xRead - Nasal Obstruction (September 2024) Full Articles

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lesion. Local trauma and hormonal influences have been proposed as possible etiologies. 817–819 Most commonly occurring around the fifth decade of life, about 80% arise from the anterior nasal septum (Little’s area), 15% from the lateral nasal wall, and 5% from elsewhere within the sinonasal cavity. 817–820 The most common presentation is epistaxis; how ever, the patient may also experience nasal obstruction, facial pain and/or pressure, and rhinorrhea as the lesion grows. 815,817–819,821 As exam findings may be difficult to discern from other lesions, frozen section at the time of planned resection is commonly recommended in lieu of in-office biopsy. Imaging can help determine the size of the lesion as well as possible involvement of adjacent structures. 821 CT may also delineate any bone destruction and show evidence of calcified thrombus (phleboliths). On MRI, hemangiomas tend to vividly enhance with gadolin ium on T1-weighted images and demonstrate flow-voids on T2-weighted images, suggesting vascularity. 821 The treatment for sinonasal hemangiomas is com plete surgical excision. Recent technological advances in endoscopic endonasal treatment have demonstrated favor able outcomes and less morbidity with this approach, as compared to open techniques. 815,816,819,822,823 To facili tate resection, some surgeons advocate for preoperative embolization for larger tumors, but this is not always necessary. 818,819 Other interventions, including laser and medical treat ment including bevacizumab and intralesional steroids, have been reported with success. 817,824,825 Overall, these treatments are considered nonstandard, and studies are limited to case reports and small series. The current evidence indicates that surgical excision is safe and effective, with low recurrence rates. A study of 37 patients showed no major complications, but two patients had recurrence at 4 and 60 months. 815 In a similar study of 14 patients, there were no major complications or recur rence at 59.9 ± 44.7 months. 816 Lastly, Smith et al. reported a series of 34 patients with a mean follow-up time of 58.6 months and found 13 patients recurred, the majority of which (7/13) underwent incisional biopsy only. 820 Collec tively, these data indicate seemingly low recurrence rates, though complete extirpation may increase the likelihood of long-term control. Additional study is needed to bet ter understand the risks of recurrence and the associated factors. Table XVII.B.1 summarizes evidence surrounding hemangioma. 2 Arteriovenous malformations Arteriovenous malformations (AVMs) are vascular mal formations that can occur in the head and neck region.

Most of these lesions involve the skin and are in the mid face region with infrequent involvement of the nasal cavity or sinuses. 826–828 These lesions do not typically involute and approximately 35% will involve bone. 829 These lesions can result in massive bleeding after what would otherwise be minor or innocuous trauma (e.g., tooth extraction). 830 AVMs can be congenital or acquired, and when acquired they can be associated with surgery or blunt trauma. Sev eral molecular pathways have been associated with AVMs and include alterations within PIK3CA and RAS signal ing pathways, as well as mutations in the MAP2K1 gene. 831 Ultimately, these alterations result in changes within vas cular growth factor-directed angiogenesis causing aberrant arteriovenous channels that communicate with each other. The presentation of AVMs can vary based on the anatomic site, size, and propensity for trauma or manipu lation to the area. The lesions are typically slow growing and can be associated with spontaneous bleeding (e.g., epistaxis). Patients may report nasal obstruction, pulsat ing sensations, and pain. Smaller lesions located within a paranasal sinus could be asymptomatic and incidentally identified on radiographic imaging for other purposes. Diagnosing AVMs includes a comprehensive history and physical examination. On examination, a raised, red, and often-pulsating lesion can be identified on anterior rhinoscopy or nasal endoscopy. Evidence of current or recent bleeding may be noted, and some authors have advocated consideration of needle aspiration to differen tiate vascular lesions from those that are inflammatory in nature. 832 However, most authors report utilization of radiographic imaging including CT and MR as the initial complementary imaging modalities of choice. 833 Com mon findings on CT include a multilobulated lesion with bone changes, and subsequent contrasted imaging on MRI reveals avid enhancement and a heterogenous-appearing soft tissue mass. Subsequent magnetic resonance angiogra phy (MRA) or computed tomographic angiography (CTA) is then indicated, with MRA considered the most informa tive. Published data regarding optimal treatment strategies for AVMs are limited to retrospective case reports only, and therefore clinical decisions are mostly informed by experience with other vascular anomalies. 826–834 A com bination of intra-arterial angiography with embolization followed by complete surgical excision is the strategy most commonly reported. Embolization alone and emboliza tion followed by curettage have been associated with higher risks of recurrence in several case reports, and most argue for embolization and complete surgical resec tion when feasible. Published reports describe a variety of surgical approaches including craniofacial, transfacial, transcranial, and endoscopic endonasal depending on dis ease extent and location. Most recent reports advocate