Hemangioma of the Ethmoid Sinus

Six months before admission a 71-year-old woman noticed increased tearing from the right eye. Two months before admission, she had nasal obstructive symptoms and epistaxis from the right nostril and was referred to our nasal dysfunction clinic. Physical examination showed a red nasal mass filling the nasal cavity. The nasopharynx was clear. A CT scan showed right ethmoid opacification with lamina papyracea dehiscence (Fig 1). Small cups resulted in profuse epistaxis, which was controlled with anterior nasal packing. The biopsied sample was dark red, multiloculated, and well circumscribed. Histologic analysis was consistent with cavernous hemangioma. On admission, the patient had normal coagulation studies and normocytic anemia with a hematocrit of 33.4%. CT studies with contrast showed a large right anterior nasal soft tissue mass eroding the anteromedial wall of the right orbit. The mass did not cross the midline. No enhancement of the mass was noted after contrast injection. Angiography showed the tumor to receive its blood supply from the right ophthalmic and the right internal maxillary arteries. An unusual finding was that the tumor received small feeders from other external carotid artery branches. Embolization of the right maxillary artery with polyvinyl alcohol foam particles was performed. The surgery was carried out with a Weber-Ferguson approach. The lip was split, and the cheek flap was retracted laterally. Anterior and posterior ethmoid arteries were dissected and ligated. The anterior ethmoid artery was enlarged 2 to 3 times its normal size. The vascular mass was identified medial to the lacrimal fossa, pushing the lacrimal sac laterally, along with the adjacent periorbita. The maxillary sinus was opened through the face of the maxilla and was filled with tenacious mucus. Bony removal was extended superiorly, exposing and preserving the nasolacrimal duct and lacrimal sac. After bone removal, the periorbita, lacrimal sac, and duct were reflected laterally to better visualize the tumor. A dissection plane surrounding the tumor was identified and contracted with bipolar cautery. The tumor was easily removed. Exploration revealed that the hemangioma was based on either the middle turbinate or the lateral nasal wall high up in the anterior ethmoid. No nasal packing was required. The patient was discharged the next morning and made an uneventful recovery.