Abstract
The management of unilateral nasal lesions can sometimes be a challenge and an ordinary bioptic assessment should be avoided in order to prevent complications due to their possible vascular or meningoencephalic origin. Narrow-band imaging (NBI) endoscopy could improve the diagnosis of vascular nasal formations by enhancing the visualisation of the mucosal microvascular supply. We describe the case of a 68-year-old male patient who was brought to our attention because of a left nasopharyngeal mass that had elsewhere been unsuccessfully biopsied (with conspicuous bleeding) and assessed by means of traditional endoscopic and radiological techniques. NBI endoscopy revealed increased vasculature covering most of the mucosal surface without any features suggestive for malignancy. Subsequent angiography showed that the feeding vessel was the left sphenopalatine artery, which was embolised using 150–250 μm Contour embospheres. The mass was then completely removed surgically using an NBI-assisted endoscopic technique, and a histopathological examination revealed it was a hemangiopericytoma-like (HPCL) tumor. This case suggests the usefulness of NBI endoscopy in diagnosing unilateral vascularised nasal lesions and guiding the therapeutic approach before and during major surgery.
1
Introduction
Narrow-band imaging (NBI) is an innovative endoscopic technique based on the use of optical filters that select specific narrow light wavelengths in order to improve the visualisation of the mucosal surface and its underlying microvascular supply . It has recently been introduced into the otorhinolaryngological field and has been found to have a good diagnostic impact in relation to malignant and pre-malignant lesions . It is now widely used for the early detection of high-grade laryngopharyngeal dysplasia, carcinoma in situ, and invasive carcinoma , and a few recent reports have described its diagnostic usefulness in the early identification of nasopharyngeal carcinomas on the basis of its increased sensitivity and specificity compared to traditional endoscopic white light imaging (WLI) .
The diagnosis of unilateral nasal lesions may sometimes be a challenging question and routine bioptic assays performance before dedicated imaging should be avoided in order to ward off unpleasant and troublesome sequelae related to their possible vascular or meningoencephalic origin . The NBI technique filters selected light waves (i.e.: 415 nm blue light and 540 nm green light) by exploiting haemoglobin bandwidth adsorption . In this way, narrow-band waves can not only penetrate the epithelium to highlight the capillary network related to neo-angiogenesis, but also reach the deeper tissues and thus enhance submucosal epithelial vessels . It is therefore potentially interesting in the diagnosis of vascular nasal formations.
This case describes its application in the management of a patient with a highly vascularised nasopharyngeal lesion.
2
Case report
A 68-year-old male patient was brought to our attention because of a left nasopharyngeal lesion that had elsewhere been unsuccessfully biopsied with conspicuous epistaxis requiring admission to an emergency department, posterior nasal packing, and an imaging assessment. In particular, contrasted maxillo-facial magnetic resonance imaging (MRI) documented the presence of an expansive formation arising from the posterior septal wall and occupying the nasopharynx, characterised by a hypointense signal in T1- and T2-weighted sequences, and showing enhanced and diffuse contrast uptake. Maxillo-facial computed tomography (CT) disclosed any sinus involvement or bony erosions ( Fig. 1 ).
During the clinical examination, the patient reported that he had suffered from chronic left nasal obstruction, anterior siero-mucosal rhinorrhea and recurrent bleeding since adolescence. Flexible WLI fibre endoscopy revealed a reddish polypoid mass, covered with crusting mucosa occupying the lower and middle portion of the left nasal fossa and extending into the nasopharynx the posterior aspects of the inferior and middle turbinates could not be clearly identified. NBI performed with a high-definition videoendoscopy system (CLV-S40 light source OTV-S7 processor; optical magnifying endoscope ENF-VT2 videoendoscope; Olympus Optical Co., Ltd., Tokyo, Japan) showed an increased vascular pattern with elongated, dilated and worm-like venous vessels covering the whole mucosal surface, but no brownish areas or intra-papillary capillary loops and spots indicative of malignancy ( Fig. 2 ).
Selective angiography through the left external carotid artery was used to evaluate the vascular network, showing a supply by the homolateral sphenopalatine artery. The neoformation was therefore embolised through the left maxillary artery using 150–250 μm Contour embospheres (BioSphere Medical Inc., South Jordan, Utah) 24 h before surgery without any untoward effect ( Fig. 3 ).
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