolaryngol Head Neck Surg 1982;90:37-47. 22. Dixon JA, Davis RK, Gilbertson JJ. Laser photocoagulation of vascular malformations of the tongue. Laryngoscope 1986;96:537-41. 23. Anderson's pathology Kissane JM, ed. 8lh ed. Sl. Louis: C. V. Mosby Company, 1985:721-2. Henry Ford Hosp Med J—Vol 38. No I , 1990 Hemangiomas of the Nasal Septum—Sheppard & Mickelson 27 

Hemangiomas of the Nasal Septum and Paranasal Sinuses

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