Diagnostic characteristics of sinonasal organizing hematomas: avoiding misdiagnosis

Sinonasal Organizing Hematoma: Demographics, Diagnosis, and Treatment Outcomes of 112 patients

INTRODUCTION

Sinonasal organizing hematoma (OH) is a rare, nonneoplastic lesion that often presents with epistaxis, a reddish mass, and destruction of the involved sinonasal structures. Due to its rarity, the demographics, diagnostic modalities, treatment strategies, and outcomes have not yet been studied in a large, long-term study.

MATERIALS AND METHODS

Retrospect cohort of 112 sinonasal OH patients treated between 1997 and 2020 in a tertiary, university hospital were evaluated. Demographics, systemic comorbidities, sinonasal surgery history, serum laboratory tests, radiological findings, and treatment results were collected. The present study aimed to assess the accuracy of preoperative computed tomography (CT), Gadolinum-enhanced magnetic resonance (MR), and punch biopsies in detecting sinonasal OH as the most likely diagnosis. In addition, incidental differences by age and year of diagnosis were calculated using the Poisson log-linear regression model.

RESULTS

The median age was 44, and 58% were male. Fewer than 20% of these cases had a chronic systemic comorbidity, bleeding tendency, or sinonasal surgery history. MR had the highest accuracy of (87%) to detect sinonasal OH as the most likely diagnosis, compared with contrast-enhanced-CT (53%), punch biopsy (49%), and non-enhanced-CT (16%) (all <0.05). Sinonasal OH incidence did not vary by age, but the yearly rate significantly increased by 1.05 times over 23 years (p < 0.05). Notably, 84% of 112 patients received surgical removal through the assistance of an endoscope, and none had substantial bleeding without preoperative embolization.

CONCLUSION

Sinonasal OH was observed regardless of age, sex, systemic comorbidities, bleeding tendency, prior sinonasal surgery, or trauma. Preoperative MR gives the highest accuracy for detecting this disease. Sinonasal OH may be safely managed with endoscopic-assisted surgery removal without embolization.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1581-1590, 2024.

Organized hematoma of the sphenoid sinus with epistaxis

Few reports have been made on organized hematoma (OH) originating in the sphenoid sinus. We report the case of a 24-year-old man who presented to the hospital with consistent epistaxis for 1 month. Preoperative computed tomography and magnetic resonance imaging (MRI) detected an expansive heterogeneous mass with minimal bone destruction and hypointense peripheral rim in T2-weighted images of the left sphenoid sinus as a solitary lesion. An OH was suspected first based on the history of repeated epistaxis and characteristic imaging findings, although quite rare. Preoperative vascular embolism was not performed because its effects on the ocular artery should be considered. With endoscopic sinus surgery under hypotensive anesthesia, the mass was carefully and successfully removed without bleeding and diagnosed as OH based on postoperative pathological examination. When solitary lesions are found in the sphenoid sinus with epistaxis, this disease should be differentiated. If it increases, complications, such as visual impairment, frequently occur, and control of intraoperative bleeding is sometimes difficult. Not only missing the characteristic imaging findings, especially MRI with contrast administration but also evaluating the anatomical relationship between OH and other important organs is important for a successful intervention of sphenoid sinus OH.

Successful Endoscopic Transsphenoidal Approach Treatment of Sphenoid Sinus Organized Hematoma Causing Visual Deficit: A Case Report

Background: Organized hematoma in the sphenoid sinus is rare, but serious complications, such as visual deficits, can occur. Three such case reports have been published previously in the literature; however, none have achieved complete recovery of the vision. Case presentation: A 69-year-old male patient was referred to the ear, nose, and throat department with an expansile soft tissue mass filling the right sphenoid sinus and blurry vision in his right eye. Complete mass removal was achieved by a wide opening of the sphenoid sinus via an endoscopic transsphenoidal approach, followed by cauterization of the feeding artery and coverage by a nasoseptal flap. The patient's vision was restored after the operation, and he declared no visual symptoms until the latest follow-up (one year after the surgery). Conclusions: Complete excision with an endoscopic endonasal transsphenoidal approach can restore visual deterioration caused by a sphenoid sinus organized hematoma.

Organized Hematoma after Intra-Arterial Chemoradiotherapy for Maxillary Sinus Cancer: A Case Report

An organized hematoma (OH) is a relatively rare benign lesion of the paranasal sinuses. Traditionally, it has been reported to occur following trauma, surgery, and sinus hemorrhagic lesions and in various bleeding predispositions. OHs are sometimes difficult to differentiate from malignancy because of the similar clinical symptoms and bone destruction. It is especially difficult when OHs occur in the same location as the primary tumor after treatment of a malignant tumor. In this paper, we report two cases of OH that occurred after intra-arterial chemoradiotherapy (IACRT) for maxillary sinus cancer. In one case, FDG accumulation was found in PET/CT and suspected to be a cancer recurrence. However, the postoperative pathology showed no malignant findings. This suggests that OH may show accumulation on 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET). In both cases, bleeding from the maxillary sinus continued after surgery. In one case, recurrence was observed, and in the other, nasal irrigation prevented the pooling of blood in the maxillary sinus, and no recurrence was observed. These cases suggest that OH after IACRT may easily recur because the bleeding continues even after surgery. In such cases, nasal irrigation or preoperative embolization may be helpful to avoid recurrence.

Organised hematoma mimicking sino-nasal malignancy in patients post-radiotherapy

INTRODUCTION

Organised hematoma (OH) in the para-nasal sinus and nasal cavity is a rare, non-neoplastic, benign disease which can be locally aggressive. In clinical practice, OH is easily misdiagnosed as malignancy and over-treated.

CASE SUMMARY

These patients with OH had a common history of malignant neoplasms post-radiotherapy, including two cases of nasopharyngeal carcinoma and one case of tonsil cancer with jaw osteosarcoma. All of the patients presented with symptoms of epistaxis and blood-tinged rhinorrhea. All of the patients received endoscopic endonasal surgery under navigation.

DISCUSSION

All of the patients had a good recovery after surgery. There's no recurrence after follow-up at 6 months. We therefore hypothesised that radiotherapy could be a cause of the OH. Although OH is uncommon and difficult to diagnose, a history of malignancy and imaging features with appropriate treatment are key.

Diagnostic dilemma - sinonasal organizing hematoma

Sinonasal organizing hematomas are benign lesions often mistaken for malignancy due to their aggressive appearance on diagnostic imaging and endoscopic findings that favor advanced disease. The destructive nature of this pathology paired with the rarity of the presentation often results in diagnostic deception that may escalate intervention planning and affect discussion of prognosis with patients. Herein, we present a case of a 56-year-old male with left-sided nasal obstruction and daily epistaxis, where computed tomography imaging revealed heterogeneous opacification of the left maxillary sinus, erosion of the left inferior orbital wall and extension into the nasal cavity. Although clinical and radiographic presentations of sinonasal organizing hematomas can be managed definitively with endoscopic intervention, there is a need to increase awareness of this entity among clinicians to improve our prognostic counseling with patients.

Organized Hematoma of the Sphenoid Sinus With Acute Blindness: Insight Into Pathogenesis of Disease

Sinonasal organized hematomas (OHs) are rare lesions that primarily localize to the maxillary sinus. The rate of growth of these masses has not been described in the literature. We present a case of a 59-year-old gentleman with polyostotic fibrous dysplasia who presented with acute loss of vision in the left eye from an expanding OH of the sphenoid sinusitis. After expanded endonasal, transpterygoid approach and debulking, patient experienced significant vision improvement. Close follow-up imaging preoperatively allowed radiologic documentation of the rate of OH growth and this is presented in detail.

Sinonasal organised haematoma: clinical features and successful application of modified transnasal endoscopic medial maxillectomy

OBJECTIVE

Although organised haematoma often induces bone thinning and destruction similar to malignant diseases, the aetiology of organised haematoma and the optimal treatment remain unclear. This paper presents the clinical features of individuals with organised haematoma, and describes cases in which a novel modified approach was successfully applied for resection of organised haematoma in the maxillary sinus.

METHOD

Pre-operative examination data were evaluated retrospectively. Modified transnasal endoscopic medial maxillectomy was employed.

RESULTS

Fourteen patients with organised haematoma were treated. Contrast-enhanced computed tomography showed heterogeneous enhancement in all patients. Eight patients underwent modified transnasal endoscopic medial maxillectomy, without complications such as facial numbness, tooth numbness, facial tingling, lacrimation and eye discharge. Dissection of the apertura piriformis and anterior maxillary wall was not necessary for any of these eight patients. No recurrence was observed.

CONCLUSION

Pre-operative examinations can be helpful in determining the likelihood of organised haematoma. Modified transnasal endoscopic medial maxillectomy appears to be a safe and effective method for organised haematoma resection.

Sphenoid sinus organized hematoma with cranial neuropathies masquerading as a malignancy: A case report

Sinonasal organized hematoma (SNOH) is rarely encountered in clinical practice. The disease demonstrates a high tendency for occurrence in East Asian individuals, and in the majority of cases, is located in the maxillary sinus. The current report presents the case of an 81-year-old female who developed a space-occupying lesion, which masqueraded as a skull base malignancy, following surgery for the treatment of isolated sphenoid sinus aspergilloma. Subsequent endoscopic endonasal surgery confirmed the diagnosis of an OH of the sphenoid sinus. The patient recovered from all neurological deficits within two months, with the exception of the loss of visual perception. Although SNOH presents a diagnostic challenge, when physicians possess knowledge of its typical imaging features, this facilitates the achievement of a correct diagnosis and the prescription of optimal treatment.

Organized Hematoma: An Analysis of 84 Cases with Emphasis on Difficult Prediction and Favorable Management

OBJECTIVE

To characterize features of organized hematoma (OH) that may cause considerable diagnostic difficulties.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Eighty-four patients with pathologically confirmed OH over a 10-year period were retrospectively reviewed for clinical features, imaging findings, pathologic characteristics, and treatment modalities.

RESULTS

This study included 39 males and 45 females who presented with frequent epistaxis and nasal obstruction. There were 62 (74%) patients >40 years old (mean, 50; range, 9-81). OH mainly originated in the maxillary sinus (n = 82) or nasal cavity (n = 2) unilaterally, and most were expansile masses (n = 73) that extended into nasal cavity (n = 71) or choanae (n = 17). Several lesions were locally aggressive and simulated a malignant process that involved the ethmoid sinus (n = 22), orbit (n = 11), pterygopalatine fossa (n = 16), infratemporal fossa (n = 9), cheek (n = 3), and hard palate (n = 3). Internal architecture on computed tomography (CT) scans showed OH with expansile remodeling of the maxillary wall (82.1%) and smooth bony destruction (70.2%), whereas T2-weighted magnetic resonance (MR) images showed inhomogeneity with a notable hypointense peripheral rim in all lesions. CT and MR contrast-enhanced images revealed patchy heterogeneous enhancement that could be interpreted according to histopathologic findings of hemorrhage and neovascularization. OH was successfully removed with endoscopic surgery, although 5 cases recurred.

CONCLUSIONS

OH can be successfully treated by endoscopic surgery. CT and MR examination provide characteristic findings for prediction and careful surgical planning.

Organizing Hematoma of the Maxillary Sinus Mimicking Malignancy Diagnosed by Fluorodeoxyglucose Positron-Emission Tomography (FDG PET/CT): A Case Report

Organizing hematoma of the paranasal sinuses is a diagnostic dilemma clinically and radiographically, mimicking benign or malignant neoplastic processes. Although the diagnostic rate of this disease has increased as characteristic imaging findings are somewhat elucidated, endoscopic examination, preoperative biopsy, and computed tomography (CT) imaging do not give helpful information in differentiating these lesions from malignant neoplastic processes.

A 55-year-old man presented with a 4-month history of recurrent nasal bleeding. He also complained of a left-sided nasal obstruction. CT findings were highly suggestive of a malignant tumor of the maxillary sinus. However, based on fluorodeoxyglucose F¹⁸ positron-emission tomography (PET/CT) and magnetic resonance imaging (MRI), the provisional diagnosis of benign tumor rather than malignancy was made. Complete resection of the mass was achieved by simple transnasal endoscopic surgery using the Caldwell-Luc approach. Organizing hematoma of the maxillary sinus was diagnosed by histopathologic evaluation. The clinical, radiological, and histopathologic findings of the patient are presented.

In this report, we have presented ¹⁸FDG-PET findings of organized hematoma of the maxillary sinus (OHMS) that showed an increased FDG uptake in the peripheral rim of the mass with central photopenia. To our knowledge, this is the first case report in the literature reporting FDG-PET/CT findings of OHMS. Careful interpretation of metabolic (FDG-PET/CT) and anatomic (CT and MRI) images should be performed to accurately characterize the expansile lesion of the maxillary sinus in order to increase specificity and reduce equivocal findings significantly.

Giant Organized Hematoma Originating From the Inferior Turbinate

We reported CT of a case of giant organized hematoma originating from the inferior turbinate without any paranasal sinuses involvement, with an emphasis on different patterns of enhancement of the tumor on enhanced CT scans. This case was exceptional because of unusual location and difficulties in diagnosis. Moreover, organized hematoma of nasal cavity should be considered in the differential diagnosis of a unilateral, huge and easy bleeding lesion in the nasal cavity. A high clinical suspicion based on endoscopic and radiologic findings plays an important role to make an accurate diagnosis.

Sinonasal organized hematoma: Clinical features of seventeen cases and a systematic review

OBJECTIVES/HYPOTHESIS

Organized hematoma (OH) is a rare non-neoplastic disease. We studied the clinical characteristics of 17 patients with sinonasal OH and those of 75 cases in the English literature.

STUDY DESIGN

Retrospective review of medical records and systematic review of the literature on OH.

METHODS

Comprehensive review of the English-language literature on OH was performed. We screened all eligible cases based on initial features, and 75 eligible cases found in 15 publications were analyzed. We also retrospectively analyzed and compared medical records of 17 patients diagnosed with pathologically proven sinonasal OH. Data such as demographics, clinical characteristics, pathologic features, radiologic findings, treatment modalities, and follow-up results were compared to the 75 previously mentioned cases.

RESULTS

Fifteen cases involved the maxillary sinus, one case involved the frontal sinus, and one case involved the sphenoid sinus. There were six patients over 60 years old, and all were taking an antiplatelet agent. The paranasal sinus computed tomography (CT) of seven patients showed bony destruction of the involved sinus. A review of the available literature revealed mostly similar results with our cases, except for the proportion of patients taking aspirin (5.3%) and sex distribution (male:female = 49:25).

CONCLUSIONS

We reported 17 cases of OH, including a case of frontal sinus and a case of sphenoid sinus lesion. A large proportion of OH patients had bony destruction of the affected sinus on CT. In these patients, a careful diagnosis should be made to distinguish them from a malignant tumor or other expansile diseases.

LEVEL OF EVIDENCE

4.

Magnetic resonance imaging in sinonasal disease

Computed tomography (CT) is often the primary imaging modality for the evaluation of sinonasal disease. For some indications, magnetic resonance imaging (MRI) may provide additional information. There are established indications for using MRI in complicated sinonasal inflammatory disease, invasive fungal sinus disease, and sinonasal mass lesions. When MRI is used in the evaluation of sinonasal disease, it is usually used as a complementary modality in addition to CT. Magnetic resonance imaging in sinonasal disease can be used to further characterize the primary sinonasal disease process and to evaluate the extent of complications such as orbital or intracranial involvement. When MRI is used in sinonasal disease, it should be evaluated in the context of the clinical situation and CT imaging features. This will help radiologists provide a meaningful differential diagnosis to assist in clinical management.