Pleomorphic Adenoma a Salivary Gland Tumor
as Nasal Mass; Rarest Presentation
*Bhushan Kathuria1, Dinesh Madhur2, Himani Dhingra3 and Mohit Pareek4
1Consultant, Department of Otolaryngology, Head & Neck Surgery, Aadhar Hosital, India
2Senior resident, Department of Otolaryngology, Head & Neck Surgery, Agroha medical college, India
3Senior resident, Department of paediatric, Sion hospital Mumbai, India
4Resident, Department of Otolaryngology, Head & Neck Surgery, Post Graduate Institute of Medical Sciences, India
Submission: December 27, 2016; Published: January 23, 2017
*Corresponding author: hushan Kathuria, Consultant, Department of Otolaryngology, Head & Neck Surgery, Aadhar Hosital, Hissar, Haryana, India, Email:[email protected]
How to cite this article: Bhushan K, Dinesh M, Himani D, Mohit P. Pleomorphic Adenoma a Salivary Gland Tumor as Nasal Mass; Rarest Presentation. Glob J Oto 2017; 3(3): 555613. DOI: 10.19080/GJO.2017.03.555613
Pleomorphic adenoma of minor salivary glands can be seen at any location where minor salivary glands are present such as neck, ear, external nose and nasal cavity. However the lesions detected in nasal cavity are extremely rare. Here we describing a case of intranasal pleomorphic adenoma of the nasal septum who was previously treated as chronic sinusitis but after further investigation the correct diagnosis was made and treated accordingly.
Salivary gland tumors represent 3% of all head and neck tumors. Among these 85-90% originates from the major salivary glands. Pleomorphic adenoma is the most common benign salivary gland tumor. Although parotid gland constitutes 60% of all pleomorphic adenomas, minor salivary glands constitute only 8% of them . Pleomorphic adenoma of minor salivary glands can be seen at any location where minor salivary glands are present such as neck, ear, external nose and nasal cavity . However the lesions detected in nasal cavity are extremely rare. Nasal pleomorphic adenoma is seen predominantly in females usually between the third and fifth decades of life [3,4].
A 32 years female presented to us with history of right sided nasal obstruction for the last 4 years with off and on history of nasal bleeding. There was no history of previous trauma to the nose. Before this patient was treated with oral antibiotics, oral antihistamincs, local nasal decongestant and local steroid spray by his family physician as chronic sinusitis with no improvement. Anterior Rhinoscopy revealed septum deviated to right side with a grayish, polypoidal, non-sensitive, friable mass in right nasal cavity covered with mucopurulent discharge at level of middle turbinate. Mass completely obstructing the right nasal cavityrigid endoscopy of the nose showed that the polypoidal mass seemed to originate from the nasal septum and protruding into right nasal cavity with mucopurulent discharge, touching lateral nasal wall at level of the middle turbinate and blocking right side osteomeatel complex. On left side there was a spur with enlarged middle turbinate. His weight was stable and his general health was satisfactory.
CECT paranasal sinuses (Figure 1) was done which revealed soft tissue mass in right nasal cavity originating from nasalseptum blocking right osteomeatel complex. Bilateral ehmoids,
frontal and sphenoid sinuses were clear. The lesion displaced the
lateral nasal wall laterally and did not show any evidence of bony
destruction. Biopsy was taken from the mass endoscopically
and sent for histopathological examination. The biopsy report
suggested the specimen to be fibroepithelial polyp. However
considering the age of the patient, clear paranasal sinuses and
nasopharynx on CECT paranasal sinuses, endoscopic removal
was planned. Incision given over septum anterior to attachment
of the mass, mucoperichondrial flap elevation was done with
cottle’s elevator under direct visualization with a 0-degree
endoscope. Mass was found not adherent to nasal septum.
A tumor mass of size approximately 2.5x1.5x1cm was excised
with small part of septal mucoperichondrium around and sent
for histopathological examination. Post-operative period was
uneventful and patient was discharged after 2 days of hospital
stay. Histopathological report revealed features of pleomorphic
adenoma revealing epithelial lined tubules, ducts, proliferation
of myoepithelial cells and pseudocartilaginous areas (Figure 2).
At 6 months follow up period patient is relieved of symptoms
of obstruction and epistaxis, and nasal examination shows no
abnormality or recurrence.
The most common tumors of the major salivary glands
are pleomorphic adenomas, but in rare instances, they can
occur in respiratory tract (via minor salivary glands). In the
upper respiratory tract, the most favoured site is the nasal
cavity, followed by maxillary sinus and the nasopharynx. Cases
have been reported in the nasal cavity, paranasal sinuses,
nasopharynx, oropharynx, hypopharynx and the larynx . The
first reported case in the literature of a pleomorphic adenoma of
nasal cavity was in 1929 . There is no reported correlation with
occupational exposure or inhaled toxic chemical compounds.
Compagno and Suzuki presented their series of pleomorhic
adenoma located in nasal cavity . The most common site of
origin was the bonycartilaginous septum. Although the vast
majority of minor mucosal and serous glands are located on thelateral nasal wall, pleomorphic adenomas in the nasal cavity
mostly originate from the nasal septum .
It is generally known to be a slow-growing tumour and,
therefore, clinical symptoms appear after a long silent period.
Patients commonly present with gradual worsening of unilateral
nasal obstruction and occasional epistaxis. Less commonly,
when the tumoural mass reaches a relatively large size, to
that of the nasal cavity, external swelling of the nasal pyramid
as well as pain may be present. The clinical features, such as
absence of superficial ulceration, no bleeding either on touch or
spontaneously and lack of invasion of surrounding structures
suggest a benign nature of the mass.
Differential diagnosis of intra-nasal pleomorphic
adenoma includes both malignant and benign tumours such
as squamous cell carcinoma, adenocarcinoma, adenoid cystic
carcinoma, mucoepidermoid carcinoma, melanoma, olfactory
esthesioneuroblastoma , polyps, papillomas (including inverted
papilloma), angiofibromas and osteomas . Differential diagnosis
can also be difficult in the presence of a neuroestesioepithelioma.
Diagnosis is possible on account of the lack of an extracellular
neurofibrillar structure, neurotubules, neurosecretive granules
and due to the presence of mucinous material and the rarity of
malpighian lobules disseminated in the pleomorphic adenoma
While complete excision of the tumour with histologically
clear margins is mandatory, the surgical approach will depend
upon the size, location and extension. A radical and wide
resection lowers the risk of recurrence, especially when the
capsule is interrupted and a direct contact with the surrounding
normal tissue is present. Approaches include lateral rhinotomy
[11,12], trans-nasal or mid-facial degloving and intra-nasal
excision . The present patient underwent endoscopic
resection since the tumour was small enough to observe under
the endoscope. The advantages of endoscopic resection include
no external scar, less blood loss. Recurrences are not frequent,
Compagno and Wong reported 3 cases of local recurrences in 40
patients (7.5%), probably, as they thought, due to the amount
of myxoid stroma of the tumour, which could be split into the
surgical field .
The potential risk of malignant transformation of the
pleomorphic adenoma is about 6% and is predominantly seen in
the female patients . The risk is increased by delay in diagnosis.
There has also been a report of metastasis to the submandibular
lymph-node, in a recurrent septal pleomorphic adenoma, 17
years after the first diagnosis. Even in this case, the microscopic
features of both the primary and metastatic lesion were benign
as a result of incomplete excision or inadvertent disruption of
the tumour with consequent spread through haematogenous or
lymphatic routes . The outlook for intranasal pleomorphic
adenomas tumors is better than for those in other ectopic sites,
because they show early symptoms leading to an early diagnosis.Involvement of surrounding structures like bone is rare since
tumors have sufficient space to expand in nasal cavity .
Early diagnosis offers the possibility of a more complete
excision with adequate care being taken not to disrupt the
tumour in order to prevent local and distant spread of neoplastic
cells. The endoscopic approach is preferred, as it allows
complete control of the margins under direct vision and reduces
the post-operative recovery period when compared to open
surgery. Long-term follow-up, both endoscopic and radiologic,
to exclude malignancy is mandatory, even if the tumour appears
to be clinically benign and resected completely.
The case highlights the importance of keeping the possibility
of pleomorphic adenoma whenever a patient presents with the
slow-growing unilateral mass in the nasal cavity even if it is not