Squamous cell carcinoma originating from the nasal septal perforation: a rare nasal tumor

Abstract

Primary squamous cell carcinoma of the nasal septum is an extremely rare malignancy. In this article, we report a case of 52-year-old female with a complaint of nasal obstruction along with occasional nasal bleeding for one year. Endoscopy showed a 2.5x2 cm perforation originating from the anterior nasal septum. Incisional biopsy result was reported as squamous cell carcinoma. The tumor was removed by functional endoscopic surgery. Histopathological examination revealed squamous cell carcinoma with safe surgery borders. No recurrence and complications were noticed after one year of follow-up. The functional impact of the treatment with high mortality rates highlights the importance of early diagnosis. We recommend the differential diagnosis of septal perforation and early wide surgical excision for such cases.

Full text

177Kulak Burun Bogaz Ihtis Derg 2014;24(3):177-180
Case Report / Olgu Sunumu
doi: 10.5606/kbbihtisas.2014.77200
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Squamous cell carcinoma originating from the nasal septal
perforation: a rare nasal tumor
Nazal septal perforasyondan kaynaklanan skuamöz hücreli karsinom:
Nadir bir burun tümörü
İbrahim Çukurova, M.D., Murat Gümüşsoy, M.D., Suat Kaptaner, M.D., Ömer Uğur, M.D.,
Metin İber, M.D., İlker Burak Arslan, M.D., Sinan Uluyol, M.D.
Primary carcinomas of the nasal septum are
very rare malignancies.[1, 2] Mostly originate from
the tip of the caudal septum. Squamous cell
carcinoma is the most common and malignant
melanoma is the second most common patholog ic
diagnosis for primary nasal septal malignancies.[3]
Smoking and tobacco use are important factors
in etiolog y.[3,4] Most common symptoms of septal
carcinomas are nasal obstruction, recurrent
epistaxis, nasal discharge, facial pain, nasal
mass, and orbital complaints such as epiphora,
diplopia, and proptosis.[5,6] In this article, a case
with septal perforation and without risk factors
for nasal septal carcinoma will be presented.
Department of Otolaryngology, Tepecik Training and Research Hospital, İzmir, Turkey
Received /
Geliş tarihi:
November 16, 2012
Accepted /
Kabul tarihi:
April 28, 2013
Correspondence / İletişim adresi:
Murat Gümüşsoy, M.D. İzmir Tepecik Eğitim ve
Araştırma Hastanesi Kulak Burun Boğaz Hastalıkları Kliniği, 35460 Tepecik, İzmir,
Tur key.
Tel: +90 505 - 424 52 78 e-mail
(e-posta):
mgumussoy@hotmail.com
Primary squamous cell carcinoma of the nasal septum is an extremely rare malignancy. In this article, we report a case
of 52-year-old female with a complaint of nasal obstruction along with occasional nasal bleeding for one year. Endoscopy
showed a 2.5x2 cm perforation originating from the anterior nasal septum. Incisional biopsy result was reported as
squamous cell carcinoma. The tumor was removed by functional endoscopic surgery. Histopathological examination
revealed squamous cell carcinoma with safe surgery borders. No recurrence and complications were noticed after one
year of follow-up. The functional impact of the treatment with high mortality rates highlights the importance of early
diagnosis. We recommend the differential diagnosis of septal perforation and early wide surgical excision for such cases.
Key Words:
Nasal septum; septum perforation; squamous cell carcinoma.
Nazal septumun primer skuamöz hücreli karsinomu oldukça nadir görülen bir malignitedir. Bu yazıda, bir yıldır burun
tıkanıklığı ve bazen burun kanaması yakınması olan 52 yaşında bir kadın olgu sunuldu. Endoskopide 2.5x2 cm boyutla-
rında anterior nazal septum kaynaklı perforasyon gözlendi. İnsizyonel biyopsi sonucu, skuamöz hücreli karsinom olarak
bildirildi. Tümör fonksiyonel endoskopik cerrahi ile çıkarıldı. Histopatolojik incelemede skuamöz hücreli karsinom güvenli
cerrahi sınırıyla birlikteydi. Bir yıllık takip sonrası nüks ve komplikasyon gözlenmedi. Tedavinin fonksiyonel etkisi ve yüksek
mortalite oranları, erken tanının önemini vurgulamaktadır. Septal perforasyonun ayırıcı tanısı ile birlikte bu olgularda erken
geniş cerrahi eksizyon önermekteyiz.
Anahtar Sözcükler:
Nazal septum; septum perforasyonu; skuamöz hücreli karsinom.
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178 Kulak Burun Bogaz Ihtis Derg
CASE REPORT
A 52-year-old women complaining of nasal
obstruction, occasional recurrent epistaxis and
headache for one year, was admitted to our
hospital. A 2.5x2 cm septal perforation was
seen in the caudal septum on nasal endoscopy.
The posterior and posterosuperior borders of
the perforation had hemorrhagic crusting and
abnormal mucosal hypertrophy. Other sides were
smooth and clean (Figure 1).
After diagnosis of nasal septal perforation,
detailed medical history about tobacco use and
smoking, previous nasal surgery, nasal trauma,
nasal decongestant, and cocaine use, exposure to
nickel or any petroleum products, tuberculosis,
Wegener’s granulomatosis, syphilis were taken.
Routine ear, nose and throat examination was
performed. As laboratory examinations and
tests; purified protein derivative (PPD), the anti-
neutrophil cytoplasmic antibody (ANCA), the
angiotensin converting enzyme (ACE), venereal
disease research laboratory (VDRL), C-reactive
protein (CRP), erythrocyte sedimentation rate
(ESR), chest radiograph, biochemistry and
coagulation screen were performed. No etiological
factor was identified.
Incisional biopsies were taken from the superior,
posterosuperior, posterior, posteroinferior and
inferior borders of perforation. Pathology results
were reported as squamous cell carcinoma for
only the posterior and posterosuperior biopsies.
Other directions were clean. For local and
distant metastases, neck, thyroid, and abdominal
ultras o n o g raphy (USG), neck and thorax computed
tomography (CT) and neck magnetic resonance
imaging (MRI) were done. No pathology was
detected (Figure 2). Panendoscopic examination
was normal except for the septal perforation and
hemorrhagic crusting.
The patient underwent a functional transnasal
endoscopic removal of the tumor under general
anesthesia with clean 1 cm margins superiorly
and inferiorly and 2 cm posteriorly (Figure 3).
Intraoperative frozen section examination used
to achieve safe surgical margins. The septal
defect area was reconstructed with septal splints,
Spongostan (Spongostan® Johnson & Johnson,
Skipton, UK) and Merocel (Merocel®, Medtronic
Xomed, Jacksonville, FL) swabs. Postoperatively
no complications were seen. The histopathologic
diagnosis was micronvasive squamous cell
carcinoma. Surgical margins were reported as
safe. Radiotherapy was not planned. On one-
year follow-up with endoscopic examination,
neck USG, neck and thorax CT no recurrence or
complication was observed.
DISCUSSION
Primary squamous cell carcinoma of the nasal
septum is very rare. The usual age of presentation
varies over 50 years, with a higher incidence
among males.[1-3] There is an increased risk of
nasal carcinoma especially in smokers,[3,4] nickel
refinery workers,[7] woodworkers and through
exposure to petroleum products and solvents.[8]
In our patient's history there was no smoking and
exposure to nickel or any petroleum products.
The symptoms are generally non-specific
with nasal obstruction and recurrent epistaxis
reported. Most common symptoms of septal
carcinomas are nasal obstruction, recurrent
epistaxis, nasal discharge, facial pain, nasal mass,
and orbital complaints such as epiphora, diplopia,
proptosis.[5, 6] In our case the main symptoms were
nasal obstruction, occasional recurrent epistaxis
and headache for one year.
Endoscopic nasal examination is important for
diagnosis. In addition, USG, CT and MRI are useful
for staging the malignancy. Definitive diagnosis is
made by histopathological examination.[5,6,9] For
our case after diagnosis of nasal septal perforation,
a detailed medical history about the possible
Figure 1. Septal perforation and hemorrhagic-crusting at
posterior and superior borders.

179
Squamous cell carcinoma originating from the nasal septal perforation
et iologic factors for sept a l perforation was taken.[10 ]
Routine ear, nose and throat examination was
performed. Various laboratory examinations and
tests PPD, ANCA, ACE, VDRL, CRP, ESR, chest
radiograph, biochemistry and coagulation screen
were also performed. But no etiological factor
was determined.[10] Our patient was diagnosed by
pathological investigation.
Treatment of the primary tumor is excision of
tumoral tissue with 1 cm safety margins under
frozen section control. Endoscopic methods can
be applied for early-stage lesions as in our case.
Due to the possibility of submucosal spread of
the tumor, wide surgical excision is required.
Some of the lesions were removed totally by alar
or lateral rhinotomy approaches. For removing
large lesions, approaches such as septectomy,
rhinectomy, maxillectomy with orbital
exantration can be applied. In patients with
lymphadenopathy, a neck dissection should be
added. If necessary, postoperative radiotherapy
can be applied.[8,11-13]
In our case, intranasal endoscopic excision
was chosen because of the mass size and location.
Intraoperative frozen examination was used to
achieve safe surgical margins. Since the tumor was
at early age and there were no lymphadenopathies
in the neck, postoperative radiotherapy was not
planned after radiation and medical oncology
consultation. No complications or recurrence was
detected in the follow-up period of 12 months.
Nasal septal carcinomas have better prognosis
when diagnosed earlier.[7,11,12] The most important
prognostic factor is tumor stage.[8,12,13] In our case,
the detailed medical history and the examinations
for the etiology of perforation did not expose any
risk factor for the development of perforation and
Figure 2. Septal perforation at kaudal septum. (a) Computed tomography. (b) Magnetic resonance imaging.
(a) (b)
Figure 3. Endoscopic removal of tumoral mass.
Table 1. Relationship between nasal septum squamous
cell carcinoma and septal perforation in literat ure
Reference n Septal perforation
Le Liever et al.[1] 22 -
Leeman et al.[2] 1 -
Beatty et al.[3] 85 -
Deutsch et al.[6] 1 -
Fradis et al.[7] 16 -
Kızılkaya et al.[6] 1 -
Özkırış et al.[12] 1 -
Echeverria-Zumarraga et al.[13] 1 +

180 Kulak Burun Bogaz Ihtis Derg
malignancy. Biopsies showed malignancy only
in two areas. All these indicate that malignancy
occurred secondarily on a spontaneously formed
septal perforation. A small number of cases of
nasal septum originated tumors in the literature
are available. Our case of squamou s cell carcinoma
that occurred secondarily on a spontaneously
formed septal perforation is only the second to be
reported since 1988.[13] Our patient is probably the
second reported case of squamous cell carcinoma
occurring secondarily on a spontaneously formed
septal perforation (Table 1). Thus our case has
been the second case of septal perforation with
squamous cell carcinoma association.
As a result, diagnostic approaches to these cases
are important due to squamous cell carcinoma
originating from the nasal septal perforation has
rarely been seen.
Declaration of conflicting interests
The authors declared no conflicts of interest
with respect to the authorship and/or publication
of this article.
Funding
The authors received no financial support for
the research and/or authorship of this article.
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