Sinonasal masses: modalities, clinical presentation, and management in Sudan

Sinonasal masses are not an uncommon spectrum of diseases. They are frequently encountered in Sudan, sometimes with variability in modalities across the country. The objective of this study is to document the pattern of sinonasal masses in Sudanese patients and to highlight the knowledge of the modalities, clinical presentations, and management. As a consequence, this will raise awareness especially of the general practitioners and family physicians and hence the community locally and regionally. Early diagnosis and appropriate management can reduce the rate of recurrence, fatal complications, and hence morbidity and mortality. This is a prospective descriptive, comparative hospital-based study conducted from January 2020 to January 2021. All patients with sinonasal masses, who came to Khartoum ENT Teaching Hospital seeking medical advice during the above-mentioned period were included in the study provided they satisfy the inclusion criteria. Enrollment was optional with the right to withdraw at any time. Consent was verbal with the reassurance about the aspect of confidentiality, privacy, and consent of the data. Ethical clearance was obtained from the ethical committee (EDC) SMSB and from the research committee of Khartoum teaching hospital. Analysis was done using a computer and the statistical package of social sciences SPSS V.25 A total number of 244 patients were studied. The age group of 21–40 years was the most encountered with the disease (42.6%). Two hundred three patients (83%) had a non-neoplastic disease, (9%) benign neoplastic lesions, and (8%) malignant neoplastic lesions. The non-neoplastic group was dominated by nasal polyposis of which the fungal were the most common (50%). Among benign neoplastic lesions, pyogenic granuloma ranked first (24%). Among malignant neoplastic lesions, squamous cell carcinoma dominated the epithelial origin lesions (71%) and Rhabdomyosarcoma dominated the connective tissue cell types (50%). Nasal obstruction is the most common complaint (94.7%) followed by nasal discharge (64.8%) then anosmia (53.3%). Endoscopic surgery was done in (84.4%) of patients, combined approach endoscopic and open surgery in (5.3%) while open surgery alone was done in 2.5%. Radiation and chemotherapy were used in 2% each, while chemo-radiation was used in (2.5%). The rest of the cases (1.3%) were managed by surgery followed by chemoradiation. Patients with sinonasal masses in Sudan especially the age group 21–40 years must be seen in specialized Otolaryngology 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 in non-neoplastic lesions, 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.


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%).
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).

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 nonneoplastic 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 nonneoplastic 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.