Sinonasal Mucosal Melanoma: A Rare Intranasal Tumor in an 89-Year-Old Woman

Abstract

     Mucosal melanomas are malignant tumors from melanocytes found in epithelium of nasal, oral, reproductive and gastrointestinal mucosa of the body.^1,2 As early as 1869, cases of mucosal melanomas have been described as rare and aggressive but insidious in nature.³ The mean age of diagnosis in some studies is 60 - 70 years old,1-7 with early detection proving to be a challenge due to non-specific early stage symptoms.^1,4 They generally have poor prognosis, high tumor recurrence and high prevalence of tumor metastasis in around 23 - 50%.4,5 Treatment may involve surgical excision, radiotherapy or chemotherapy.⁶ However, adequate and appropriate treatment can only be initiated once the diagnosis and staging are established through proper imaging and histopathologic support.4 We present one such case.

CASE REPORT

     An 89-year-old woman consulted our out-patient department (OPD) for right nasal obstruction that started two years prior with progressive hypo-nasal speech. No medications were taken nor any consult done. Ten months prior to consult, there was development of recurrent watery rhinorrhea, progressing right nasal obstruction and occasional hyposmia. A gradually enlarging fleshy mass was noted within the right nasal cavity, as well as intermittent right nasal epistaxis, initially attributed to frequent manipulation of the nares. Increasing nasal mass size and newonset right facial pain and headache prompted OPD consult. On examination, anterior rhinoscopy showed an obstructing, irregularly shaped, smooth, painless, fleshy-colored right intranasal mass with areas of beefy-red discoloration. Bulging of the right ala was noted as well. (Figure 1) Examination of the left nares showed no visible masses or polyps with the nasal septum showing no signs of deviation or breaks in the mucosal surface. Endoscopy of the left nasal cavity revealed the posterior extension of the aforementioned mass from the right posterior choanae. (Figure 2) Otoscopic, oral, and neck examination findings were unremarkable. Due to the presence of a  unilateral nasal mass with non-specific characteristics and symptoms, initial assessment favored a benign pathology, without totally ruling out malignancy. Patchy tissue discoloration and history of intermittent epistaxis warranted further investigation. Intranasal saline irrigation was initially advised while the patient underwent further work ups