Not Every Anosmia is COVID, a Case of Nasal Mass

Abstract

Smell and test problems especially anosmia is a frequent symptom for COVID infection. Anosmia was experienced by almost 53% of those affected, in some cases persisting for longer periods after resolution of respiratory symptoms. Nasal blockage is another common symptom for emergency department patients and frequently associated with allergic rhinitis. A 25-year-old male patient presented with persistent bilateral nasal blockage, blood-stained nasal discharge, anosmia, and headache since last 1 year. During the peak of the pandemic, he was diagnosed with COVID. He was complaining of anosmia and nasal blockage and was treated with antihistaminic medicine for allergic rhinitis, but his symptoms persisted. He had breathing, bleeding and smelling problems in the last 2 years and started complaining of left sided proptosis for 3-4 weeks before being admitted to our department and had computerized tomography (CT) imaging at another facility. He was referred by an ophthalmologist to our hospital for advanced imaging with magnetic resonance (MRI) with contrast. He was investigated for exophthalmos in his left eye. He denied any other prior disease or medication. On examination he has nasal voice, left side exophthalmos, no diplopia or vision problem. The right tympanic membrane (TM) was intact, left sided dull TM with effusion. Other system evaluations were unremarkable. The patient was referred to Ear Nose and Throat consultant for further examination. Nasal endoscopy revealed fungating mass with covered blood clots and engorged vessels filling both the nasal cavities. MRI report described soft tissue mass, infiltrating the nasal cavity, paranasal sinuses and clivus with intracranial extension, to involve the left sub frontal region. Also noted associated destruction of the left lamina papyracea, showing orbital extension, compressing the orbital muscle cone, and compressing the medial rectus, with consequent left sided unilateral proptosis. In addition, there was nasopharyngeal extension. The epicenter of the mass was likely to be the ethmoid sinuses. His MRI revealed complete obstruction of the osteomeatal complexes, complete obliteration of the maxillary, ethmoids and frontal sinuses, due to retention of secretions and mass infiltration. Biopsy was taken and patient was followed up for surgical intervention. The differential diagnosis included vascular tumor, meningothelial tumor, undifferentiated carcinoma, and neuroendocrine carcinoma. Smell and taste disorders emerge during COVID infection, seem to be more common than other upper respiratory tract infections. Allergic rhinitis is also common amongst emergency department patients and frequently associated with nasal blockage. Rhinitis can be differentiated from sinus problems by the increased response of nasal obstruction to treatment, clear nasal discharge, and absence of pain or fever. Rhinitis does not lead to ostial obstruction, and patients do not complain of facial pain or headache. For suspected rhinitis or acute sinusitis, routine radiographic examination is not recommended and should be limited to the diagnosis of chronic or recurrent admissions, cases of questionable diagnoses, patients with unresponsive disease, or investigation of complications. Axial and coronal CT is the imaging modality of choice. In this case the patient was investigated for sinusitis complications and additional further imaging was necessary like MRI with contrast for proper diagnosis and management of the patient. Nasal blockage and upper respiratory system findings may be overseen by the patients or even the healthcare workers. Especially repeated admissions and persistence of these symptoms should be suspicious for the emergency physicians. Additional imaging and thorough examination are crucial for differential diagnosis and proper management of these patients. Emergency physicians should be careful on their diagnoses for common symptoms like nasal blockage especially for the patient