Nodular fasciitis of the nasal cavity: a case report

Ear, Nose & Throat Journal, Dec, 2007 by David Mullin, Fred W. Lindsay, Michael A. Keefe

Abstract

Nodular fasciitis is an uncommon tumor-like fibroblastic proliferation of the head and neck that is difficult to differentiate from its more malignant counterparts. Despite modern advances, making this distinction is challenging because the clinical presentation is nonspecific and the histologic and radiologic features are variable. Once nodular fasciitis is diagnosed, the primal, treatment is conservative resection and observation. We describe a case of nodular fasciitis of the nasal cavity in a 43-year-old woman. To the best of our knowledge, this is only the second reported case of nodular fasciitis arising in the nasal cavity, and the first such case in an adult.

Introduction

Nodular fasciitis is an uncommon tumor-like fibroblastic proliferation known for its propensity to mimic more aggressive lesions. It was first described in 1955 by Konwaler et al, who called the lesion subcutaneous pseudosarcomatous fibromatosis, t In the early 1960s, the disease became known as nodular fasciitis; other terms used in the literature include proliferative fasciitis, infiltrative fasciitis, productive fasciitis, subcutaneous fibromatosis, and nodular fibrositis.

In this article, we report a case of nasal cavity nodular fasciitis in a 43-year-old woman. We performed a comprehensive literature search (Ovid, MEDLINE) for articles pertaining to the presentation, diagnostic evaluation, and outcomes of patients with nodular fasciitis, and we found no previously reported case of nodular fasciitis arising in the nasal cavity of an adult. In fact, we found only 1 report of such a lesion arising in the nasal cavity of a child; in that case, the lesion was based on the lateral wall of the nasal cavity. (2) One other case of a pediatric cranial lesion with intranasal and orbital involvement has been described. (3)

Case report

A 43-year-old woman presented with a several-year history of nasal congestion, allergic rhinitis, sinus headaches, and intermittent sinusitis. She denied epistaxis and anosmia. Findings on the physical examination were consistent with a mucosalized mass of the midline and right nasal cavity. The cranial nerves were grossly intact. The patient had no history of surgery or major nasal trauma.

Fine-needle aspiration of the mass revealed the presence of some atypical cells, but it was not diagnostic for malignancy. Computed tomography (CT) demonstrated a midline nasal mass with erosion of the bony septum (figure 1, A). Magnetic resonance imaging (MRI) detected no intracranial involvement, but it did reveal extension of the mass up to and abutting the cribriform plate (figure 1, B and C).

The patient underwent endoscopic sinus surgery with directed biopsies and conservative resection. Histopathology showed hyperactive fibroblasts on the characteristic background of a benign stroma (figure 2). The diagnosis of nodular fasciitis was made.

One year postoperatively, the patient's symptoms had diminished significantly, and she had no evidence of recurrent disease.

Discussion

The presentation of nodular fasciitis is highly variable from an epidemiologic, clinical, and histologic standpoint.

Epidemiologic findings. Nodular fasciitis has been found to occur in all age groups. Patients in the fourth and fifth decades of life have accounted for nearly 50% of cases. (2,4-7) Less than 20% of cases have occurred in children. (2,4,8) No predilection for sex or race has been noted.

Clinical characteristics. Patients typically present within a few weeks of noticing a rapidly growing, solitary mass. At presentation, most lesions are small (typically <2 cm) and well circumscribed. (5) A lesion larger than 3 cm is exceedingly rare, and a diagnosis of nodular fasciitis in such a case can be virtually ruled out. (9)

[FIGURE 1 OMITTED]

Although multicentricity and pain have been described, these findings are highly variable. In a review of 134 cases, Bernstein and Lattes found multiple lesions in only 2 patients and a complaint of pain in fewer than 9% of patients? Other reviews have shown that mild pain and tenderness were more consistent findings. (6-8,10)

Trauma was once hypothesized to have a role in the pathogenesis of nodular fasciitis in view of histologic characteristics that often mimic reparative granulation tissue. (5) However, multiple authors have refuted this theory, finding a history of trauma in only a small percentage of cases. (2,5,11) For example, Bernstein and Lattes found a history of trauma in only 5 of the 134 patients they studied. (5)

The anatomic location of the tumor varies greatly, although several studies have shown that nearly 50% of all lesions arise on the upper extremity--primarily the ventral aspect of the forearm. (2,5,7,10) Other common locations, in order of decreasing frequency, include the trunk, lower extremities, buttocks, and head and neck region. Nodular fasciitis of the head and neck is relatively uncommon in adults, accounting for 10 to 20% of cases. (5-7,11) In contrast, the head and neck region is the most common location of nodular fasciitis in children; such cases have involved the oral cavity, skin, parotid gland, tongue, and nose. (2,8,10)