www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Sinonasal
organising
haematoma
---
a
little
known
entity
夽
Lalee
Varghese
a,∗,
Sramana
Mukhopadhyay
b,
Raghav
Mehan
a,
Regi
Kurien
a,
Meera
Thomas
b,
Rupa
Vedantam
aaChristianMedicalCollege,DepartmentofOtorhinolaryngology,Vellore,India bChristianMedicalCollege,DepartmentofPathology,Vellore,India
Received20February2018;accepted29May2018 Availableonline17July2018
KEYWORDS Haematoma; Paranasalsinuses; Unilateral; Neoplasms; Benign; Epistaxis; Surgery Abstract
Introduction:Sinonasalorganisinghaematomaisarecentlydescribed,rare,benign inflamma-torycondition,whichcloselyresemblesmalignancyinitsclinicalpresentation.
Objective:Todescribetheclinicalfeaturesoforganisinghaematomaandtoreviewthe evolu-tionofsurgicaloptionssuccessfullyused.
Methods:Aretrospectivereviewofchartsofallpatientswithahistopathologicaldiagnosisof sinonasalorganisinghaematomawasperformed.
Results:Six(60%)ofthe10patientswere malewithameanageof47.4years.Allpatients hadunilateraldiseasewithrecurrentepistaxisasthepresentingsymptom.Maxillarysinuswas themostcommonly involvedsinus. Therewas no historyoftraumainany ofthepatients. Hypertension(80%)wasthemostcommonlyassociatedcomorbidity.Contrast-enhancedCTscan oftheparanasalsinusesshowedheterogeneoussinusopacificationwith/withoutboneerosion. Histopathologicalexaminationwasdiagnostic.Completeendoscopicexcisionwasdoneinall patientsresultinginresolutionofthedisease.
Conclusion:Awarenessofthisrelativelynewclinicalentityanditsevaluationandtreatment isimportantfor otolaryngologists,maxillofacialsurgeonsandpathologists alike.Despitethe clinicalpictureofmalignancy,histopathological featuresofbenigndiseasecansafelydispel suchadiagnosis.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:VargheseL,MukhopadhyayS,MehanR,KurienR,ThomasM,VedantamR.Sinonasalorganisinghaematoma ---alittleknownentity.BrazJOtorhinolaryngol.2019;85:698---704.
∗Correspondingauthor.
E-mail:laleevarghese@yahoo.co.in(L.Varghese).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2018.05.013
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Hematoma; Seiosparanasais; Unilateral; Neoplasias; Benigno; Epistaxe; Cirurgia
Hematomanasossinusalemorganizac¸ão---umaentidadepoucoconhecida
Resumo
Introduc¸ão: Hematomanasossinusalemorganizac¸ãoéumacondic¸ãoinflamatóriabenignarara, recentementedescrita,queseassemelhaalesõesmalignasemsuaapresentac¸ãoclínica.
Objetivo: Descrever as características clínicas do hematoma em organizac¸ão e analisar a evoluc¸ãodasopc¸õescirúrgicasusadascomsucesso.
Método: Foifeitaarevisãoretrospectivadosprontuáriosdetodosospacientescomdiagnóstico histopatológicodehematomanasossinusalemorganizac¸ão.
Resultados: Seis(60%) dos10 pacienteseram dosexo masculino,commédia de47,4anos. Todosospacientesapresentavamdoenc¸aunilateralcomepistaxerecorrentecomosintomade apresentac¸ão.Oseiomaxilareraomaiscomumenteafetado.Nãohaviahistóricodetrauma emqualquerdospacientes.Hipertensão(80%)foiacomorbidademaiscomumenteassociada. A tomografiacomputadorizadadosseiosparanasaiscomcontrastemostrouopacificac¸ão het-erogêneadoseiocom/semerosãoóssea.Oexamehistopatológicofoidiagnóstico.A excisão endoscópicacompletafoifeitaemtodosospacientes,resultounaresoluc¸ãodadoenc¸a.
Conclusão:A conscientizac¸ão a respeito dessa entidade clínica relativamente nova e sua avaliac¸ão e tratamento são importantes para os otorrinolaringologistas, cirurgiões buco-maxilo-faciais e patologistas. Apesar do quadro clínico de malignidade, as características histopatológicasdadoenc¸abenignapodemdescartarcomseguranc¸aessediagnóstico. © 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Sinonasalorganisinghaematoma(OH)isanuncommon,
non-neoplastic condition, which is locally aggressive. It was
first reported in Japanese literature in 1917 by Tadokoro
as a ‘‘blood boil of the maxillary sinus’’.1 It has also
been referred toashaematoma,2 haematoma-likemass,1
pseudotumour3 or organisinghaematoma of the maxillary
sinus.4 The maxillarysinus is knownto bethe most
com-monlyinvolvedsinus.5,6Theaetiopathogenesisofthisentity
isstillambiguous.
The disease is mostly unilateral and usually presents
withnasalobstruction andepistaxis.4,5 Contrast-enhanced
CTscanoftheparanasalsinusesmayrevealbony
destruc-tion, erosions and heterogeneous soft tissue densities in
theinvolvedsinuses.Thecloseresemblance ofthese
radi-ologicalfindingstoamaxillarysinus malignancycreates a
diagnosticdilemma.Multiplebiopsiesareoftenperformed
becausetheyoftenresultina‘‘negativebiopsy’’.Complete
surgicalexcisioneitherbyanendoscopicoracombined
sub-labialandendoscopicapproachisthedefinitivetreatment
for OH.Totalexcision alsoenablesthe pathologistto
sys-tematicallyexcludeotherpathologicaldiagnoseswhichmay
presentinasimilarmanner.
AwarenessregardingOHisstillverylow,bothamongthe
cliniciansaswellasthepathologists.Inthepresentreport,
we aimed to study the clinical profile, management and
treatmentoutcomesofallpatientsdiagnosedwithsinonasal
OHseenoverthelast6years.
Methods
Weconductedaretrospectivechartreviewofpatientswho
werediagnosedwithOHbetween2010and2016atatertiary
care hospital in South India. Data regarding demography,
clinicalfeatures, radiology,histopathology,treatment and
follow up was collected and analysed. The study was
approvedbytheInstitutionalReviewBoard.
Results
Demography
Atotalof 10patients werediagnosed withOH duringthe
study period. Most(60%) patients were males. The mean
age at presentation was 47.4±12.3 years (range 28---63
years).Allpatientshadunilateraldisease.Therewasnoside
predilection,pathology beingpresent on theright side in
fivepatients andontheleftsideinanotherfivepatients.
Thedurationofsymptomsrangedfrom2monthsto12years
(mean=28.4months)(Table1).
Clinicalfeatures
Most(80%)patientshadipsilateralnasalobstruction.There
wasahistoryofrecurrentepistaxisinallpatients,withonly
onepatient having blood-stained nasal discharge and the
resthavingmoderateepistaxis.Onepatientcomplainedof
periorbitalswellingandepiphoraofrecentonset.Headache,
facialpain, cheek swellingand numbness were the other
symptomsthatpatientscomplainedof.
Hypertensionwasthemost common(80%)comorbidity.
Onepatientsuffered frommildfactor XI deficiencywhich
wasindicatedbyaderangedactivatedpartial
thromboplas-tintime (APTT). This patient also had hypertension.One
Table1 Demographicsandclinicalprofileofthestudypatients(n=10). Caseno. Age
(years)/Sex
Side Symptoms Durationof
symptoms (months) Nasal endoscopy findings Comorbidities
1 54/M R Nasalobstruction,epistaxis 12 Bulgingoflateralwall, MassinMM
HTN,FactorXI deficiency 2 32/M R Nasalobstruction,epistaxis,
headache,
periorbitalswelling, epiphora
144 Massfillingnasalcavity Nil
3 57/F R Nasalobstruction,epistaxis, facialpain
6 Bulgingoflateralwall HTN 4 28/M L Nasalobstruction,epistaxis 48 Bloodstaineddischarge
inMM
Nil
5 63/M L Nasalobstruction,blood
staineddischarge cheekswelling
12 Bulgingoflateralwall HTN
6 52/M L Epistaxis 2 BloodclotinMM HTN
Thrombocytopenia 7 55/M L Nasalobstruction,epistaxis,
nasalmass
24 Blackfleshyfriablemass HTN
8 57/F R Epistaxis 18 Fleshymass HTN,DM
9 42/F R Nasalobstruction,epistaxis, headache,
cheeknumbness
6 Fleshypolypoidalgritty mass
HTN,DM
10 34/F L Nasalobstruction,epistaxis, headache
12 Fleshyvascularmass HTN
M,Male;F,Female;R,Right;L,Left;MM,MiddleMeatus;HTN,Hypertension,DM,Diabetesmellitus.
wascorrectedbeforethesurgicalintervention.Noneofthe patients were taking anticoagulant drugs. Three patients hadundergone endoscopicsinussurgeryatanothercentre beforepresentation,buttwopatientshadnobiopsyreport. Inthethirdpatientthereportwasofabenignpolyp.
Preoperativerigid nasal endoscopyrevealed a vascular nasalmassin sixpatients(60%) andbulging ofthelateral nasal wall in three patients (30%). Two patients did not haveanyoftheabovefeatures,butshowedbloodstained dischargeor blood clot in the middle meatus.Biopsy was donebeforethedefinitivesurgicalexcision inseven(70%) patients, none of which wassuggestive of malignancy. In four patients pre-operative histopathological examination was suggestive of OH whereas in the other three it was reportedasfibrinousexudateandnoviabletissue.
Radiology
Contrast-enhanced CT scan of the paranasal sinuses was obtained for each patientbefore surgery. Mild to moder-ately enhancing, heterogeneous, soft tissue opacification fillingthe sinuseswas observedin all thescans (Fig.1a).
Inaddition,80%scansshowedmultiple intralesionalareas
ofcalcification.Table2depictsthevarioussitesof
involve-ment.
The maxillary sinus was involved in all cases with a
unilateralsofttissuedensitymasscausingexpansionofthe
sinus,corticalthinning,boneremodellingandwideningof
theinfundibulum inallpatients (Fig.1a).Infourpatients
(40%),extensionofthemassintotheanteriorandposterior
ethmoidsinuseswasnoted.Thefrontalsinuswasinvolved
intwopatientsandthesphenoidsinusinonepatient.Bony
erosions ofthe sinus walls wereevident in threepatients
(30%). In one patient (Case 5), therewas extensive bony
destruction(Fig.1b). Themass(6.2×4.5×5.6cminsize)
was seen eroding all walls of the left maxillary sinus,
laminapapyracea,orbitalfloorandhardpalate.Thelesion
wasextending intothepterygopalatine and infratemporal
fossae eroding the lateral pterygoid plate, superiorly
extending into the orbit abutting the inferior rectus and
inferiorobliquemuscles andanteriorly extending intothe
premaxillaryregionandsubcutaneousplane.
Treatmentandintraoperativefindings
All10 patientsunderwentcomplete excision ofthe lesion
undergeneralanaesthesia.Eightpatientsunderwent
endo-scopicexcisionalonewhiletwopatientsunderwentexcision
viaacombinedendoscopicandsublabialapproach(Table3).
Inferior turbinectomy was combined withexcision of the
mass in fourpatients toprovide adequate airway, as the
inferior turbinate was floppy andmedialised due to mass
effect.Inmostpatients(80%),thesinonasalmasswasfriable
andnecroticandinterspersedwithbloodclots.Therewasa
polypoidalmassinonepatientandacysticmasswithblood
clotsinanotherpatient.Thelesiondidnotinvolveor
Figure 1 (a) Contrast-enhanced CT scan of the paranasal sinusesaxialviewshowingheterogeneous, softtissue opacifi-cation(blackarrow) fillingtherightmaxillarysinusandright nasal cavity pushing the septum to the left. (b) CT scan of theparanasal sinusescoronal view showing expansion ofthe leftmaxillarysinuscavity, boneremodelling,wideningofthe infundibulumanderosionoftheorbitalfloor(blackarrow).
separated fromit. The sinonasal mucosaappeared mildly
oedematousandwassentseparatelyforhistopathology.
Histopathology
Histopathological examination of the specimens showed
a polypoidal mass with overlying mucosal ulceration and
acute inflammatory exudates. Viable respiratory mucosa
usuallyshowedsquamousmetaplasiainfoci(Fig.2a).The
histopathologicalfindingsinthesubepithelialstroma were
acombination of haemorrhage, oedema,infarction,fibrin
exudate, stromal hyalinisation and vascular proliferation
with ectatic vascular channels and organising thrombi
(Fig.2b---d). Oldhaemorrhage with haemosiderindeposits
and focal dystrophic calcification were seen in a few
cases.Manyhadassociatedinflammatorygranulationtissue
with moderate-to-dense mixed inflammatory infiltrates.
Occasionalmultinucleategiantcells andcholesterolclefts
were also noted in a case each. Although surface
bac-terial colonisation was seen, fungal organisms were not
demonstrated. There was no cellular atypia. Associated
inflammatory polyps and features of mild-to-moderate
chronicsinusitiswereseeninmostofthepatients(70%).
Followup
Theimmediatepostoperativeperiodwasuneventfulinall
the patients. None of the patients had excessive
haem-orrhage in the perioperative period or required blood
transfusion.Allpatientswereasymptomatic atsixmonths
andfivepatients whounderwentpostoperativerigidnasal
endoscopyhadwellmucosalisedmaxillarysinuses withno
evidenceofresidualdisease.
Discussion
OH is a rare, benign condition with locally aggressive
behaviour.The pathogenesis of thelesion is haemorrhage
intoa sinus (typically, the maxillary sinus) and formation
ofa chronic haematoma. This is followed byorganisation
throughfibrosis and neovascularisation. Song et al.4 have
described‘‘organization’’as‘‘replacementofbloodclotsby
fibroustissue’’andintroducedtheterminology‘‘organising
haematoma of the maxillary sinus’’. The previously used
terminologies were haematoma,2 haematoma-like mass,1
pseudotumour3 and organised haematoma. The cause for
haemorrhageisoftenunclear.Allexcepttwoofourpatients
werehypertensiveandthiscouldbeacauseforthebleed.
Twopatientswhowerehypertensivehadcoagulation
disor-ders, furtherincreasing theirrisk for an intrasinus bleed.
Whenbleedingoccurswithinthenasalcavity,theclotsare
easilyexpelledeitherbyforcefulblowingofthenosebythe
patient,manualremovalorciliaryactionalongwithmucus.
Incontrast,whenbleedingoccursintoaclosedsinus,
par-ticularly if the blood clot is large, a chronic haematoma
results.Thishaematomathengetsreplacedbyfibroustissue
andnewlyformed blood vessels, leadingtothe formation
ofOH.
Mostreportssuggestthatthecommonestparanasalsinus
tobeaffectedisthemaxillarysinus.5,6 Obstructionofthe
sinus ostium leads to negative intraluminal pressure and
decreasedventilation.7Inourstudy,themaxillarysinuswas
involvedinallthe patients.Additionally,in somepatients
thelesion extended beyondthe confines of the maxillary
sinus. Previously, only three cases (one involving frontal
sinusandtwoinvolvingsphenoidsinus-)ofextramaxillary
sinonasalOHhavebeenreported.5Wereportfournewcases
of extra-maxillary involvement of OH involving the
ante-riorandposteriorethmoidsinuses(n=4),frontal(n=2)and
sphenoidsinuses(n=1).Themeanageofpresentationinour
serieswas47.4yearswithamalepredominance, whichis
similartothatreportedinotherstudies.4,5,7,8
The aetiopathogenesis of OH is stillnot clearly
under-stood. Accumulation of blood in the maxillary sinus is
believed tobe the trigger for OH.The cause of bleeding
Table2 Radiologicalprofileofthestudypatients(n=10).
Casen CTscan
sitesinvolved Boneerosion Intralesional
hyperdensities
1 MS+NC No No
2 MS+AE+PE+FS+NC+NPX Yes(LP+hardpalate) Yes
3 MS+AE+PE+FS+SS+NC Yes(orbitalfloor) Yes
4 MS No Yes
5 MS+AE+PE+NC Yes(LP+orbitalfloor+hard
palate+anteriorandposteriorwall MS) Yes 6 MS No Yes 7 MS+AE+PE+NC No Yes 8 MS No No 9 MS No Yes 10 MS+NC No Yes
NC,NasalCavity;MS,MaxillarySinus;AE,AnteriorEthmoidsinuses;PE,PosteriorEthmoidsinuses;FS,FrontalSinus;SS,SphenoidSinus; LP,LaminaPapyracea;NPX,Nasopharynx.
Table3 Surgicalprofileandoutcomesofthestudypatients(n=10).
Casen Treatment Followup
Surgery Intraopfindings Symptomsat6
months
Endoscopic finding
1 ESS+inferior
turbinectomy
FriablemassfillingMS Nil Nodisease
2 ESS Polypoidalmassfillingsinuses
andnasalcavity
Nil
---3 ESS+CL+inferior turbinectomy
Friablenecroticmasswith bloodclots
Nil
---4 ESS FriablenecroticmassfillingMS Nil Nodisease
5 ESS+CL+inferior turbinectomy
Fleshynecroticmass Nil
---6 ESS Bloodclot,cysticswellingwith
solidcomponent
Nil Nodisease
7 ESS+inferior
turbinectomy
Blackfleshyfriablemass, septalperforation
Nil Nodisease
8 ESS Fleshymass Nil Nodisease
9 ESS Fleshypolypoidalgrittymass Nil
---10 ESS Yellowishfleshynecroticmass Nil
---ESS,endoscopicsinussurgery;CL,CaldwellLuc.
ahaemorrhagiclesionwithinthesinus.Someauthorshave suggested that either a ruptured aneurysm of a medium-sizedvessel relatedtotheaffected sinusor inflammatory erosionof anarterialwall maybecausativeaswell.8 The
aetiologicalfactorsrelatedtothiscouldbeaggressive
fun-galinfection,radiationtherapy andrecurrentepistaxis.7,9
InastudybyChoietal.,5about30%(6outof17patients)
ofpatientswithOHwerehypertensiveandwereonaspirin.
Theantiplateletagentwasproposedasapossiblecausative
factorin thesepatients. Inour study,80% of thepatients
werehypertensive.Amongthosewhohadhypertension,one
patienthadfactorXIdeficiencyandanother.had
thrombocy-topenia.Theeffectofthesecomorbiditiescouldhavebeen
cumulative.Noneofthepatientsinourserieswereonany
antiplateletmedications.Threepatients,however,gave
his-toryofrecentnasalsurgeryandthiscouldalsohavebeena
causeforhaematomaformation.Inviewofthehigh
preva-lenceofhypertensionamongourseriesofpatientsdiagnosed
withOH,webelievethathypertensionitselfmaybearisk
factorfordevelopingOH.
A number of theories have been proposed to explain
pathogenesis of this condition.7---10 The ‘‘negative spiral
theory’’ proposedby Omuraet al.10 is based on
immuno-histopathological evidence,11 and is the most accepted
theory at present. Collection of blood in the paranasal
sinuses with poor sinus ventilation and drainage can lead
to haematoma formation, which remains in the sinus for
Figure2 (a)Squamous metaplasiaand ulcerationreplaced byacuteinflammatoryexudate,arrowpointingtowards subep-ithelial fibrinous exudate (H&Estain at 40×). (b) An ectatic bloodvesselwithorganisingthrombus(arrowhead)andarrow pointingtowardsadjacentareaofstromalfibrosis(H&Estainat 40×).(c)Respiratorymucosawithmarkedsubepithelialoedema (arrow)andectaticbloodvessels withthrombosis(H&Estain at40×). (d)Polypoidal respiratorymucosa withsubepithelial oedema,markedfibrinexudationandareasofrecent haemor-rhage(H&Estainat40×).
necrosis, fibrosis and hyalinisation occur leading to a
capsule formation around the haematoma, thus
prevent-ing its reabsorption. Later, neovascularisation develops
within the capsule, where the new vessels are weak,
andrebleedingmight easilyoccur.Recurrentintracapsular
bleeding,leadstotheeventualformationofOH.Progressive
expansion causes pressure demineralisation of adjacent
bony sinus walls, leading to remodelling and subsequent
bony erosion. Imayoshi et al.12 have observed that
vas-cular endothelial growth factor (VEGF) and its receptors
(VEGFR2) are related to the neovascularisation seen in
OH.
The radiological appearance of sinonasal OH is rather
nonspecific. On CT scans without contrast the lesion is
seen as a large mass causing expansion of the maxillary
sinus withbony erosion and variousdegrees of
heteroge-neous high attenuation within the lesion. Post contrast,
patchyheterogeneousenhancementisseen, probablydue
totheneovascularisation.7Thesurroundinginflammedsinus
mucosainspiteofthebonyerosionspointstowardsabenign
process.9 On MRI scanning,the lesion is heterogeneousin
signalintensityonbothT1andT2weightedimagesandis
always well demarcated from the surrounding structures.
Theheterogeneoussignalintensityreflectsthevarious
com-ponentscontainedwithinthelesion,suchashaemorrhagein
variousstages,fibrosis,andvaryingamountsofvascular
pro-liferation.T2weighted imagesdemonstrate ahypointense
peripheral rim which corresponds histologically with an
attenuatedfibrouspseudocapsule.Thisbiphasicappearance
isanimportantimagingcharacteristicofOH.4Huretal.13
have demonstratedirregular nodular, frond-like,papillary
orcerebriformenhancementinalltheircases.
OHsarediagnosticdilemmasclinicallyand
radiographi-cally,mimickingbenignormalignantneoplasticprocesses.
Various differential diagnoses to be considered for
uni-lateral mass in the sinonasal cavity detected on CT and
MR images include mucocoele, fungus ball, inflammatory
polyp, cholesterol granuloma, inverted papilloma,
hae-mangioma, and carcinoma. Contrast-enhanced CT or MRI
scanning of the paranasal sinuses is extremely useful in
excludingmucocoele,fungalball,inflammatorypolyp,and
cholesterol granuloma as they do not usually enhance.
Invertedpapillomaprimarilyshowsacharacteristic
convo-lutedcerebriformpatternonT2-orenhancedT1-weighted
MR images. Clear cut bony destruction associated with
adjacenttissueinvasionisahallmarkofcarcinoma.In
con-trast, OHtypically shows thinning, expansion andsmooth
erosion of the sinus walls. The most difficult lesion
to differentiate from OH both clinically and
radiologi-cally is sinonasal haemangioma, especially the cavernous
type.
OnhistopathologicalexaminationOHcasesshowa
com-binationofvascular ectasia,recentandoldhaemorrhage,
oedema, fibrin exudation, fibrosis and hyalinisation and
neovascularisation.Occasionalcasesmayshowsome
inflam-matorygranulation tissuein the subepithelial tissue. The
primaryhistopathologicaldifferentialdiagnosis considered
in thepresent serieswashaemangioma. Although dilated
bloodvesselsandvascularproliferationwhichoccurin
abundant fibrin deposits with hyalinisation, haemorrhage
and neovascularisation precluded the diagnosis. Surgical
samples were processed in entirety to avoid missing any
overtfocusofatypiaormalignancy.Fungalstainsweredone
toexcludeany invasivefungal sinusitis. Despitethe
pres-enceofclinicalandradiologicalfeatureswhichbearastrong
resemblancetomalignancy,anegativehistopathologyresult
doesnotwarrantfurthersurgery.Ahighindexofsuspicion
withcareful histopathological examination is essential to
arriveatthediagnosis.
ThetreatmentofOHiscompletesurgicalexcision.
Var-ious approaches such as lateral rhinotomy, Caldwell-Luc,
Denker’s surgery, combined endoscopic and
Caldwell-Luc approach and endoscopic sinus surgery have been
described.1,4,5Only 2ofour patientsrequireda combined
approach(Caldwell Luc plus endoscopic sinus surgery) to
completelyremove thedisease. Mostpatients (80%)were
managedby anendonasal endoscopicapproachalone.We
noted that we adopted a less invasive procedure with
each subsequent case in our series and this could be
attributed to increased awareness of the condition with
time.
Conclusion
Sinonasal OH is a rare, benign, locally aggressive
dis-ease which mimics sinonasal malignancy both clinically
andradiologically.Histopathologyisconfirmatory.Complete
endonasal endoscopicsurgical excision is sufficient in the
majorityofpatients.
Ethical
approval
Sincethisisaretrospectivestudy,informedconsentwasnot
required.However,theinstitutionalreviewboardapproval
wasobtained.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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