Angiectatic Nasal Polyp - The Great Imitator

摘要

Introduction: Angiectatic nasal polyps are a rare and distinct type of inflammatory sinonasal polyp, which can clinically and radiologically mimic a sinonasal neoplasm. We describe a unique case of an angiectatic nasal polyp in an 80 year old lady presenting with recurrent epistaxis and radiological features suggestive of an inverted papilloma.Management: Initial biopsies proved inconclusive. Complete resection was performed through an endoscopic medial maxillectomy approach based on the suspicion of an inverted papilloma. Initially, the histopathology was reported as an inflammatory polyp but this was subsequently revised to an angiectatic nasal polyp. Histopathology Findings: A well-defined polyp with stromal degenerative hyaline change, stromal haemorrhage and telangiectasia, lined by flattened surface epithelium.Conclusion: Angiectatic nasal polyps are a rare pathological entity and as such can cause a significant diagnostic dilemma as illustrated in this case. Therefore, an awareness of different clinical presentations and distinct histopathological features is important in establishing an early definitive diagnosis. Furthermore, there is little precedent in the literature to guide management in such a case, and we therefore consider this report to be noteworthy and instructive in this respect. Introduction Angiectatic nasal polyps, also known as angiomatous nasal polyps, are rare and only account for approximately 5% of all inflammatory sinonasal polyps.1 Indeed only a very small number have been reported within the literature to date. These polyps present in a myriad of ways, often simulating other pathologies including malignancy.We present the case of an 80 year old patient presenting with a unilateral nasal mass and epistaxis in whom the radiological findings were initially suggestive of an inverted papilloma, but the histopathological findings subsequently revealed an angiectatic nasal polyp. Case report An 80 year old lady presented to accident & emergency (A&E) with a 5 week history of recurrent epistaxis. Inability to control the bleeding with conservative measures during the presenting episode led to anterior nasal packing by the referring ENT unit. Her co-morbidities included hypertension which was well controlled with anti-hypertensives, and previous transient ischaemic attacks for which she was on Aspirin.On admission bilateral nasal packs were in situ, and there was no active bleeding. The patient was admitted for observation. On removal of the packs 48 hours later the bleeding recurred. A bedside rigid endoscopy performed to identify the cause of intractable epistaxis revealed a polypoidal mass filling the posterior half of the nasal cavity and extending into the middle meatus. An examination under general anaesthetic was therefore undertaken where the mass was biopsied and cautery applied to the bleeding surface. After a further 24 hour period of observation, the patient was discharged and a computed tomography (CT) scan of the sinuses arranged as an outpatient to assess the extent of the pathology.The initial biopsy results proved inconclusive with features of an organising thrombus. The CT scan revealed a completely opacified right maxillary antrum , with the antral disease being contiguous with further soft tissue thickening within the right nasal cavity and enveloping middle and inferior turbinates (Fig 1).