Abstract
Epistaxis in patients on antiplatelet and anticoagulant therapy is common and typically benign. We present a case of a rare nasal septal malignancy in a patient on antiplatelet therapy and discuss worrisome symptoms and signs which should prompt early referral to a specialist.
1
Introduction
Epistaxis in patients on antiplatelet and/or anticoagulant therapy is common, sometimes difficult to manage but rarely due to anything other than nasal dryness and trauma and the resultant effects of therapy. However, we present a patient with a history of recurrent epistaxis while on antiplatelet medication who was found to have a rare malignancy of the nasal septum.
2
Case reports
A 78-year old male presented with a 2-year history of recurrent left sided epistaxis which increased in frequency over that time to almost daily episodes. The bleeding was significant enough to wake him from sleep at times, but would stop with holding pressure. Of significance, he had a coronary artery stent placed approximately 2 years prior and was then initiated on daily Aspirin 81 mg and Clopidogrel. After 1 year, the Clopidogrel was discontinued by his cardiologist but the patient still experienced significant epistaxis. The patient then attributed his nasal bleeding to having a long-standing deviated septum. In addition, the patient did have some point tenderness on the tip of his nose. He denied a history of smoking or alcohol use and had no family history of bleeding disorders or head and neck cancer.
Nasal examination revealed that his external nose was straight and the skin was normal. Intranasal exam revealed normal septal mucosa on the right. On the left there was severe crusting and irritation. The oral cavity and oropharyngeal exam was unremarkable, and neck was without adenopathy including careful palpation of facial nodes. The intranasal exam on the left was repeated after application of topical anesthetic and decongestant solution. Suction debridement of the area revealed that the underlying mucosa was irregular, irritated, and bled easily. The size of the abnormal area was 1.5 by 1.5 cm. The posterior septal mucosa looked healthy.
An endoscopic biopsy was performed under local anesthesia. Pathology revealed invasive squamous cell carcinoma with basaloid features ( Fig. 1 ). On an architectural level the specimen demonstrated slight peripheral palisading but lacked frank comedo type necrosis or cystic spaces with PAS positive material. There were abundant basaloid appearing cells with hyperchromatic nuclei and no nucleoli.
Further workup included contrast enhanced computed tomography scan (CT) and positron emission tomography (PET) for metastatic workup ( Fig. 2 ). Findings on contrast enhanced CT were minimal and demonstrated only slight fullness along the anterior septum ( Fig. 2 A). PET demonstrated marked hypermetabolic activity along the anterior aspect of cartilaginous septum at the midline ( Fig. 2 B). Imaging was negative for signs of nodal involvement or metastases to other organs. The tumor was staged according to the AJCC 2010 TMN classification as T1N0M0. The patient was offered primary surgery followed by external beam radiation therapy versus primary external beam radiation therapy with surgical salvage if necessary. The patient chose to undergo external beam radiation therapy, and eventually went on to receive surgical salvage for residual disease with subsequent reconstruction of the defect.
2
Case reports
A 78-year old male presented with a 2-year history of recurrent left sided epistaxis which increased in frequency over that time to almost daily episodes. The bleeding was significant enough to wake him from sleep at times, but would stop with holding pressure. Of significance, he had a coronary artery stent placed approximately 2 years prior and was then initiated on daily Aspirin 81 mg and Clopidogrel. After 1 year, the Clopidogrel was discontinued by his cardiologist but the patient still experienced significant epistaxis. The patient then attributed his nasal bleeding to having a long-standing deviated septum. In addition, the patient did have some point tenderness on the tip of his nose. He denied a history of smoking or alcohol use and had no family history of bleeding disorders or head and neck cancer.
Nasal examination revealed that his external nose was straight and the skin was normal. Intranasal exam revealed normal septal mucosa on the right. On the left there was severe crusting and irritation. The oral cavity and oropharyngeal exam was unremarkable, and neck was without adenopathy including careful palpation of facial nodes. The intranasal exam on the left was repeated after application of topical anesthetic and decongestant solution. Suction debridement of the area revealed that the underlying mucosa was irregular, irritated, and bled easily. The size of the abnormal area was 1.5 by 1.5 cm. The posterior septal mucosa looked healthy.
An endoscopic biopsy was performed under local anesthesia. Pathology revealed invasive squamous cell carcinoma with basaloid features ( Fig. 1 ). On an architectural level the specimen demonstrated slight peripheral palisading but lacked frank comedo type necrosis or cystic spaces with PAS positive material. There were abundant basaloid appearing cells with hyperchromatic nuclei and no nucleoli.
