Full text of DOI:10.1007/BF02910986

INTRODUCTION
On anterior rhinoscopy - left lateral wall of nose was
pushed medially, obstructing proper view to the nasal
cavity. Nasal septum was mildly deviated to right side.
Posterior rhinoscopy didn't reveal any abnormality. Left
side of hard palate was buldged, and on palpation egg-cell
crackling was noticed. Gingivo-labial groove on left side
was normal without any loosening of teeth.
Ophthalmologic evaluation revealed medial movement of
the left eye ball was restricted; visual acquity of left eye
was 6/9 and that of right eye 6/6. Other cranial nerves
were normal. Fundoscopy did not reveal any abnormality.
Neurological examination was essentially within normal
limits. He was admitted for investigations and surgery.
Routine blood test (TC, DC, Hb%, ESR, BT, CT ) were
suggestive of mild hypochromic normocytic anaemia.
Haemangioma of mucosa of paranasal sinuses are very
rare. Eggston and Wolff ( 1947 ) reviewed a series of 359
cases of neoplastic diseases of nose and paranasal sinuses
- found 14 cases of haemangioma - none of which
originated from maxillary sinus mucosa.
Fu and Perzin ( 1974 ) in their study of 256 cases of
nonepithelial tumor of nasal cavity, para nasal sinuses and
nasopharynx have found 38 cases of haemangioma - but
no case of haemangioma of maxillary or ethmoidal sinuses
was found.
CASE REPORT
A 30 years male patient ( Fig. I ) attended in ENT
Outpatient's Dept. of Medical College Hospital with
recurrent attacks of epistaxis for past 2 years - there was
15 episodes of epistaxis; last 2 episodes were severe and
had to be controlled by anterior nasal packing.
Plain X-ray showed haziness of left maxillary and
ethmoidal sinuses. Anterolateral wall of left maxilla was
buldged out. CT scan showed homogenous soft tissue
shadow in the left maxillary and ethmoidal region, eroding
the lamina papyracia and involving the orbit. Nasal septum
was mildly deviated towards right side (Fig. II).
Since past V/i years he also noticed gradually increasing
nasal obstruction on left side; Initially, nasal obstruction
was partial but since past' 1 year it became complete.
Since past 1 year he noticed gradually increasing swelling
of upper part of left cheek, later on forward and outward
displacement of left eye was also noticed.
The patient had mild anaemia. Examination revealed
variegated nontender swelling at left infraorbital region,
extending to left nasofacial angle. Eyeball was pushed
upward, outward and forward. There was no palpable
cervical lymph node.

removal of anterolateral wall. During removal, the mass
was bled freely but after entire removal of the tumour,
there was no abnormal bleeding. Macroscopically, the
resected specimen consisted of a very vascular 4 to 5 cm
diameter mass. The microscopic appearance of the
tumour (Fig.Ill) showed a proliferation of thin-walled
blood vessels of different sizes lined by endothelium.
Diagnosis of haemangioma was confirmed following
histology. There was no evidence of malignancy.
The patient came for follow up after about one year when
there was no recurrence and the cavity was well healed.
His proptosis also subsided. (Fig.IV)
DISCUSSION
Haemangioma is a benign vascular lesion but whether it is
a true neoplasm or a vasoformative disorder - is debatable
( Batsakis 1979). But most authors believe that it is a
neoplasm.
Over half of all haemangiomas are found in head and neck
region and can originate in the skin, mucosae and deep
structures such as bones, muscles and glands (Raboso et
al, 1979 ).
Although histological findings of all of them are similar
with only minor variations, their clinical features,
management and prognosis are different according to
their location. Therefore, the classic histological
classification of capillary, cavernous, mixed. Juvenile and
hypertrophic has no clinical relevance. In fact, they are
practically different stages of the same disease process.
There is considerable overlap with features of each type,
particularly the capillary and cavernous types in any given
lesion. Zone of transition lends some support to the
supposition that the hypertrophic (Juvenile) form of
haemangioma is an immature form of capillary
haemangioma and that the cavernous haemangioma,
results from "maturation" of the capillary variety
(Batsakis, 1979).
Haemangioma of maxillary sinus may originate from the
bone or mucosa. They are different in their clinical
behaviour, histopathology and treatment (Kalpan et al,
1991; Dillon et al, 1991; Raboso et al, 1997). In
haemangioma of mucosal origin, history of epistaxis is
more common as in the present case. Histopathological
examination shows bony specules along with the picture
of haemangioma,if it is of bony origin (Ghosh et al, 1988).

Preoperative histopathological examination of the tissue of cases, preoperative angiography may be of immense
from nasal mass was fibrous dysplasia. This may be due value.
to hyperaemic decalcificiation of bone (Ghosh et al, 1988).
In our opinion, treatment of haemangioma originating from
In bony haemangioma, treatment of choice is maxillectomy maxillary sinus mucosa should be surgical excision
but in mucosal haemangioma only excision of the mass - because peroperative bleeding can be controlled by packing
as done in the present case suffices. Laws (1968) reported the cavity after removal of the mass. Radiotherapy should
one case where maxillary haemangioma disappeared be avoided to reduce radiation induced head and neck
without recurrence after a dose of 8300 of Cobalt 60. He malignancy in later period.
believed that surgery is dangerous because of operative
haemorrhage. However, some authors believed that REFERENCES
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Perzin (1977) recommended limited local excision as
treatment of choice in their series of vascular tumours.
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During enmass removal, the mass bled freely and bleeding
stopped after removal of the mass which suggests that
the mass has no connection with large vessels, but only
to small to medium size vessels for which the mass was
not pulsatile and throbbing ( Das et al,1991).
Raboso et al ( 1997 ) opined that surgical approach should
be chosen after radiological assessment of the extension
and vascular supply keeping in mind that profuse bleeding
might be expected and an unrestricted field of view is
advisable in order to control the haemorrhage. Blood
transfusion should be planned in advance.
So, in cases of clinical benign nasal / naso-maxillary
tumour, if the tumour bleeds profusely during biopsy, we
may suspect benign tumors in relation to vascular channel Dr. Sudip Kumar Das
where repeat biopsy or excisional biopsy in the posto- Deep Villa
Address for Correspondence :
275, Mitra Compound-
Midnapore - 721 101
perative period may confirm the diagnosis. In these types