K. Christopher

When presented with the prospect of evaluating a patient whose chief complaint is “nasal mass,” a wide variety of considerations come into play, each affecting the differential diagnosis and driving evaluation. Because many masses within the nasal cavity and sinuses are initially discovered incidentally during workup for other issues, or cause fairly nonspecific symptoms such as nasal airway obstruction, epistaxis, and hyposmia, many masses are identified late within their course. Facial distortion, nerve dysfunction, or evidence of bony destruction suggests more aggressive disease and is important to elicit for this reason. Once a nasal mass has been identified, the differential diagnosis is vast. Possibilities include anatomical variant (such as enlarged turbinate), congenital or developmental defect, result of traumatic injury, inflammatory/infectious mass, obstructive mass, and benign or malignant neoplasm. Often, thorough history and anterior rhinoscopic exam are sufficient to guide diagnosis. Rigid or flexible endoscopy can serve as a useful adjunct for posteriorly and superiorly based masses and in establishing the relationship between the mass and other structures. Radiographic investigation with computed tomography (CT), magnetic resonance imaging (MRI), or both may be of benefit in certain cases. This chapter is dedicated to the overall issues pertinent to the differential diagnosis of nasal masses.

Presentation

History: Key factors to consider:

Nerve dysfunction: Malignant neoplastic disease must be excluded if this is identified and not otherwise explained.

Serous middle ear effusion: Nasal masses that extend into the nasopharynx can physically obstruct eustachian tube outflow; unilateral middle ear effusion mandates investigation of the nasopharynx to rule out neoplasm.

Physical examination

Radiological evaluation

CT: A scan should be completed before biopsy unless a clear plane can be seen between attachment of the nasal mass and the skull base.

MRI: Enhancement can be affected by biopsy.

Differential Diagnosis of Intranasal Mass

Normal anatomy mimicking a mass: Enlarged or inflamed inferior turbinates can be mistaken for nasal masses; these are usually obvious to the specialist and will shrink with topical decongestion.

Anatomical variant

— Nasal septum

Maxillary crest: A maxillary crest gives the appearance of a prominence when quadrangular cartilage is completely off of the crest and protruding into one side.

Deviated nasal septum: Septal spurs or fractured cartilage can protrude unnaturally into the nasal cavity, giving the illusion of a nasal mass.

Concha bullosa: Extensive pneumatization of the middle turbinate can expand this structure and appear as a well-mucosalized, unilateral mass posterior and superior to the inferior turbinate.

Duplicate middle turbinate: This is a relatively rare anatomical variant resulting from atypical embryological progression from the ethmoturbinals to the turbinates.

Congenital/developmental

Glioma: Ectopic rest of glial tissue. Some can be visible outside the nasal vault, whereas others are located completely within the nasal cavity in the vicinity of the foramen cecum; usually well mucosalized, these do not expand with crying, although they may have a dural stalk.

Meningocele: Extensions of the meninges outside of the cranial vault. Without a history of trauma, meningoceles are often located in the area of the foramen cecum; these lesions do not contain neuronal or glial tissue and are usually well mucosalized; they may expand with crying.

Mucocele: Occurs as a result of entrapped, but productive, respiratory epithelium that continues to produce mucus and can deform or erode bony structures; usually covered with healthy mucosa.

Dermoid: Results from ectopic rests of ectodermal tissue; often associated with a draining tract and repeated infections; draining tracts can exit in the midline or in the medial canthal region.

Inflammatory/infectious

Rhinoscleroma: Infectious disease resulting from Klebsiella rhinoscleromatis. this is usually nasal, though it may involve the nasopharynx and larynx. The process may be suppurative, granulomatous (often at the mucocutaneous junction), or cicatricial in appearance, depending on the stage of disease. Lesions may extend to distort the external nasal pyramid. Mikulicz cells are organism-containing vacuolated histiocytes characteristic of rhinoscleroma.

Sarcoidosis: Granulomatous autoimmune disease associated with hilar lymphadenopathy; noncaseating granulomas on pathology; more common in females and African Americans; may be associated with cranial and peripheral neuropathies; commonly involves painful mucosal and submucosal granulomata with associated crusting.

Wegener granulomatosis: Autoimmune disease involving necrotizing granulomatous vasculitis; associated with lower airway disease and glomerular disease; nonspecific symptoms are common, though an ill-described “deep pain” of the nose below the bony/cartilaginous junction can be the presenting symptom.

Syphilitic gumma: Results from untreated infection with Treponema pallidum; may result in an intranasal plaque, extranasal plaque, erosive septal lesion, submucosal gummas, saddle nose deformity, or more severe architectural deformity of the nose.

Blastomycosis: Results from infection with Blastomyces dermatitides; nasal involvement may be verrucous, granulomatous, or erosive and is far less common than pulmonary and laryngeal forms; associated with residents of the Ohio and Mississippi river valleys as well as immuno- compromised individuals.

Pyogenic granuloma: Misnomer referring to a type of hemangioma; may cause nasal airway obstruction, epistaxis, or purulence.

Nasal polyp

Foreign body

Iatrogenic: Usually following surgery or office procedures; can be reactive or inert materials; often accompanied by fetid odor, purulence, and nasal obstruction.

Patient-placed: Most common among pediatric and developmentally disabled populations; often not visible using anterior rhinoscopy alone; note: disc batteries can have similar erosive effects in the nose as in the esophagus and require immediate removal.