Nasal Septum Glomus Tumor: A Rare Cause of Unilateral Nasal Obstruction

Significance Statement

Glomus tumors or glomangiomas are rare neoplasms arising from the glomus body, which is a perivascular temperature regulating structure. They are primarily cutaneous, mainly found in the subungual region of young adults, but they may occur anywhere. Nasal glomus tumors are extremely uncommon and they manifest with symptoms such as stuffiness, rhinorrhea, epistaxis, and pain. We present a case of nasal glomus tumor, arising from the nasal septum, that was surgically removed with no evidence of recurrence at 21 months of follow-up.

Case Presentation

A 73-year-old woman presented at our Ear, Nose, and Throat (ENT) Department, complaining right-sided nasal obstruction combined with intermittent intense pain for the last 2 years. She also reported a sensation of slowly growing mass just inside her right nostril that tended to bleed when touched. She did not mention any other symptoms such as headache, nasal discharge, or hypoesthesia. She reported a history of hypertension, totally controlled with medications, a previous colon cancer surgery, and a breast lump removal. She denied tobacco use. For the past 2 months, she had been treated with local and systemic antistaphylococcal antibiotics, as nasal vestibulitis was the primary diagnosis, without, however, any signs of improvement.

The clinical examination showed a healthy but overweight woman. Anterior rhinoscopy on the right side revealed a well-defined tumor arising from the mucosa of the superior part of the caudal end of the nasal septum, 5 to 10 mm in diameter. The mass covered the area of the internal nasal valve and was reddish and friable, without stigmata of hemorrhage (Figure 1). Posterior rhinoscopy demonstrated no other nasal pathology. The external nose was normal too. A full ENT examination did not show any pathological findings. Routine blood tests were also normal.

Figure 1.

Endoscopic view of the right nasal cavity showing a well-defined tumor arising from the mucosa of the superior part of the caudal end of the nasal septum (black arrows: glomus tumor, white star: caudal nasal septum, black star: area of the internal nasal valve).

The patient underwent a biopsy under local anesthesia. In order to take the decision for the type of anesthesia, we took under consideration the patient’s preference and the fact that the mass was easily accessible. Three biopsy samples were taken without significant intraoperative bleeding. The right anterior nasal cavity was packed for a couple of hours postoperatively. Histopathology and immunochemistry findings were consistent with a glomus tumor. Specifically, the tumor cells were round and regular with uniform circular nuclei. Degenerative changes might sometimes be noted in the nuclei (Figure 2A and B). Solid areas with an organoid growth pattern could be seen (Figure 2C), while myxoid stroma could be seen in some areas (Figure 2D). Variably sized vessels surrounded by collars of glomus cells in a hyalinized stroma were also noted (Figure 2E).

Figure 2.

Histopathological examination. A, The tumor cells are round and regular with uniform circular nuclei. Degenerative changes may sometimes be noted in the nuclei. B, The tumor cells are round and regular with minimal atypia. C, Glomus tumor: solid areas with an organoid growth pattern. D, Myxoid stroma can be seen in some areas. E, Variably sized vessels surrounded by collars of glomus cells in a hyalinized stroma.

Patient was informed about the diagnosis and gave her consent for a wide tumor excision. Two weeks after the first biopsy, the patient underwent a total removal of the nasal mass under general anesthesia. The pathological tissue was removed en bloc, including a part of normal mucosa. The specimen was sent for permanent histopathologic examination, which validated the initial diagnosis (Figure 2). The surgery was uneventful and the right nasal cavity was packed for 2 days. Follow-up after 6 and 12 months did not reveal any recurrence, and the nasal mucosa was intact without perforation. Interestingly, the patient reported significant improvement in her nose breathing.

Discussion

Glomus tumors or glomangiomas are benign neoplasms of the glomus body mainly found on the digits, under the nails and they are rarely located in the head and neck area.^1-3

Epidemiological data demonstrate that most cases have been reported in older population with a mean age of 54 years. ⁴ Females are twice as likely to develop these tumors comparing with males.^3,4 The first complete clinical description was given by Mason in 1924, while the first nasal glomus tumor was reported in 1965.^5,6 The classic triad of symptoms includes pain, tenderness, and cold intolerance. ⁷ Glomus tumors may occur as small, painful nasal nodules, which cause nasal obstruction and epistaxis.^3,4 Macroscopically they appear as reddish, stiff nodules, mainly in the Kiesselbach area, resembling hemangioma or hemangiopericytoma.^1,3,8

While the majority of nasal glomangiomas are histologically benign, there have been reported cases of locally invasive tumors. ⁹ Magnetic resonance imaging (MRI) with gadolinium administration and computed tomography scan are used to assess the extension of these neoplasms. ⁹ Computed tomography is preferred in most cases because of its easier availability and its lower cost, and it can better evaluate bone erosions. On the other hand, MRI has the advantage of excellent identification of the soft tissues. In our case, we considered the size (less than 1 cm in diameter) and the location of the tumor, and we decided not to perform a preoperative scan.

Marginal excision is sufficient in most cases of glomus tumors and local recurrence is uncommon and associated with incomplete excision.^3,9 Another option for locally invasive neoplasms is radiotherapy, which may be a better choice for older patients with underlying chronic health conditions.^9,10 In conclusion, despite their rarity, glomus tumors should be taken into consideration in the differential diagnosis of unilateral nasal obstruction.