233Case Report

Fibromas are rare tumors of the nasal cavity, pos-sibly resulting from nasal mucosal progressive

inflammation. The tumors are usually too small tocause symptoms. In 1976, Fu and Perzin reported256 cases of upper respiratory non-epithelial tumorsin the nasal cavity.(1) Only four of the 256 cases wereclassified as nasal fibroma, and their sizes weresmaller than 1 cm in diameter. One of the tumorswas found in the posterior nasal vestibule, one wasin the nasal floor and the other two were in the nasalseptum; all were found incidentally. We report acase of gigantic sinonasal fibroma, measuring 4.53 3 cm, which was successfully resected usingendoscopic sinus surgery.

CASE REPORT

A 47-year-old woman had suffered from pro-gressively severe headaches, insomnia, and right

purulent rhinorrhea for 6 months. She was referredto our hospital by a local clinic, under the suggestionof a right nasal tumor. The patient had a history ofchronic allergic rhinitis, but no chronic paranasalsinusitis or other associated signs and symptomssuch as epistaxis. She also denied a history of headinjury and other major systemic diseases. Our physi-cal examinations revealed that the right nostril wasoccupied by a gray-white, smooth-surfaced, giganticfirm mass (Fig. 1). Under the impression of a rightnasal tumor, she underwent sinus computed tomog-raphy (CT), which revealed that the right nasal cavi-ty was occupied by a huge, soft-tissue-density mass(Fig. 2). The margin of the mass was well definedand no bony erosion was noted. Additionally, rightmaxillary sinusitis was also noted. Biopsy in theoutpatient department was not available because thesurface of the tumor was too hard for biopsy punchforceps and poor patient's tolerance. Therefore, we

Endoscopic Sinus Surgery Treatment for a Huge Sinonasal Fibroma

Hsiao-Lun Lin, MD; Chi-Che Huang, MD ; Ta-Jen Lee, MD

Fibromas are rare tumors of the nasal cavity, which may result from progressive inflam-mation or fibroblastic proliferation of the nasal mucosa. The tumors are usually too small tocause symptoms. We present a 47-year-old woman suffering through right nasal obstruction,purulent rhinorrhea and severe headaches for 6 months. A gray-white, smooth-surfaced,gigantic firm mass occupying the right nostril was found in physical examination. Sinuscomputed tomography revealed 4 3 3 cm soft-tissue-density mass in the right nasal cavi-ty and right maxillary sinusitis. The huge sinonasal fibroma measuring 4.5 3 3-cm in theright posterior ethmoid sinus, which was successfully endoscopically resected. The finaldiagnosis of fibroma was made histologically, according to light microscopy and immuno-histochemical stain examinations, which were important for determining the patient's treat-ment. After endoscopic resection, her initial signs and symptoms were relieved and no recur-rence was noted after 2 years of follow up. (Chang Gung Med J 2004;27:233-7)

Key words: fibroma, paranasal sinus, endoscopic surgery.

Presented at the 71st Scientific Meeting of the Taiwan Otorhinolaryngological Society, Taipei, Taiwan ROC; November 10, 2001.From the Department of Otolaryngology, Chang Gung Memorial Hospital, Taipei; Chang Gung University, Taoyuan.Received: Dec. 11, 2002; Accepted: Jul. 10, 2003Address for reprints: Dr. Ta-Jen Lee, Department of Otolaryngology, Chang Gung Memorial Hospital. 5, Fushing Street, GueishanShiang, Taoyuan, Taiwan 333, R.O.C. Tel.: 886-3-3281200 ext. 3967; E-mail: drhllin@ms13.hinet.net

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performed endoscopic sinus surgery (ESS) to obtaina biopsy specimen. However, a small piece of speci-men by biopsy punch forceps for frozen section wasnot obtained due to the nature of the tumor.

The 4.5 3 3 cm encapsulated tumor wasfound occupying the whole ethmoid sinus and onethird of the right maxillary sinus with a wide-basedstalk attached to the right posterior ethmoid sinus.The tumor was dissected from the stalk and wasfreed. Before removal, we made an incision in thelimen vestibulum nasi for dilatation of the anterior

Fig. 1 Sinoscopic examination revealed a capsulated gigantictumor occupying the right nasal cavity.

Fig. 3 The 4.5 3 3 cm gray-white, smooth-surfaced tumorwas removed as a whole via the anterior nare.

Fig. 4 Histological examination showed that the tumor wascomposed of interlacing bundles of spindle cells withentrapped mucous glands. No nuclear pleomorphism, mitoticactivity, or necrosis was seen. ( Haematoxylin and Eosin (H &E) stain, 100)

Fig. 2 Sinus CT, (A) coronal and (B) axial section withoutcontrast, showed that the tumor in the right nasal cavity whichcaused lateral bulging of the medial wall of the right maxil-lary sinus. An air-fluid level in the right maxillary sinus wasnoted and sinusitis was suggested.

A

B

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nare for passage of the large tumor specimen.Because the tumor was gigantic and very adamant, itcould only be removed as a whole and not dividedinto pieces (Fig. 3). After removal, the specimenwas sent for frozen section and the initial diagnosisidentified the tumor as a benign solitary fibroustumor (Fig. 4).

After immunohistochemical staining with S-100(negative), desmin (negative), vimentin (positive),CD 34 (negative), MIB-1 (0%) and smooth muscleactin (negative),(2) the final pathologic diagnosis wasfibroma. The patient was discharged after 5 days ofhospitalization and had follow-up examinations at 1month, 6 months and 2 years after the operation. Norecurrence was observed in local findings or sinusCT scan (Fig. 5). The patient's complaints ofheadache and purulent rhinorrhea resolved and herallergic rhinitis was under medical control.

DISCUSSION

Fibromas of the upper respiratory tract, likefibromas in other parts of the body, may originatefrom previous inflammatory reactions or fibroblastproliferations such as in aggressive fibromatosis,which may result in tumors composed of collagenfiber and mature spindle cells. In the nasal cavity, itmight also originate from previous polypoid changesor tumors, such as inflammatory polyp or lobularcapillary hemangioma. Neither cell infiltration norperipheral invasion was noted. Fibromas in theupper respiratory tract are found mostly in the phar-ynx and larynx, but rarely in the nasal cavity. Inaddition, they are classified as fibrous polyps.(1)

The most common symptoms of fibromas arenasal obstruction, purulent rhinorrhea and headache,which are induced by compression due to the large,sinonasal space-occupying tumor. However, usually,they are smaller then 1 cm and are without clinicalsigns and symptoms.(3)

Imaging studies can distinguish between solitaryand multiple tumors. Furthermore, these examina-tions show the extent of tumor distribution, invasion,or infiltration of peripheral tissue, and the shape andimage density of tumors.(4) Sinus CT scans show thesurrounding bony structure and the margin of thetumor. Magnetic resonance imaging (MRI) providesinformation on the infiltrated margin and invasivedepth of the surrounding soft tissue. In our patient,we realized that the tumor was probably benignbecause of its well-defined margin, intact bony struc-ture, and soft tissue density on sinus CT. Sinus MRIwas not necessary for the management of our patient.

The differential diagnosis of sinonasal fibromaincludes nasal polyp, solitary fibrous tumor,(2) invert-ed papilloma, neurofibroma, aggressivefibromatosis,(5) angioma, lobular capillary heman-gioma, osteoma, ossifying fibroma,(6) and othermalignant tumors. Immunohistochemical stainingand light microscopic features provide evidence forthe differential diagnosis and prevent the oversight ofother systemic diseases such as aggressive fibro-matosis, which we would have had to monitor moreclosely and arrange for further examinations becauseof its high recurrence rate and the possibility ofabdominal involvement.(5,7)

The appearance of a fibroma is a smooth-sur-faced, clear margined, polypoid tumor usually small-

Fig. 5 After following up for 2 years, her sinus CT scanshowed no recurrent tumor and right maxillary sinusitis wascured.

A

B

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er than 1 cm in diameter.(3) In our patient, the tumorwas composed of interlacing bundles of spindle cells,collagen fibers, and few entrapped mucus glands onmicroscopy. No smooth muscle, large vessel compo-nent, nuclear pleomorphism, necrosis, or mitoticactivity was noted.

For distinguishing between fibroma and theother nasal non-epithelial tumors, immunohisto-chemical staining might be a more accurate tool thanlight microscopy. If smooth muscle actin positivelyindicates the presence of smooth muscle compo-nents, the S-100 positivity would indicate the pres-ence of neurogenic tumor components. Desmin andvimentin are found in muscle cell intermediate fila-ments.(8) In our patient, the tumor marker CD 34 wasnegative; but for a solitary fibrous tumor, it shouldhave been positive.(9) Because aggressive fibromato-sis usually presents with an infiltrative growth pat-tern and displays localized smooth muscle actin, weruled out the possibility of that disease.(10) These spe-cial staining results not only support the diagnosis offibroma, but also are beneficial for treatment plan-ning.

Before endoscopic surgery, it was suggested thatthe non-epithelial tumor was an osteoid fibroma,according to the patient's history, local physical find-ings and the location and characteristics of the tumor.However, no calcification or bone density was foundin the tumor in sinus CT scan, and the pathologyconfirmed that the tumor was a fibroma without theevidence of an osteoid component or infiltration ofthe peripheral tissue.

Like other non-epithelial tumors, fibromas havewell-defined margins in the nasal cavity. Only whenthey are symptomatic or exhibit rapid growth, istumor excision indicated.(11) Traditionally, patientshave undergone a variety of external approaches forresection of larger tumors, but with the advent ofsinonasal endoscopic surgery in the middle 1980s,subsequent advances in technology and surgicaltechniques, endoscopic surgery is now feasible fortreatment of these large tumors.(6)

In our patient, sinus CT scan and endoscopicexamination findings showed a clear tumor marginand the broad tumor stalk. Because no local invasionof bone and tissue were found, we dissected thetumor from its stalk with endoscopic surgical instru-ments. However, the tumor was huge and firm, thus,we needed to make a 1-cm longitudinal incision

along the limen vestibulum nasi to dilate thevestibule for removal of the whole tumor via theanterior nare. Local recurrences of sinonasal fibro-mas after surgical treatment have not been docu-mented.

For sinonasal tumors with well-defined margins,excision using endoscopic sinus surgery could be analternative to traditional sinus surgery. Using theendoscopic sinus surgery enables the patients to haveshortened hospitalization, shorter recovery time,reduced wound size, and increased cosmetic benefits.

REFERENCES

1. Fu YS, Perzin KH. Non-epithelial tumors of the nasalcavity, paranasal sinuses and nasopharynx: a clinicopatho-logic study. IV. Fibrous tissue tumors (fibroma, fibro-matosis, fibrosarcoma). Cancer 1976;37:2912-28.

2. Hanau CA, Miettinen M. Solitary fibrous tumor: histolog-ical and immunohistochemical spectrum of benign andmalignant variants presenting at different sites. HumPathol 1995;26:440-9.

3. Hashimoto K, Mase N, Iwai K, Shinoda K, Sairenji E.Desmoplastic fibroma of the maxillary sinus. Report of acase and review of the literature. Oral Surg Oral Med OralPathol 1991;72:126-32.

4. Ikeda K, Tanno N, Suzuki H, Oshima T, Kano S,Takasaka T. Unilateral sinonasal disease without bonedestruction. Differential diagnosis using diagnostic imag-ing and endonasal endoscopic biopsy. Arch OtolaryngolHead Neck Surg 1997;123:198-200.

5. Siegel NS, Bradford CR. Fibromatosis of the head andneck: a challenging lesion. Otolaryngol Head Neck Surg2000;123:269-75.

6. Choi YC, Jeon EJ, Park YS. Ossifying fibroma arising inthe right ethmoid sinus and nasal cavity. Int J PediatrOtorhinolaryngol 2000;54:159-62.

7. Vallat-Decouvelaere AV, Dry SM, Fletcher CD. Atypicaland malignant solitary fibrous tumors in extrathoraciclocations: evidence of their comparability to intra-thoracictumors. Am J Surg Pathol 1998;22:1501-11.

8. Lee Min W, Qureshi Hina S, Ho Khang L, Min Kyung W.Cellular inclusions: diagnostic clues in surgical pathology.Pathol Case Rev 2002;7:186-92.

9. Westra WH, Gerald WL, Rosai J. Solitary fibrous tumor.Consistent CD34 immunoreactivity and occurrence in theorbi. Am J Surg Pathol 1994;18:992-8.

10. Mills SE, Gaffey MJ, Frierson HF. Atlas of TumorPathology-Tumors of the upper aerodigestive tract andear. Washington, D.C. Armed Forces Institute ofPathology, 1997:273-8.

11. Lawson W, Reino AJ. Isolated sphenoid sinus disease: ananalysis of 132 cases. Laryngoscope 1997;107:1590-5.

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91 12 11 92 7 10333 5 Tel.: (03)3281200 3967; E-mail:

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