Subcutaneous Cavernous Hemangioma in the Nasal Dorsum: Report of Case Treated with Endoscopic Rhinoplasty

THIEME Case Report Subcutaneous Cavernous Hemangioma in the Nasal Dorsum: Report of Case Treated with Endoscopic Rhinoplasty Jan Alessandro Socher1 Maurício F. de Sá Marchi2 1 Department of Otorhinolaryngology, Regional University of Blumenau Foundation (Fundação Universidade Regional de Bumenau–FURB), Blumenau/SC, Brazil 2 Department of Medicine, Regional University of Blumenau Foundation (Fundação Universidade Regional de Bumenau–FURB), Blumenau/SC, Brazil Jeniffer C. Kozechen Rickli2 Address for correspondence Prof. Dr. Jan Alessandro Socher, PhD, Alameda Duque de Caxias, 145 sala 306, Bairro Centro, CEP 89015-010, Blumenau/SC, Brazil (e-mail: ). Int Arch Otorhinolaryngol 2014;18:213–216. Abstract Keywords ► hemangioma ► cavernous ► rhinoplasty ► natural orifice endoscopic surgery Introduction Hemangiomas are vascular malformations, with slow blood flow, that can occur in any part on the body. They are more common in women and, predominantly, are isolated lesions. The malformation does not spontaneously regress. Subcutaneous hemangioma is a rare variant with an aggressive growth pattern that sometimes recurs after excision. Objective Case report of a subcutaneous cavernous hemangioma in the nasal dorsum treated with endoscopic rhinoplasty. Resumed Report A 27-year-old woman had a fibroelastic tumor mass in the midline of the nasal dorsum, which was pulsatile; she had obstruction and nasal congestion with associated rhinorrhea, with evolution and worsening over the previous 2 years. Computed tomography showed a tumor demarcated in the nasal dorsum without evidence of intracranial communication. Endoscopic rhinoplasty with septoplasty and associated paranasal sinus sinusectomy was performed without arteriography embolization, sclerotherapy, or laser. Pathologic diagnosis showed cavernous hemangioma. Postoperative follow-up shows no recurrence at 3 years. Discussion This case presented with atypical features, thus making the diagnosis a challenge. Imaging studies were required to confirm the vascular nature of the tumor. Excisional biopsy is the procedure of choice for pathologic examination. Subcutaneous hemangiomas never involute and always need treatment. The surgical approach is exceptional because there was no preoperative diagnosis. In addition, the closed technique provided best aesthetic results in this case. Conclusion Endoscopic rhinoplasty is suitable for nasal dorsum tumor resection and has superior aesthetic result to open techniques. Introduction Subcutaneous hemangioma is a rare variant of slow-flow venous malformations.1 It occurs in both adults and children and is more prevalent in females.2 It shows an aggressive growth pattern, can occur in any part of the body, and received September 30, 2012 accepted April 15, 2013 DOI http://dx.doi.org/ 10.1055/s-0033-1351675. ISSN 1809-9777. sometimes recurs after excision.1,3,4 The clinical features include local whitening of the skin, followed often by the formation of thin telangiectasias progressing to a cherry-red stain. They are usually papular lesions of a variable thickness that may encompass both superficial and deep layers of the dermis, including subcutaneous regions, giving the lesion a Copyright © 2014 by Thieme Publicações Ltda, Rio de Janeiro, Brazil 213 214 Subcutaneous Cavernous Hemangioma in the Nasal Dorsum Socher et al. bluish aspect.5,6 Nasal hemangiomas account for 15.8% of all the facial hemangiomas. The complications caused by the tumor include uni- or bilateral nasal obstruction, changes in valve and nasal septum, ulcerations, amblyopia, heart and respiratory failure, feeding difficulties, bleeding, and infections, along other psychosocial factors.7,8 The differential diagnosis includes lymphatic malformations, pyogenic granuloma, gliomas, and other benign and malignant tumors.9 Objective We report a case of localized subcutaneous cavernous hemangioma of the nasal dorsum treated through endoscopic rhinoplasty. Fig. 2 Computed tomography scan in sagittal plane identifying discrete area of contrast enhancement of soft tissue in the nasal dorsum. Case Report A 27-year-old woman was sent to an otolaryngology service in Blumenau/SC for evaluation of a tumor mass in the midline of the nasal dorsum, with a history of worsening over the past 2 years. The patient complained of nasal congestion associated with obstruction and rhinorrhea. Physical examination revealed a tumor in the midline of the nasal dorsum, with a fibroelastic, pulsatile, and motionless aspect, presenting hyperemia of the skin color and no sign of ulceration (►Fig. 1). The videoendoscopic exam showed a deviated nasal septum, hypertrophy of the inferior turbinates, and bilateral hyaline rhinorrhea in the middle nasal meatus. The computed tomography (CT) scan and nuclear magnetic resonance (NMR) of the paranasal sinuses and nasal cavity, with and without contrast, in the axial, coronal, and sagittal planes revealed a tumor restricted to the nasal dorsum, without evidence of intracranial communicationto the nasal cavities, with little contrast impregnation (►Figs. 2 and 3). Endoscopic rhinoplasty was planned for resection of the tumor, along with septoplasty surgery and sinusotomy of the paranasal sinuses. The patient was treated in the hospital under general anesthesia and orotracheal intubation. Closed rhinoplasty was performed, with an intercartilaginous incision to approach the nasal dorsum, using an endoscopic technique for complete resection of the subcutaneous tumor with a margin of safety and Fig. 1 Front and profile photographs showing the detail of the tumor mass in the midline of the nasal dorsum, along with fibroelastic, pulsatile, and motionless aspect, presenting hyperemia of the skin. International Archives of Otorhinolaryngology Vol. 18 No. 2/2014 Fig. 3 Nuclear magnetic resonance in sagittal plane identifying discrete area of contrast enhancement in the nasal dorsum. preservation of the cutaneous tissue of the nasal dorsum (►Fig. 4). Arteriography with superselective embolization, sclerotherapy, and laser were not used beforehand or even during the surgical procedure. The pathologic diagnosis was confirmed postoperatively as cavernous hemangioma of the nasal dorsum (►Fig. 5). The patient was followed weekly for the first postoperative month, biweekly during the second postoperative month, then monthly until the sixth month. Fig. 4 Intraoperative endoscopic visualization with 30-degree optic demonstrating complete tumor resection of the nasal dorsum. Subcutaneous Cavernous Hemangioma in the Nasal Dorsum While monitoring every 6 months until postoperative year 3, there were no detectable signs of tumor recurrence and the patient was satisfied with cosmetic and functional results. Discussion Cavernous hemangiomas are tumors formed by vascular ectasia. They can be located deeper in the skin and mucous membranes, but also can involve deeper structures such as subcutaneous tissue, muscle, bone. Hema (...truncated)