Case Study - Nasal obstruction: a sinister cause

Dr Bhavna Batohi and Dr Jack Hickey investigate a sinister cause of nasal obstruction.

Tumour: marked destruction (Photograph: Author image)
Tumour: marked destruction (Photograph: Author image)

A 47-year-old male smoker presented with eye watering, rhinorrhoea and nasal obstruction. He had no significant medical or family history and was not taking any medication.

A soft, smooth left nasal polyp was seen on examination and he was commenced on oral steroids and antibiotics for symptoms suggestive of frontal sinusitis. These initially improved his symptoms.

Worsening symptoms

Five days later he presented with expressive dysphasia, worsening headache, and bilateral extensor plantar responses and brisk reflexes.

CT and MRI scans showed a 5cm extra-axial mass displacing the left frontal lobe, extending inferiorly, destroying the left ethmoid sinus and filling the nasal cavity.

The patient was referred to neuro-oncology and underwent a left frontal craniotomy and debulking of the mass. A diagnosis of primary undifferentiated sinonasal carcinoma was made.

Sinonasal undifferentiated carcinomas (SNUC), which originate in the superior nasal cavity and paranasal sinuses,1 are highly aggressive and are often already metastasised at presentation.

The mean age of presentation is 55-60 years and there is a male:female predominance of 2-3:12. Clinical features include olfactory loss, bloody rhinorrhoea, visual changes, unilateral nasal obstruction, headache and facial pain.2

Patients frequently present with locally advanced disease. SNUC can affect several sites within the sinonasal tract, most commonly the nasal cavity, maxillary sinus and ethmoid sinus.3

This tumour exhibits marked destruction and direct spread.3 It is common for cranial nerves to be involved so neurological examination is also necessary.

SNUC requires aggressive treatment with surgery, chemotherapy and radiotherapy.2 Prognosis is poor, with less than 20% five-year survival.3

The sequence of the required multimodality treatment has yet to be determined but ideally should include platinum-based chemotherapy and surgery as a minimum.2

Red flags

Any unilateral nasal polyp should raise suspicion of a tumour affecting the sinonasal tract and should be referred for urgent specialist assessment.

Particular attention should be paid to patients with prolonged symptoms and those with red flags (hard fixed mass on examination, dysphagia, hoarse voice, olfactory loss and headache). In this case, the patient remains under regular review with the neurosurgical team, with good disease control after one year.

  • Dr Batohi is a radiology registrar at King's College Hospital, London; Dr Hickey is a GP in Ashford, Kent

References

1. Jones AV, Robinson I, Speight PM. Sinonasal undifferentiated carcinoma: report of a case and review of literature. Oral Oncol Extra 2005; 41(10): 299-302.

2. Enepekides DJ. Sinonasal undifferentiated carcinoma: an update. Curr Opin Otolaryngol Head Neck Surg 2005; 13: 222-5.

3. Thompson LDR. Sinonasal carcinomas. Curr Diagnostic Pathol 2006; 12: 40-53.

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