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Organized hematoma in the paranasal sinus and nasal cavity—Imaging diagnosis and pathological findings
Auris Nasus Larynx 37 (2010) 173–177 www.elsevier.com/locate/anl
Organized hematoma in the paranasal sinus and nasal cavity—Imaging diagnosis and pathological findings Go Omura *, Kenta Watanabe, Yoshinori Fujishiro, Yasuhiro Ebihara, Kazunari Nakao, Takahiro Asakage The Department of Otorhinolaryngology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan Received 2 March 2009; accepted 21 June 2009 Available online 20 August 2009
Abstract Objectives: The ‘‘organized hematoma’’ is a non-neoplastic, hemorrhagic lesion, which can develop in the paranasal sinus and nasal cavity. This is the first report on the relationship between the imaging and pathological findings. Methods: We diagnosed organized hematoma, based on three criteria: no existence of neoplastic cells; consistency of hematoma and fibrosis; and development from the paranasal sinus and nasal cavity. We retrospectively investigated six cases from the patients’ medical records. Results: On the imaging findings, the central part of the lesion was enhanced more strongly than the lesion periphery. All of the pathological findings were hematoma at the center, and fibrosis at the periphery. In three of the cases, dilated vessels were found but not in the other three. Conclusion: We found that the biphasic appearance of the imaging findings correlated with that of the pathological findings. There are two pathological types – the dilated vessel type and the non-dilated vessel type. # 2009 Elsevier Ireland Ltd. All rights reserved. Keywords: Organized hematoma; Pathological findings; Dilated vessels; Imaging findings; Blood boil
1. Introduction The ‘‘organized hematoma’’ is a non-neoplastic, hemorrhagic lesion causing mucosal swelling and bone thinning, and can develop in the paranasal sinus and nasal cavity. The first report of this lesion was introduced in the Japanese literature as the ‘‘blood boil’’ by Tadokoro in 1917, and it is relatively difficult to differentiate the lesion from a malignant lesion only with the imaging findings, and biopsy specimen [1,2]. Until now, all of the reports about this lesion have discussed the clinical course, and no previous report has closely considered the correlations between the pathological and imaging findings, and the cause of this lesion from the view of pathological findings. * Corresponding author at: University of Tokyo, 7-3-1 Hongo, Bunkyoku, Tokyo 113-8655, Japan. Tel.: +81 3 5800 8665; fax: +81 3 3814 9486. E-mail addresses: [email protected], [email protected] (G. Omura).
We recently experienced six cases of organized hematoma, and investigated the imaging diagnosis and histological characteristics of this lesion.
2. Materials and methods To diagnose the ‘‘organized hematoma’’, we applied the following criteria reported by Yagisawa et al. and Song et al. [1,2]: first, no existence of neoplastic cells; second, the lesion consists of hematoma and fibrosis; third, it develops from the paranasal sinus and nasal cavity. All of six cases were referred to our department between January 2000 and June 2006, and were conclusively diagnosed as ‘‘organized hematoma’’ from the pathological findings based on the above criteria. Data concerning the patient characteristics, the clinical disease characteristics, the imaging findings, the surgical procedure employed and the pathological findings were obtained from a review of the patients’ medical records.
0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2009.06.009
174
G. Omura et al. / Auris Nasus Larynx 37 (2010) 173–177
Table 1 Clinical characteristics of the six cases.
I II III IV V VI
Age
Gender
Chief complaint
Location
Side
Diagnosis at the initial visit
41 56 30 38 26 31
M M F M M M
Nasal obstruction Nasal obstruction Epistaxis Epistaxis Nasal obstruction Nasal obstruction
Maxillary sinus Nasal cavity Maxillary sinus Maxillary sinus Maxillary sinus Maxillary sinus
Right Right Left Left Right Right
Malignant tumor Malignant tumor Organized hematoma Hemangioma Juvenile angiofibroma Malignant tumor
3. Results Five men and one woman were included in the study, all of whom were Japanese with ages ranging from 26 to 56 years (median 35 years). The first symptoms were epistaxis and nasal obstruction in three cases each. The maxillary sinus was occupied in five cases, and nasal cavity in one case. All of them occurred unilaterally, four cases on the right and two cases on the left. The diagnoses when they were referred to us were ‘‘organized hematoma’’ in only one case, hemangioma in one case, juvenile angiofibroma in one case, and malignancy for the other three cases (Table 1). On computed tomography (CT), lateral wall of nasal cavity and posterior wall of maxillary sinus were thinning and diminished in two cases, only the lateral wall of the nasal cavity was compressed in one case, and no bone abnormality was seen in the other three cases. In all of the cases heterogeneous enhancement was noted only in the central region (Fig. 1). On magnetic resonance imaging (MRI), the central region showed low intensity and was strongly enhanced with Gd-DTPA on T1-weighted imaging, with high intensity on T2-weighted. On the other hand, low to isointensity was noted in the peripheral region on T1, and isoto high intensity on T2 imaging. The central region was more strongly enhanced than the peripheral region. The paranasal sinus mucosa of its surroundings thickened (Table 2) (Fig. 2). Three patients underwent endonasal endoscopic surgery (ESS), and two patients were treated with surgery via transmaxillary approach with gingival incision. The remaining patient was hospitalized urgently due to epistaxis of the right nasal cavity, and we found the neoplastic-like lesion in his right nasal cavity. So we underwent nasal packing promptly. Several days after, when we released the
Fig. 1. A 41 years old male had a two-month history of bilateral nasal obstruction. He also complained of recurrent epistaxis. Enhanced CT of the paranasal sinuses revealed a 50 45 mm heterogeneous enhanced mass in the right maxillary sinus, the central region of which was in particular strongly enhanced. Compression and thinning of the posterior wall of the right maxillary sinus and the lateral wall of the right nasal cavity was also noted. The nasal septum was displaced (case I).
nasal packing, the lesion dropped out spontaneously. The intraoperative bleeding volume excepting non-operative case (case II), was from 250 to 700 ml (median 425 ml). Before the operation, two cases were performed angiography, and found that maxillary artery was the feeding artery. One of them (case IV) showed strongly enhanced lesion, and was performed embolization. The
Table 2 The CT and MRI findings of the six cases. Bane thinning
I II III IV V VI
L,P – – L,P L –
Diameter (mm)
50 45 18 14 Ø Ø Ø Ø
25 30 40 30
MRI (T1-weighted)
MRI (T2-weighted)
MRI (Gd-DPTA enhanced)
Central
Surrounding
Central
Surrounding
Central
Surrounding
Low – Low Low Low Low
Low – Low to iso Low to iso Low Low to iso
High – High High High Low
Iso to high – Iso to high Iso to high Low Low to iso
High – High High High –
Low – Low Low Low –
L: Lateral wall of nasal cavity; P: Posterior wall of maxillary sinus.
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Fig. 3. The dilated vessels (*) were found in the hematoma in three of these cases (a), but not in the others (b).
other (case I) showed weakly enhanced one, and was not performed (Table 3). All of the pathological findings were hematoma surrounded with fibrotic tissue. No neoplastic cell was existed. There are two pathological types; in three cases the dilated vessels were found in the hematoma, but not in the other three (Table 3) (Fig. 3). No recurrence has been seen in any patient.
Fig. 2. MRI showed as follows. (a) On T1-weighted images, the central region (*) had slightly low intensity comparable with muscle. (b) On T2weighted images, the central region (*) had high intensity, and the peripheral region ($) had lower than the central. Thickening of the paranasal sinus mucosa was found ("). (c) On T1-weighted images with contrast, the central region was strongly enhanced (*), and the peripheral region ($) demonstrated less enhanced effect than the central. And thickening mucosa of the paranasal sinus was strongly enhanced too (").
4. Discussion The organized hematoma is rare. The term ‘‘organized hegmatoma’’ is not unified in the English literature and many terms, such as blood boil, hematoma, hematoma-like mass, hematocele, blutbeule, and organizing hematoma are used [1–13]. Song et al. state that ‘‘organization’’ means ‘‘replacement of hematoma by fibrous tissue’’, and the recently proposed term ‘‘hematoma-like mass’’ is inadequate to explain the histopathology and clinical behavior [2]. Most of the reports are from Japan and Korea [2]. It occurs in
176
G. Omura et al. / Auris Nasus Larynx 37 (2010) 173–177
Table 3 Treatment and pathological finding.
I II III IV V VI *
Angiography
Existence of the feeding artery
Embolization
Bleeding volume (ml)
Operation method
Existence of the dilated vessels
Performed Not performed Not performed Performed Not performed Not performed
Maxillary artery
Not performed
610 – 700 425 250 380
Transmaxillary
– – – + + +
Maxillary artery
Performed
*
ESS ESS Transmaxillary ESS
Dropped out by itself in several days after the astriction with nasal packing.
patients from 20 to 40 years old, and the age of the patients is younger than that of maxillary carcinoma [7,8]. The majority of the lesions arise in the nasal cavity and maxillary sinus, however, it has been reported to originate in the ethmoid and frontal sinuses. In these latter cases a craniotomy was performed because of the destruction of the skull base bone [9]. Pathological findings include hematoma, fibrosis, neovascularization, and no evidence of neoplasm. As for the disease etiology, Ozaki et al. suggest the negative spiral theory during the repairing process as follows. At first, a blood clot accumulates in the closed space due to various causes of bleeding, including hemangioma formation, facial injury, or inflammation. Next necrosis, fibrosis, and hyalinization occur in turn, and neovascularization develops as part of these biologically healing processes. But blood flow becomes sluggish at the lead of new vessels. As a result, the new vessels become dilated, and rebleeding occurs (Fig. 4) [8].
Fig. 4. We made a schema of the growing organized hematoma advocated by Ozaki et al. At first, a blood clot accumulates in the closed space due to various causes of bleeding, including hemangioma formation, facial injury, and inflammation. Next necrosis, fibrosis, hyalinization, neovascularization, and vascular dilatation happen in turn. Finally, bleeding again occurs.
In all of the six cases in the current study, the lesion consisted of a hematoma surrounded by fibrosis. There are two pathological types. Dilated vessels were found in the hematoma in three of these cases. But these vessels were not found in others. The dilated vessel type in particular was similar to the hemangioma in the pathological findings, reflecting the stage between the neovascularization period and the vascular dilation period in the negative spiral. On the other hand, the non-dilated type reflects the stage between the bleeding period and the period of fibrosis formation. The difference between the dilated vessel type and the nondilated vessel type supports the theory; the ‘‘organized hematoma’’ is the secondary change of the easy bleeding lesion like hemangioma and vascular malformation (Fig. 3). The old fibrosis additionally forms a capsule around the hematoma (Fig. 5). Concerning the pre-operative evaluation with CT and MRI, three image findings are found in this lesion, as follows. First, it is an expansive, clearly demarcated, heterogeneously enhanced mass, and never infiltrative. Second, it is compressive lesion, and diminishes the bone structure. But it is never destructive on CT findings [10]. Third, the MRI shows thickening of the paranasal sinus mucosa of its surroundings. The mucosa is well enhanced on T1-weighted images with contrast, and high intensity on T2weighted images. It suggests the inflammatory change due to the obstruction by the lesion. These points differ from a malignant tumor that causes the invasive bone destruction, and mucosal invasion [11–13]. In addition, the central part of the lesion had low intensity on T1-weighted imaging, high intensity on T2-weighted imaging and was well enhanced (Table 2). The existence of blood with a low flow speed was therefore considered at the central region, which matched the presence of a hematoma in the pathological findings. Meanwhile, the peripheral part was less enhanced, which were matched the zone of fibrosis. Such biphasic appearance is therefore an important imaging aspect of this lesion to cite as a differential diagnosis before deciding on the treatment strategy. To recognize the location of the hematoma, could be useful volume of intraoperative bleeding. An operation is necessary to cure the organized hematoma and no other treatment is available to relieve the associated symptoms. To differentiate the organized hematoma from a malignant tumor, the confirmation of
G. Omura et al. / Auris Nasus Larynx 37 (2010) 173–177
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with angiography. But, in the six cases, the angiography was performed in two cases, and the embolization was performed in only one case. Unfortunately, it is difficult to define the necessity of the preoperative embolization from this report (Table 3).
5. Conclusion The ‘‘organized hematoma’’ destroys the bone structure of its surroundings when it develops. Difficulty in differentiating it from a malignant tumor has been reported, but we have suggested some imaging findings to help the preoperative diagnosis. In the pathological findings, the lesions in all of the cases were hematomas surrounded with fibrotic tissues. This point strongly backs up the biphasic appearance of the imaging findings. As for the pathological findings, the dilated vessel type and non-dilated vessel type are found. These findings suggest that the organized hematoma is a secondary change of a previously formed hemangioma like lesion.
References
Fig. 5. We performed total removal of the contents of the right maxillary sinus by the transmaxillary approach. In the intraoperative findings, the lesion had invaded the right maxillary sinus, and destroyed the bone structure of the posterior wall. The lesion was, however, easily separated from the maxillary sinus mucosa, and the periosteum of the posterior wall was preserved. (a) The appearance of the specimen. (b) The specimen slice. The central region is hematomatous ($), and the surrounding region is fibrotic (*).
complete lack of neoplastic cells in the totally removed specimen is needed. From these points, the total removal under general anesthesia should be undertaken. Regarding the operative approach, if the lesion is small and an adequate endoscopic operative field working space can be achieved, ESS should be chosen. On the other hand, if the lesion is big and has been thinning the bone structure of the paranasal sinuses, the transmaxillary approach should be chosen. There is little difference in the intraoperative bleeding volume between the ESS and the transmaxillary approach cases. To decrease the intraoperative bleeding volume, embolization can be performed if the feeding artery is found
[1] Yagisawa M, Ishitoya J, Tsukuda M. Hematoma-like mass of the maxillary sinus. Acta Otolaryngol 2006;126:181–277. [2] Song HM, Jang YJ, Chung YS, Lee BJ. Organizing hematoma of the maxillary sinus. Otolaryngol Head Neck Surg 2007;136:616–20. [3] Unlu HH, Mutlu C, Ayhan S. Organized hematoma of maxillary sinus mimicking tumor. Auris Nasus Larynx 2001;28:253–5. [4] Lee BJ, Park HJ, Heo SC. Organized hematoma of the maxillary sinus. Acta Otolaryngol 2003;123:869–72. [5] Yoon TM, Kim JH, Cho YB. Three cases of organized hematoma of the maxillary sinus. Eur Arch Otorhinolaryngol 2006;263:823–6. [6] Tabaee A, Kacker A. Hematoma of the maxillary sinus presenting as a mass—a case report and review of literature. Int J Pediatr Otorhinolaryngol 2002;65:153–7. [7] Hukumoto A, Ikezono T, Nakamizo M, Kokawa T, Nakajima H, Yokoshima K, et al. Three cases of so-called ‘‘blutbeule’’. Otolaryngol Head Neck Surg [Tokyo] 2000;72:660–5. [8] Ozaki M, Sakai S, Ikeda H. Hemangioma of the nasal cavity and sinuses—a report of twenty five cases. Otolaryngol Head Neck Surg [Tokyo] 1977;49:53–8. [9] Endo Y, Kikuchi J, Seki H, Sugawara T, Ogawa T. Two cases of socalled ‘‘blutbeule’’ in the frontal sinus and ethmoid sinus. Practica Otologica [Kyoto] 2005;51:120–3. [10] Lee HK, Smoker WR, Lee BJ, Kim SJ, Cho KJ. Organized hematoma of the maxillary sinus: CT findings. Am J Roentgenol 2007;188:W370–3. [11] Matsuda M, Yamazaki M, Morimitsu T, Fukiyama M. The usefulness of MRI for detecting hematocele in the maxillary sinus. Practica Otologica [Kyoto] 1996;42:1072–5. [12] Nagato S, Sugawara K, Watanuki K, Tanaka K, Mikuriya T, Hashimoto M, et al. Examination of MRI and histopathological findings of hematocele in the maxillary sinus. Practica Otologica [Kyoto] 2006;99:929–34. [13] Okukubo A, Ishida H, Amatsu M, Takao M. Preoperative diagnosis of so-called ‘‘blutbeule’’ in the maxillary sinus. Otolaryngol Head Neck Surg [Tokyo] 1998;70:35–8.
Organized hematoma in the paranasal sinus and nasal cavity—Imaging diagnosis and pathological findings Go Omura *, Kenta Watanabe, Yoshinori Fujishiro, Yasuhiro Ebihara, Kazunari Nakao, Takahiro Asakage The Department of Otorhinolaryngology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan Received 2 March 2009; accepted 21 June 2009 Available online 20 August 2009
Abstract Objectives: The ‘‘organized hematoma’’ is a non-neoplastic, hemorrhagic lesion, which can develop in the paranasal sinus and nasal cavity. This is the first report on the relationship between the imaging and pathological findings. Methods: We diagnosed organized hematoma, based on three criteria: no existence of neoplastic cells; consistency of hematoma and fibrosis; and development from the paranasal sinus and nasal cavity. We retrospectively investigated six cases from the patients’ medical records. Results: On the imaging findings, the central part of the lesion was enhanced more strongly than the lesion periphery. All of the pathological findings were hematoma at the center, and fibrosis at the periphery. In three of the cases, dilated vessels were found but not in the other three. Conclusion: We found that the biphasic appearance of the imaging findings correlated with that of the pathological findings. There are two pathological types – the dilated vessel type and the non-dilated vessel type. # 2009 Elsevier Ireland Ltd. All rights reserved. Keywords: Organized hematoma; Pathological findings; Dilated vessels; Imaging findings; Blood boil
1. Introduction The ‘‘organized hematoma’’ is a non-neoplastic, hemorrhagic lesion causing mucosal swelling and bone thinning, and can develop in the paranasal sinus and nasal cavity. The first report of this lesion was introduced in the Japanese literature as the ‘‘blood boil’’ by Tadokoro in 1917, and it is relatively difficult to differentiate the lesion from a malignant lesion only with the imaging findings, and biopsy specimen [1,2]. Until now, all of the reports about this lesion have discussed the clinical course, and no previous report has closely considered the correlations between the pathological and imaging findings, and the cause of this lesion from the view of pathological findings. * Corresponding author at: University of Tokyo, 7-3-1 Hongo, Bunkyoku, Tokyo 113-8655, Japan. Tel.: +81 3 5800 8665; fax: +81 3 3814 9486. E-mail addresses: [email protected], [email protected] (G. Omura).
We recently experienced six cases of organized hematoma, and investigated the imaging diagnosis and histological characteristics of this lesion.
2. Materials and methods To diagnose the ‘‘organized hematoma’’, we applied the following criteria reported by Yagisawa et al. and Song et al. [1,2]: first, no existence of neoplastic cells; second, the lesion consists of hematoma and fibrosis; third, it develops from the paranasal sinus and nasal cavity. All of six cases were referred to our department between January 2000 and June 2006, and were conclusively diagnosed as ‘‘organized hematoma’’ from the pathological findings based on the above criteria. Data concerning the patient characteristics, the clinical disease characteristics, the imaging findings, the surgical procedure employed and the pathological findings were obtained from a review of the patients’ medical records.
0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2009.06.009
174
G. Omura et al. / Auris Nasus Larynx 37 (2010) 173–177
Table 1 Clinical characteristics of the six cases.
I II III IV V VI
Age
Gender
Chief complaint
Location
Side
Diagnosis at the initial visit
41 56 30 38 26 31
M M F M M M
Nasal obstruction Nasal obstruction Epistaxis Epistaxis Nasal obstruction Nasal obstruction
Maxillary sinus Nasal cavity Maxillary sinus Maxillary sinus Maxillary sinus Maxillary sinus
Right Right Left Left Right Right
Malignant tumor Malignant tumor Organized hematoma Hemangioma Juvenile angiofibroma Malignant tumor
3. Results Five men and one woman were included in the study, all of whom were Japanese with ages ranging from 26 to 56 years (median 35 years). The first symptoms were epistaxis and nasal obstruction in three cases each. The maxillary sinus was occupied in five cases, and nasal cavity in one case. All of them occurred unilaterally, four cases on the right and two cases on the left. The diagnoses when they were referred to us were ‘‘organized hematoma’’ in only one case, hemangioma in one case, juvenile angiofibroma in one case, and malignancy for the other three cases (Table 1). On computed tomography (CT), lateral wall of nasal cavity and posterior wall of maxillary sinus were thinning and diminished in two cases, only the lateral wall of the nasal cavity was compressed in one case, and no bone abnormality was seen in the other three cases. In all of the cases heterogeneous enhancement was noted only in the central region (Fig. 1). On magnetic resonance imaging (MRI), the central region showed low intensity and was strongly enhanced with Gd-DTPA on T1-weighted imaging, with high intensity on T2-weighted. On the other hand, low to isointensity was noted in the peripheral region on T1, and isoto high intensity on T2 imaging. The central region was more strongly enhanced than the peripheral region. The paranasal sinus mucosa of its surroundings thickened (Table 2) (Fig. 2). Three patients underwent endonasal endoscopic surgery (ESS), and two patients were treated with surgery via transmaxillary approach with gingival incision. The remaining patient was hospitalized urgently due to epistaxis of the right nasal cavity, and we found the neoplastic-like lesion in his right nasal cavity. So we underwent nasal packing promptly. Several days after, when we released the
Fig. 1. A 41 years old male had a two-month history of bilateral nasal obstruction. He also complained of recurrent epistaxis. Enhanced CT of the paranasal sinuses revealed a 50 45 mm heterogeneous enhanced mass in the right maxillary sinus, the central region of which was in particular strongly enhanced. Compression and thinning of the posterior wall of the right maxillary sinus and the lateral wall of the right nasal cavity was also noted. The nasal septum was displaced (case I).
nasal packing, the lesion dropped out spontaneously. The intraoperative bleeding volume excepting non-operative case (case II), was from 250 to 700 ml (median 425 ml). Before the operation, two cases were performed angiography, and found that maxillary artery was the feeding artery. One of them (case IV) showed strongly enhanced lesion, and was performed embolization. The
Table 2 The CT and MRI findings of the six cases. Bane thinning
I II III IV V VI
L,P – – L,P L –
Diameter (mm)
50 45 18 14 Ø Ø Ø Ø
25 30 40 30
MRI (T1-weighted)
MRI (T2-weighted)
MRI (Gd-DPTA enhanced)
Central
Surrounding
Central
Surrounding
Central
Surrounding
Low – Low Low Low Low
Low – Low to iso Low to iso Low Low to iso
High – High High High Low
Iso to high – Iso to high Iso to high Low Low to iso
High – High High High –
Low – Low Low Low –
L: Lateral wall of nasal cavity; P: Posterior wall of maxillary sinus.
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175
Fig. 3. The dilated vessels (*) were found in the hematoma in three of these cases (a), but not in the others (b).
other (case I) showed weakly enhanced one, and was not performed (Table 3). All of the pathological findings were hematoma surrounded with fibrotic tissue. No neoplastic cell was existed. There are two pathological types; in three cases the dilated vessels were found in the hematoma, but not in the other three (Table 3) (Fig. 3). No recurrence has been seen in any patient.
Fig. 2. MRI showed as follows. (a) On T1-weighted images, the central region (*) had slightly low intensity comparable with muscle. (b) On T2weighted images, the central region (*) had high intensity, and the peripheral region ($) had lower than the central. Thickening of the paranasal sinus mucosa was found ("). (c) On T1-weighted images with contrast, the central region was strongly enhanced (*), and the peripheral region ($) demonstrated less enhanced effect than the central. And thickening mucosa of the paranasal sinus was strongly enhanced too (").
4. Discussion The organized hematoma is rare. The term ‘‘organized hegmatoma’’ is not unified in the English literature and many terms, such as blood boil, hematoma, hematoma-like mass, hematocele, blutbeule, and organizing hematoma are used [1–13]. Song et al. state that ‘‘organization’’ means ‘‘replacement of hematoma by fibrous tissue’’, and the recently proposed term ‘‘hematoma-like mass’’ is inadequate to explain the histopathology and clinical behavior [2]. Most of the reports are from Japan and Korea [2]. It occurs in
176
G. Omura et al. / Auris Nasus Larynx 37 (2010) 173–177
Table 3 Treatment and pathological finding.
I II III IV V VI *
Angiography
Existence of the feeding artery
Embolization
Bleeding volume (ml)
Operation method
Existence of the dilated vessels
Performed Not performed Not performed Performed Not performed Not performed
Maxillary artery
Not performed
610 – 700 425 250 380
Transmaxillary
– – – + + +
Maxillary artery
Performed
*
ESS ESS Transmaxillary ESS
Dropped out by itself in several days after the astriction with nasal packing.
patients from 20 to 40 years old, and the age of the patients is younger than that of maxillary carcinoma [7,8]. The majority of the lesions arise in the nasal cavity and maxillary sinus, however, it has been reported to originate in the ethmoid and frontal sinuses. In these latter cases a craniotomy was performed because of the destruction of the skull base bone [9]. Pathological findings include hematoma, fibrosis, neovascularization, and no evidence of neoplasm. As for the disease etiology, Ozaki et al. suggest the negative spiral theory during the repairing process as follows. At first, a blood clot accumulates in the closed space due to various causes of bleeding, including hemangioma formation, facial injury, or inflammation. Next necrosis, fibrosis, and hyalinization occur in turn, and neovascularization develops as part of these biologically healing processes. But blood flow becomes sluggish at the lead of new vessels. As a result, the new vessels become dilated, and rebleeding occurs (Fig. 4) [8].
Fig. 4. We made a schema of the growing organized hematoma advocated by Ozaki et al. At first, a blood clot accumulates in the closed space due to various causes of bleeding, including hemangioma formation, facial injury, and inflammation. Next necrosis, fibrosis, hyalinization, neovascularization, and vascular dilatation happen in turn. Finally, bleeding again occurs.
In all of the six cases in the current study, the lesion consisted of a hematoma surrounded by fibrosis. There are two pathological types. Dilated vessels were found in the hematoma in three of these cases. But these vessels were not found in others. The dilated vessel type in particular was similar to the hemangioma in the pathological findings, reflecting the stage between the neovascularization period and the vascular dilation period in the negative spiral. On the other hand, the non-dilated type reflects the stage between the bleeding period and the period of fibrosis formation. The difference between the dilated vessel type and the nondilated vessel type supports the theory; the ‘‘organized hematoma’’ is the secondary change of the easy bleeding lesion like hemangioma and vascular malformation (Fig. 3). The old fibrosis additionally forms a capsule around the hematoma (Fig. 5). Concerning the pre-operative evaluation with CT and MRI, three image findings are found in this lesion, as follows. First, it is an expansive, clearly demarcated, heterogeneously enhanced mass, and never infiltrative. Second, it is compressive lesion, and diminishes the bone structure. But it is never destructive on CT findings [10]. Third, the MRI shows thickening of the paranasal sinus mucosa of its surroundings. The mucosa is well enhanced on T1-weighted images with contrast, and high intensity on T2weighted images. It suggests the inflammatory change due to the obstruction by the lesion. These points differ from a malignant tumor that causes the invasive bone destruction, and mucosal invasion [11–13]. In addition, the central part of the lesion had low intensity on T1-weighted imaging, high intensity on T2-weighted imaging and was well enhanced (Table 2). The existence of blood with a low flow speed was therefore considered at the central region, which matched the presence of a hematoma in the pathological findings. Meanwhile, the peripheral part was less enhanced, which were matched the zone of fibrosis. Such biphasic appearance is therefore an important imaging aspect of this lesion to cite as a differential diagnosis before deciding on the treatment strategy. To recognize the location of the hematoma, could be useful volume of intraoperative bleeding. An operation is necessary to cure the organized hematoma and no other treatment is available to relieve the associated symptoms. To differentiate the organized hematoma from a malignant tumor, the confirmation of
G. Omura et al. / Auris Nasus Larynx 37 (2010) 173–177
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with angiography. But, in the six cases, the angiography was performed in two cases, and the embolization was performed in only one case. Unfortunately, it is difficult to define the necessity of the preoperative embolization from this report (Table 3).
5. Conclusion The ‘‘organized hematoma’’ destroys the bone structure of its surroundings when it develops. Difficulty in differentiating it from a malignant tumor has been reported, but we have suggested some imaging findings to help the preoperative diagnosis. In the pathological findings, the lesions in all of the cases were hematomas surrounded with fibrotic tissues. This point strongly backs up the biphasic appearance of the imaging findings. As for the pathological findings, the dilated vessel type and non-dilated vessel type are found. These findings suggest that the organized hematoma is a secondary change of a previously formed hemangioma like lesion.
References
Fig. 5. We performed total removal of the contents of the right maxillary sinus by the transmaxillary approach. In the intraoperative findings, the lesion had invaded the right maxillary sinus, and destroyed the bone structure of the posterior wall. The lesion was, however, easily separated from the maxillary sinus mucosa, and the periosteum of the posterior wall was preserved. (a) The appearance of the specimen. (b) The specimen slice. The central region is hematomatous ($), and the surrounding region is fibrotic (*).
complete lack of neoplastic cells in the totally removed specimen is needed. From these points, the total removal under general anesthesia should be undertaken. Regarding the operative approach, if the lesion is small and an adequate endoscopic operative field working space can be achieved, ESS should be chosen. On the other hand, if the lesion is big and has been thinning the bone structure of the paranasal sinuses, the transmaxillary approach should be chosen. There is little difference in the intraoperative bleeding volume between the ESS and the transmaxillary approach cases. To decrease the intraoperative bleeding volume, embolization can be performed if the feeding artery is found
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