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Presented by William Westra, M.D. and prepared by Greg Seidel, M.D.
Case 1: 13 year-old boy with a unilateral mass involving the posterior nasal cavity
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1. Question
Week 115: Case 1
13 year-old boy with a unilateral mass involving the posterior nasal cavity/images/1202021a.jpg
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/images/1202021d.jpgCorrect
Answer: Sinonasal papilloma, antrochoanal type
Histology: The polypoid nature of the specimen is largely due to accumulation of submucosal edema fluid with microcyst formation. The inflammatory infiltrate is rather scant and composed mostly of lymphocytes and plasma cells. Eosinophils are notably absent. The stromal fibroblasts are stellate in shape and have enlarged hyperchromatic nuclei. The overlying surface epithelium is not proliferative.
Discussion: By far the most common sinonasal polyp encountered by surgical pathologists is the inflammatory (i.e. allergic) polyp. These typically are encountered in patients older than 30, and they generally occur as bilateral and multiple lesions in patients with allergic sinusitis. Outside of this typical setting, other types of sinonasal polyps should be considered. For example, bilateral multiple polyps in children should always prompt consideration of polyps of cystic fibrosis. Although the clinical history will often point to this diagnosis, in a small percentage of individuals polyp formation will be the initial manifestation of disease.
The presence of a sinonasal polyp that is solitary and unilateral raises the concern of a neoplastic process such as Schneiderian papilloma or embryonal carcinoma. Schneiderian papillomas are usually encountered in adults. Embryonal carcinoma is a tumor of children and a diagnosis that needs to be excluded on microscopic grounds.
Antrochoanal polyp is an important exception to the generalized rule that nasal polyps are multiple, bilateral, and occur in adults. These are typically solitary lesions that occur in adolescent males. Although they usually present as nasal cavity masses, they originate in the maxillary antrum and then involve the nasal cavity secondarily as they extend through the ostium via a long pedicle. The distinction from an inflammatory polyp is mostly clinical, but there are some subtle histologic differences. Compared to inflammatory polyps, sinonasal polyps tend to have a more fibrous stroma, they lack eosinophils, they contain fewer glandular elements, and they do not demonstrate thickening of the basement membrane. Like sinonasal polyps, the stromal fibroblasts may be atypical – a finding that should not be mistaken for a sarcoma.
Incorrect
Answer: Sinonasal papilloma, antrochoanal type
Histology: The polypoid nature of the specimen is largely due to accumulation of submucosal edema fluid with microcyst formation. The inflammatory infiltrate is rather scant and composed mostly of lymphocytes and plasma cells. Eosinophils are notably absent. The stromal fibroblasts are stellate in shape and have enlarged hyperchromatic nuclei. The overlying surface epithelium is not proliferative.
Discussion: By far the most common sinonasal polyp encountered by surgical pathologists is the inflammatory (i.e. allergic) polyp. These typically are encountered in patients older than 30, and they generally occur as bilateral and multiple lesions in patients with allergic sinusitis. Outside of this typical setting, other types of sinonasal polyps should be considered. For example, bilateral multiple polyps in children should always prompt consideration of polyps of cystic fibrosis. Although the clinical history will often point to this diagnosis, in a small percentage of individuals polyp formation will be the initial manifestation of disease.
The presence of a sinonasal polyp that is solitary and unilateral raises the concern of a neoplastic process such as Schneiderian papilloma or embryonal carcinoma. Schneiderian papillomas are usually encountered in adults. Embryonal carcinoma is a tumor of children and a diagnosis that needs to be excluded on microscopic grounds.
Antrochoanal polyp is an important exception to the generalized rule that nasal polyps are multiple, bilateral, and occur in adults. These are typically solitary lesions that occur in adolescent males. Although they usually present as nasal cavity masses, they originate in the maxillary antrum and then involve the nasal cavity secondarily as they extend through the ostium via a long pedicle. The distinction from an inflammatory polyp is mostly clinical, but there are some subtle histologic differences. Compared to inflammatory polyps, sinonasal polyps tend to have a more fibrous stroma, they lack eosinophils, they contain fewer glandular elements, and they do not demonstrate thickening of the basement membrane. Like sinonasal polyps, the stromal fibroblasts may be atypical – a finding that should not be mistaken for a sarcoma.
