Hemangiomas are benign head and neck tumors which constitute less than 20% of all benign nasal cavity tumors[1]. Hemangiomas are considered by some authors as hamartomas or congenital vascular anomalies[2]. The exact cause of hemangiomas is yet unknown. The primary etiological variables are believed to be hormonal and traumatic[2]. Hemangiomas are common in cervical-facial areas, primarily affecting the tongue, lips, gingiva, and oral mucosa[3].

Only ten percent of hemangiomas in the head and neck areas are sinonasal hemangiomas, making them extremely uncommon[4]. The locus Valsalvae, or area of Little, in the nasal vestibule is the exact point of origin, which is typically found in the anterior part of the nasal septum. Other sites include lateral wall of nose, inferior

turbinate, the floor of the nasal cavity and the roof of the vestibule[3].

Unilateral nasal obstruction, recurrent epistaxis, mucopurulent rhinorrhea, epiphora, headache, and hyposmia are common symptoms in patients with sinonasal hemangiomas[5].Other less common symptoms include progressive, painless swelling and nasal deformity. Anemia and bleeding are the primary issues related to these conditions[6].

A 55 year old male presented to the ENT outpatient clinic with complaints of  right sided nasal mass, nasal obstruction and intermittent epistaxis for 6 months.

The obstruction was progressive, non-alternating, and more noticeable on exertion. There was no history of nasal trauma, previous nasal surgery, allergy symptoms, facial pain, anosmia, or systemic illness.The nasal mass was reddish in colour , present on the right nostril and soft to firm in consistency. Reddish soft-tissue mass in the right anterior nasal cavity was round in shape and bled on touch. The patient also complained of nasal bleeding since 6 months. Bleeding was profuse and stopped on applying pressure for a long time. Patient had visited nearby hospitals for management of nasal bleeding.

General physical examination was unremarkable. On anterior rhinoscopy, a well-defined, smooth-surfaced, reddish soft-tissue mass was noted occupying the right anterior nasal cavity, arising from the anterior septum [FIGURE 1] . The lesion was tender ,bled on gentle probing and appeared congested and vascular. The left nasal cavity was normal.

FIGURE 1 – PREOPERATIVE PICTURE SHOWING REDDISH MASS IN RIGHT NASAL CAVITY

Diagnostic nasal endoscopy revealed a homogenous, reddish, sessile mass. The lesion occupied the right anterior nasal cavity, causing partial obstruction but without extension into the middle meatus, floor, nasopharynx, or posterior nasal cavity. There was no discharge, no ulceration, and no evidence of bony destruction.

NCCT PNS demonstrated, a well-defined homogenous soft-tissue density lesion in the right nasal cavity. No intralesional calcification, no bony erosion and no extension into paranasal sinuses were seen[FIGURE 2]. Nasal septum was seen deviated towards left side.

NCCT PNS DEMONSTRATING WELL DEFINED HOMOGENOUS SOFT TISSUE DENSITY IN

RIGHT NASAL CAVITY

Radiologic differentials offered included nasal polyp, leiomyoma, and hemangioma, with the vascular appearance on clinical examination favoring hemangioma.

Routine blood tests including complete blood count and coagulation profile were within normal limits.

The patient was planned for endoscopic excision under general anesthesia. Intraoperatively, a reddish, well-encapsulated vascular mass was seen originating from the anterior nasal septum . The mass was carefully dissected and excised in toto[ FIGURE 3]. Intraoperative bleeding was minimal, controlled with suction cautery.

FIGURE 3 – EXCISED SPECIMEN

The excised specimen was sent for histopathological examination, which confirmed the diagnosis of capillary hemangioma with features of dilated vascular channels lined by endothelial cells, without atypia or malignant change[FIGURE 4].

FIGURE 4 – MICROPHOTOGRAPH DEMONSTRATING FEATURES OF CAPILLARY HEMANGIOMA WITH DILATED VASCULAR CHANNELS LINED BY ENDOTHELIAL CELLS, WITHOUT ATYPIA OR MALIGNANT CHANGE

The postoperative period was uneventful. The patient was discharged on the second postoperative day . At follow-up visits at 1 week and 1 month, the patient reported complete resolution of nasal obstruction with no recurrence of the lesion.

Nasal hemangioma was first described by Poncet A and Dor L in 1897 as human botryomycosis[6]. More than half of the hemangiomas affect the head and neck region; rarely the nasopharynx. Therefore, it is safe to presume that hemangioma in the nasal region is a rare disease[4]. Unlike infantile hemangiomas, adult hemangiomas have a tendency to progressively enlarge and do not spontaneously regress. Thus, given its nature, a suspected nasal hemangioma in an adult warrants the need for further investigation and treatment.

In 1982, Mulliken JB and Glowacki J characterized hemangiomas as rapidly proliferating vascular tumors and divided them into three subtypes: capillary hemangiomas, which primarily arise from the hypervascular septal region known as locus Valsalvae; cavernous hemangiomas, which are typically found along the lateral wall of nasal cavity; and mixed forms[1].

Since the hemangioma often mimics malignancy, it is important to rule out alternative diagnoses (especially malignant tumors) and assess the extent of the lesion before beginning any treatment[7]. Before undergoing surgical excision of a suspected vascular lesion, proper radiological assessment should be done[8].

The differential diagnosis includes inflammatory lesions, such as Wegener granulomatosis, angiofibromas, and other neoplasms such as sinonasal papilloma, hemangiopericytoma, esthesioneuroblastoma, and angiosarcomas, given the similar clinical characteristics of epistaxis and unilateral nasal obstruction.

Despite being uncommon, sinonasal hemangioma should always be taken into account when making a differential diagnosis for vascular lesions in the nasal cavity. This lesion can be treated with a variety of surgical techniques, such as electrocoagulation, laser ablation, cryotherapy, and excisional surgery. The best method for completely removing the lesion is endoscopic guided sinus surgery, which has demonstrated successful results with improved visibility of the mass and surrounding anatomy, this technique allows the surgeon to completely remove the lesion with no requirement of preoperative embolization or perioperative blood transfusion.

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2. Zheng JW, Wang YA, Zhou GY, Zhu HG, Ye WM, Zhang ZY. Head and neck haemangiomas: how and when to treat. Int J Oral Maxillofac Surg. 2007;36(11):1037.
3. Socher J, Marchi M, Rickli J. Subcutaneous cavernous hemangioma in the nasal dorsum: report of case treated with endoscopic rhinoplasty. Int Arch Otorhinolaryngol. 2013;18(02):213–216.
4. Patil M, Jagdale K, Joshi S. Osseous hemangioma of nasal cavity. Int J Adv Med. 2014;1(2):173–175.
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