Extra—Nasalglioma

K. SRINIVASA RAOS. SATYAMURTHIVisakhapatnam

The appreance of Ectopic GlialTissue in the nose is rare. Many nameshave been given to this condition in theliterature as fibroglioma, ganglioblas-toma, ganglioma, astrocytoma, gangli

-oneuroschwanno-spongioblastoina, gli-oma, NASAL GLIOMA encephalo-choristoma-naso frontalis, encep-haloma, encephalocoele andchoristoma. It is characterized by amass which is usually present at birthand which may be intra-nasal, extra-nasal or both. A case has already beenreferred to from this hospital of acombined type (Dr. K. Srinivasa Raoet at 1966). This is an additional casereport of nasal glioma but of purelyextra-nasal type and the diagnostic andsurgical principles involved in themanagement of this problem will bediscussed in this paper.

A. review of the literature byDeutsch H J (1965) revealed 65 casesso far reported in the world literatureof which 20 cases of intranasal as wellas 39 cases of extranasal gliomas and 6cases of combined intra and extra nasal

Dr. K. Srinivasa Rao, B. Sc., M.D, Addl.Professor of Pathology, Andhra MecicalCollege, Visakhapatnam-2., and Dr. S. SatyaMurthi, M.S., D.L.O., Addl. Professor ofE.N.T. Diseases, Andhra Medical College,Visakhapatnam-2

Received for publication on 1-8 -72

gliomas. Deutsch (1965) quoted thatBerger in 1890 first referred to nasalgliomas and used the term "ENCEP-HALOMA" and Schmidt in 1900reported the first complete descriptionand Robinson (1946) termed this nasal-nasal tumour as Glial Ectopia inpreference to nasal glioma. Jones(1958) called these lesions as Hama-rtomata. Willis (1958) stated them asEncephalocoele which is not a hernia-tion of parts which were originallyintracranial but primary anomaly ofgrowth and separation of the neuraltube from the overlying ectoderm.S'nce then many other theories oforigin have been proposed but thedefinite origin is still unknown.

Review of extranasal gliomas in theliterature are sparsely described.Dawson and Muir (1955) reported 2cases of extranasal into the cranium.Low et at (1956) reported two extranasal gliomata one of which extendedunder the nasal bone towards the crib-riform plate and was shown to havecerebral hypoplasia.

Moreley and Cross (1958) reviewedthe literature and reported an extra-nasal tumour with a pedicle passingunder the nasal bone. Borsanyu (1960)accounted a case presenting as a bonytumour on the bridge of the nose in a

106

16 year old boy and this was found tobe a nasal Glioma communicating withthe frontal sinus and enclosed in bonycapsule. Musser et at (1961) describedan extranasal glioma which had alsoseveral glial nodules in the scalp.

This case is one of extranasal gliomawith a pedicle and a narrow defect inthe nasal bone present though thepedicle was not seen to have any intra-cranial connections.

Fig. 1. Clinical photo of the child showingextranasal glioma.

Case Report :

On 2-12-'71 a male boy of 4months age (T.T T) was broughtto E.N.T. Unit II O.P. by his parents.He was shown for a swelling on theright side of the face present sincebirth and gradually increasing in size.Patient was in excellent general health.Local examination revealed a rightintra-orbital smooth fluctuant swelling4 cm. x 3 cm. size, oval, extendingfrom the roof of nose down to the alaof the right side of the nose, thus,filling up the entire front of the rightside of face below the orbit. It wastranslucent, non-compressible, nottender, and the colour of the swellingwas dark as the skin.

A tentative diagnosis of meningo-cele was made and patient admitted

into E.N T. ward on 2-12-71. Subse-quently, various investigations werecarried out. On 3-12-71 understrict aseptic precautions the cyst wasaspirated. 10cc. of clear pale whitefluid was aspirated and pressure ban-dage applied. The next morning cystwas found to be fully reformed. Aspi-ration was again done on 6-12-'71 andfluid sent for histopathological andbiochemical analysis. Pathology repor-ted 7176/71, dt. 6-12-'71 showed onlyalbuminous material present and nocells seen. Biochemical report No.27712-15 showed protien 1.8 mg;%;sugar 40 mg. Chorides 584.

An L.P. was attempted but failedto tap C.S.F. Under general anaesthe-sia at this time examination revealed uscross fluctuation. X-rays of the skull,spine and extremeties and chest weretaken and showed no congenitalabnormalities. X-ray of the skull PAview showed a faint dehiscence wasfound besides the roof of the nose inthe right side of the anterior cranialfossa.

Motion and urine was normal

Haemogramshowed Hb 7 gm.%

RBC 2.42 millions/cm.

Rest were normal.

On 27-12-71, under endotrachealgeneral anaesthesia,operation was done.

Fig. 2. Microphotograph of the nasal gliomashowing astrocytes and neuroglialtissue H. & E. x 100.

107 Ind. J. Otol. Vol. XXVI, No. 2, June, 1974

A right lateral rhinotomy incision wasmade, extending from the medial endof the right eye-brow to the ala of thenose. The cyst wall was exposed andseparated all round of the attachmentto skin and maxilla underneath withblunt dissection and lifted up towardsthe frontal bone. It was found to becommunicating through the upper partof Nasal cavity with the anterior cranialfossa. Cyst fluid could not be compres-sed into the cranial cavity, through thepedicle. A silk thread was passedaround the pedicle thus made, ligatedand excised. Facial graft was thoughtto be unnecessary at this site. A smallrubber drain was kept in the dependantportion and skin incision was suturedand a firm dressing was applied.

Post-operative recovery under peni-cillin cover was totaly uneventful. Therewas a small bulge on the 4th day. Onthe sixth P.O. day sutures were remo-ved and sanguineous fluid oozed out.Patient was discharged on 13-1-1972with a normally healed wound andwithout any bulging present at opera-tion site.

The histopathological report wasNASALGLIOMA. Patient was seenagain on 10-3-72 and no recurence wasfound. There was blackish pigmenta-tion noted at upper part of incisionalarea. Patient was in robust health,:

GROSS PATHOLOGY: B12665-A/72

This tumour was smooth and firmon cut section. The tumour tissue waslight grey to yellow and streaked withwhitish fibrous tissue. The extra-nasaltumours are usually attached to thesubcutaneous tissues without a clearline of demarcration. Usually the stalkor pedicle did not contain glial tissueand is of fibrous tissue.

1Vlicropathology

Tumour tissue compossed of nestsof glial tissue interlaced with vascularfibrous tissue septa. The cells areastrocytes with their processes and

occasional multi-nucleated ones arealso seen. The cytoplasm is pale stai-ning. The differentiation of giant gialcells from ganglan cells is difficult. Thehistological appearance is typical offibrillary neuroglial tissue interesectedwith bands of fibrous tissue and resem

-bling a glioma. Most sections showeda considerable vascularity and manyshowed a few neurones. Althoughthere was never any true capsule shownand the tumour tended to infiltrate intothe surrounding subcutaneous tissuethere was no evidence of true malig-nant growth. The recurrences werein most cases due to incompleteexcision.

Discussion

Nasal Glioma is characterised by amass usually present at birth and itmay be intranasal, extranasal or both.The extranasal tumours are smooth,firm, elastic and incompressible and aresituated on the bridge of the nose to-wards one side or the other so that theeyes seen further apart and there maynot be any nasal obstruction in this. Inthis case it did contain some C.S.F. butwas not seen to communicate with theintra cramial cavity. The intarnasalvariety resembles a nasal polyp and isa fleshy growth, pale or greyishsmooth. It pushes the septum to theopposite side and Produces nasalobstruction (1966)

In the mixed type there may be acommunication between the twothrough a defect in the nasal bone.It may or may not have intracranialconnections. When intracranial com-munication exist the connection ordi-narily passes through a defect in thecribriform plate or nasal attachment offrontal bone. Radiographs may failto show the bony defect. Radicalsurgical excision is the treatment ofchoice. This case is reported for therarity of the lesion.

Summary :1. A rare case of extranasal glioma

is being presented in this paper.

Extra—Nasalglioma/K. Srinivasa Rao at el 108

2. The origin of nasal glioma is notknown. The various views aboutthe origin is being discussed.

3. These are cases mostly of thepathologist diagnosis.

4. Surgical excision is the treatmentof choice.

Acknowledgement:

Thanks are due to Dr. K. Surya-narayana, M.D., Superintendent, K.G.Hospital, Visakhapatnam, for permit-ting to record this case. The authorsacknowledge the help rendered by SriK. Ch. Appalaswamy, Photo-artist,for photography.

REFERENCES:

1. Borsanyu S. Arch. Otolaryngol 72, 376-379. Sept. 1960.

2. Crosby J.F. Plast and Reconst. Surg.19, 143-149, Feb. 1957.

3, Dawson R.L.G, an) Muir I.F.K. Brit.Jour. Plast. Surg. 81, 136-143, 1955.

4. Deutsch H.J. "ANNALS OF OTOLOGYAND RHINOLOGY" Vol. LXXIV.1965,637-643.

5. Jones J.A. S.J. of Laryngology andOtology,Vol. 77, 85-92, 1963.

6. K.S. Rao and K.K. Murthi: "Ind. J.of Oto-Rninology" Vol. XVIII, 4, Dec.1966.

7. Lister J.J. of Laryngology, Vol. LXXVII1, 34-42, Jan. 1963.

8. Low N.L, Scheinberg L. and AndersonD.H. pediat 18, 254-259, 1956.

9. Musser AtW. and Camp Bell R. NasalOl ioma, Arch. Otolaryngol 73, 732-736,1961.

10. Morley G.H. and Cross R. M, Jaur.Path and Bact. 76, 590-592, Oct. 1958.

11. Schnidt M.B. Virchow Arch. Path. Anat162, 340-370, 1900, as quoted by walkeret al 1963.

12. Walker E.A. Jr. and D.R. Resler : TheLaryngoscope. Vol. LXXIII, 1, 93-107,Jan. 1963.

109 Ind. J. Otol. Vol. XXVI, No. 2, June, 1974