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Clinical Challenge
January 2018

Unilateral Nasal Obstruction

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
  • 2Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Suburban Hospital, Bethesda, Maryland
  • 3Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
JAMA Otolaryngol Head Neck Surg. 2018;144(1):80-81. doi:10.1001/jamaoto.2017.1801

A woman in her 30s presented with a 7-month history of right-sided nasal obstruction. She had been treated with several courses of oral antibiotics and intranasal steroids without improvement of symptoms. She had no history of sinus infections or allergic rhinitis. Nasal obstruction was constant and associated with right paranasal pressure. Results from a head and neck examination, including cranial nerve, were normal, except for the results from nasal endoscopy, which showed a deviated septum and a soft-tissue mass emanating from the right middle meatus inferior to the middle turbinate that seemed to have a polypoid appearance superiorly and a papillomatous appearance inferiorly. A computed tomographic (CT) scan of the sinuses without contrast showed complete opacification of the right paranasal sinuses with mass effect on the medial maxillary wall with mild hyperostosis posterolaterally. The patient underwent an endoscopic right sinonasal mass biopsy. Intraoperatively, further excision of the mass was aborted owing to an unusual appearance of the mass as well as clear fluid exuding from the mass during microdebridement. Pathologic analysis of the biopsied tissue revealed a uniform spindle cell tumor comprised of cellular fascicles and tumor cells with bland nuclei (Figure, A and B). A magnetic resonance image (MRI) of the face with contrast was obtained postoperatively to further delineate the mass and evaluate for intracranial extension. Initial histologic stains showed the tumor to be positive for S-100 and actin (Figure, C and D) and negative for GFAP, CD34, and cytokeratin. Additional immunostains showed the tumor to be negative for SOX-10 and B-catenin.

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