Case Report

A Case of Nasal Cavity Hemangioma at the Nasolabial Fold: A Case Report

Seung Yup Son1https://orcid.org/0009-0003-0887-3498, Se Hyeon Jin1https://orcid.org/0009-0009-7932-7068, Kun Hee Lee1,*https://orcid.org/0000-0002-5380-3726
Author Information & Copyright
1Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
*Corresponding author: Kun Hee Lee, Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea, Tel: +82-2-440-6181, E-mail: nose4u@gmail.com

© Copyright 2023 xxxxxxxxxxxxxxx. This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: Aug 29, 2023; Revised: Sep 28, 2023; Accepted: Oct 10, 2023

Published Online: Dec 31, 2023

ABSTRACT

Hemangiomas of the head and neck region is known to be common, but rarely involves the sinonasal cavity, If it were to be found, most hemangiomas occur in the nasal septum or vestibule. We report a case of a 54-year old women with left nasolabial fold mass, which was diagnosed as nasolabial hemangioma. We present the clinical features, radiologic findings, and treatment of nasolabial hemangioma.

Keywords: Hemangioma; Nasolabial fold; Nasal obstruction

Introduction

Hemangiomas of the head and neck are known to be common, but they are found to be rare in the sinonasal cavity. Most of the sinonasal hemangiomas are capillary type hemangiomas and originate from the nasal septum or vestibule.1)

The authors report a case of a mass in the left nasolabial fold that was diagnosed as hemangioma after resection using trans-nasal approach along with a review of the literature.

Case

A 54-year-old female patient presented with a complaint of left sided nasal obstruction. The patient had no significant medical history other than the use of hormone medication. She had been experiencing nasal obstruction for a while, but experienced worsening one week ago. She denied any other symptoms such as rhinorrhea or epistaxis. Physical examination showed a soft mass about a size of 1.5×1.5 cm at the nasolabial fold area, which was palpable but no signs of tenderness. Endoscopic findings showed septal deviation to left and edematous changes at the nasolabial area (Fig. 1).

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Fig. 1. Endoscopic view showing bulging contour of left nasolabial fold area.
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To determine the location and extent of the lesion, contrast-enhanced paranasal sinus computed tomography was done. 1.3×0.9×1.3 cm sized heterogeneously enhancing mass was found at the nasolabial area. Surrounding bone erosion was observed and no calcifications were found within the lesion (Fig. 2). Considering the patient’s medical history and examination findings, possible benign soft tissue origin tumors such as nasolabial cyst or hemangioma were considered. Biopsy was performed during an outpatient visit which showed chronic inflammation. Prior to surgery, paranasal sinus magnetic resonance imaging (MRI) was done for additional evaluation of the mass. 1.3×0.9×1.3 cm sized, peripheral rim enhancing mass, surrounding bone remodeling was observed and no diffusion weighted image (DWI) restriction was seen. T2 weighted image showed a round mass with heterogenic signal intensity within the mass (Fig. 3). Based on these findings, nasolabial cyst and hemangioma were considered and a plan was made for left nasal mass removal by intranasal or sublabial approach.

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Fig. 2. Contrast-enhanced computed tomography axial view showing a heterogenous enhancing mass (1.3×0.9×1.3 cm) at left nasolabial angle with bone remodeling.
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Fig. 3. Contrast-enhanced MRI T2-weighted image showing peripheral rim enhancing mass (1.3×0.9×1.3 cm) at left nasolabial angle with bone remodeling. MRI: magnetic resonance imaging.
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After receiving the prescribed antibiotics after the biopsy performed on January 3rd, patient developed diarrhea and was admitted to the Department of Infectious Diseases and started oral vancomycin treatment. During hospitalization, diarrhea symptoms improved, so the patient transferred to the Otorhinolaryngology department on January 16th for surgery scheduled on the following day. The surgery was performed on general anesthesia using a trans-nasal approach. After making an incision at the left nasal floor mucosa, flap was raised and the mass was dissected. Mass was found to be adhered to the maxillary bone anterior nasal spine. After the removal of the main mass (Fig. 4), the remaining mass was completely excised using a debrider. Histopathological examination showed a mass mainly composed of vessels leading to the final diagnosis of hemangioma (Fig. 5). According to the Pathology department, the hemangioma subtype was not clearly able to be confirmed, however, the findings are consistent with characteristics resembling a venous hemangioma. The patient is currently under postoperative follow-up observation.

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Fig. 4. Gross finding of the lesion showing 1.0×0.7 cm sized mass.
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Fig. 5. Thick-walled vessels with red blood cells inside their lumens are seen (H&E) A. Magnified image showing red blood cells within vessel lumen (×200) B. Multiple vessels with red blood cells are seen (×100).
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Discussion

Hemangioma is the most common congenital benign tumor, over 50% cases occurring in the head and neck region.2,3) It is known to primarily occur congenitally, but can also be caused by errors in vascular formation, hemodynamic abnormality, and local trauma.4,5) Approximately 95% of cases develop within the first 6 months of birth, and undergo natural regression by the age of 12.6) However, hemangiomas persisting beyond that age are known to have difficulty undergoing natural regression.6) According to the WHO classification of hemangiomas, they can be classified as cavernous, capillary, arteriovenous, venous, intramuscular, synovial hemangiomas based on their histopathology.7) Cavernous hemangiomas consist of dilated large vessels or sinusoidal blood space. Due to its low rate of regression, incidence rate of cavernous hemangioma is higher in adults compared to capillary hemangioma. Capillary hemangiomas consist of capillary sized vessels with flattened endothelial cells. Mostly they are found at childhood and spontaneous regression is common.8) Venous hemangiomas consist of veins with small thick walls and elastic plate and fiber rarely exists inside. This feature makes it possible to distinguish venous hemangiomas with other types of hemangiomas.4) In our case, histopathologic characteristics of the hemangioma did not follow cavernous nor capillary. According to the Pathology department, a definitive conclusion is difficult to be made but venous type can be considered. The authors concluded as venous hemangioma due to the features of thick walled vessels.

Diagnosis of hemangioma is carried out by careful history taking, medical and physical examination, and imaging studies such as computed tomography (CT), MRI, angiography.2,9) Symptoms of sinonasal hemangiomas include nasal obstruction, recurrent epistaxis, cheek swelling and bulging of the eyeball.10) Our patient presented with only nasal obstruction. CT shows a highly vascularized tumor, and shape, size relations with the surrounding structures, and extension to soft tissue.9,10) MRI shows a high signal intensity due to abundant blood flow on T2-weighted images. In the case with our patient, CT showed a heterogenous mass with bone remodeling and MRI T2-weighted image showed peripheral rim enhancement which was not the typical characteristics of the features above.

Differential diagnosis of hemangiomas in the sinonasal cavity include inverted papillomas, neuromas, polypoid masses mucoceles, or other benign or malignant vascular tumors.10) In our case, because of the location of the mass, nasolabial cyst was needed to be differentiated.

Treatment of hemangioma must consider patient age, the location and size, histopathologic characteristics of the hemangioma.3,6) Hemangiomas of the childhood mostly spontaneously involute, therefore can be observed.2,3,6) However in adults, spontaneous involution is rare, and surgical treatment must be considered. Prior to surgery, CT or angiographic evaluation must be performed due to massive bleeding risk during surgery.8,11) In order to prevent relapse, total resection of the mass is important.8) Nonsurgical treatments include local steroid injections which helps slowing the progression of the hemangioma. Pulsed dye laser, photocoagulation with laser also can be an effective method to reduce the volume of hemangioma.3)

In our case, due to the location of the mass, nasolabial cyst was the first impression to be considered. Also heterogenic enhancing characteristics found on computed tomography images, and T2-weighted images of MRI did not follow the standard characteristics of a hemangioma. Because of the bleeding risk during surgery, when encountering a nasolabial fold mass, hemangioma should be an impression to be considered. Previous studies report cases of intranasal hemangiomas, but cases of nasolabial fold hemangiomas were rare.12) Furthermore, the features of our case did not follow the typical characteristics of hemangiomas on imaging studies. Therefore, we report a rare case diagnosed as hemangioma in the nasolabial fold we have experienced.

Acknowledgements

Not applicable.

Funding Information

Not applicable.

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Author Contribution

Conceptualization: Son SY, Lee KH.

Data curation: Son SY.

Investigation: Son SY.

Writing - original draft: Son SY.

Writing - review & editing: Son SY, Jin SH, Lee KH.

Ethics Approval

Following the enforcement rules (article 13 and article 33 of the Bioethics & Biosafety Act) and article 7 of the KHNMC SOP, It’s allowed to extempt of review.

References

1.

Palacios E, Daroca PJ Jr. Nasal cavernous hemangioma. Ear Nose Throat J 2007;86(6):326-8.

2.

Shpitzer T, Noyek AM, Witterick I, Kassel T, Ichise M, Gullane P, et al. Noncutaneous cavernous hemangiomas of the head and neck. Am J Otolaryngol 1997; 18(6):367-74.

3.

Pitanguy I, Machado BH, Radwanski HN, Gontijo Amorim NF. Surgical treatment of hemangiomas of the nose. Ann Plast Surg 1996;36(6):586-93.

4.

Kang CY, Cho SI, Do NY, Lee JH. A case of maxillary venous hemangioma with invasion to hard palate and nasal cavity. Korean J Otorhinolaryngol Head Neck Surg 2007;50(10):954-7.

5.

Lee JH, Jun KH, Yun KJ. A case of cavernous hemangioma of maxillary sinus. Korean J Otorhinolaryngol Head Neck Surg 2006;49(5):565-7.

6.

Waner M, Suen JY, Dinehart S. Treatment of hemangiomas of the head and neck. Laryngoscope 1992; 102(10):1123-32.

7.

Fletcher CDM, Krishnan Unni K, Mertens F. Pathology and genetics of tumours of soft tissue and bone. In: Kleihues P, Sobin LH, editors. World Health Organization classification of tumours. Lyon; IARC Press; 2002.

8.

Moon JH, Hwang DJ, Kim JS, No HS, Lee SE, Kim SH, et al. Clinical study of the hemangioma of the head and neck in adult. Korean J Otorhinolaryngol Head Neck Surg 2000;43(8):878-82.

9.

Byun JY, Kim KH, Park DW, Lee JY. A case of subcutaneous cavernous hemangioma presenting as a nasolabial fold mass. Korean J Otorhinolaryngol Head Neck Surg 2010;53(6):386-9.

10.

Jammal H, Barakat F, Hadi U. Maxillary sinus cavernous hemangioma: a rare entity. Acta Otolaryngol 2004;124(3):331-3.

11.

Bartlett JA, Riding KH, Salkeld LJ. Management of hemangiomas of the head and neck in children. J Otolaryngol 1988;17(2):111-20.

12.

Chang DS, Choi MS, Lee HY, Cho CS, Park SG, Park NS, et al. Clinical study of the intranasal hemangioma. Korean J Otorhinolaryngol Head Neck Surg 2015; 58(5):324-9.

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정답 ②

- 소음환경에서의 청취 편의성과 음성 명료성을 위하여 
디지털 신호 처리 기술이 사용되고 있는데 
그중 대표적인 것이 디지털 소음 감소(digital noise reduction, DNR) 기능과  
방향성 기술(directionality) 사용이다.

- 미국의 Food and Drug Administration(FDA)의 정의에 따르면 PSAP는 
단순히 소리를 증폭하는데 사용되며, 정상 청력을 가진 모든 연령의 
일반인에게 특정상황에서 소리를 증폭하는데에 사용되는 일반 전자제품이다. 
하지만 최근의 제품들은 경도와 중등도 난청 환자에서 보청기와 유사한 효과를 
보인다는 연구 결과를 보이기도 하였다. 아직 고도난청 환자에게 PSAP 를 
적용하는 것에 대한 효과는 증명되어 있지 않다.

- 최신 보청기에는 심박동 센서와 움직임 센서를 탑재 하여 걸음 수, 심박동변화, 
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기능을 탑재 하였다.

- 저전력 블루투스 기술을 사용할 경우 더 낮은 전력소모량으로 
더 나은 음질을 확보할 수 있다.
 

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