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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Sinonasal

organising

haematoma

---

a

little

known

entity

Lalee

Varghese

a,

,

Sramana

Mukhopadhyay

b

,

Raghav

Mehan

a

,

Regi

Kurien

a

,

Meera

Thomas

b

,

Rupa

Vedantam

a

aChristianMedicalCollege,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/).

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/).

(2)

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

(3)

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

(4)

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

(5)

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

(6)

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

(7)

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.

References

1.YagisawaM,IshitoyaJ,TsukudaM.Hematoma-likemassofthe maxillarysinus.ActaOtolaryngol.2006;126:277---81.

2.TabaeeA,KackerA.Hematomaofthemaxillarysinuspresenting asamass----acasereportandreviewofliterature.IntJPediatr Otorhinolaryngol.2002;65:153---7.

3.OzhanS,Arac¸ M,IsikS,OznurII,AtillaS,KemalogluY. Pseudo-tumorofthemaxillarysinusinapatientwithvonWillebrand’s disease.AmJRoentgenol.1996;166:950---1.

4.SongHM, JangYJ,Chung YS, LeeBJ. Organizinghematoma of the maxillary sinus. Otolaryngol Head Neck Surg. 2007;136:616---20.

5.ChoiSJ,SeoST,RhaKS,KimYM.Sinonasalorganizedhematoma: clinicalfeaturesofseventeencases andasystematicreview. Laryngoscope.2015;125:2027---33.

6.KimJS,OhJS,KwonSH.Theincreasingincidenceofparanasal organizinghematoma:a20yearexperienceof23casesat a singlecenter.Rhinology.2016;54:176---82.

7.Lee HK, Smoker WR, Lee BJ, Kim SJ, Cho KJ. Organized hematomaofthemaxillarysinus:CTfindings.AmJRoentgenol. 2007;88:W370---3.

8.KimEY,KimHJ,ChungSK,DhongHJ,KimHY,Yim YJ,et al. Sinonasalorganizedhematoma:CTandMRimagingfindings.Am JNeuroradiol.2008;29:1204---8.

9.Nishiguchi T, NakamuraA, Mochizuki K, Tokuhara Y, Yamane H,InoueY.Expansileorganizedmaxillarysinushematoma:MR and CT findingsand review ofliterature. AmJ Neuroradiol. 2007;28:1375---7.

10.OmuraG,WatanabeK,FujishiroY,EbiharaY,NakaoK,Asakage T.Organizedhematomaintheparanasalsinusandnasal cavity-imagingdiagnosisandpathologicalfindings.AurisNasusLarynx. 2010;37:173---7.

11.Ohta N, Watanabe T, Ito T, Kubota T, Suzuki Y, Ishida A, et al. Clinical and pathological characteristics of organized hematoma.IntJOtolaryngol.2013;2013:1---6.

12.ImayoshiS, Kanazawa T, Fukushima N, Kikuchi H, Hasegawa M, Nagatomo T, et al. Three cases of organized hematoma ofthemaxillarysinus:clinicalfeaturesand immunohistologi-calstudiesforvascularendothelialgrowthfactorandvascular endothelialgrowthfactorreceptor2expressions.CaseRep Oto-laryngol.2015;2015:32---846.

13.Hur J, KimJK, Byun JS, Lee WJ. Imaging characteristics of sinonasalorganizedhematoma.ActaRadiol.2015;56:955---9.

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Contrast-enhanced axial (A) and coronal (B) computed tomography of the paranasal sinus, showing a voluminous mass in the right nasal cavity that extended as far as the

(a) CT scan of the facial sinuses: ethmoidal sinuses filled by soft tissue and maxillary sinuses showing uneven bone thickening in the maxillary walls; (b) and (c) Numerous large

A: CT scan (axial view) showing a tumor in the right nasal cavity inserted in the posterior nasal septum. B: CT scan (coronal view) showing the tumor inserted in the septum

A: (Left) axial CT scan of sinuses shows complete opa- ciication of the left sphenoid sinus with dehiscence in the left optic canal (white arrow), opticocarotid recess (black

Computed tomography (CT) evidenced a lesion with soft tissue consistency at the ethmoid, right maxillary sinus, and nasal cavity, showing erosion of the lamina papyracea,