Nasal cavity eosinophilic angiocentric fibrosis: CT and MR imaging findings

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Eosinophilic angiocentric fibrosis of the sinonasal tract: a case report and review of the literature

Eosinophilic angiocentric fibrosis (EAF) is a rare chronic benign disorder of unknown etiology and is characterized by submucosal thickening and fibrosis in the upper respiratory tract. In this report, we describe a case of EAF in the nasal cavity of a woman who underwent elective surgery for division of adhesions and has had no recurrence during 2 years of postoperative follow-up. A review of the literature on the clinical manifestations of EAF, sites of lesions, management, and outcomes identified 48 articles that included 72 cases. A summary of these reports is presented, including our present case. The most common anatomic site involved was the nose (77.8%), the most common manifestation was nasal obstruction (66.7%), and the most common treatment modality was surgical resection (83.3%). After surgery, 36% of patients remained free of EAF. The most common pharmacologic agent used was a corticosteroid (38.9%).

Challenges in Medicine: The Odyssey of a Patient with Isolated IgG4-Related Eosinophilic Angiocentric Fibrosis Presenting as a Locally Destructive Sinonasal Mass

Eosinophilic angiocentric fibrosis (EAF) is an exceeding rare clinical entity and is considered a part of the spectrum of IgG4-related disease (IgG4RD). We hereby present such an unusual case of a 60-year-old female who presented to us with recurrent sinonasal mass, after a decade long haul of multiple clinical evaluations, biopsies, and debulking surgery without a definitive diagnosis. Over this period, the mass eroded through the ethmoid cells along with nasal septal destruction leading to saddle nose deformity, extended superiorly through the cribriform plates to right frontal lobe, and compressed the optic nerve leading to visual loss. Although initial biopsy was negative, repeat biopsy was performed owing to high clinical suspicion due to all the classic histopathological findings compatible with the diagnosis of eosinophilic angiocentric fibrosis IgG4-related disease (EAF-IgG4RD). Steroids are the recommended first-line therapy; however, our case was resistant to steroids needing rituximab to halt the disease progression. Our case interestingly also had T-cell clonality and isolated isocitrate dehydrogenase 2 enzyme mutation on next-generation sequencing, suggesting a possible role of novel molecular-targeted therapies in this rare disease. This case highlights the clinical challenges physicians face towards diagnosing and treating EAF-IgG4RD, emphasizing the need for high clinical suspicion and the possible role of targeted therapies for this rare disease.

Eosinophilic Angiocentric Fibrosis: A Review and Update of Its Association With Immunoglobulin G4-Related Disease

Eosinophilic angiocentric fibrosis is a rare indolent lesion of the head and neck region that has characteristic histologic findings of onionskin fibrosis and prominent eosinophils. Its pathogenesis has been poorly understood and has been most commonly attributed to hypersensitivity or previous trauma. Recently, the lesion has been included in the spectrum of immunoglobulin G4 (IgG4)-related disease. However, few of the existing cases of eosinophilic angiocentric fibrosis have been evaluated for IgG4⁺ and IgG⁺ plasma cells. Therefore, we provide an update on the clinical and histologic features of eosinophilic angiocentric fibrosis to increase awareness of the entity and encourage its further characterization as an IgG4-related disease.

Nasal Framework Reconstruction in Patient with Eosinophilic Angiocentric Fibrosis

Eosinophilic angiocentric Fibrosis (EAF) is a rare condition involving the sinonasal tract and nasal septum which is mostly considered as a benign condition. EAF could present with progressive nasal obstruction as its most common symptom. In this case report, we try to report a case of middle aged man with nasal septum tumor-link lesion which was diagnosed with EAF. A 45 years old man presented with complete nasal obstruction who described a growing nasal cavity mass for over 6 months. Anterior rhinoscopy revealed bilateral mass with a smooth surface on the nasal septum and mass protruded into both nasal cavities. CT scan showed a 28 × 18 mm soft tissue mass in nasal cavity mostly in right side with erosion of right maxillary alveolar ridge. Microscopic examination of a biopsy taken from the mass showed dense infiltration of inflammatory cells rich in eosinophils as well as perivascular condensation of fibrotic bundles creating onion-skin appearance was noted. The patient went under surgical ablation of the tumor and has been followed up every 2-3 month for about 1 year and there was no evidence of recurrent disease. The complete surgical excision may eradicate the allergic manifestations in the EAF patients and cartilage graft such as rib graft seems to be safe if the reconstruction is needed. It is important to prevent tumor from recurrence by totally resecting the involved tissues.

A Case Report and Systematic Review of Eosinophilic Angiocentric Fibrosis of the Paranasal Sinuses

OBJECTIVE

There is a paucity of literature discussing prognostic factors or comparing outcomes in eosinophilic angiocentric fibrosis (EAF). This review aims to analyze tumor and patient characteristics as possible prognostic markers and compare surgical approaches.

METHODS

Systematic literature review and case report analyzing available cases of EAF located within the paranasal sinuses.

RESULTS

The literature search yielded 39 articles meeting criteria for a total of 59 cases (including 1 from our institution). Median patient age was 46 years. The most common presenting symptoms were nasal obstruction (69%, n = 41) and change in external nasal appearance (39%, n = 32). The majority of cases (85%) were treated with surgical resection alone or in combination with medication. Of surgical patients, 62% underwent a complete resection with a recurrence rate of 20%. Median follow-up duration was 2 years. Endoscopic approach showed a significant positive correlation with complete resection ( P = .045). Patient sex ( P = .6), tumor location (range, P = .32-.98), lateral rhinotomy ( P = .26), septoplasty ( P = .84), and external rhinoplasty ( P = .28) were not significantly correlated with total resection. Insufficient sample size precluded calculation of predictors of recurrence following surgery.

CONCLUSION

This review suggests that an endoscopic approach to EAF tumor is a viable option, frequently yielding complete resection.

Eosinophilic Angiocentric Fibrosis as a Stenosing Lesion in the Subglottis

Subglottic Eosinophilic Angiocentric Fibrosis (EAF) is an extremely rare disease of an elusive aetiology. It is chronically progressive benign condition that causes narrowing of the subglottic region leading to dysphonia and airway compromise. The diagnosis is historical and imaging is nonspecific. We report a case xc of 56-year-old lady referred to our institution with globus sensation, hoarseness, and mild stridor. Incidental subglottic mass was found at time of diagnostic microlaryngoscopy and biopsy confirmed subglottic EAF. All laboratory investigations were unremarkable. Lesion was removed with laryngeal microdebrider and three courses of intravenous dexamethasone were administered. Patient's postoperative period was uneventful and had remained disease free for 1 year. To date, no consensus has been reached on the optimal treatment of subglottic EAF. We recommend regular follow-up to detect early recurrence.

Eosinophilic angiocentric fibrosis of the sinonasal tract

Eosinophilic angiocentric fibrosis (EAF) is an exceedingly rare and potentially disfiguring and obstructing benign lesion involving the upper airways. We report two cases of EAF originating from the nasal cavity in a 31-year-old female and a 58-year-old male exhibiting nasal obstructive symptoms, with imaging features and histopathology characteristic of EAF. Surgical excision was performed on one patient with a disfiguring nasal mass at a tertiary referral rhinology practice within a university centre. Summarized are the relevant clinical issues to increase awareness of this disease. The slow progression and rarity of the disease has previously resulted in diagnostic difficulty. We review the limited current literature surrounding the clinical features and treatment options for this progressive and potentially morbid condition. These cases reinforce that, while rare, inflammatory and fibrosing lesions in general should still be considered as part of the differential diagnosis in patients presenting with obstructive lesions in the sinonasal tract.

Orbital Compartment Syndrome in Eosinophilic Angiocentric Fibrosis

A 43-year-old man reported right visual loss after biopsy of an intranasal mass, which improved after treatment at another hospital. On first examination at our hospital, his visual acuity was 1.2 OD, and MRI showed a right intraorbital mass involving the ethmoid sinus. His visual acuity decreased to 0.08 OD 12 days after orbital biopsy, with right globe tenting shown by MRI. An emergent lateral canthotomy and cantholysis were performed. The histopathological diagnosis was eosinophilic angiocentric fibrosis, and treatment with intravenous methylprednisolone (125 mg/day) and oral diaminophenyl sulfone (75 mg/day) was started immediately after surgery. One month later, the diaminophenyl sulfone was discontinued and cyclophosphamide (50 mg/day) was started. The methylprednisolone and cyclophosphamide doses were tapered over 9 months and 7 months, respectively. At the 1.5-year follow-up examination, his visual acuity was 1.0 OD. The lesions did not grow in size.

Eosinophilic Angiocentric Fibrosis of Sinonasal Region: A Rare & Under Reported Entity

Eosinophilic angiocentric fibrosis is a rare pathology of the sinonasal tract and the upper respiratory system characterised by fibrosis with poorly understood pathogenesis. A 47-year-old male presented with a swelling over the dorsum of the nose. The possibility of fungal granuloma was being suggested on Magnetic Resonance Imaging (MRI). Histopathology showed thick collagen bundles whorling around vessels giving an onion skin appearance with focal area of vasculitis. An inflammatory reaction rich in eosinophils along with a fibrotic stroma was seen which was highly characteristic of eosinophilic angiocentric fibrosis. Clinically & microscopically it mimics Granuloma faciale, Wegener's Granulomatosis, Churg-Strauss Syndrome, Kimura's disease and few other granulomatous conditions thus making diagnosis difficult. A probable allergic origin is being suggested because of the typical eosinophil-rich inflammatory reaction. Finally the diagnosis of Eosinophilic Angiocentric Fibrosis was given. It is a diagnosis of exclusion having characteristic histomorphological findings thus biopsy is always required to distinguish it from other lesions whose treatment differs.

Nasal Eosinophilic Angiocentric Fibrosis with Orbital Extension

Eosinophilic angiocentric fibrosis (EAF) is an extremely rare, chronic, benign, idiopathic disorder that mostly affects the upper respiratory tract, particularly the nasal cavity, and features progressive submucosal perivascular fibrosis. To the best of our knowledge, only seven cases of EAF with orbital involvement have been reported. We report a case of sinonasal EAF with orbital extension that presented with left nasolacrimal duct obstruction. A 35-year-old man presented with left epiphora, proptosis, anterolateral globe displacement and nasal obstruction. Endoscopic sinus examination showed a firm, gritty, creamy, yellow, fibrous, adherent mass of maxillary sinus. Diagnosis was established with histopathological examination of excisional biopsy of the lesion. Although EAF is very rare, it should be considered in the differential diagnosis of lesions of upper airway tract, particularly the nasal cavity. Biopsy is necessary for diagnosis and treatment planning. Resecting of the involved tissues completely is essential for prevention of recurrence.

Eosinophilic angiocentric fibrosis of the nose and sinuses

BACKGROUND

Eosinophilic angiocentric fibrosis is a rare benign disorder of the upper respiratory tract. It is slow growing and progressive, with characteristic histological appearances.

METHODS

We report the largest single-institution case series of sinonasal eosinophilic angiocentric fibrosis to date, comprising nine patients. The current literature is reviewed, showing emerging evidence that this condition may belong to the immunoglobulin G4-related disease spectrum.

RESULTS

The series comprised five female and four male patients, with a mean age at presentation of 53 years. All were treated surgically. Six patients had no signs of recurrent disease after an average of 8.5 years. One patient went on to develop granulomatosis with polyangiitis (Wegener's granulomatosis), which required immunosuppressive therapy.

CONCLUSION

The first-line management of this rare condition is complete surgical excision. Chronic granulomatous conditions, including granulomatosis with polyangiitis, should be excluded before a diagnosis is made, and patients should be carefully followed.

Sinonasal eosinophilic angiocentric fibrosis: a systematic review

BACKGROUND

Eosinophilic angiocentric fibrosis (EAF) is a benign rare lesion of the upper respiratory mucosa. EAF most commonly presents with an obstructive nasal mass. Due to the rarity of EAF, case reports and case studies have predominated the literature. This systematic review discusses the demographics, clinical presentation, associated findings, management, and outcomes of this uncommon entity.

METHODS

The PubMed database was searched for all articles describing patients diagnosed with sinonasal EAF. Additional cases were examined from the bibliographies of selected articles. Demographics, clinical presentation, associated findings, radiography, management, and outcome were analyzed.

RESULTS

Fifty-two cases were included from 34 articles, including 1 case from our institution. The most common presenting symptom was nasal obstruction (78.8%). Fourteen patients (26.9%) had a previous history of nasal surgery or trauma. Surgical resection alone was the most commonly used primary treatment approach (50.0%), resulting in the greatest proportion of disease-free patients (55.6%) over a median follow-up period of 36 months. A combination of surgery and corticosteroids was the second-most-common treatment modality, used in 28.8% of cases. Of the 40 cases reporting patient outcomes, 100% of patients were alive at follow-up independent of treatment modality.

CONCLUSION

To date, this review contains the largest number of patients with sinonasal EAF. Aggressive surgical resection alone constitutes the most common treatment modality and may be most effective at eradicating disease.

Primary orbital eosinophilic angiocentric fibrosis with intranasal extension

BACKGROUND

Eosinophilic angiocentric fibrosis is a chronic, idiopathic disorder that usually involves the upper respiratory tract and features progressive submucosal perivascular fibrosis of unknown etiology. To our knowledge, only 5 cases of eosinophilic angiocentric fibrosis with primary orbital involvement have been reported.

METHODS AND RESULTS

We report the case of a 46-year-old man with right proptosis and lateral globe displacement caused by a primary eosinophilic angiocentric fibrosis extending from the orbit into the anterior ethmoid. The nasal extension of the lesion helped in establishing the correct diagnosis.

CONCLUSION

Physicians involved in the treatment of orbital pathologies should be familiar with this entity, because it may manifest as an intraorbital mass growing primarily or secondly into the orbit. The clinical manifestations of eosinophilic angiocentric fibrosis with orbital involvement often mimic other more common ophthalmological diseases. Biopsies are necessary for diagnosis and treatment planning, although cures are usually of palliative effect.

Eosinophilic angiocentric fibrosis of the nasal septum

Background. Eosinophilic angiocentric fibrosis (EAF) is a rare benign condition of unknown aetiology that causes stenosis of the upper respiratory tract. It is most commonly found at the nasal septum and sinus mucosa causing mucosal thickening and nasal obstructive symptoms. The diagnosis is mainly based on characteristic histologic findings. Case Report. A 27-year-old young woman presented with a slow growing mass at her anterior nasal septum for over eight years. She complained of persistent nasal obstruction, epistaxis, sometimes diffused facial pain, and chronic headache. 3 years ago, the tumor was partially resected for ventilation and a nasal septum perforation was left. Imaging findings indicated soft-tissue thickening of the anterior part of septum and adjacent lateral nasal walls. Pathological examination showed numerous inflammatory cells infiltrates containing eosinophils, fibroinflammatory lesion with a whorled appearance fibrosis which typically surrounded vessels. A diagnosis of eosinophilic angiocentric fibrosis was made. All laboratory tests were unremarkable. Skin prick test was positive. The tumor-like lesion was totally resected. Conclusions. EAF is a rare benign and progressive disorder causing destruction. Combined with radiological imaging of EAF historical findings contribute to the diagnosis. It is important to prevent tumor from recurrence by total resection of the lesion.