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Vascular leiomyoma of the nasal septum
Vascular leiomyoma of the nasal septum LEON ARDEKIAN, DDS, NAAMA SAMET, DMD, YOAV P. TALMI, MD, YEHUDA ROTH, MD, EREZ BENDET, MD, and JONA KRONENBERG, MD, Tel Hashomer and Tel Aviv, Israel
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t e i o m y o m a is a benign smooth muscle t u m o r most commonly found in the uterus, skin, and alimentary and gastrointestinal tracts. Enzinger and Weiss I report that 95% of 7748 cases originate in the female genitalia, 3% in the skin, and the r e m a i n d e r in other sites; less than 1% occurred in the head and neck area in another series. 2 O f the 562 cases reported, 3 only 6 were located in the nose. A survey of the English literature revealed only 14 prior reports of nasal leiomyoma; none was associated with the nasal septum. 3,4 T h e purpose of this article is to report an unusual location of vascular leiomyoma invading the nasal septum. CASE REPORT
A 54-year-old woman was referred in December 1993 to the outpatient clinic of the Department of Otolaryngology at the Chaim Sheba Medical Center for a left-sided nasal obstruction, localized pain, and serosanguineous nasal discharge. Physical examination revealed an exophytic soft mass, 1 x 2 cm, in the left nasal vestibulum originating from the nasal septum (Fig. 1). The lesion was fully excised. The postoperative course was uneventful, and the patient was discharged on the second postoperative day. PATHOLOGIC FINDINGS
Grossly, the t u m o r was a well-circumscribed, glistening, white-gray, 1 × 2 cm nodule. Microscopically, it consisted of well-demarcated nodules of smooth muscle tissue, arranged in whorls and fascicles, with m a r k e d hyaline changes. Spindle cells
From the Departments of Oral and Maxillofacial Surgery (Drs. Ardekian and Samet) and Otolaryngology (Drs. Talmi, Roth, Bendet, and Kronenberg), the Chaim Sheba Medical Center, Tel Hashomer; and the Sackler School of Medicine, Tel Aviv University. Received for publication May 5, 1994; revision received May 18, 1995; accepted May 26, 1995. Reprint requests: Leon Ardekian, DDS, Department of Oral and Maxillofacial Surgery, The Sheba Medical Center, Tel Hashomer 52621, Israel. Otolaryngol Head Neck Surg 1996;114:798-800. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 + 0 23/4/68594 798
Fig. t. Coronal computed tomography scan shows the lesion on left side of the nasal septum.
were seen. T h e smooth muscle fibers were intermingled with thick-walled vessels with only partially patent lumina. In some of the vessels, the inner layers of smooth muscles were arranged in an orderly circumferential fashion, and the outer layer swirled away. A t one side the nodule was covered by respiratory epithelium with underlying chronic inflammation (Figs. 2 and 3). DISCUSSION
T h e rarity of intranasal leiomyoma is partly attributed to the fact that smooth muscle is sparsely present in the nasal cavity, apart from the walls of the blood vessels) O f all the leiomyomas in the hum a n body, less than 1% occur in the head and neck area. Vascular leiomyomas are even less common. 6'7 These tumors grow slowly and may persist for a long time. 8According to the literature, 9 the most c o m m o n symptoms are epistaxis, pain, and nasal obstruction. Generally, leiomyomas a r e divided into two g r o u p s - v a s c u l a r and nonvascular. T h e vascular type is less frequently encountered than the nonvascular type and appears as a subcutaneous encapsulated nodule, histologically containing doublewalled vessels. Most investigators report that vascular leiomyomas originate from the smooth muscles
Otolaryngology Head and Neck Surgery Volume 114 Number 6
ARDEKIAN et al.
799
Fig. 2. Photomicrograph of tissue r e m o v e d from the left nasal septum showing w e l l - d e m a r c a t e d nodules of smooth muscle tissue a r r a n g e d in whorls a n d fascicles; also, spindle cells are seen.
of the veins. 5 In the series reported by Hachisuga et al., 3 most tumors were composed of venous vessels. It is, however, possible that the lesion may represent a hamartoma rather than a true neoplasm. 4 In the nasal cavity, smooth muscle is found in venous walls as circular or longitudinal strands. It appears therefore that leiomyomas that develop in the nasal cavity are of vascular origin. Seven of the previously reported Ieiomyoma cases of the nasal cavity were classified as vascular type, 4'5'9-13five were nonvascular, 14-17and no classification was assigned to the remaining three. Histologically, interlacing bands and bundles of elongated spindle-shaped cells, whose nuclei are usually blunt ended, are found. It is not uncommon, however, to find some cells with two to three nuclei. This nuclear atypia should not be taken as evidence of malignancy, u7 Complete surgical excision is the treatment of choice and was used in all cases reported. Recurrence after complete excision is not known to have a place in these cases. REFERENCES
1. Enzinger FH, Weiss SW. Soft tissue tumors. 2nd ed. St. Louis: CV Mosby Co., 1988:383-401. 2. Barnes L. Surgical pathology of head and neck. Vol 1. New York: Marcel Dekkar, Inc. 1985:442-5. 3. Hachisuga T, Hashimoto O, Enjoji M. Angioleiomyoma: a
Fig. 3. Well-demarcated nodules of smooth muscles covered by respiratory epithelium with underlying chronic inflammation.
800
4. 5. 6. 7. 8. 9. 10.
ARDEKIAN et al.
clinicopathological reappraisal of 562 cases. Cancer 1984;54: 126-30. Lijovetzy G, Zaarura S, Gaj I. Leiomyoma of the nasal cavity. J Laryngol Otol 1985;99:197-200. McCaffrey TV, McDonald T J, Unni KK. Leiomyoma of the nasal cavity. J Laryngol Otol 1978;92:817-9. Fisher MW, Helwig EB. Leiomyoma of the skin. Arch Dermatol 1963;88:510-20. Duhig JT, Ayer JP. Vascular leiomyoma: a study of sixty-one cases: Arch Pathol Lab Med 1959;68:424-30. Ophir D, Ruchuarger E, Cordona M. Angioteiomyoma of the nasal tip. J Laryngol Otol 1993;107:448-50. Ragbeer M, James S. Vascular leiomyoma of the nasal cavity. J Oral Maxillofac Surg 1990;48:1113-7. Maesaka A, Keyaki Y, Naeahashi T. Nasal angioleiomyoma and leomyosarcoma-report of two cases. Otologia 1966;12: 42-7.
Otolaryngology Head and Neck Surgery June 1996
11. Daisley H. Leiomyoma of the nasal cavity. West Indian Med J 1987;36:181-4. 12. Hanna GS, Akosa AB, Ali MH. Vascular leiomyoma of the inferior turbinate--report of a case and review of the literature. J Laryngol Otol 1988;102:1159-60. 13. Wofowitz BL, Schmaman A. Smooth muscle tumors of the upper respiratory tract. South African Med J 1973;47:118991. 14. Papavasilion A, Michaels L. Unusual leiomyoma of the nose (leiomyoblastoma). J Laryngol Otol 1981;95:1281-6. 15. Tang SO, Tsc CH. Leiomyoma of the nasal cavity. J Laryngol Otol 1988;102:831-5. 16. Ram M. Fibromyoma of posterior end of inferior tubinate. J Laryngol Otol 1971;85:719-21. 17. Fu YS, Perzin KH. Non-epithelial tumors of the nasal cavity, paranasal sinuses and nasopharynx: a clinicopathological study. Cancer 1975;35:1300-8.
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t e i o m y o m a is a benign smooth muscle t u m o r most commonly found in the uterus, skin, and alimentary and gastrointestinal tracts. Enzinger and Weiss I report that 95% of 7748 cases originate in the female genitalia, 3% in the skin, and the r e m a i n d e r in other sites; less than 1% occurred in the head and neck area in another series. 2 O f the 562 cases reported, 3 only 6 were located in the nose. A survey of the English literature revealed only 14 prior reports of nasal leiomyoma; none was associated with the nasal septum. 3,4 T h e purpose of this article is to report an unusual location of vascular leiomyoma invading the nasal septum. CASE REPORT
A 54-year-old woman was referred in December 1993 to the outpatient clinic of the Department of Otolaryngology at the Chaim Sheba Medical Center for a left-sided nasal obstruction, localized pain, and serosanguineous nasal discharge. Physical examination revealed an exophytic soft mass, 1 x 2 cm, in the left nasal vestibulum originating from the nasal septum (Fig. 1). The lesion was fully excised. The postoperative course was uneventful, and the patient was discharged on the second postoperative day. PATHOLOGIC FINDINGS
Grossly, the t u m o r was a well-circumscribed, glistening, white-gray, 1 × 2 cm nodule. Microscopically, it consisted of well-demarcated nodules of smooth muscle tissue, arranged in whorls and fascicles, with m a r k e d hyaline changes. Spindle cells
From the Departments of Oral and Maxillofacial Surgery (Drs. Ardekian and Samet) and Otolaryngology (Drs. Talmi, Roth, Bendet, and Kronenberg), the Chaim Sheba Medical Center, Tel Hashomer; and the Sackler School of Medicine, Tel Aviv University. Received for publication May 5, 1994; revision received May 18, 1995; accepted May 26, 1995. Reprint requests: Leon Ardekian, DDS, Department of Oral and Maxillofacial Surgery, The Sheba Medical Center, Tel Hashomer 52621, Israel. Otolaryngol Head Neck Surg 1996;114:798-800. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 + 0 23/4/68594 798
Fig. t. Coronal computed tomography scan shows the lesion on left side of the nasal septum.
were seen. T h e smooth muscle fibers were intermingled with thick-walled vessels with only partially patent lumina. In some of the vessels, the inner layers of smooth muscles were arranged in an orderly circumferential fashion, and the outer layer swirled away. A t one side the nodule was covered by respiratory epithelium with underlying chronic inflammation (Figs. 2 and 3). DISCUSSION
T h e rarity of intranasal leiomyoma is partly attributed to the fact that smooth muscle is sparsely present in the nasal cavity, apart from the walls of the blood vessels) O f all the leiomyomas in the hum a n body, less than 1% occur in the head and neck area. Vascular leiomyomas are even less common. 6'7 These tumors grow slowly and may persist for a long time. 8According to the literature, 9 the most c o m m o n symptoms are epistaxis, pain, and nasal obstruction. Generally, leiomyomas a r e divided into two g r o u p s - v a s c u l a r and nonvascular. T h e vascular type is less frequently encountered than the nonvascular type and appears as a subcutaneous encapsulated nodule, histologically containing doublewalled vessels. Most investigators report that vascular leiomyomas originate from the smooth muscles
Otolaryngology Head and Neck Surgery Volume 114 Number 6
ARDEKIAN et al.
799
Fig. 2. Photomicrograph of tissue r e m o v e d from the left nasal septum showing w e l l - d e m a r c a t e d nodules of smooth muscle tissue a r r a n g e d in whorls a n d fascicles; also, spindle cells are seen.
of the veins. 5 In the series reported by Hachisuga et al., 3 most tumors were composed of venous vessels. It is, however, possible that the lesion may represent a hamartoma rather than a true neoplasm. 4 In the nasal cavity, smooth muscle is found in venous walls as circular or longitudinal strands. It appears therefore that leiomyomas that develop in the nasal cavity are of vascular origin. Seven of the previously reported Ieiomyoma cases of the nasal cavity were classified as vascular type, 4'5'9-13five were nonvascular, 14-17and no classification was assigned to the remaining three. Histologically, interlacing bands and bundles of elongated spindle-shaped cells, whose nuclei are usually blunt ended, are found. It is not uncommon, however, to find some cells with two to three nuclei. This nuclear atypia should not be taken as evidence of malignancy, u7 Complete surgical excision is the treatment of choice and was used in all cases reported. Recurrence after complete excision is not known to have a place in these cases. REFERENCES
1. Enzinger FH, Weiss SW. Soft tissue tumors. 2nd ed. St. Louis: CV Mosby Co., 1988:383-401. 2. Barnes L. Surgical pathology of head and neck. Vol 1. New York: Marcel Dekkar, Inc. 1985:442-5. 3. Hachisuga T, Hashimoto O, Enjoji M. Angioleiomyoma: a
Fig. 3. Well-demarcated nodules of smooth muscles covered by respiratory epithelium with underlying chronic inflammation.
800
4. 5. 6. 7. 8. 9. 10.
ARDEKIAN et al.
clinicopathological reappraisal of 562 cases. Cancer 1984;54: 126-30. Lijovetzy G, Zaarura S, Gaj I. Leiomyoma of the nasal cavity. J Laryngol Otol 1985;99:197-200. McCaffrey TV, McDonald T J, Unni KK. Leiomyoma of the nasal cavity. J Laryngol Otol 1978;92:817-9. Fisher MW, Helwig EB. Leiomyoma of the skin. Arch Dermatol 1963;88:510-20. Duhig JT, Ayer JP. Vascular leiomyoma: a study of sixty-one cases: Arch Pathol Lab Med 1959;68:424-30. Ophir D, Ruchuarger E, Cordona M. Angioteiomyoma of the nasal tip. J Laryngol Otol 1993;107:448-50. Ragbeer M, James S. Vascular leiomyoma of the nasal cavity. J Oral Maxillofac Surg 1990;48:1113-7. Maesaka A, Keyaki Y, Naeahashi T. Nasal angioleiomyoma and leomyosarcoma-report of two cases. Otologia 1966;12: 42-7.
Otolaryngology Head and Neck Surgery June 1996
11. Daisley H. Leiomyoma of the nasal cavity. West Indian Med J 1987;36:181-4. 12. Hanna GS, Akosa AB, Ali MH. Vascular leiomyoma of the inferior turbinate--report of a case and review of the literature. J Laryngol Otol 1988;102:1159-60. 13. Wofowitz BL, Schmaman A. Smooth muscle tumors of the upper respiratory tract. South African Med J 1973;47:118991. 14. Papavasilion A, Michaels L. Unusual leiomyoma of the nose (leiomyoblastoma). J Laryngol Otol 1981;95:1281-6. 15. Tang SO, Tsc CH. Leiomyoma of the nasal cavity. J Laryngol Otol 1988;102:831-5. 16. Ram M. Fibromyoma of posterior end of inferior tubinate. J Laryngol Otol 1971;85:719-21. 17. Fu YS, Perzin KH. Non-epithelial tumors of the nasal cavity, paranasal sinuses and nasopharynx: a clinicopathological study. Cancer 1975;35:1300-8.