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Clinical Challenge
May 2015

Nasal Obstruction and Epistaxis

Author Affiliations
  • 1SUNY Upstate Medical University, Syracuse, New York
JAMA Otolaryngol Head Neck Surg. 2015;141(5):479-480. doi:10.1001/jamaoto.2015.118

A preteen boy presented with a 1-year history of right-sided nasal obstruction and a 4-day history of intermittent right-sided epistaxis following blunt trauma to the nose. The epistaxis occurred 3 to 4 times a day and resolved with pressure. He did not have facial pain, facial paresthesia, or visual changes. There was no family or personal history of bleeding disorders. Nasal endoscopy revealed a large, well-vascularized, polypoid mass filling the right anterior nasal cavity. A computed tomographic scan showed a right nasal cavity mass (4.5 × 1.7 cm) extending to the posterior choana with opacification and bony remodeling of the right maxillary sinus. The mass had heterogeneous intermediate signal intensity on T2-weighted magnetic resonance imaging (Figure, A). The patient was taken to the operating room for biopsy and possible excision of the nasal mass. As the lesion was biopsied, there was brisk bleeding. However, the lesion was found to have a narrow pedicle of attachment and was resected in its entirety. The mass was based on the superior aspect of the nasal septum and cribriform plate. Hematoxylin-eosin stain showed a sheet-like proliferation of epithelioid and polygonal cells with pale eosinophilic granular cytoplasm and relatively uniform vesicular nuclei (Figure, B). The cells were arranged in nests. Branching, staghorn-like blood vessels were scattered throughout the tumor. The tumor cells stained positive for smooth muscle actin (Figure, C), muscle specific actin, Bcl-2, INI-1, and transcription factor E3 (Figure, D).

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