OtolaryngologyHead and Neck Surgery Case Reports renee rate with radiotherapy and a 60% recurrence rate with conservative management. Radical surgery failed to cure the disease in only 4.5% of cases." Results from other studies are comparable." The case we report is interesting from several viewpoints. The lack of prior dental history may lend support to the theory that these lesions arise from nonneoplastic or dentigerous cysts. Furthermore, the unique presentation of unilateral nasal obstruction, together with intermittent epistaxis, only occurs in previously treated patients. Finally, the location of this normally aggressive tumor in the maxilla with relatively little bony destruction allowed for an en bloc resection that did not violate adjacent anatomic fields and perhaps diminished the possibility of local spread and recurrence. Conservative local or radiation therapy should not be considered when dealing with mandibular or maxillary ameloblastomas. In accordance with Shatkin and Hoffmeister," "Radical treatment conserves the patient's appearance, function, and life. " CONCLUSION A case of a maxillary ameloblastoma presenting as unilateral nasal obstruction and epistaxis of long duration has been presented. The aggressive nature of this lesion has been stressed and the necessity of extirpation with adequate margins to obtain a cure has been emphasized. REFERENCES 1. Sedhev MK, Huvos AG, Strong EW, Gerold FP, Willis GW: Ameloblastoma of maxilla and mandible. Cancer 33:324-333, 1974. 2. Ivey RH, Churchill HR: The need of a standardized surgical and pathological classification of tumors and anomalies of dental origin. Am Assoc Dent Sch Trans 7:240-245, 1930. 3. International histological classification of tumors. Histological typing of odontogenic tumours, jaw cysts and allied lesions (Monograph No.5). Geneva, 1971, World Health Organization. 4. Bhaskar SN: Synopsis of oral pathology. St Louis, 1981, The CV Mosby Co, pp 252-256. 5. Batsakis JB: Tumors of the head and neck. Baltimore, 1980, The Williams & Wilkins Co, pp 531-536. 6. Hertz J: Adamantinoma: Histopathologic and prognostic studies. Acta Chir Scand 102:405-432, 1952. 7. Hinds EC, Pleasants JE, Snyder PL: Management of ameloblastoma. Oral Surg 7:1169-1177,1954. 8. Godin RJ, Chaudry AP, Pinborg 11: Odontogenic tumors. Cancer 14:73-101, 1961. 9. Frankel KA, Smith JD, Frankel LS: Soft tissue ameloblastoma in a 92-year-old woman. Arch Otolaryngol 103:499-500, 1977. 10. Young DR, Robinson M: Ameloblastomas in children-report of a case. Oral Surg 15:1155-1162, 1962. 11. Godin RJ, Meskin LH, Brodey R: Odontogenic tumors in man and animals: Pathological classification and clinical behavior. Ann NY Acad Sci 108:722-771, 1963. 12. Becker R, Pertl A: Zur Therapie des Ameloblastomas. Dtsch Z Mund Kiferheilkd 49:423-436, 1967. 13. Mehlisch DR, Dahlin DC, Masson JK: Ameloblastoma: A clinicopathologic report. J Oral Surg 30:9-22, 1972. 14. Shatkin S, Hoffmeister FS: Ameloblastoma-a rational approach to therapy. Oral Surg 16:1100-1101, 1963. Pleomorphic adenoma of the nasal septum BARRY L. WENIG. MD. JAMES J. SCIUBBA. DMD. PhD. ALFRED COHEN, MD, and ALLAN L.ABRAMSON, MO. New Hyde Park, New York From the Department of Otolaryngology and Communicative Disorders (Drs. Wenig, Cohen, and Abramson), and the Departments of Dentistry and Laboratories (Dr. Sciubba), the Long Island Jewish-Hillside Medical Center. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery (ScientificPoster), New Orleans, La., Oct. 17-21, 1982. Submitted for publication Oct. 16, 1982; revision received April 22, 1983; accepted May 3, 1983. Reprint requests: Barry L. Wenig, MD, Department of Otolaryngology and Communicative Disorders, the Long Island JewishHillside Medical Center, 270-05 76 Ave., New Hyde Park, NY 11042. 432 Pleomorphic adenoma is the most common type of benign epithelial salivary tumor. It most frequently presents in the major salivary glands. The appearance of this tumor in the upper respiratory tract is highly unusual. The few scattered reports indicate that the nasal cavity is the favored site of this tumor, followed distantly by the maxillary sinus and the nasopharynx. We present a case of a young white man who developed progressive unilateral nasal obstruction. The pathologic diagnosis was a benign mixed tumor, or pleomorphic adenoma. The importance of this disease Volume 93 Number 3 June 1985 Case Reports 433 Fig. 1. Areas of pseudocartilage separated from cords of cells exhibiting ductal differentiation by mature collagenous stroma. (Hematoxylin-eosin stain; x72.) entity lies in the necessity of making a correct diagnosis. Pleomorphic adenoma can easily be confused with generally more aggressive destructive lesions of the nasal septum. Treatment consists of conservative surgical excision, which will often suffice as definitive therapy. CASE REPORT A 21-year-old white man was referred because of a history of unilateral left nasal obstruction. The patient noted that the symptoms began 2 years prior to admission. Several months prior to admission he sustained a traumatic blow to the nose and 1 month prior to admission was scheduled for elective rhinoplasty to correct the nasal deformity sustained by the trauma. At the time of surgery a unilateral left nasal mass was noted and a biopsy was performed. The pathologic diagnosis was pleomorphic adenoma. On examination a grayish white mass was noted in the left nostril that completely occluded the vestibule. There was no evidence of epistaxis or rhinorrhea. The right nostril was free of any obstruction. Treatment consisted of surgical excision of the mass through a lateral rhinotomy approach with excision of the mass down to and including the mucoperichondrium. The surgical margins of the specimen were free of tumor. The postoperative course was uneventful and the patient was discharged on the sixth postoperative day. He has been followed up for 18 months since treatment and there has been no recurrence of disease. Pathologic findings. On gross examination the lesion measured 1.8 x 1.3 x 0.2 em, was polypoid in outline, grayish white in color, and firm to focally mucinous in consistency. The surrounding mucosa over the nasal septum was of normal character. On cut section the mass was pale yellow to white in color with a translucent quality and glistening appearance. Microscopically, small islands and comma-shaped cords of epithelial cells were loosely arranged within a supportive stroma that displayed significant heterogeneity. In areas of highest epithelial concentration, stromal elements were primarily collagenous in nature, with mature, elongated fibroblasts evenly distributed throughout. Sparsely cellular zones demonstrated an amphophilic to halophilic, mucinous 434 Case Reports OtolaryngologyHead and Neck Surgery Fig. 2. Myoepithelial cells of plasmacytoid type and ductal elements are juxtaposed within loose connective tissue stroma. (Hematoxylin-eosin stain; x180.) to myxochondroid background with unevenly scattered stellate to spindle-shaped cells that were singly grouped (Fig. 1). Occasional clear vacuoles were present within the stroma, especially within the mucoid material (Fig. 2). Growth patterns of epithelial cells included solid sheets, while elsewhere ductal differentiation was evident. An incomplete or pseudocapsule was noted at the tumor margins, with the most peripheral epithelial elements growing in narrow cords parallel to the outer margin of the lesion (Fig. 3). DISCUSSION The literature dealing with the mixed tumor, or pleomorphic adenoma, is vast, yet the presence of this neoplasm in the upper respiratory tract is rare.v" Batsakis! states that within the upper respiratory tract the most favored site of origin is the nasal cavity, followed by the maxillary sinus and the nasopharynx. Isolated reports documenting the presence of this tumor along the nasal septum exisr'r"; however, there is only one large series that affords precise information regarding the clinical and histopathologic features of these intranasal mixed tumors. 2 The nasal septum is sparsely populated by salivary glands. The vast majority of minor mucous and serous glands are located on the lateral nasal wall, thereby emphasizing the unique nature of the septal origin for these benign mixed tumors. Among all reported cases of pleomorphic adenomas in the nasal cavity, 80% arose from the septum and only 20% originated from the lateral wall or involved a turbinate.' The apparent discrepancy between the relative paucity of glandular elements on the septum and the predilection of the mixed tumors to originate on the septum has lead several authors to postulate the etiology of these lesions. Matthew et a1. 3 thought that misplaced embryonic ectodermal epithelial cells, carried via the nasal pits into the septal region, could account for tumors in this location. On the other hand, Stevenson" stated that the true rarity of embryonic septal growths excludes the possibility of these tumors arising in this Volume 93 Number 3 June 1985 Case Reports 435 f'.. -, I- • .'.,. ....-.1' '*, ' . \ t" -., " 4# •••• " .... • , .. . , " -\. ..\ " '1\ Fig. 3. Pseudocartilaginous areas are intersected by arcades of myoepithelial cells. Clusters of polygonal plasmacytoid myoepithelial cells are present on left portion of field. (Hematoxylin-eosin stain; x360.) area. He believed that the remnants of the vomeronasal Jacobson organ give rise to mixed tumors in this area. Evans and Cruickshank," however, thought that all mixed tumors are of epithelial origin and that they arise from fully developed salivary gland tissue rather than from embryonic remnants. The range of age of presentation of these lesions is large, spanning early childhood to old age, with the majority occurring from the third through the sixth decades." There appears to be no predominance by sex. Almost uniformly the chief complaint is nasal obstruction, usually unilateral. Rarely patients will present with a "mass" in the nose or with epistaxis. Patients usually seek medical attention within I year of the onset of symptoms.' The mixed tumor is a homogeneous, lobular mass that is often polypoid in outline and translucent. Compagno and Wong" reported that the pleomorphic adenoma of the nasal septum differs on a cellular level from mixed tumors commonly seen in the major salivary glands. They thought that the cellularity is much greater in these tumors, such that the epithelial rather than the stromal elements predominate. Batsakis ,! while concurring with this viewpoint, emphasized that at times the tumor may be composed almost entirely of epithelial cells with little or no stroma. Polypoid masses presenting as unilateral nasal obstruction should be approached judiciously in a diagnostic sense. When dealing with a unilateral nasal mass one must consider the benign polyp as the most likely entity. However, the various histologic cellular components of the nose can develop into a wide variety of tumors. Congenital lesions such as dermoid cysts, external encephaloceles, and external nasal gliomas must be considered as causes of unilateral nasal obstruction in children." Adolescents may present with the highly vascular, locally invasive juvenile angiofibroma.' The OtolaryngologyHead and Neck Surgery Case Reports more destructive lesions presenting in adults include papillomas (fungiform type)," chordomas,'? plasmacytomas,'! fibrous histiocytomas," oncocytomas," esthesioneuroblastomas," hemangiopericytomas, 15 chondromyxofibrosarcomas, and various other tumors. 16 All of these require aggressive surgical intervention that is usually combined with some sort of adjuvant therapy. Treatment of the pleomorphic adenoma by local or wide surgical excision without the necessity of radical extirpation differentiates this lesion from its more malignant counterparts. Compagno and Wong! cite a 10% recurrence rate following conservative local treatment. They attribute this to the cellular nature of this lesion, stating that the marked histologic difference between the nasal variant and the other salivary gland types in which the myxoid stroma predominates accounts for the difference in recurrence rates Y Excision of parotid or intraoral mixed tumors allows for spillage of stroma into the surgical field, thereby providing a focus for recurrence. Although the pleomorphic adenoma of the nasal septum is a relatively uncommon tumor, its importance lies in its histologic differentiation from other salivary gland tumors, its generally benign biologic behavior, and its low rate of recurrence following conservative management. CONCLUSION A case of a young white man presenting with a unilateral nasal obstruction secondary to a septal pleomorphic adenoma has been presented. The histologic nature of this lesion in comparison to other salivary gland tumors as well as its place in the differential diagnosis of unilateral nasal masses has been stressed. Its low rate of recurrence following conservative surgical management has been emphasized. REFERENCES I. Batsakis JB: Tumors of the head and neck. Baltimore, 1980, The Williams & Wilkins Co, p 84. 2. Compagno J, Wong RT: Intranasal mixed tumors (pleomorphic adenomas). Am J Clin Path 68:213-218, 1977. 3. Matthew S, Ersner MD, Saltzman M: A mixed tumor of the nasal septum. Report of a case. Laryngoscope 54:287-296, 1944. 4. Gabrial GE: A case of mixed salivary tumor of the nasal septum. J Laryngol Otol 66:329-330, 1952. 5. Majed MA: Pleomorphic adenoma of the nasal septum. J Laryngol Otol 85:975-976, 1971. 6. Stevenson HN: Mixed tumor of the septum. Ann Otol Rhinol Laryngol 41:563·570, 1932. 7. Evans RW, Cruickshank AH: Epithelial tumors of the salivary glands, vol I. In Major problems in pathology. Philadelphia, 1970, WB Saunders Co, p 167. 8. Sessions RB: Nasal dermal sinuses-new concepts and explanations. Laryngoscope (Suppl 29) 92:1-28, 1982. 9. Hyams VJ: Papillomas of the nasal cavity and paranasal sinuses. Ann 0101 Rhinol Laryngol 80: 192-206, 1971. 10. Campbell WM, McDonald TJ, Unni KK, Laws ER: Nasal and paranasal presentations of chordomas. Laryngoscope 90:612618, 1980. II. Ben-David J, Fradis M, Podoshin L, Bartal AH: Plasmacytoma arising in the vicinity of a foreign body in the nasal cavity. Laryngoscope 90: 1686·1693, 1980. 12. Del Rey E, De la Torre FE: Fibrous histiocytoma of the nasal cavity. Laryngoscope 90: 1686-1693, 1980. 13. DiMaio SJ, DiMaio VJM, DiMaio TM, Nicastri AD, Chen K: Oncocytic carcinoma of the nasal cavity. South Med J 73:803806, 1980. 14. Cantrell RW, Chorayeb BY, Fitz-Hugh GS: Esthesioneuroblastoma: Diagnosis and treatment. Ann Otol Rhinol Laryngol 86:564-565, 1977. 15. Stout AP, Murray MR: Hemangiopericytoma; vascular tumor featuring Zimmermann's pericytes. Ann Surg 116:26-33,1942. 16. Weber AL, Solis 0: Chondromyxofibrosarcoma of the nasal cavity. Ann Otol Rhinol Laryngol 86:564-565, 1977. 17. Krolls SO, Boyers RC: Mixed tumors of salivary glands. Longterm follow-up. Cancer 30:276-281, 1972. Nasal septal hemangioma BARRY L. WENIG, MD. JAMES J. SCIUBBA, DMD. PhD. ALFRED COHEN, MD, and ALLAN L. ABRAMSON, MD. New Hyde Park, New York From the Department of Otolaryngology and Communicative Disorders (Drs. Wenig, Cohen, and Abramson), and the Departments of Dentistry and Laboratories (Dr. Sciubba), the Long Island Jewish-Hillside Medical Center. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery (Scientific Poster), New Orleans, La., Oct. 17-21, 1982. 436 Submitted for publication Oct. 16, 1982; revision received April 8, 1983; accepted May 3, 1983. Reprints requests: Barry L. Wenig, MD, Department of Otolaryngology and Communicative Disorders, the Long Island JewishHillside Medical Center, 270-05 76 Ave., New Hyde Park, NY 11042.