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

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.

A destructive sinonasal organizing hematoma mimicking malignancy

Sinonasal organizing hematomas (SOH) are rare, benign lesions that can be mistaken for malignancies due to their unfamiliarity among clinicians and aggressive appearance on imaging, which can lead to aggressive and unnecessary therapeutic interventions. Herein, we report an unusual case of SOH in an 87-year-old female patient who sought care at a maxillofacial surgery service due to persistent right nasal obstruction and imaging findings that suggested the possibility of sinonasal malignancy. We highlight the importance of recognizing these lesions to ensure adequate treatment through a conservative approach.

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.

Preoperative Arterial Embolization to Avoid Intraoperative Bleeding during Endoscopic Sinus Surgery for Organized Hematoma of the Maxillary Sinus: A Case Series and Literature Review

Purpose:

This study aimed to evaluate the safety and efficacy of preoperative arterial embolization of organized hematoma of the maxillary sinus.

Material and Methods:

Seven patients who were pathologically diagnosed with an organized hematoma of the maxillary sinus and who underwent endoscopic sinus surgery following preoperative arterial embolization for the same from July 2013 to April 2020 at our hospital were included. A literature review of the PubMed database was performed to identify 13 cases on organized hematomas of the maxillary sinuses. The embolization and nonembolization groups comprised patients who underwent preoperative embolization (n = 10, seven from this study and three from literature) and those who did not undergo preoperative embolization (n = 10, from literature), respectively. Outcomes of embolization including embolization-related complications and postoperative bleeding were assessed, and volumes of intraoperative blood loss and duration of surgery were compared between the groups.

Results:

No preoperative embolization-related complications were observed in our cases. The volume of surgical blood loss in the seven cases varied from 0 to 100 mL with a median of 30 mL, and the duration of surgery ranged from 45 to 166 minutes with a median of 112 minutes. The volume of blood loss was significantly lower for the embolization group than that for the nonembolization group (p = 0.0031). There was no statistically significant difference regarding duration of surgery between the groups (p > 0.10).

Conclusions:

Preoperative embolization of an organized hematoma of the maxillary sinus is a safe and effective method that helps prevent serious intraoperative hemorrhage.

Three cases of organized hematoma of the maxillary sinus in patients who underwent preoperative arterial embolization

Organized hematoma (OH) is benign tumor in the maxillary sinus. The standard treatment for OH is complete surgical resection, however massive bleeding can occur during the procedure, albeit rarely. Some reports have suggested preoperative embolization is useful for reducing the volume of intraoperative bleeding. We report 3 cases of OH in the maxillary performed preoperative embolization. We identified the feeding arteries by angiography or IVR-CT, and we embolized them using Gelatin sponge particles. The embolized artery was the maxillary artery or both the maxillary and the facial artery. There were no major complications as a result of embolization. The mean fluoroscopy time was 35.8 minutes, and the mean fluoroscopy dose was 329.3 mGy. Tumor resection was performed the next day after arterial embolization. The mean bleeding volume for surgery was 383.3 ml, and the mean operative time was 194 minutes. No recurrence was observed in any of the cases over a 4-year follow-up period. We considered that it is possible that preoperative artery embolization is useful for decreasing intraoperative bleeding volume. Although the methods and usefulness of embolization await future reports, it is a technique that should be considered preoperatively because of its potential to prevent massive bleeding.

Endoscopic Surgical Treatment of Maxillary Sinus Organized Hematoma

OBJECTIVE

The purpose of this study was to analyze the clinical characteristics and treatment outcomes of patients who underwent endoscopic surgery for a maxillary sinus organized hematoma during a 15-year period in our hospital.

METHODS

The authors analyzed 25 patients who underwent endoscopic surgery for a maxillary sinus organized hematoma from January 2004 to December 2019.

RESULTS

Twenty-five patients with a maxillary sinus organized hematoma underwent endoscopic surgical treatment and complete removal of the maxillary sinus organized hematoma was achieved in all cases. The main symptoms were nasal bleeding in 14 patients, followed by a nasal obstruction in nine, and facial swelling in 2. Of the 25 patients, 13 underwent endoscopic medial maxillectomy and 12 underwent endoscopic sinus surgery. There were no major surgical complications or recurrences.

CONCLUSION

The authors demonstrated that endoscopic surgery is a safe and reliable treatment method for a maxillary sinus organized hematoma.

Rare Diseases of the Nose, the Paranasal Sinuses, and the Anterior Skull Base

Due to their low incidence and thus resulting limited diagnostic criteria as well as therapeutic options, rare diseases of the nose, the paranasal sinuses, and the anterior skull base are a significant challenge. The value as of which a disease has to be considered as rare amounts to a maximum of 5 patients per 10 000 people. Within these diseases, however, there are extreme differences. Some rare or orphan diseases like for example the inverted papilloma belong to regularly diagnosed and treated diseases of larger departments of oto-rhino-laryngology whereas other rare diseases and malformations have only been described in less than 100 case reports worldwide. This fact emphasizes the necessity of bundling the available experience of diagnostics and therapy. The present article gives an overview about rare diseases of the nose, the paranasal sinuses, and the anterior skull base from the field of diseases/syndromes of the olfactory system, malformations of the nose and paranasal sinuses, ventilation and functional disorders as well as benign and malignant tumors. The classification and data on diagnostic and therapeutic options were established based on the current literature.

[Rare diseases of the maxillary sinus]

BACKGROUND

Silent sinus syndrome (SSS), organized hematoma (OH), and pneumosinus dilatans (PD) are rare, usually unilateral diseases of the maxillary sinus. Due to misinterpretation, excessive diagnostics and unnecessarily aggressive surgery or a delay in diagnostics and treatment are common.

OBJECTIVE

The objective of this study was to develop reasonable and comprehensible diagnostic criteria to improve diagnosis and treatment of these rare diseases.

METHODS

In this retrospective study, all patients treated for SSS, OH, and PD from 2012 to 2019 were identified. Patient history, diagnostic tests and results, and postoperative course were analyzed and compared with the available literature.

RESULTS

During the study period, 7 patients with SSS, 3 patients with PD, and 2 patients with OH were treated and available for follow-up. Comparison of these patients with the literature allowed us to develop diagnostic criteria.

CONCLUSION

Medical history combined with endoscopic and radiologic criteria should improve preoperative diagnosis of these three rare diseases of the maxillary sinus and help to distinguish them from other differential diagnoses. This approach should minimize morbidity for the patients.

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.

Organized hematoma of the sphenoid sinus causing acute visual loss

Sinonasal organized hematoma, which has locally aggressive characteristics, is a non-neoplastic disease. We report a rare case of sphenoid sinus organized hematoma causing acute visual loss. A 35-year-old male presented with progressive headaches, retro-orbital pain, and frequent epistaxis. He had a medical history of aplastic anemia and of taking warfarin for a valvular heart disease. On image studies, an expansive soft tissue density lesion with bony destruction was found in his left sphenoid sinus. While waiting for elective surgery, acute visual loss occurred. Emergent endoscopic surgery was performed after correction of abnormal hematological profiles, but his visual disturbance did not improve. Although sphenoid sinus organized hematoma is a rare disease, organized hematoma should be considered in the differential diagnosis for sphenoid sinus lesion with acute visual loss. Rapid and correct diagnosis and timely treatment are essential to prevent permanent sequela.

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.