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Incidental Nasal Cavity Mass Identified During Preoperative Examination for Transsphenoidal Surgery

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An 80-year-old man with acromegaly due to a hypoenhancing pituitary microadenoma opted for transsphenoidal resection. Preoperative magnetic resonance imaging examination of the sella revealed a left-sided pituitary microadenoma (Figure, A) and lobulated polypoid soft tissue masses in the superior nasal cavities arising from the olfactory clefts. These lesions demonstrated avid post–contrast enhancement with small areas of cystic change and heterogeneously hyperintense T2 signal. There was mild widening of the olfactory clefts, particularly on the left side (Figure, B). The intervening nasal septum was intact, and there was no intracranial extension. The patient did not have any noteworthy rhinological symptoms on review. He later underwent nasal endoscopy, and results showed tan-colored polypoid lesions emanating from the olfactory clefts of both nasal cavities (Figure, C). Biopsy findings revealed submucosal proliferation of seromucinous and respiratory epithelial glands (Figure, D).

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D. Nasal cavity hamartoma

There are 2 types of sinonasal hamartomas identified on histopathologic analysis: respiratory epithelial adenomatoid hamartoma (REAH) and seromucinous hamartoma. The latter of these is included as a new entity in the fourth edition of WHO Classification of Head and Neck Tumours.1 These lesions are described as respiratory epithelial lesions in the current classification. It is difficult to differentiate the 2 types using histopathologic, endoscopic, or imaging analysis, and they are believed to represent a spectrum. Recently, a possible new subtype containing olfactory neuroepithelial cells was also described.2 It is still unclear whether these sinonasal lesions represent nonneoplastic lesions (hamartomas) or true benign neoplasms. Ozolek and colleagues3 demonstrated significant allelic loss in REAH, which raises the possibility of these being true neoplasms.

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Article Information

Corresponding Author: Joseph H. Donahue, MD, Department of Neuroradiology, University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22908 (jd2uc@virginia.edu).

Published Online: May 16, 2019. doi:10.1001/jamaoto.2018.3983

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Thompson  LDR, Franchi  A.  New tumor entities in the 4th edition of the World Health Organization classification of head and neck tumors: nasal cavity, paranasal sinuses and skull base.  Virchows Arch. 2018;472(3):315-330. doi:10.1007/s00428-017-2116-0PubMedGoogle ScholarCrossref
2.
Kossai  M, El Zein  S, Wassef  M,  et al.  Olfactory epithelial hamartoma: a new subtype of sinonasal hamartoma.  Am J Surg Pathol. 2018;42(1):9-17.PubMedGoogle Scholar
3.
Ozolek  JA, Hunt  JL.  Tumor suppressor gene alterations in respiratory epithelial adenomatoid hamartoma (REAH): comparison to sinonasal adenocarcinoma and inflamed sinonasal mucosa.  Am J Surg Pathol. 2006;30(12):1576-1580. doi:10.1097/01.pas.0000213344.55605.77PubMedGoogle ScholarCrossref
4.
Rom  D, Lee  M, Chandraratnam  E, Chin  R, Sritharan  N.  Respiratory epithelial adenomatoid hamartoma: an important differential of sinonasal masses.  Cureus. 2018;10(4):e2495.PubMedGoogle Scholar
5.
Huang  YW, Kuo  YJ, Ho  CY, Lan  MY.  Sinonasal seromucinous hamartoma.  Eur Arch Otorhinolaryngol. 2018;275(3):743-749. doi:10.1007/s00405-018-4885-8PubMedGoogle ScholarCrossref
6.
Tong  KN, Serra  RM, Shih  RY, Foss  RD.  Seromucinous hamartoma of the nasal cavity [published online March 28, 2018].  Head Neck Pathol. doi:10.1007/s12105-018-0914-6PubMedGoogle Scholar
7.
Lorentz  C, Marie  B, Vignaud  JM, Jankowski  R.  Respiratory epithelial adenomatoid hamartomas of the olfactory clefts.  Eur Arch Otorhinolaryngol. 2012;269(3):847-852. doi:10.1007/s00405-011-1713-9PubMedGoogle ScholarCrossref
8.
Hawley  KA, Ahmed  M, Sindwani  R.  CT findings of sinonasal respiratory epithelial adenomatoid hamartoma: a closer look at the olfactory clefts.  AJNR Am J Neuroradiol. 2013;34(5):1086-1090. doi:10.3174/ajnr.A3345PubMedGoogle ScholarCrossref
9.
Chambers  KJ, Sedaghat  AR, Roberts  DS, Caradonna  DS.  Nasal obstruction and anosmia.  JAMA Otolaryngol Head Neck Surg. 2013;139(8):851-852. doi:10.1001/jamaoto.2013.3823PubMedGoogle ScholarCrossref
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