Presentation
Right nasal obstruction and epistaxis.
Patient Data
Large irregular soft tissue mass lesion is seen centered upon the right nasal cavity. The mass appears of homogeneous high density at the non contrast series, with faint non homogeneous contrast enhancement at the post contrast series. It show the following extensions:
- Anteriorly, it extends via the right nasal nare anteriorly
- Laterally, it extends within the right maxillary antrum with bone thinning and pressure erosion of the lateral wall with small extra-sinus extension
- Medially, it causes erosion of the nasal septum and extend into the left nasal cavity
- Posteriorly, it extends posteriorly reaching the posterior choana and nasophayrnx.
- Superiorly, it erodes the floor of both ethmoidal complexes, extending into both ethmoid air cells with bony erosions of their bony septae. It also erodes the right nasal process of maxillary bone showing small right intra-orbital extension along the infero-medial floor of the orbit. Right proptosis is noted
- No intra-cranial extension noted.
3D reconstruction showed widening of the right nasal cavity and pressure bony erosion of the right nasal bone and nasal process of right maxillary bone.
3D surface rendering reconstruction images shows right nasal enlargement and right proptosis.
Frontal and sphenoid sinusitis.
Contrast-enhanced MRI examination of the paranasal sinuses shows the forementioned nasal cavity mass lesion eliciting heterogeneous signal with areas of high signal at T1 WI and areas of dark signal at T2 WI. It shows heterogeneous contrast enhancement at the contrast enhanced series.
Case Discussion
The patient had surgical excision of the mass, histopathology of the mass revealed pieces of tissue showing stretched stratified squamous covering overlying dense inflammatory reaction formed of lymphocytes, plasma cells with Russell bodies, together with foamy macrophages (Mikulicz’s cells) showing abundant clear vacuolated cytoplasm and intracytoplasmic bacilli. The patient then received antibiotic (rifampin) treatment.
Rhinoscleroma is a chronic granulomatous bacterial disease of the nose that can sometimes infect the upper respiratory tract. Rhinoscleroma predominantly involves the nasal mucosa, but it can also involve the larynx; nasopharynx; oral cavity; paranasal sinuses; trachea, bronchi or soft tissues of the lips and nose.
Radiological imaging is essential for differentiation of rhinoscleroma from similar granulomatous and neoplastic lesions.
On CT scan, bilateral or unilateral expansile nasal masses. Lesions are usually homogeneous, hyperdense and non-enhancing masses. No bone destruction which helps to differentiate it from malignant lesions.
On MRI, it shows mild to marked high signal intensity on both T1 and T2 weighted images. On T2 weighted images, it shows foci of fibrosis. It typically shows an inhomogeneous pattern of contrast enhancement following contrast administration secondary to the presence of areas of fibrosis. At diffusion images, the lesion shows diffusion restriction with low apparent diffusion coefficients values which could mimic malignancy secondary to high cellularity.