Background

Sino-nasal masses are not an uncommon ailment in ORL practice. The patients commonly present with complaints of nasal obstruction, nasal discharge, epistaxis, or disturbances of smell. Disturbances of vision, proptosis, and deformities of the nasal framework are also possible presentations. The differential diagnosis of Sinonasal masses is variable, they may be congenital, inflammatory, traumatic, allergic, or neoplastic (benign or malignant) [1].

Polyps include allergic, inflammatory, or fungal polyps which are well known for their recurrences. Other benign masses include haemangioma, angiofibroma, mucoceles and inverted papilloma. Malignant masses in addition to their nasosinus origin may arise or extend into the nose and para-nasal sinuses from the oropharynx or nasopharynx. Certain hematological malignancies may also present as Sino nasal masses [1]. In this study, the modalities, clinical presentation, and management of sinonasal masses in Sudan are discussed.

Methods

This is a prospective, hospital-based observation descriptive, comparative study carried in Khartoum ENT teaching hospital during the period from January 2020 to January 2021. The study targeted all patients with sinonasal masses presenting to the hospital seeking medical advice. Enrollment was optional with the right to withdraw at any time. Consent was verbal with reassurance about the ethical aspects of the confidentiality, privacy, and consent of the data. Ethical clearance was obtained from the ethical committee of (EDC) SMSB and from the research committee of Khartoum ENT teaching hospital. Through a well-structured questionnaire, demographic data, clinical features, and the primary modality of treatment information were recorded. Analysis was done using a computer and Statistical Package for Social Sciences (SPSS) v25.

Results

In this study, two hundred forty-four patients were enrolled, and all of them were managed in Khartoum ENT teaching hospital. Their age ranged from 5 to 72 with a mean age of 38.5 years. The age group of 21–40 years (42.6%) showed the highest percentage followed by 10–20 years (27.5%), 41–60 years (16%), >60 years (9.4%) and the least were <10 years (4.5%).

One hundred twenty-three were males represent 50.4%, and one hundred twenty-one were females represent 49.6% with a M:F ratio of 1.02:1. The common presenting symptoms in order of frequency were nasal obstruction in 231 patients (94.7%), nasal discharge in 158 patients (64.8%), anosmia in 130 patients (53.3%), post nasal dripping in 101 patients (41.4%), facial pain 88 patients (36.1%), epistaxis 32 patients (13.1%), and cacosmia in 24 patients (9.8%). Other presenting symptoms included: headache in 111 patients (45%), proptosis 33 patients (13.5%), cranial neuropathy 4 patients (1.6%), and diplopia 3 patients (1.2%).

Unilateral symptoms were more common (75%) while bilateral symptoms were present in 25%. The duration of symptoms was up to six months in more than 50% of cases (Table 1).

Table 1 Number of nasal symptoms with duration among patients with sinonasal masses in Khartoum ENT teaching hospital (study 2020–2021)
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Clinical diagnosis after histopathology showed non-neoplastic mass in 203 patients (83%); fungal associated polyps 102 patients (41.8%) allergic polyps 76 patients (31.1%), antrocoanal polyps 19 patients (7.8%), congenital cyst 4 patients (1.6%), and mucocele 2 patients (0.8%) (Table 2).

Table 2 Clinical diagnosis after histopathology: non-neoplastic masses among patients with sinonasal masses in Khartoum ENT teaching hospital (study 2020–2021)
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Benign neoplastic mass in 21 patients (8.5%): pyogenic granuloma 5 patients (2%), angiofibroma 4 patients (1.6%), inverted papilloma 4 patients (1.6%), fibrous dysplasia 4 patients (1.6%), ossifying fibroma 2 patients (0.8%), and dentigerous cyst 2 patients (0.8%) (Table 3).

Table 3 Clinical diagnosis after histopathology: benign neoplastic masses among patients with sinonasal masses in Khartoum ENT hospital (study 2020–2021)
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Malignant neoplastic (epithelial) mass in 14 patients (6%): SCC 10 patients (4.1%), adenoid cystic carcinoma 2 patients (1.6%), malignant melanoma 2 patients (1.6). Malignant neoplastic (connective tissue) in 6 patients (2.5%): rhabdomyosarcoma 3 patients (1.2%), lymphoma 2 patients (0.8%), and haemangiopericytoma 1 patient (0.4) (Table 4).

Table 4 Clinical diagnosis after histopathology: malignant neoplastic masses among patients with sinonasal masses in Khartoum ENT teaching hospital (study 2020–2021).
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As for treatment modalities, endoscopic surgery was at the top of the list (84.4%), combined approach (endoscopic + open surgery) (5.3%) and open surgery (2.5%), chemoradiation (2.5%), chemotherapy (2%), radiotherapy (2%), and chemoradiation + surgery (1.3%) (Table 5).

Table 5 Treatment modalities among patients with sinonasal masses in Khartoum ENT teaching hospital (study 2020–2021)
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Discussion

Analysis of the clinical and demographic data of 244 patients with sinonasal masses in this study shows that the nose is a home for a variable spectrum of diseases some of which carry significant morbidity. The nose and paranasal sinuses are the origin of sinonasal masses but in addition, lesions may originate from the nasopharynx or oropharynx. The ages affected covered a wide range from 5-72 years with a mean age of 38. Males and females were affected almost with equal percentages, ratio 1.02:1. In contrast with some other studies which suggested males predominance [2,3,4]. Among the nasal and paranasal sinuses masses there were (83%) of non-neoplastic nature. This is consistent with several studies [2,3,4]. Further in our study, benign neoplasms were 9% and malignant neoplasms were 8%. There is agreement and disagreement from Indian studies [5,6,7]. Those who disagreed suggested 7.7% non-neoplastic,72% benign neoplasms, and 21%malignant neoplasms. This is a great difference, but these are reports from a different continents. In our study our histopathology reports especially in squamous cell carcinomas and rhabdomyosarcomas, the radiology added the confirmation and differentiation between the benign and malignant lesions showing very clearly the expansion in the benign and the destruction in the malignancy. A wide range of age groups was affected with variation in the type of masses. Fungal-associated polyps were the commonest non-neoplastic sinonasal masses mostly in ages 21-40. The diagnosis is confirmed by histopathology, hematoyxlyn and eosin stain (Hand E) and Periodic Acid-Schiff (PAS) revealed dense eosinophilic rounded fungal rod structures in the center of granuloma. Further confirmation was done by culture and immunodiagnosis. Others suggested inflammatory polyps to be the commonest [2, 7, 8]. As for the reason why fungal polyps are common in Sudan, this is because the disease is endemic in the country. This is documented by previous studies [9]. Non-neoplastic masses being common in ages 11–30 years is reported from India [4]. Other types of polyps were allergic polyps and antrocoanal polyps. Pyogenic granuloma is the most common among benign neoplastic lesions then angiofibroma, fibrous dysplasia, inverted papilloma, and ossifying fibroma in descending order. Squamous cell carcinoma is the most common malignant epithelial lesion. This is consistent with several studies [2,3,4, 10,11,12]. Adenoid cystic carcinoma followed. Rhabdomyosarcoma is the most common type of malignant connective tissue lesion, this is consistent with similar reports [2, 4, 13, 14]. Lymphoma and haemangiopericytoma followed. Rhabdomyosarcoma occurred in ages 10–20 years and inverted papilloma and squamous cell carcinoma in up to 60 years of age. Variation in age limit was reported [15].

Symptomatology revealed nasal obstruction was the most common complaint followed by nasal discharge then anosmia, headaches and proptosis This is consistent with several studies [1, 5, 6, 11, 16]. Unilateral presentation and symptoms formed (75%) of patients, similar studies agreed [1, 5]. Up to half of the patients came with a duration of symptoms of more than 6 months, which agrees with a Nigerian study [2]. About 20% of patients have histories of previous endoscopic surgery which may affect the duration of the presenting symptoms. Septal deviation was seen in almost one-third of patients, it could possibly be a result of the disease, or it could an aggravating factor in others. Most of our sinonasal masses were related to the lateral wall of the nasal cavity. This varied with the clinical presentation [15].

Some of the allergic polyps and an appreciable number of the fungal polyps and malignant neoplasms were associated with bone erosion. Bone erosion is a known feature of malignancy but occurs with the invasive type of nasosinus fungal disease. The majority of our patients (92.1%) were managed by surgery: endoscopic sinus surgery (ESS) 84.4%, combined ESS and open surgery 5.3%, and open surgery 2.5%. In addition, 1.3% were treated with combined surgery and chemoradiation. This agrees with the trend nowadays [14]. Chemotherapy alone and radiotherapy as for the treatment basically the tools are the same, it only differs in the pattern of placement accordingly to the clinical presentation and regimen adopted in each center [17,18,19,20,21]. To our knowledge and after a computerized literature search this is the first communication to target and highlight the trend of sinonasal masses in Sudan. The non-neoplastic masses are the commonest. Among these, nasal polyposis predominates with fungal nasal polyposis being the commonest pathology. In addition, fungal sinonasal polyposis stands as the commonest among all sinonasal masses added together.

Conclusion

Patients with sinonasal masses in Sudan especially the age group 21–40 years, being the most affected, must be seen in specialized ORL clinics to pick, diagnose and treat significant diseases in an early stage. Radiology and histopathology are a must in sinonasal swellings to diagnose malignant diseases, at an early stage. Nasosinus fungal polyposis being the commonest non-neoplastic lesion, the commonest among all sinonasal masses added together, and a known reported endemic disease in the country must receive special consideration and investigation for early diagnosis and treatment.