Case Report:
A 38-years old female presented to Outpatient department of otolaryngology and head and neck surgery, Benazir Bhutto Hospital, Rawalpindi with complaints of bilateral complete severe nasal obstruction from 3 months and intermittent epistaxis from 3 days. Patient also has history right sided nasal obstruction 13 years back with epistaxis for which intranasal polypectomy was done and symptoms of nasal obstruction and epistaxis were resolved. But now patient again presented with symptoms of B/L nasal obstruction and epistaxis. At presentation patient was vitally stable and laboratory analysis was also normal with no significant abnormalities except low hemoglobin (8.1 g/dl) for which 3 pints of transfusion was done with improvement in hemoglobin levels.
On external nasal examination a deformity (expanded vestibule was observed) with increased inter-canthal and inter-pupillary distance but Normal eye movement and reflexes, on anterior rhinoscopy B/L completely obstructing nasal mass was observed that was bleeding with probing. On palpation, the mass was painful and tender sinuses were present. Nasal patency was absent bilaterally with anosmia bilaterally. On probing mass originating from lateral aspect of nasal cavity was observed. No neurological dysfunction was present at the time of presentation. Posterior rhinoscopy was insignificant and there were no significant findings in throat and ear examination. Cervical level II lymph nodes on left side of the neck were palpable.
On X ray (water’s view) of nose and paranasal sinuses, homogeneous haze in B/L maxillary and frontal sinuses and nasal cavity was observed suggesting polypoidal mass formation as shown in figure 1. On CECT aggressive looking polypoidal heterogeneously enhancing soft tissue density mass measuring 9x6.3x5.6cm involving nasal cavity and all paranasal sinuses causing their expansion, obliteration, and bony erosions with intracranial extension was observed as shown infigure 2 . MRI scan was suggesting a highly neoplastic mass with bony erosions with intracranial extension and involving right cavernous sinus as well. Tumour was also encircling the internal carotid artery covering 90% of its circumstance validating the unresectable mass with intracranial extension. On incisional biopsy, microscopy showed low grade spindle cell proliferation in fascicular herring bone pattern suggesting sinonasal sarcoma as shown in figure 3. On immunohistochemistry analysis, S-100 was positive.
After all baseline and specific investigation and work up a final diagnosis of sinonasal sarcoma was made and it was labelled as unresectable mass due to intracranial extension and vascular invasions and patient was referred for radiotherapy for reduction in mass volume.