Bleeding septal polyp, a rarity becoming common – A report of four cases

Ahmad Rufai Tukur; Ahmad M Aldhafeeri; Faisal Hazaa Abohelaibah; Rania G Roshdy; Yousif Ali Aldhafeeri; Fahad Salih Aldhafeeri; Madallah Mutlaq Alanazi

doi:10.4103/sjoh.sjoh_50_22

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CASE REPORT

Year : 2023 | Volume : 25 | Issue : 1 | Page : 42-46

Bleeding septal polyp, a rarity becoming common – A report of four cases

Ahmad Rufai Tukur¹, Ahmad M Aldhafeeri¹, Faisal Hazaa Abohelaibah¹, Rania G Roshdy², Yousif Ali Aldhafeeri³, Fahad Salih Aldhafeeri⁴, Madallah Mutlaq Alanazi⁴
¹ Department of Otolaryngology, Hafr Albaten Central Hospital, Hafr Al-Batin, Kingdom of Saudi Arabia
² Department of Pathology, Faculty of Medicine, Banha University, Banha, Egypt; Department of Pathology, Hafr Albaten Central Hospital, Hafr Al-Batin, Kingdom of Saudi Arabia
³ Department of General Medicine, Hafr Albaten Central Hospital, Hafr Al-Batin, Kingdom of Saudi Arabia
⁴ Department of General Surgery, Hafr Albaten Central Hospital, Hafr Al-Batin, Kingdom of Saudi Arabia

Date of Submission	10-Oct-2022
Date of Decision	05-Dec-2022
Date of Acceptance	11-Dec-2022
Date of Web Publication	01-Feb-2023

Correspondence Address:
Dr. Ahmad M Aldhafeeri
Department of Otolaryngology, Hafr Albaten Central Hospital, Hafr Al-Batin
Kingdom of Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_50_22

Abstract

Bleeding septal polyp is a benign, previously assumed very rare lesion that usually presents as unilateral epistaxis, nasal blockage, and intranasal mass. It can occur spontaneously or posttraumatic. We report four cases of three young adult females and one pediatric male. All of them presented with recurrent, spontaneous, torrential, unilateral epistaxis with progressive unilateral nasal blockage of varied durations. Anterior rhinoscopy was done in all cases, and it revealed a polypoidal mass in the cartilaginous septum and ulcerated mucosa in some cases that easily bleeds on contact. A clinical diagnosis of a bleeding septal polyp was made. Patients were evaluated and underwent excisional biopsy using the transnasal endoscopic resection technique. Histology revealed hemangiomatous lesions for the females and angiofibroma for the male. They were followed up for 6 months, with complete healing of the excision site and without any complaint. Bleeding septal polyp is becoming a common cause of spontaneous, recurrent unilateral epistaxis. This case report is an addition to the literature to increase awareness in clinical practice.

Keywords: Adult female, bleeding septal polyp, intranasal mass, pediatric male, unilateral epistaxis

How to cite this article:
Tukur AR, Aldhafeeri AM, Abohelaibah FH, Roshdy RG, Aldhafeeri YA, Aldhafeeri FS, Alanazi MM. Bleeding septal polyp, a rarity becoming common – A report of four cases. Saudi J Otorhinolaryngol Head Neck Surg 2023;25:42-6

How to cite this URL:
Tukur AR, Aldhafeeri AM, Abohelaibah FH, Roshdy RG, Aldhafeeri YA, Aldhafeeri FS, Alanazi MM. Bleeding septal polyp, a rarity becoming common – A report of four cases. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2023 [cited 2023 Jun 4];25:42-6. Available from: https://www.sjohns.org/text.asp?2023/25/1/42/369032

Introduction

A bleeding septal polyp is a polypoidal growth that usually arises from the cartilaginous septum and is commonly unilateral. It is a growing benign tumor that can be spontaneous or posttraumatic, in mainly young postpubertal adults without a sex preponderance.^[1] However, the condition has recently been reported in a 9-year-old boy.^[2] Bleeding septal polyp, or septal hemangioma, often presents with clinical symptoms and signs that mimic nasal granulomatous diseases or malignancy that include nasal blockage, nasal discharge, epistaxis, and intranasal mass. A biopsy for histologic confirmation of the diagnosis is crucial.^[3] Nasal septum hemangioma represents about 31% of the entities of intranasal hemangiomas in adults.^[4] Capillary hemangioma is more frequently observed than the cavernous type, and very rarely, other vascular lesions like angiofibroma can present in a similar way. This lesion does not present spontaneous involution, and treatment is based on a surgical excision, including the mucosa and the underlying perichondrium.^[1],[5]

We reported four cases of bleeding septal polyps that presented to our hospital over a period of 1 year. All cases were successfully managed with no complications. The aim of this report is to increase awareness among professionals about such rare cases of benign intranasal tumor.

Case Reports

Case I

A 17-year-old medically free female patient was referred to the otolaryngology department with recurrent right-sided epistaxis and progressive nasal obstruction of 6-month duration. No other symptoms were reported. There was no history of nasal trauma or surgery. The patient was not on any medication and has no family history of a similar condition.

Endoscopic nasal examination of the right nasal cavity revealed a polypoidal lesion arising from the cartilaginous septum that easily bleeds on contact, measuring 1.0 cm × 0.8 cm in size, arising from the right side of the anterior septum [Figure 1]a.

Figure 1: (a) Right anterior rhinoscopy showing septal polyp in an adult. (b) Axial CT scan showing the lesion in the right nasal cavity arising from the nasal septum. (c) Coronal CT scan showing the lesion in the anterior inferior part of the right nasal septum. (d) Excised lesion (septal polyp) from the right nasal cavity of the patient. CT: Computed tomography

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A computed tomography (CT) scan of the paranasal sinuses, with enhancement, was done, and it revealed a circumscribed soft tissue lesion limited to the cartilaginous septum [Figure 1]b and [Figure 1]c. The patient had endoscopic transnasal excision of the lesion, under general anesthesia. The mass was excised en bloc with its pedicle, using a 0° 4-mm nasal endoscope [Figure 1]d. Hemostasis was adequately secured with bipolar diathermy. Nasal pack was removed and the patient was discharged from the hospital after 24 h.

Histopathological sections showed benign capillary proliferations with a distinctive lobular structure, separating stroma and enclosing acute inflammatory components, mainly polymorphonuclear leukocytes (PLNs). Surface epithelial erosion is considered with necrotic debris. The overall feature is consistent with a lobular capillary hemangioma [Figure 2]a.

Figure 2: (a) Lobular capillary hemangioma (H and E, ×200): Black line denoting acute inflammatory cells. Blue arrow showing blood vessels. Star showing surface erosion, replaced by necrosis. (b) Hemangioma (H and E, ×100): Blue arrow denoting, surface squamous epithelium. Black arrow showing variable shape and size vessels. (c) Hemangiopericytoma (H and E, ×200): Star denoting staghorn proliferating blood vessels

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The patient was followed up for 6 months, during which the septal mucosa wound healed with complete resolution of symptoms.

Case II

A 32-year-old female patient presented to the emergency department with torrential right-sided epistaxis and further history revealed previous episodes of epistaxis and progressive nasal obstruction of about 5-month duration. The patient had no similar family history. The patient had no history of nasal trauma or surgery and was not on any medication, including oral contraceptives; she was not pregnant and had no comorbidities.

Endoscopic nasal examination of the right nasal cavity demonstrated active bleeding from a huge ulcerated hemorrhagic pedicled mass arising from the cartilaginous septum that easily bleeds on contact, measuring 3 cm × 2 cm in size, projecting through the anterior naris. It was challenging to locate the origin of the mass, though it appeared to be arising from the anterior septum.

The patient had baseline investigations (complete blood count, chemistry, and clotting profile), the results of which were within normal limits, and CT scan of the paranasal sinuses revealed a soft tissue lesion limited to the anterior nasal cavity [Figure 3]a and [Figure 3]b.

Figure 3: (a) Axial section CT scan of paranasal sinuses showing the lesion in the right nasal cavity over the anterior part of the nasal septum of a 32-year-old female. (b) Coronal section CT scan of paranasal sinuses showing a large right nasal cavity lesion causing significant obstruction and deviating the nasal septum towards the left. CT: Computed tomography. Red arrow: Shows the lesion in the right nasal cavity

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The patient had elective endoscopic transnasal resection of the lesion under general anesthesia. The mass was excised en block with its pedicle endoscopically. The packing of the nasal cavity was removed after 24 h.

Histopathological examination reveals polyp growth lined by stratified squamous epithelium. The underlying tissue exhibits proliferating variable size and shape vascular spaces, lined by benign endothelium that is surrounded by granulation tissue. The histological findings were in keeping with hemangioma [Figure 2]b. The patient was followed up for 6 months, during which the septal mucosa wound healed with complete resolution of symptoms.

Case III

A 34-year-old female patient was referred to the otolaryngology department with recurrent right-sided epistaxis and progressive nasal obstruction for about 3-month duration. Previous episodes of epistaxis were also said to be severe, necessitating hospital admission and blood transfusion twice. No other symptom was reported. The patient is not pregnant, medically free, and not on any medications. There was no history of nasal trauma or previous nasal surgery. No family history of similar presentation.

Endoscopic nasal examination of the right nasal cavity demonstrated a hemorrhagic pedicled mass, 1.0 cm × 0.5 cm in size, arising from the right side of the anterior septum [Figure 4]a.

Figure 4: (a) Nasal endoscopy view of SP in an adult patient. (b) CT scan showing the lesion located anteriorly. (c) Excised lesion. CT: Computed tomography. Green star: Shows intranasal lesion in the right nasal cavity. Red arrow: Demonstrate the lesion located anteriorly

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The patient had baseline investigations (complete blood count, chemistry, and clotting profile), the results of which were within normal limits, and a CT scan of paranasal sinuses revealed a circumscribed lesion limited to the anterior part of the cartilaginous septum [Figure 4]b.

The patient had endoscopic transnasal resection of the lesion under general anesthesia. The mass was excised en block with its pedicle endoscopically using bipolar diathermy and 0° 4-mm nasal endoscope [Figure 4]c. The packing of the right nasal cavity was removed after 24 h.

Histopathological findings are diffuse growth of vascular channels, mainly a staghorn pattern embedded in prominent granulation tissue with no necrosis or atypical changes. Overall is covered by respiratory epithelium. The histological findings were in keeping with hemangioma [Figure 2]c.

The patient was discharged home and seen 6 weeks after; the symptoms were resolved, and the septal mucosa was resolved. The patient was subsequently followed up for 6 months with no evidence of recurrence.

Case IV

An 8-year-old male patient was referred from a pediatric hospital to the otolaryngology department with recurrent left-sided epistaxis and nasal blockage of about 2-month duration. The patient had no similar family history. There was no history of snoring, no nasal trauma or surgery, and no bleeding from any other body part.

Endoscopic nasal examination of the left nasal cavity demonstrated an easily bleeding hemorrhagic mass, 1.0 cm × 0.5 cm in size, arising from the left side of the anterior septum.

The patient had baseline investigations (complete blood count, chemistry, and clotting profile), the results of which were within normal limits, and a CT scan of the paranasal sinuses revealed a circumscribed lesion limited to the anterior part of the cartilaginous septum with no evidence of bony destruction [Figure 5]a, [Figure 5]b, [Figure 5]c.

Figure 5: (a) Sagittal section of CT scan of paranasal sinuses of an 8-year-old male. (b) Coronal section of CT scan of paranasal sinuses demonstrating the polyp in the left anteroinferior part of the nasal septum. (c) Axial section of CT scan showing the polyp in the left nasal cavity of the patient. (d) Left anterior rhinoscopy showing the lesion intranasally (green star), in the patient. (e) Showing the excised lesion. CT: Computed tomography. Red arrow: Shows the lesion in the left nasal cavity

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The patient had transnasal resection of the lesion under general anesthesia. The mass was excised en block with its pedicle, and hemostasis was achieved using bipolar diathermy [Figure 5]d and [Figure 5]e.

Discussion

Nasal septal hemangiomas are rare benign tumors. They are more common among young adults with no sex preponderance. However, the lesions have rarely been reported in children and the elderly.^[2],[6] Three out of four cases we reported in this article were females aged 17 years, 32 years, and 34 years (average 28 years). This is similar to a study that reported that more females were affected than males, with a ratio of 4:11.^[7] However, another study found the male-to-female ratio to be 2.4:1, and the patient age ranged between 14 years and 63 years (average: 39 years).^[4] This is an established diverse epidemiological variation found in different environments in which the various studies were conducted.

The exact origin of septal hemangioma is unknown. Trauma and hormonal factors may play a role in the pathogenesis of hemangioma.^[1] There was no history of trauma or hormonal factors in the cases we reported. Three of the four reported cases were found in the right nostril. This is similar to a study that found unilateral lobular capillary hemangioma of the nasal cavity, with 60% of lesions on the right side and 40% on the left side.^[7] There are three distinct histologic subtypes: capillary, cavernous, and mixed hemangiomas.^[8] The subtype of cavernous hemangioma occurs on the lateral nasal wall, mainly in adulthood. At the same time, capillary hemangioma occurs more often on the nasal septum in children.^[9] Three out of the four cases we reported were capillary hemangioma. The only nonhemangioma lesion was found in a pediatric male patient.

However, angiofibroma, the locally aggressive mesenchymal tumor, clinically and grossly mimics hemangioma, but it displays prominent and characteristic fibrous components besides the classic slit-like vascular spaces with scattered mast cells. It has a predilection for the adolescent male that may suggest the hormonal role in its unknown pathogenesis. Angiofibroma registers a higher recurrence rate (up to 20%) than capillary hemangioma, especially if there are cranial involvement and/or postoperative residual vascularity on imaging studies.^[10]

The main presenting symptoms in all reported cases were epistaxis and progressive nasal obstruction. Various other studies reported that the signs and symptoms of septal hemangioma are mainly epistaxis, nasal obstruction, rhinorrhea, and occasional pain. However, the most common symptom is nasal bleeding.^[3],[4] The duration of symptoms varied between 1.5 months and 4 years (average, 13 months).^[3] We found the average presenting duration to be 4 months in our cases. Almost all lesions were located anteriorly in the cartilaginous septum.^[4] This is similar to all the cases we reported.

Endoscopic examination is necessary to fully evaluate and diagnose septal hemangioma. Generally, it presents as a red or purple mass that bleeds easily on touch at endoscopy.

Radiological CT scan with contrast imaging plays an essential role in outlining the full extent of the lesion. On CT scan, intranasal hemangioma appears as a well-defined and homogeneous soft tissue mass on the cartilaginous septum.^[4],[8] Magnetic resonance imaging is sometimes indicated when malignancy is suspected.

The prompt treatment of septal hemangioma is critical as episodes of epistaxis tend to be torrential, and lesions may eventually ulcerate with an attendant risk of becoming infected. Two of the cases we reported had torrential bleeding that warranted admission and blood transfusion in one of them, and two of the cases had their lesions ulcerated. Various therapeutic approaches have been developed, including electrocoagulation, laser, excisional surgery following angiography with embolization, and cryotherapy.^[11] The most common therapeutic approach of choice is the endoscopic excision with bipolar electrocautery because it offers good hemostasis.^[11] All the cases we reported were managed using endoscopic excision with bipolar electrocautery with good postoperative outcome and no recurrence has been reported. Similarly, a separate study reported the successful treatment of two patients with septal hemangioma using a harmonic scalpel.^[12] The authors recommend that excisional biopsy is essential in such cases to examine for other possible differentials such as malignancy. The recurrence rate of these hemangiomas varies from 0% to 42% and usually occurs within the 1^st year.^[11] Incomplete excision has been reported as the most common cause of recurrence. However, some studies reported no recurrence after endoscopic surgery in all cases.^[5],[7]

Conclusion

Bleeding septal polyp is becoming a common cause of spontaneous, recurrent unilateral epistaxis. This case report is an addition to the literature to increase awareness in clinical practice. The most effective form of treatment is endoscopic intranasal resection. Other conditions such as vascular lesions, granulomatous nasal diseases, or even malignancy may mimic the condition. Hence, histological evaluation is of paramount importance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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