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Clinical Problem Solving: Pathology
Apr 2012

Pathology Quiz Case 2

Arch Otolaryngol Head Neck Surg. 2012;138(4):429. doi:10.1001/archoto.2011.1267a

A 50-year-old man presented with a 3-month history of a progressively enlarging septal mass, rhinorrhea, and nasal congestion. He also had a history of right septal deviation and associated nasal airway obstruction. His medical history was remarkable for urolithiasis, end-stage renal disease, and hemodialysis. His medications included cinacalcet, which is a calcium mimetic, and sevelamer, a phosphate chelating agent. Physical examination revealed a 3-cm rubbery mass in the caudal septum that extended anteriorly to the columella and obstructed the right nasal valve. There were no mucosal changes. Nasal endoscopy, which was limited on the right because of the mass, revealed a normal left middle meatus and posterior nasal cavity. Computed tomography (Figure 1) and magnetic resonance imaging (not shown) were performed before the patient was referred to our clinic.

He was taken to the operating room for an external septorhinoplasty approach to resect the mass, which was 3.1 × 1.6 × 1.0 cm, firm, pink-tan, nodular, well circumscribed, and sharply demarcated from both the surrounding mucosa and the cartilaginous septum (Figure 2). The sectioned specimen revealed a cut surface that was tan-white with red septations. Histopathologic analysis revealed nodular calcifications and associated nonnecrotizing granulomatous inflammation with multinucleated giant cells (Figure 3 and Figure 4). The patient did well after surgery, without any recurrence of the mass. He underwent renal transplantation several months later.

What is your diagnosis?