Unilateral friable nasal mass in an anticoagulated smoker
A 64-year-old man is referred by his GP with a 7-week history of right-sided nasal obstruction, blood-streaked mucus and reduced sense of smell. He has had three courses of antibiotics and a 6-week course of intranasal corticosteroid with no improvement. His medications are apixaban for atrial fibrillation (CHA2DS2-VASc 4) and ramipril. He smokes 20 cigarettes a day and drinks about 20 units of alcohol weekly. Anterior rhinoscopy shows a fleshy, friable, polypoid mass filling the right middle meatus that bleeds on contact; the left nasal cavity is clear. There is no cervical lymphadenopathy, no facial numbness, no diplopia and no loosening of teeth. He is otherwise well and works as a delivery driver. He asks whether he can 'just have a stronger antibiotic and a steroid spray, because I can't take time off for an operation'.
1. What is your next step in this clinic visit, and what would you deliberately not do? Justify each decision.
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What I would not do. I would not prescribe a fourth antibiotic or continue the steroid spray. A unilateral, bleeding, friable mass in a 64-year-old smoker that has failed maximal medical therapy is a red flag for neoplasia, and further empirical treatment only delays diagnosis. I would also not take a blind 'grab' biopsy of a vascular-looking lesion without preparation.
What I would do, in this order. (1) Full flexible nasendoscopy with documentation of the origin - lateral wall versus vault versus septum - extent, attachment and whether the lesion reaches the choana, septum or skull base, with photo or video recording. (2) Palpate the neck and examine the oral cavity and dentition. (3) Arrange urgent contrast-enhanced CT of the sinuses, face and neck within 1–2 weeks, with MRI if there is any suggestion of orbital, pterygopalatine or skull-base involvement, or if an inverted papilloma is suspected (focal hyperostosis, cerebriform T2 pattern). (4) Take tissue - in clinic with cup forceps under topical vasoconstriction if the lesion is anterior and accessible, or in theatre if it is posterior, very vascular, or if the anticoagulation cannot be safely managed. Send for histology with fungal stains and microbiology if there is crusting. (5) Explain that this is being handled on a suspected-cancer pathway and give written information and a contact number.
Why it matters. Unilateral obstruction with epistaxis in an adult, per EPOS and national referral guidance, warrants imaging and histology, not repeated antibiotics; the delay to biopsy is the main modifiable factor in sinonasal malignancy outcomes.
2. Give the differential diagnosis for this lesion and state the specific clinical, radiological or histological features that would discriminate between the main candidates.
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A unilateral middle-meatus mass has a wide differential, and biopsy is mandatory because imaging alone cannot separate them.
- Inverted papilloma. Unilateral, lobulated, lateral-wall origin, tends to recur; CT shows focal hyperostosis at the attachment site, MRI shows a 'cerebriform' convoluted pattern on T2 and post-contrast T1. Coexisting squamous cell carcinoma in 5–10%, so the specimen must be examined carefully and the base resected.
- Squamous cell carcinoma. Smoking and alcohol, bone destruction, paresthesia, loose teeth, cervical nodes, necrotic or ulcerated surface. Imaging shows aggressive bone erosion and invasion of fat, orbit or skull base.
- Sinonasal undifferentiated carcinoma and other high-grade tumours. Rapid growth, pain, orbital or cranial nerve signs, poor differentiation on histology requiring immunohistochemistry (cytokeratins, p63, INSM1, NUT).
- Lymphoma (including NK/T-cell). Fleshy, destructive, midfacial necrosis, B symptoms, EBV association; histology plus immunohistochemistry and clonality studies.
- Esthesioneuroblastoma. Superior vault origin near the cribriform plate, hyposmia and epistaxis, 'dumbbell' through the cribriform plate with an intracranial cyst, synaptophysin and chromogranin positive.
- Sinonasal melanoma. Pigmented or amelanotic, immunohistochemistry for S100, HMB-45, Melan-A.
- Benign mimics that would change management entirely: fungal ball (unilateral, calcification on CT, no mucosal invasion, cured by surgery alone), allergic fungal disease, granulomatosis with polyangiitis (crusting, septal perforation, ANCA, renal and pulmonary involvement), rhinosporidiosis or rhinoscleroma in endemic exposure, and an organised haematoma. A single biopsy that shows only inflammation does not exclude malignancy - repeat or excise the lesion.
3. How would you manage his apixaban around a diagnostic biopsy and around a possible endoscopic resection, and what would you document?
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Do not stop anticoagulation reflexively. With a CHA2DS2-VASc of 4 he is at meaningful stroke risk, and an unnecessary interruption carries more harm than a small controlled bleed.
Clinic biopsy. For a superficial, accessible biopsy, continue apixaban and control bleeding locally: topical adrenaline 1:1000, bipolar or silver-nitrate cautery, and a haemostatic pack. Warn him that the tumour itself may bleed briskly and give him an emergency plan (pressure, pack, where to attend). If bleeding cannot be controlled, stop and book a theatre biopsy rather than persisting.
Theatre biopsy or endoscopic resection. Use a PAUSE-type protocol agreed with cardiology: omit apixaban for 1 day before a low-bleeding-risk procedure and 2 days before a high-risk one (longer if creatinine clearance is below 50 mL/min), with no heparin bridging; resume 24 hours after a low-risk procedure and at 48–72 hours after a high-risk one once haemostasis is secure. Document the CHA2DS2-VASc, renal function, the agreed plan, who approved it, the date and time of the last dose, and the resumption instruction given to the patient in writing. Where endoscopic resection of an inverted papilloma or a vascular lesion is likely, have diathermy, a suction coagulator and nasal packing ready, and discuss pre-operative embolisation with interventional radiology if imaging suggests a highly vascular tumour such as a juvenile angiofibroma-like or arterial feeder pattern.
Governance. Record the shared decision with the patient, including his concern about time off work, and the reasoning behind not giving further antibiotics.