Excission of Nasal Septum Hemangioma with Endoscopic Approach

Budi Santoso, Ferryan Sofyan

Introduction

There are intranasal mass that have to be differentiated from tumor or inflamation
process. Intranasal tumor such as intranasal papiloma, capilary hemangioma, osteoma,
squamous cell carcinoma, melanoma and angiosarcoma. Other than that intranasal
mass due to inflamation process, present in sarcoidosis and wagener syndrome cases. 1
Whereas, in children we have to think that intranasal mass maybe a foreign body in
nasal cavity which has similar clinical symptom as hemangioma.2

For head and neck region, hamangioma is a benign vascular tumor commonly
found. Sixty percent of the benign tumor develop in the head and neck region whereas
30% hemangioma occur in newborn.3,4 More than 70% hemangioma undergo
regression at the age of 7.5

Commonly hemangioma happen at body parts which can easily susciptable to

trauma, such as upper and lower extremities. In rare cases hemangioma can be found
in gingiva. Hormonal factor also play an important role in gingiva hemangioma, which
can be seen granuloma gravidarum.1

The etiology of hemangioma still unknown, same as etiology of hemangioma in

head and neck region. Hence, hemangioma in head and neck is suspected as a
congenital anomali or there is history of head and neck trauma.6

Intranasal or paranasal sinus hemangioma is a rare cases yet it may cause

serious problems. Patient may came with nasal bleeding or recurent epistaxis. 1
Epistaxis and nasal obstruction are the common complaint of the patient with intranasal
hemangioma.7 Stamataki (2008), reported intranasal hemangioma case with severe
clinical symptom such as fullfil nasal cavity and paranasal sinus with hemangioma
mass, and effect cranial nerve function.6

The therapy for hemangioma still controversial issue. The old extranasal
approach has been replace with endoscopy approach. At the last decade endoscopy
approach has prove to be a good approach to remove benign tumor such as inverted
papiloma, blood vessel lession, fibroosseus tumor, pleomorphic adenoma, glioma and
schwannoma.8 In some cases, this operation technicque can be used to remove the
entire tumor, reduce treatment period in hospital, less lost of blood and a cleare
visualisation of the tumor.4,8

1
Case report

A 30 years old female (Mrs. R) came to ENT clinic at Adam Malik hospital on 21 st
April 2015 with chief complaint of reccurent nasal bleeding from her right nose since 2
years ago. Previosly patient having a normal activity in her home, suddenly she found
out nasal bleeding from right nose, more or less 1 table spoon of blood. Then, the
patient went to nearby clinic for treatment. The nasal bleeding stop without treatment
spontenously.

The patient also went for treatment at Haji hospital with a same complaint 3
month ago. Hence, FNAB examination was taken from nasal septum mass. The FNAB
result is hemangioma, but the patient discontinue for further treatment.

History of exterior nasal trauma or interior nasal trauma denied by patient. Nasal
obstruction and rhinorea was not found. History of reccurent sneezing during cold
climate or contact with dush, post nasal drip denied by patient.

Tinnitus and double vision was not found. History of hipertention, trauma,
difficulty in breathing, hoarseness, mass in the neck was not found. The is no loss of
weight since the patient sick. The patient is a housewife and there is no history of other
illness previously. There is no history of malignancy disease in her family.

On physical examination, current condition is good, fully allert, cooperative and

there is no fever.

There is no deformity in external nose, nasal mass, deformity in cheek on the

external nose examination. On the anterior rhinoscopy and nasal endoscopy, in the right
anterior nasal septal found mass which can easily bleed and the diameter of the mass is
1x1x0,5 cm. inferior and media turbinate was normal and there is no septum deviation
was found. Left nasal cavity also normal, the inferior and media turbinate was normal.

Fig. 1 A mass was found on the right anterior nasal septum with 1x1x0,5cm in size

2
 There is no abnormalities in ear and throat examination. There is no palpable
lymph node swelling in the neck region.

From the clinical findings, the patiens was diagnose as right nasal septum
hemangioma. The patient wil undergo surgery to remove the hemangioma mass with
endoscopic approach and with general anesthesia on 30th april 2015. The laboratorium
examination and thorax x-ray shows normal finding.

During the surgery we perform a nasoendoscopy examination on the right nasal

cavity with 0° telescope guidance. A mass was found on the nasal septum with
1x1x0,5cm in size, oedem on the inferior and medial turbinate, on left nasal cavity
oedem of the inferior and medial turbinate. Hance, an adrenaline tamponade was
placed in right nasal cavity with the ratio of 1:4 and the tamponade was left for 15
minutes. After 15 minutes the tamponade was removed. On the right nasal cavity with
0° telescope guidance, pehacain injection was injected at the tip of septum, right after
the lower septum. Injection was injected slowly with a stable pressure, which cause
seperation of mucosa from layer of cartilage. Hemitransfication incission on anterior
septum. Using freer device, blunt dissection between septal cartilage and perichondrium
was performed and afterwards mass excision within the septal mucosa was conducted
towards the tumor free margins. After the mass was removed entirely, control of
bleeding was conducted, there is minimal bleeding, then anterior tamponade was
inserted and the surgery is done.

Fig 2 excised specimen of the lesion

The histopathologic finding reveled vascular proliferation filled with erythrocytes

and also fibrous connective tissue and interstitial bleeding, under the impression of
hemangioma.

3
Discussion

Hemangioma are benign slow-growing vascular neoplasms. They are classified

as either capillary, cavernous or mixed. Although hemangioma are commonly found in
the head and neck, hemangiomas of the nasal cavity and paranasal sinuses are
relatively uncommon with only a few case report in the literature. Clinically, its main
complaints include nasal obstruction and nasal bleeding.9

The hemangioma in the nasal cavity is commonly occurs in the anterior nasal
septum in Little’s area because the area has a rich blood vessel distribution and is
largely exposed to repeated digital trauma.6

There has been reported one case 30 years old female with nasal septum
hemangioma. Citied from Bailey, most of hemangioma cases was reported occur in
female compare to male with the ratio of 6:1.4 Although hemangioma can occur in all
age group, but most commonly occur at 3rd or 4th decade of life.2 Moreover, Lee et al
reported hemangioma in nasal cavity happens inbetween 3 rd to 5th decade.10 In this
case, its happen in the 3rd decade.

Hemangioma in the region of head and neck is a rare case. Stamataki et al

reported in Johns Hopkins Hospital inbetween 1980 to 2003, there is 23 cases of
hemangioma in head and neck region. From 23 cases of hemangioma only 1 case
reported as intranasal hemangioma.6

In nasal cavity, the clinical sign of hemangioma commonly found as nodule with
variety of size 1-8cm. hemangioma not only found in nasal septum but also can be
found on the lateral wall of nose and nasal vestibuli. sometimes it is spreading out to the
surrounding area of the nasal cavity to invade neighboring structure.11

Recurent nasal bleeding and nasal obstruction is a common clinical symptom of

intanasal hemangioma.4 Citied from Nadev, unilateral nasal bleeding is common
symptom complaint by patient which is 93% and nasal obstruction around 35%. 11 In this
case patient complaint recurrent nasal bleeding last 2 years.

Usually hemangioma does not required immidiate treatment. About 20-40%

hemangioma patient who have been treated with surgical treatment can suffer from
recurrent hemangioma.11 The recommendation for surgical treatment only when
hemangioma interfere with function and for estetic purpose.11

In the intranasal or paranasal sinus hemangioma, the external approach usually

conducted to control on bleed during the surgery. Hance, access to removal of entire
tumor would be easy. Disadvantage of endoscopy approach is due to difficulty in
controling bleeding, which make difficulty to determine tumor border. But with an

4
adequate and a good control of bleeding during surgery, the endoscopic approach in
intranasal hemangioma can be successful.12

Various treatment modalities have been described for this condition like
intralesional injection, laser, but surgical excision under endoscopic control remains the
treatment of choice.13 Surgical treatment with endoscopic approach have to be
considerated for cases which has clinical symtom, history of previous illness, size and
location of hemangioma. In this case the patient treated with a surgical intervention with
endoscopic approach.14

Conclusions

We have reported a rare case of hemangioma nasal septum in 30-year-old

woman and she was treated with a surgical intervention with Endoscopic approach.
After intervention we performed, pasient had satisfied result.

5
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