Pleomorphic Adenoma of The Nasal Septum

Pleomorphic adenomas are uncommon tumors of the nasal cavity. They arise from minor salivary glands, and usually originate from the nasal septum. The tumors are more common in middle-aged females. We present a series of 8 cases of intranasal pleomorphic adenomas. Seven of these tumors originated from the nasal septum, and only one of them originated from the lateral nasal wall. Histopathologic examination of the tumors showed that these tumors have higher epithelial and lower stromal components compared to pleomorphic adenomas of major salivary glands. Endoscopic resection was performed in all cases and the patients were followed up for one year. No recurrences or complications were observed in this series. Endoscopic resection is recommended as the treatment of choice because of its proven efficacy and low morbidity. DOI : 10.14302/issn.2379-8572.joa-14-561 Corresponding author: Samy Elwany, MD, FACS email: samyelwany@msn.com Samy.elwany@alexmed.edu.eg Address: 4 Kafr Abdou # 605, Alexandria, Egypt


Introduction
Salivary gland neoplasms are uncommon and make up less than 5% of all head and neck neoplasms.
Pleomorphic adenoma is the most common benign salivary gland tumor. Parotid gland tumors constitute 60% of all pleomorphic adenomas, while minor salivary glands constitute only 8% of them 1 . Pleomorphic adenomas of minor salivary glands may develop in any site where the minor salivary glands exist 2 . Rare cases have been reported in the nasal cavity, nasopharynx, oropharynx, and larynx. Intranasal pleomorphic adenomas are rare, slow growing tumors 3 . These tumors are frequently misdiagnosed because they are usually highly cellular and have few myxoid stroma 4,5,6 .In this paper, we present a case series of pleomorphic adenomas of the nasal cavity and discuss the literature on this uncommon tumor. In addition, we discuss relevant issues about the pathology, diagnosis, and management of the tumor.

Patients and Methods
The study included 8 patients (5 females and 3 males) with the diagnosis of nasal pleomorphic adenoma during the period from January 2003 to December 2012. Endoscopic examination was done, and radiological studies included computed tomography (MDCT) with ultra-thin 1mm cuts and multiplanar reconstruction, and magnetic resonance imaging (MRI).
Complete endoscopic excision of the mass, including the surrounding mucosa / mucoperichondrium, was performed in all cases.
The patients were followed up weekly for the first month and then every 2 weeks until complete healing has occurred. Complete healing usually took place after 8 -12 weeks. All cases were then reexamined one year postoperatively.
Informed consents from all the patients was taken prior to surgery after they were fully informed about the details of the surgical procedure. The Institutional Review Board (IRB) approved the study.

Results
The study series included 8 patients with nasal pleomorphic adenoma ( Table 1). The series included 5 females and 3 males, with a mean age of 38.8 years (32 -47 years). All patients presented with unilateral nasal obstruction Three of them presented with external nasal swelling, and two of them presented with mild epistaxis.
Endoscopic examination, in all cases, revealed a well-defined moderately firm mass that did not bleed on gentle touch (Fig. 1a). CT scans showed a well-defined soft tissue mass with a smooth border. The mass expanded the external nose in 3 cases (Fig. 1b).
In all cases, the mass was excised endoscopically under general hypotensive anesthesia.   (Fig 2).

Discussion
Pleomorphic adenomas are the most common    19 . No recurrences were observed in our series.
Krolls and Boyce suggested the histologic characteristic most frequently associated with recurrent pleomorphic adenomas was the myxoid stroma, which might easily spills into the surgical field. 20 Compagno and Wong attributed the low recurrence rate of intranasal pleomorphic adenomas to its high cellularity and little myxoid stroma. 5 Analysis of the results of the present series that endoscopic excision is an effective, reliable, and safe procedure for resection of intranasal pleomorphic adenomas with minimal morbidity, no facial scars, and low rates of recurrence. The approach is equally suitable for both adenomas of the nasal septum as well as adenomas arising from the lateral nasal wall.
In conclusion, pleomorphic adenomas are uncommon tumors of the nasal cavity. They arise from minor salivary glands, and usually originate from the nasal septum. The tumors are more common in middleaged females. Histologically, they have higher epithelial and lower stromal components compared to pleomorphic adenomas of major salivary glands. Endoscopic resection is the treatment of choice because of its proven efficacy and low morbidity.