Intraosseous Hemangioma of the Ethmoid Sinus

Abstract

Intraosseous hemangiomas, also referred to as bony hemangiomas, arising within the nasal cavity are exceedingly rare with only 2 cases arising in the ethmoid region. Despite their rarity, they are important to consider in a patient presenting with long-standing nasal congestion. While characteristic findings on computed tomography imaging may be observed, biopsy is diagnostic. En bloc resection using a transnasal endoscopic approach with or without preoperative embolization is the treatment of choice for intranasal intraosseous hemangiomas.

Rhinoscopic Clinic

A 70-year-old male with a remote history of prostate cancer as well as a nasal fracture following a motor vehicle accident presented with complaints of long-standing nasal congestion worse on the right side, postnasal drip, rhinorrhea, and decreased sense of smell. His nasal symptoms were refractory to topical nasal steroid sprays. He denied fever, unintentional weight loss, headaches, epistaxis, or facial swelling/pain. He was a nonsmoker.

On examination, his external nose was normal in appearance. In-office nasal endoscopy revealed a significant right-sided septal deviation and a firm, erythematous mass in the right middle meatus. The remainder of his physical examination was unremarkable, including neck and cranial nerve exams. Computed tomography (CT) of the sinuses revealed an approximately 2-cm mass in the right anterior ethmoid sinus with an internal calcified matrix that approached but did not penetrate the skull base (Figure 1).

Figure 1.

Computed tomography coronal view of the ethmoid mass abutting the orbit showing stippled and linear calcifications suggestive of a cartilaginous matrix.

Due to the persistent nasal congestion and the mass seen on exam and CT, the patient underwent a septoplasty and right-sided endoscopic sinus surgery with complete excision of the mass. The vascular-appearing mass was noted to be attached to the lamina papyracea laterally, the basal lamella inferiorly, the septum medially, and ethmoid roof superiorly (Figure 2A-C).

Figure 2.

A, Intraoperative view of the firm, vascular appearing lesion in the middle meatus. B, Trabecular bone debris within the mass itself. C, Part of the final specimen.

Surgical pathologic analysis determined that the mass was a bony hemangioma of the ethmoid sinus, more commonly referred to as an intraosseous hemangioma in the literature. Histological examination revealed large blood-filled vascular channels intermixed with thin strips of mature trabecular bone consistent with an intraosseous cavernous hemangioma (Figure 3). Other intraosseous hemangiomas, including capillary and mixed, are less common. Capillary hemangiomas have smaller dominant vessels than the cavernous type, and mixed hemangiomas are comprised of thin-walled blood vessels of varying sizes lined by endothelium. ¹

Figure 3.

A, H&E-stained sections at ×20, demonstrating blood- filled vascular channels (asterisk) intermixed with thin strips of mature trabecular bone (arrow), characteristic of intraosseous hemangioma. B, H&E section at ×100 highlights thin-walled vessels of angioma (arrow).

Hemangiomas account for approximately 20% of all benign tumors within the nasal cavity. Intraosseous hemangiomas within the nasal cavity are particularly rare with only a handful of cases reported in the literature. ^2,3 The pathogenesis of intraosseous hemangiomas remains largely unknown. However, nasal trauma, as was sustained by our patient due to a motor vehicle accident, has been reported to contribute to their formation. ^{2 -4} Its slow-growing nature allows the tumor to remain clinically silent and present only after it has grown large enough to obstruct the nasal cavity. Like other neoplasms of the nasal cavity and paranasal sinuses, intraosseous hemangiomas may mimic symptoms of chronic rhinosinusitis including nasal obstruction, postnasal drip, and hyposmia. ⁵

Computed tomography is the imaging modality of choice for intraosseous hemangiomas as CT delineates margins and may illuminate a characteristic appearance of a “soap-bubble” or “honeycombed” mass with multiple cavernous spaces as seen in our patient. ^{2 -5} En bloc resection using an endoscopic approach with or without preoperative embolization is the treatment of choice for intranasal intraosseous hemangiomas. Preoperative embolization has been reported to reduce intraoperative bleeding. However, it is not necessary when complete surgical resection may be performed further highlighting the value of CT imaging in the assessment of an intraosseous hemangioma. ⁶ In our patient, the mass was small and firm, and preoperative embolization was not considered. Complete resection of the hemangioma with minimal blood loss was achieved and the patient currently remains without recurrence at 16 months following surgery.