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Clinical Challenge
August 2017

Unilateral Nasal Congestion in an Elderly Man

Author Affiliations
  • 1Columbia University College Of Physicians and Surgeons, New York, New York
  • 2Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia
JAMA Otolaryngol Head Neck Surg. 2017;143(8):839-840. doi:10.1001/jamaoto.2016.4515

A man in his 70s presented to an outside institution with a 4-month history of right-sided nasal congestion, which failed to resolve with nasal sprays, antibiotics, and oral prednisone. He also reported intermittent right-sided epistaxis occurring multiple times per day. He had not experienced prior nasal trauma or surgery and had quit smoking 30 years ago. At the outside institution, a nasal mass was found on examination and biopsied. He was referred to our office for further management. Endoscopic examination showed a dark, soft-tissue mass filling the right nasal cavity. Computed tomography (CT) of the sinuses revealed opacification of the right nasal cavity with tissue protruding into the nasopharynx and complete opacification of the right maxillary, anterior ethmoid, and frontal sinuses (Figure, A and B). The patient underwent surgical resection. Removal of the mass required a right medial maxillectomy, septectomy, and excision of the right nasolacrimal duct via endoscopic approach. Resection also necessitated removal of the anterior maxillary sinus wall via Caldwell-Luc procedure. Biopsy specimens were taken throughout. Histopathologic analysis from both the outside hospital and our institution revealed sheets of atypical, pleomorphic epithelioid cells, some with prominent pigment (Figure, C). Immunohistochemical stains were positive for HMB-45 (Figure, D) and S-100.

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