The nasal cavity and paranasal sinuses (PNS) are anatomically complex regions that can harbor a variety of pathological masses. These may originate from diverse tissues such as epithelium, mucous glands, bone, salivary glands, nerves, or lymphatics. Among all sinonasal masses, approximately 60% arise from the maxillary sinus, 20% from the nasal cavity, and about 5% from the ethmoid sinus, while masses of frontal and sphenoid sinus origin are relatively rare (1). Unilateral sinonasal masses (SNMs) account for around 6% of all paranasal sinus pathologies (2).

SNMs may be congenital, inflammatory, or neoplastic. Inflammatory lesions such as nasal polyps are common, and while usually bilateral, a unilateral presentation necessitates thorough evaluation to rule out neoplastic causes. Chronic granulomatous infections such as rhinosporidiosis, mycosis, tuberculosis, or leprosy also fall under this category. Neoplasms may be benign (e.g., osteomas, inverted papillomas) or malignant (e.g., squamous cell carcinoma, lymphoma), with benign tumors being more common. (3-7)

Clinical presentation is often nonspecific—nasal obstruction or discharge—but late-stage disease may involve adjacent structures like the orbit or cranial cavity, causing visual changes, facial swelling, or neurological symptoms (3). Nasal endoscopy and imaging (CT for bony changes and MRI for soft tissue assessment) are essential for evaluating the extent of disease (4). Histopathological examination remains the gold standard for definitive diagnosis and management planning.

Unilateral sinonasal masses are frequently encountered in otorhinolaryngology. Though many resemble benign lesions such as nasal polyps, some may conceal aggressive or malignant pathology. Despite their clinical importance, there is a paucity of literature addressing the comprehensive clinicopathological features of these lesions. A structured study of their presentation, diagnosis, and histological spectrum can guide timely and appropriate treatment strategies, especially in a tertiary care setting where a wide spectrum of pathologies is encountered.

AIM AND OBJECTIVE

Aim:

To describe the clinicopathological profile of unilateral sinonasal masses in patients presenting to a tertiary care centre.

Objective:

To evaluate the demographic characteristics, clinical presentation, and histopathological diagnosis of unilateral sinonasal masses encountered at a tertiary care centre.

Study Design and Setting

This study was designed as a hospital-based descriptive study and was conducted in the Department of Otorhinolaryngology, Government Medical College, Thiruvananthapuram. The study focused on evaluating the clinicopathological features of patients presenting with unilateral sinonasal masses.

Study Population and Participants

The study population included all patients who presented with a unilateral sinonasal mass during the study period. Patients of all ages and both sexes who underwent complete evaluation and management for unilateral sinonasal mass at the department were considered eligible for participation. Patients who did not provide informed consent or those found to have anatomical variations such as concha bullosa or a deviated nasal septum mimicking a unilateral mass were excluded from the study.

Study Period

The study was conducted over a period of 18 months, commencing after obtaining ethical clearance from the Institutional Research Committee (IRC) and the Institutional Ethics Committee (IEC).

Sample Size Estimation

Sample size was calculated using the formula, n = [Z (1-α)]² pq / d²

The study used to calculate sample size was that by Shuaibu et al (9).

Z (1-α) value when α=0.05 is 1.96

p is the proportion of inflammatory nasal polyp among patients with unilateral sinonasal mass p=42.1 %

q = 100-p q=57.9%

d is absolute precision taken as 10, d= 10 Hence, sample size = (1.96)² x 42.1x 57.9

                    100

n = 93.64

Sample size = 95

Sampling Technique

A consecutive sampling technique was adopted. All eligible patients who met the inclusion criteria were recruited into the study until the desired sample size was achieved.

Study Variables

The variables included in the study were: sociodemographic characteristics (age, sex, occupation, socioeconomic status, addiction history), comorbidities (such as allergy, diabetes mellitus, hypertension, malignancy), presenting symptoms, clinical findings (rhinoscopy, probing of mass, endoscopy), radiological findings (CT/MRI), and final histopathological diagnosis.

Data Collection Tools and Techniques

A semi-structured proforma was used to collect all relevant data. After obtaining informed written consent, detailed history was taken and physical examination including anterior and posterior rhinoscopy and diagnostic nasal endoscopy was carried out. Where indicated, radiological imaging such as CT or MRI was done to assess lesion extent and tissue involvement. Patients were then posted for surgical intervention or biopsy under local or general anesthesia. The excised mass or biopsy specimen was sent for histopathological examination, and the diagnosis was recorded accordingly.

Data Analysis

Data were entered and organized using Microsoft Excel, and statistical analysis was performed using SPSS software version 27.0. Categorical variables were expressed as frequencies and percentages, while continuous variables were described using mean and standard deviation.

Ethical Considerations

The study was initiated only after obtaining approval from the Institutional Research Committee (IRC) and Institutional Ethics Committee (IEC). A detailed patient information sheet was provided, and informed written consent was obtained from all participants. No additional cost was incurred by patients for participating in the study. Confidentiality of personal information was strictly maintained, and participants retained the right to withdraw from the study at any stage. The data collected were used solely for academic and research purposes.

A total of 95 cases of unilateral sinonasal masses were evaluated in this study. The majority of patients were in the 30–39 years age group, with a male-to-female ratio of 1.4:1, indicating a slight male predominance.

Clinical Presentation

The most commonly reported symptom was nasal obstruction (89%), followed by nasal discharge (79%) and nasal bleeding (49%). Among facial and orbital symptoms, facial pain (17%) was most frequent, while vision loss (1%) was the least commonly observed.

Table 1: Clinical Symptoms Reported (n = 95)

Attachment Sites and Sinus Involvement

The middle meatus was the most common site of attachment in the nasal cavity, observed in 63% of cases. Septal attachment was seen in 25%, and floor of nasal cavity involvement was seen in 5%.

Table 2: Nasal Cavity Attachment Sites (n = 95)

The maxillary sinus alone was the most frequently involved sinus (52%), followed by maxillary and ethmoidal sinuses (29%), maxillary, ethmoidal and frontal sinuses (8%), ethmoidal sinus alone (6%), and all unilateral sinuses (5%).

Table 3: Sinus Involvement Patterns (n = 95)

Extension to Adjacent Structures

Out of the 95 cases studied, extension of the sinonasal mass to adjacent anatomical structures was observed in 9% of patients. The most common site of extension was into the orbit, noted in 7 patients (7.4%), followed by intracranial extension and oral cavity involvement, each seen in 3 patients (3.2%).

Table 4: Extension to Adjacent Structures (n = 95)

The majority of unilateral sinonasal masses in this study were benign in nature, accounting for 85% of cases. Malignant lesions constituted 13%, while premalignant lesions were relatively rare (2%).

Table 5: Nature of Lesions in Unilateral Sinonasal Masses (n = 95)

In the present study, the age group most frequently affected was 30–39 years (21%), with a mean age of approximately 44.7 years. This aligns with the findings of Adegbiji et al., who reported peak prevalence in the 31–40 age group. Among the 95 patients evaluated, there was a male predominance with 57 males and 38 females, yielding a male-to-female ratio of 1.4:1. Specifically, among the 12 malignant cases, the ratio increased to 5:1, indicating a stronger male predilection. Similar trends were observed in studies by Nair et al. (2:1) and Shuaibu et al. (1.9:1) [8,9]. This gender disparity in malignancy cases may be attributed to higher exposure to risk factors such as smoking and occupational hazards among males.

The most common symptom in our study was nasal obstruction (89%), followed by nasal discharge (79%). Nasal bleeding was reported in 83% of the malignant cases, which is consistent with findings by Lathi et al., (13) who observed that all malignant lesions presented with blood-stained discharge or intermittent epistaxis. A history of similar illness and previous surgery was documented in 22% of cases, with recurrence noted primarily in inverted papilloma (11%), followed by rhinosporidiosis (6.3%) and inflammatory polyps (4.2%).

Clinical examination with anterior rhinoscopy was effective in visualizing the lesion in 81% of patients, while diagnostic nasal endoscopy (DNE) identified the remaining 19% not seen on anterior examination. In terms of surface characteristics, smooth masses (primarily polyps) accounted for 50%, lobulated masses (mostly inverted papilloma) for 20%, and irregular masses (such as rhinosporidiosis and malignancies) for 30%. Regarding coloration, pale lesions (inflammatory polyps) were 32%, pink lesions (inverted papilloma and similar) were 35%, red lesions (rhinosporidiosis or haemangiomas) constituted 30%, and a single case of black mass was identified as malignant melanoma (1%).

Imaging played a critical role in evaluation. CT scans of the nose and paranasal sinuses were performed in 75% of cases. MRI was utilized in 7% of patients, particularly those with suspected involvement of adjacent structures. Radiological features such as bone expansion were seen in 8% of patients (2% benign, 6% malignant), while bone erosion was noted in 16% (6% benign, 10% malignant). In comparison, Nair et al. reported intrasinus densities in 17%, bone expansion in 32% (23% benign, 9% malignant), and bone erosion in 19% (8% benign, 11% malignant).

The middle meatus was the most frequent attachment site within the nasal cavity (63%), followed by the septum (25%) and floor of the nasal cavity (5%). Lathi et al. (13) similarly observed that 54.5% of lesions originated from the middle meatus, 16.1% from the lateral wall, and 10.7% from the superior meatus. In our cohort, 9% of cases demonstrated extension to adjacent structures, with orbital involvement in 7%, intracranial extension in 3%, and oral cavity involvement in 3%. This contrasts with Adegbiji et al., who reported orbital extension in 34%, intracranial in 12%, and orodental in 6%.(7)

In terms of pathology, 85% of cases were benign, 2% premalignant, and 13% malignant. Shuaibu et al. (9) found 82% benign and 18% malignant lesions, while Nair et al. (10) reported 91% benign and 9% malignant lesions. Belli et al. (11) noted an even higher proportion of benign lesions at 96%, with 4% malignancy among 195 patients. In our study, inflammatory polyps (32%) were the most common non-neoplastic lesion, followed by rhinosporidiosis (21%). Among neoplastic lesions, inverted papilloma (21%) was the most frequent benign tumor, and squamous cell carcinoma (5%) was the predominant malignant tumor.

Table 6: Comparison of Histological Distribution with Other Studies

Surgical intervention remained the mainstay of treatment. The most common procedures performed were FESS (32%) and excision with cauterization (32%). Inverted papilloma cases underwent endoscopic medial maxillectomy (17%) or pedicle-oriented sinus surgery (4%). ESS was used for one case of exuberant granulation, and medical therapy with antifungals was provided for a patient with entomophthoromycosis (1%).

Management of malignant lesions was multimodal. Adenoid cystic carcinoma cases underwent excision plus radiotherapy (2%), lymphomas were managed with chemotherapy, and rhabdomyosarcoma and HPV-related multiphenotypic carcinoma were treated with combined chemoradiotherapy (2%). Two cases of SCC received radiotherapy, while two additional SCC cases and a malignant melanoma patient were managed with palliative care (3%).

Adegbiji et al.(7) observed that 76.3% of their patients were managed surgically, 16.5% with surgery plus radiotherapy, and 7.2% with chemoradiotherapy. Across the literature, the trend remains consistent: benign lesions are predominantly managed surgically, while malignant tumors require adjuvant radiotherapy or chemoradiotherapy.

This study underscores the diverse clinical and pathological spectrum of unilateral sinonasal masses and emphasizes the importance of a vigilant and systematic diagnostic approach. While symptoms such as nasal obstruction and discharge are common, a unilateral presentation may conceal a premalignant or malignant lesion. Therefore, clinicians must approach all unilateral sinonasal masses with a high index of suspicion.

A comprehensive evaluation—combining clinical examination, nasal endoscopy, radiological imaging, intraoperative assessment, and histopathological analysis—is essential for accurate diagnosis and effective management. Among these, histopathological examination remains the gold standard for definitive diagnosis, guiding appropriate treatment and ensuring optimal patient outcomes.

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