Pleomorphic adenoma of the nasal septum: a case report

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Pleomorphic Adenoma of the Nasal Septum: A Case Report Anita Tahlan, MD, DNB, Annu Nanda, MD, Nitin Nagarkar, MS, DNB, and Sandeep Bansal, MS Pleomorphic adenomas arise most commonly in the major salivary glands; the minor salivary glands are affected in only 8% of the cases. Intranasal pleomorphic adenoma being extremely rare originates most commonly from the nasal septum. We present a case of a 55-year-old man who presented with complaints of right-sided nasal obstruction and occasional nasal bleed for the last 6 months. Examination showed a mucosa-covered, fleshy 2 ⫻ 2 ⫻ 1.5 cm mass in the right nasal cavity. Computed tomogram showed right-sided polypoidal mass with attachment to the cartilaginous nasal septum without any erosion of the surrounding structures. The clinical presentation, gross and microscopic appearance, and treatment of intranasal pleomorphic adenoma is briefly discussed. (Am J Otolaryngol 2004;25:118-120. © 2004 Elsevier Inc. All rights reserved.)

Pleomorphic adenoma has been reported in various anatomical sites the major salivary glands being the most common site; the minor salivary glands are affected in only 8% of the cases. Intranasal pleomorphic adenoma is extremely rare, and there are isolated case reports.1-3 A large number is required to be able to have a valid statistical analysis and prognostication. There is need for further information, and this is a justification for recording another case. CASE REPORT A 55-year-old man presented with complaints of right-sided nasal obstruction and occasional nasal bleed for the last 6 months. There was no history of weight loss or fever or

From the Department of Pathology and Otolaryngology, Government Medical College and Hospital, Chandigarh, India. Address correspondence to: Anita Tahlan, MD, DNB, Department of Pathology, Government Medical College and Hospital, Sector 32A, Chandigarh 160030, India. E-mail: [email protected]. © 2004 Elsevier Inc. All rights reserved. 0196-0709/$ - see front matter doi:10.1016/j.amjoto.2003.09.004 118

any previous nasal surgery. Examination showed a 2 ⫻ 2 ⫻ 1.5 cm mass in the right nasal cavity. It was mucosa covered and fleshy and did not bleed on touch. The left nasal cavity and nasopharynx were clear. Computed tomogram showed right-sided polypoidal mass with attachment to the cartilaginous nasal septum without any erosion of the surrounding structures (Fig 1). He was subsequently taken up for endoscopic removal of the mass under local anesthesia. Histological examination revealed a wellcircumscribed tumour with a predominant epithelial element admixed with stroma (Fig 2). The epithelial component of the neoplasm showed small- to medium-sized ducts surrounded by epithelial and myoepithelial cells. Some ducts contained eosinophilic material. Small cellular nests, solid sheets, and anastomosing trabeculae were also noted with areas of squamous metaplasia at places (Fig 3). These duct-like structures were embedded in myxoid stroma with foci of chondroid differentiation at places. Mitotic activity was negligible. There was no evidence of invasion or anaplasia. At 6-month follow-up, the patient is relieved of symptoms of obstruction and nasal examination shows no abnormality.

American Journal of Otolaryngology, Vol 25, No 2 (March-April), 2004: pp 118-120

PLEOMORPHIC ADENOMA

Fig 1. Computed tomogram showing right intranasal mass.

DISCUSSION Pleomorphic adenomas arise predominantly from the parotid gland. The other sites of origin are the minor salivary glands of the hard and soft palate.2 Rarer sites are the upper aerodigestive tract including the nasal cavity, pharynx, larynx, trachea, and lacrimal glands.3 Nasal cavity is the most common site of involvement of mixed tumour in the upper respiratory tract.4,5 Intranasal pleomorphic adenoma most commonly originates from the nasal septum, even though anatomically most of the salivary glands are located in the lateral nasal wall and turbinates.6 The presenting symptom is nasal obstruction in 75% of the patients,4 as in our case. Less commonly, the patients may present with epistaxis, intermittent nasal discharge or

Fig 2. Microphotograph showing stratified squamous lining and epithelial cells forming acini in fibromyxoid stroma (hematoxylin and eosin ⴛ100).

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Fig 3. Microphotograph showing pseudostratified columnar lining undergoing squamous metaplasia. The underlying stroma shows epithelial and mesenchymal components of tumour (hematoxylin and eosin ⴛ200).

with complaints related to the size of the mass. The clinical features of the mass such as smooth surface, broad-based attachment, no bleeding on touch, and lack of destruction of surrounding structures favor a benign nature. Tumor can range in size from less than 0.5 cm to over 7 cm. It is often polypoid, broadbased, soft, and fleshy with a blue-gray translucency. Intranasal pleomorphic adenoma shows an unusually high cellularity as compared with the major salivary gland tumors. Occasionally, carcinoma expleomorphic adenoma has been noted.7 The epithelial component transforms into malignancy and has a potential to metastasize. The immunohistochemical findings are similar to those of pleomorphic adenoma of the parotid gland.8 The treatment involves surgical excision with histologically clear margins. Approaches depend on size and location and include intranasal excision, midfacial degloving, and lateral rhinotomy.9 Wide septal excision and radical neck dissection is reserved for tumors metastasizing to regional lymph nodes.10 Intranasal mixed tumors have a relatively low rate of recurrence (10%) compared with recurrence rates as high as 50% of parotid gland mixed tumors.4 The predominance of epithelial elements rather than stromal elements may account for the relatively low recurrence rate. Intranasal pleomorphic adenomas are unique lesions of the nasal cavity. Although generally similar to mixed tumour of major salivary glands, they differ in extent of cellularity, rate of recurrence, and biologic aggressiveness.

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The case highlights the importance of keeping the possibility of pleomorphic adenoma whenever a patient presents with mass in the nasal cavity. REFERENCES 1. Haberman RS, Stanley DE: Pleomorphic adenoma of the nasal septum. Otolarygol Head Neck Surg 100:610612, 1989 2. Jassar, Stafford ND, MacDonald AW: Pleomorphic adenoma of the nasal septum. J Laryngol Otol 113: 483485, 1999 3. Suzuki K, Morbi K, Baba S: A rare case of pleomorphic adenoma of the lateral wall of the nasal cavity with special reference of statistical observation of pleomorphic adenoma of the nasal cavity in Japan. Nippon Jibiinkoka Gakkai Kaiho 93:740-745, 1990 4. Compagno J, Wong RT: Intranasal mixed tumours

TAHLAN ET AL

(pleomorphic adenomas): A clinicopathologic study of 40 cases. Am J Clin Pathol 68:213-218, 1977 5. Golz A, Ben-Arie Y, Fradis M: Pleomorphic nasoseptal adenoma. J Otolaryngol 26:399-401, 1997 6. Wallace RD, Ardent MD, Irene RT: Pathologic quiz case 1. Pleomorphic adenoma. Arch Otolaryngol Head Neck Surg 116:486-488, 1990 7. Cho KJ, el-Naggar AK, Mahanupab P, et al: Carcinoma ex-pleomorphic adenoma of the nasal cavity: A report of two cases. J Laryngol Otol 109:677-679, 1995 8. Hirai S, Matsumoto A, Suda K: Pleomorphic adenoma in the nasal cavity: Imunohistochemical study of three cases. Auris Nasus Larynx 29:291-295, 2002 9. Torrico RP, Lopez-Rios VJ, Puente LG, et al: Pleomorphic adenoma of the nasal septum. A case report. Acta Otorrinolaringol Esp 51:373-376, 2000 10. Freeman SB, Kennedy KS, Parker GS, et al: Metastasizing pleomorphic adenoma of the nasal septum. Arch of Otolaryngol Head Neck Surg 116:1331-1333, 1990

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