A Case Report of Aggressive Chronic Rhinosinusitis with Nasal Polyps Mimicking Sinonasal Malignancy

Hindawi Case Reports in Otolaryngology Volume 2019, Article ID 3725720, 5 pages https://doi.org/10.1155/2019/3725720 Case Report A Case Report of Aggressive Chronic Rhinosinusitis with Nasal Polyps Mimicking Sinonasal Malignancy S. Velegrakis, N. Chatzakis, E. Prokopakis, M. Papadakis, E. Panagiotaki, M. Doulaptsi, and A. Karatzanis Department of Otorhinolaryngology, University of Crete School of Medicine, Heraklion, Crete, Greece Correspondence should be addressed to A. Karatzanis; Received 14 January 2019; Revised 7 March 2019; Accepted 20 May 2019; Published 9 June 2019 Academic Editor: Hidenori Yokoi Copyright © 2019 S. Velegrakis et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Cases of extensive nasal polyps rarely occur and may mimic more aggressive lesions of the nose and paranasal sinuses. A case of extensive nasal polyposis with unusually aggressive behavior and its management is presented. Presentation of Case. A 27-year-old male patient visited the emergency department of a tertiary center, complaining of recurrent episodes of epistaxis. The patient presented with a large polypoid lesion protruding from the right nostril and producing asymmetry of the face. Diagnostic imaging illustrated a lesion of the right maxillary sinus producing excessive bone remodeling and extension into neighboring structures in every direction. Fine limits were noted, however, with no invasive characteristics. Biopsy under local anesthesia was performed, showing findings consistent with nonspecific inflammation. Open surgery through a lateral rhinotomy under general anesthesia was performed, and the mass was readily mobilized and removed. No macroscopic invasion of neighboring structures was noted. Permanent histology confirmed the diagnosis of nasal polyposis. Postoperative follow-up has shown no evidence of recurrence after 12 months. Conclusion. Nasal polyps do not typically expand in an aggressive manner, producing bone resorption or extending into neighboring structures. However, nasal polyposis should be included in the differential diagnosis of nasal tumors with such behavior. 1. Introduction Sinonasal tumors are rare entities with distinctive clinical, etiological, and pathological features. Nasal and paranasal cavities, although small spaces, represent complex areas, where a wide range of benign and malignant tumors may occur. Primary benign and malignant tumors account for approximately 3% of all head and neck neoplasms [1–3].The diagnosis and treatment of these tumors is challenging because of their low incidence, histological diversity, and indolent clinical course. Malignancies have a variable prognosis depending on histology, origin, and clinical stage. Proximity to vital anatomical structures makes their management quite complex [2]. High morbidity and mortality are generally expected. Nasal polyposis develops in 0.2-1% of the general population and concerns all races, increasing with age [3]. Prevalence is much higher in individuals with comorbidities such as asthma, aspirin intolerance, or cystic fibrosis [4]. In some rare cases, nasal polyposis may behave aggressively and mimic other pathologies of nasal-paranasal cavities [5]. Pathogenesis of sinonasal polyposis remains unclear, but it has been shown that eosinophil-dominated inflammation plays a major role in the development and progression of the disease. In this case report, we present a patient with aggressive nasal polyposis causing bone remodeling and extension into neighboring structures, and thus mimicking much more aggressive disease. We present in detail the clinical evaluation as well as surgical technique and postoperative followup. This case report is compliant with the SCARE Guidelines and PROCESS Guidelines. 2. Case Presentation A 27-year-old male, with Crouzon syndrome phenotype, visited the emergency department of a tertiary referral 2 center, reporting multiple episodes of epistaxis in the past few days. The patient also reported nasal obstruction and impaired nasal breathing for the previous several months. Rest of the medical history was free. On clinical examination, a polypoid lesion protruding from the right nostril was noted. In addition, asymmetry of the face and projection of the ipsilateral canine fossa were evident. Computed tomography of the paranasal sinuses showed an inhomogeneous soft-tissue mass, which completely occupied the right nasal cavity, maxillary sinus, and anterior and posterior ethmoidal cells. The lesion produced extensive bone remodeling of the right maxillary sinus with complete absence of its anterior wall, as well as erosion of the posterior wall and entry of the lesion in the pterygopalatine fossa. There was also erosion of the ipsilateral lower as well as median orbital wall, and entry of the lesion in the orbital cavity. Despite its large size, the lesion seemed to be well defined without invasive characteristics (Figures 1–5). Routine laboratory tests were within normal range. Preoperative maxillofacial consultation excluded pathology of odontogenic origin. The patient underwent a biopsy under local anesthesia, and the findings showed nonspecific inflammation. Open surgery under general anesthesia was undertaken via lateral rhinotomy and medial maxillectomy (Figure 6). The maxillary sinus mucosa was completely replaced by inflammatory tissue simulating a benign mass. This mass was readily mobilized and dissected free from surrounding tissues within the orbit and pterygopalatine fossa, as no macroscopic invasion of any neighboring structures was noted. Histopathological examination revealed typical nasal polyposis with mixed population of eosinophils, neutrophils, and macrophages, with no evidence of fungal invasion (Figures 7–9). Antibiotic and corticosteroid treatment was performed for a short period postoperatively. Local nasal mometasone furoate was used for 2 months after surgery. Intensive saline solution irrigations were additionally administered. There are no clinical/radiological signs or symptoms of recurrence 12 months postoperatively (Figures 10 and 11). Case Reports in Otolaryngology Figure 1: Preoperative CT, coronal plane. 3. Discussion Nasal polyposis is a very common entity with prevalence between 6 and 11% in the Western world. Cases with aggressive behavior [6, 7], however, are rare [8, 9]. In fact, only a few cases with bony destruction and erosion have been reported. Turel et al. reported a case of nasal polyposis resulting in fibro-osseous thickening of sinonasal, maxillofacial bones, and proptosis [9]. Arvind et al. presented a case of osteolytic nasal polyps of the maxillary sinus, mimicking malignancy with invasion to the facial soft tissue [10]. Majitha et al. presented intracranial expansion of nasal polyps in patients with Samter’s triad [2]. Rejowski (...truncated)