|Year : 2017 | Volume
| Issue : 1 | Page : 52-55
Organized hematoma of the maxillary sinus mimicking tumor
Jeong Hwan Choi
Department of Otorhinolaryngology Head and Neck Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Republic of Korea
|Date of Web Publication||6-Feb-2017|
Prof. Jeong Hwan Choi
Department of Otorhinolaryngology Head and Neck Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, 761-1 Sanggye-7-dong Nowon-gu, Seoul 139-707
Republic of Korea
Source of Support: None, Conflict of Interest: None
Sinonasal organized hematomas are rare, nonneoplastic, benign lesions that usually arise in the maxillary sinus. They are composed of neovascularization in a hematoma and surrounding organizing fibrotic tissue. Factors that may predispose a patient to hematoma formation are vary, and the pathogenesis of the mass is still uncertain. They have the potential for progressive bony erosion and compression of adjacent structures. They are a diagnostic dilemma clinically and radiologically mimicking benign diseases such as inverted papilloma or even malignant neoplasms and causing clinicians undue worry regarding these diagnoses.
Keywords: Maxillary sinus, organized hematomas, sinus tumor
|How to cite this article:|
Choi JH. Organized hematoma of the maxillary sinus mimicking tumor. Indian J Otol 2017;23:52-5
| Introduction|| |
Sinonasal organized hematomas (SOHs) are benign, nonneoplastic, hemorrhagic lesions. Since the first report of SOH in the Japanese literature in 1917, wherein it was called a “blood boil.” It had been described as a hemorrhagic, nonneoplastic mass causing mucosal swelling and bony destruction. The maxillary sinus has been the only sinus involved with this disease. To the best of my knowledge, there was only one case report of organized hematomas (OHs) before the 2000s in the English literature.
| Cases Reports|| |
A 74-year-old male with a history of hypertension, myocardiac infarction, and diabetes mellitus presented with worsening diplopia and left periorbital swelling, despite conservative management. He also complained of mucopurulent rhinorrhea, recurrent epistaxis, and nasal obstruction on the left side. On nasal endoscopic examination, the left lateral nasal wall was medially displaced toward nasal septum and blocked the nasal cavity completely. It was impossible to examine the nasal cavity and left maxillary sinus endoscopically further. Paranasal sinus (PNS) computed tomography (CT) with enhancement showed heterogeneous opacification associated with expansion of the left maxillary sinus and smooth bony dehiscence and remodeling of the walls of the maxillary sinus [Figure 1]. Caldwell-Luc approach in conjunction with endoscopic sinus surgery was used to gain wide exposure to excise mass totally and to control bleeding. After window was opened on the anterior wall of the maxillary sinus, a mass filled the entire maxillary sinus. The mass had a smooth surface and brownish-red looking. Intraoperative frozen biopsy revealed benign inflammation. During the dissection, the mass was broken into multiple pieces and organized blood was drained. The maxillary sinus mucosa was slightly edematous and kept in intact. There were no complications during and after the operation. Histopathologic examination of the mass revealed amorphous eosinophilic, relatively acellular fibrinous mass with erythrocytes in it [Figure 2]. In addition, marginal areas of the lesion showed fibrin deposition beneath the normal respiratory epithelium. The mass consisted of dilated vessels, hemorrhage, fibrin exudation, fibrosis, hyalinization, and neovascularization, without tumor cells.
|Figure 1: Paranasal sinus computed tomography with enhancement of Case 1 showing heterogeneous opacification associated with expansion of the left maxillary sinus and smooth bony dehiscence and remodeling of the walls of the maxillary sinus. Asterisk (*) indicating fluid collection caused by secondary obstruction (a: Axial, b: Coronal, c: Sagittal).|
Click here to view
|Figure 2: Histopathologic examination of the mass revealed amorphous eosinophilic, relatively acellular fibrinous mass with erythrocytes in it. In addition, marginal areas of the lesion showed fibrin deposition beneath the normal respiratory epithelium (a). The mass consisted of dilated vessels, hemorrhage, fibrin exudation, fibrosis, hyalinization, and neovascularization, without tumor cells (b).|
Click here to view
A 22-year-old male with a history of frequent visit for the left epistaxis presented for left cheek pain and swelling. He also complained of left nasal obstruction. On nasal endoscopic examination, the left lateral nasal wall was found to be medially displaced toward nasal septum and blocked the nasal passage completely. PNS CT with enhancement showed heterogeneous opacification associated with expansion of the left maxillary sinus, bony defect, and remodeling at the posterior wall of the maxillary sinus [Figure 3]. In the magnetic resonance imaging (MRI) [Figure 4], multiloculated bright signal portion was seen at the left maxillary sinus on T2-weighted images. The surrounding mucosa is well enhanced on T1-weighted images with contrast. It suggests the inflammatory change due to the obstruction by the lesion. The mass was totally removed by Caldwell-Luc approach in conjunction with endoscopic sinus surgery. Postoperative course was uneventful. Histopathologic report of the mass was as same as Case 1.
|Figure 3: Paranasal sinus computed tomography with enhancement of Case 2 showing heterogeneous opacification associated with expansion of the left maxillary sinus, bony defect, and remodeling at the medial and posterior wall of the maxillary sinus (a: Axial, b: Coronal plane).|
Click here to view
|Figure 4: Magnetic resonance imaging of Case 2 showing biphasic appearance of centrally multiloculated bright signal portion at the left maxillary sinus and heterogeneous but predominantly intermediate T1 signal intensity (a) and high T2 signal intensity with a thin hypointense peripheral rim (b). (c and d) The surrounding mucosa is thickened and well enhanced on T1-weighted images with contrast (a and b; T1- and T2-weighted axial image, c and d; T1-weighted coronal and axial image with contrast [gadolinium]).|
Click here to view
| Discussion|| |
SOH has had many different terms such as blood boil, OH, organizing hematoma, hematoma-like mass, hematoma mimicking tumor  hemangioma, inflammatory pseudotumor, and hemorrhagic pseudotumor.
Although the precise etiology of SOH is unclear, a bleeding diathesis, aggressive fungal infection, radiation therapy, postoperative complication, or trauma are potential causes of a similar condition., The histopathologic findings showed excessive endothelial proliferation with adjacent subacute and chronic hematoma and surrounding fibrous tissue margin [Figure 3]. A possible mechanism for the formation of SOH has been suggested, according to this theory. The fibrous capsule impedes resorption of the hematoma and induces neovascularization, which in turn promotes recurrent intracapsular rebleeding and increasing pressure within the hematoma. This sequence of events accounts for progressive expansion, with demineralization of adjacent bony structures.
Approximately 70% of patients with SOH present with recurrent episodes of epistaxis. Other presenting symptoms include progressive cheek swelling and unilateral nasal obstruction. Physical examination often reveals medial displacement of the lateral nasal wall, proptosis, and hypoesthesia in the distribution of the second division of the trigeminal nerve. Furthermore, locally aggressive behavior caused by increasing pressure within the hematoma can lead to erosion of the sinus walls, thus making differentiation from the locally aggressive lesion difficult on the clinical basis alone.
Preoperative diagnosis of SOH is important to avoid unnecessary extensive surgery because this condition is curative with a simple, conservative surgical approach  and rarely recurs.
Concerning the preoperative evaluation with PNS CT and MRI, several characteristic image findings are found in this lesion as follows. First, it is an expansile, clearly demarcated, heterogeneously centrally enhanced mass., The existence of blood with a low flow speed and neovascularization was therefore considered at the central region, which matched the presence of a hematoma in the pathological findings. A marked irregular, nodular, papillary, or frond-like enhancement at the area of neovascularization is also a typical finding. Meanwhile, the peripheral part was less enhanced, which was matched the zone of fibrosis. As described by Song et al., a surrounding hypointense peripheral rim was also demonstrated on T2-weighted images in all of the lesions, which corresponded histologically with an attenuated fibrous pseudocapsule. Such biphasic appearance is therefore an important imaging aspect of this lesion to cite as a differential diagnosis before deciding on the treatment strategy. Second, it is compressive lesion causing bony thinning or erosion. However, it is never destructive as seen in malignancy. The fact that bone destruction was not particularly extensive considering the size of the masses suggests that this finding is important in differentiating SOH from a malignant mass., Third, the MRI shows thickening of the PNS mucosa of its surroundings. MRI was superior to CT for determining the margin and extent of the lesion. The surrounding mucosa is well enhanced on T1-weighted images with contrast and high intensity on T2-weighted images. It suggests the inflammatory change due to the obstruction by the lesion. The opacities of the adjacent PNS caused by secondary obstruction and inflammation could be differentiated easily from the lesion on T2-weighted MRI [Figure 4]. These points differ from a malignant tumor that causes the invasive bone destruction and mucosal invasion.
Therefore, SOH must be included in the differential diagnosis when a patient with an enlarging maxillary mass is evaluated. My cases highlight the importance of clinical suspicion in the evaluation of a patient with an enlarging maxillary mass. In addition to OH, there is a long list of the differential diagnoses of a unilateral mass in the sinonasal cavity detected on CT and MR images.
Benign conditions that may be considered in the differential diagnosis of a soft-tissue mass in the maxillary sinus in a pediatric patient include antrochoanal polyp, hemorrhagic polyp, inflammatory polyp, pseudotumor secondary to inflammation, fungus ball, cholesterol granuloma, mucocele, and neoplastic lesion such as inverted papilloma, odontogenic tumor, minor salivary gland tumor, juvenile angiofibroma, and hemangioma.,,, Administration of contrast material is extremely useful because mucocele, fungus ball, inflammatory polyp, and cholesterol granuloma do not usually enhance.
Because mucocele, fungus ball, and cholesterol granuloma do not usually enhance and inflammatory polyps do not show central enhancement, they can be easily differentiated from an OH.
Malignant lesions that may be also considered in the differential diagnosis for a soft-tissue mass in the maxillary sinus in a pediatric patient include squamous cell carcinoma, undifferentiated carcinoma, rhabdomyosarcoma, adenocarcinoma, fibrosarcoma, melanoma, and lymphoma.,,
OH of maxillary sinus can be misdiagnosed as malignancy because it can present as a huge mass with bony destruction. If there is bony destruction but the pathology result is negative, thus making malignancy unlikely, high clinical suspicion is needed to avoid excessive surgical approaches. Carcinoma occurring in the sinonasal cavity commonly shows frank bony destruction associated with adjacent tissue invasion, rather than smooth erosion of the sinus walls. The presence of an intact sinus mucosa separating the lesion from the areas of bony demineralization and well-defined margins of the lesion on MR images in this patient was particularly suggestive of a chronic pressure-induced process.
Correct diagnosis of OH is even confused in the pathologists. Histologically, fibrosis, hematoma, neovascularization, and no evidence of neoplasm are the necessary components of a diagnosis of OH. Careful investigation of all aspects of the mass is important, otherwise otolaryngologists, radiologists, and pathologists can misdiagnose this disease.
An expansile soft-tissue mass, smooth sinonasal wall dehiscence, marked heterogeneous signal intensity with a hypointense peripheral rim on T2-weighted MR images, and irregular nodular, papillary, or frond-like enhancement are characteristic CT and MRI findings of SOH.,, Although uncommon, SOH should be included in the differential diagnosis in a young patient with recurrent epistaxis and a sinonasal mass that exhibits the appropriate imaging findings. SOH can be cured with a conservative surgical approach and rarely recurs.,
| Conclusion|| |
It is important to include SOH in the differential diagnosis of an expansile, hemorrhagic maxillary sinus mass so that inappropriate surgery can be avoided. However, SOH can be mistaken for malignant tumors because of their potential for progressive bony erosion and compression of adjacent structures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yagisawa M, Ishitoya J, Tsukuda M. Hematoma-like mass of the maxillary sinus. Acta Otolaryngol 2006;126:277-81.
Ozhan S, Araç M, Isik S, Oznur II, Atilla S, Kemaloglu Y. Pseudotumor of the maxillary sinus in a patient with von Willebrand's disease. AJR Am J Roentgenol 1996;166:950-1.
Kim EY, Kim HJ, Chung SK, Dhong HJ, Kim HY, Yim YJ, et al.
Sinonasal organized hematoma: CT and MR imaging findings. AJNR Am J Neuroradiol 2008;29:1204-8.
Unlu HH, Mutlu C, Ayhan S, Tarhan S. Organized hematoma of the maxillary sinus mimicking tumor. Auris Nasus Larynx 2001;28:253-5.
Tabaee A, Kacker A. Hematoma of the maxillary sinus presenting as a mass – A case report and review of literature. Int J Pediatr Otorhinolaryngol 2002;65:153-7.
Lee PK, Wu JK, Ludemann JP. Hemorrhagic pseudotumour of the maxillary sinus. J Otolaryngol 2004;33:206-8.
Lee HK, Smoker WR, Lee BJ, Kim SJ, Cho KJ. Organized hematoma of the maxillary sinus: CT findings. AJR Am J Roentgenol 2007;188:W370-3.
Song HM, Jang YJ, Chung YS, Lee BJ. Organizing hematoma of the maxillary sinus. Otolaryngol Head Neck Surg 2007;136:616-20.
Nishiguchi T, Nakamura A, Mochizuki K, Tokuhara Y, Yamane H, Inoue Y. Expansile organized maxillary sinus hematoma: MR and CT findings and review of literature. AJNR Am J Neuroradiol 2007;28:1375-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]