ABSTRACT

Sinonasal lobular capillary hemangiomas (LCH) are rare benign vascular lesions commonly arising from the nasal septum. Nasopharyngeal, nasal mid-turbinate, and anterior nasal swabbing is the preferred method of screening for coronavirus disease-2019 (COVID-19). Herein, we present a case of a sinonasal LCH in a child after continuous self-tests for COVID-19, with an anterior nasal swab. The child presented with a well-defined red mass in the anterior part of the nasal septum, which was removed endoscopically. Histopathology revealed a LCH. This is the first report of a complication other than epistaxis with the use of an anterior nasal swab. Our literature review identified 32 studies reporting complications of COVID-19 screening. Cerebrospinal fluid leaks and foreign body retention are the most common ones. A proper specimen collection technique and a quick patient history with an emphasis on risk factors are the best practices to prevent complications from COVID-19 screening.

INTRODUCTION

Lobular capillary hemangiomas (LCH) are benign vascular lesions, commonly affecting the skin and oral cavity mucosa¹. Hemangiomas are common lesions of the head and neck area, although they rarely derive from the nasal cavity². Sinonasal LCH most commonly present with nasal obstruction, epistaxis, nasal discharge, and postnasal drip³. Their etiology is not completely understood, but trauma, hormonal stimulation, and microscopic arteriovenous malformations are thought to play a role in the pathogenesis^1,2. Since March 2020, coronavirus disease-2019 (COVID-19) has been recognized as a pandemic, and every effort has been put to identify patients early in the disease course and stop its spread⁴. Nasopharyngeal, nasal mid-turbinate, and anterior nasal specimen collection by swabbing is the preferred method of initial diagnostic testing for COVID-19⁵. Herein, we present a case of a sinonasal LCH in a child after continuous self-tests for COVID-19 with a nasal swab.

CASE REPORT

A 9-year-old boy presented to our department with a 4-month history of recurrent epistaxis and nasal obstruction. The episodes of epistaxis were self-limited and increased in frequency. Anterior rhinoscopy revealed a well-defined red mass in the anterior part of the nasal septum of the left nostril (Figure 1). Nasal endoscopy did not reveal any other lesions. The child’s caregiver reported that before the onset of epistaxis, the child was attending a series of school lessons on how to properly perform a self-test for COVID-19 using a nasal swab in the left nostril.

The child had a normal birth, no other health problems were reported, so he was scheduled for surgical excision under general anesthesia. The mass was removed endoscopically, and the patient was discharged the next day. The histopathological report was consistent with a diagnosis of LCH (Figure 2a, b). No recurrence was noted on a 1-year follow-up.

Written informed consent was obtained from the patient’s caregiver for the publication of this case report and the accompanying images.

DISCUSSION

Sinonasal LCH are rare lesions, and a few case series and case reports have been published in the literature. They arise most frequently from the nasal septum in Kiesselbach’s area between the 3^rd and 5^th decade of life⁶. Differential diagnosis includes hematomas or abscesses, nasal polyps, benign tumors of the nasal cavity such as juvenile angiofibromas, hemangiopericytomas, paragangliomas, and papillomas, as well as malignant tumors of the nose. In this case, the mass was red, well-circumscribed, and located in Kiesselbach’s area, and a hematoma was ruled out, making hemangioma the most likely diagnosis.

Trauma, as mentioned, is one of the postulated etiopathogenic factors of LCH^2,3,6,7. Specifically, in this case, we consider that continuous trauma in the nasal septum by a nasal swab led to the formation of a hemangioma. This is the first case of LCH formation secondary to nasal swab collection for COVID-19 screening. However, whether the hemangioma was present, the nasal swab triggered the episodes of epistaxis, or the nasal swab itself led to its formation cannot be proven.

Several other complications of COVID-19 screening have been reported in the literature, with the most common being epistaxis⁸. Some rarer complications are presented in Table 1, and foreign body retention in the nasal cavity and gastrointestinal tract (GIT) and cerebrospinal fluid (CSF) leaks are the most frequent. To our knowledge, 13 reports of CSF leaks have been published, and four of them have been complicated with meningitis or meningoencephalitis^9,10,11,12. Of note, in 7 of these 13 cases, several predisposing factors have been recognized, with encephalocele as the most common. Most of these cases have been managed surgically, and just in one case, minimal neurologic sequelae were reported⁹. The most frequent areas of the leak were the sphenoid sinus^4,11,13,14, cribriform plate^5,10,15,16, and fovea ethmoidalis^17,18. This means that a correct specimen collection technique, with the direction of the swab just above and parallel to the floor of the nasal cavity, would have prevented the leak. Foreign body retention in the nasal cavity and GIT was reported in 15 and 8 patients, respectively. In all of them, the foreign bodies were successfully removed, apart from one patient, with a history of multiple surgeries in the GIT, in whom swallowing of the swab led to intestinal perforation¹⁹. Specimen collection swabs have a breakpoint mechanism to prevent contamination when transferring the shaft into the container, which makes them susceptible to accidental rupture²⁰. In the presence of predisposing factors, such as nasal septal deviation^20,21, or in an uncooperative patient^20,22,23, the risk of accidental breakage of the swab increases. Dislocation of the temporomandibular joint²⁴, nasal septal⁸ and pharyngeal abscesses²⁵, orbital cellulitis^26,27, ethmoidal silent sinus syndrome²⁸ and neurally mediated syncope²⁹ have also been reported as complications of screening for severe acute respiratory syndrome coronavirus-2. Interestingly, the vast majority of the reported adverse events were caused by nasopharyngeal swabs, suggesting that this specimen collection technique bears the highest risk. The LCH formation, presented in this paper, is the first reported complication following the use of an anterior nasal swab.

These cases underline that despite nasal and nasopharyngeal swab sampling being safe and well-tolerated procedures8, serious adverse events can occur. During the current COVID-19 pandemic, thousands of rapid and self-tests are performed daily as a public health strategy to detect suspicious cases early. These tests are performed by physicians, nurses, pharmacists, and individuals, who, in many cases, are not familiar with the anatomy of the nasal cavity, increasing the risk of adverse events. To minimize complications, proper knowledge of the sampling technique and the anatomy of the nose is important. The three main swab collection methods are the anterior nasal, mid-turbinate, and nasopharyngeal methods⁵. Nasopharyngeal swabs are considered more reliable than the other methods but are more invasive¹⁰. Nasopharyngeal and mid-turbinate swabs should be inserted in a plane parallel to the floor of the nasal cavity, pointing to the level of the external auditory canal. The inclination of the swab should not exceed 30° from the floor of the nasal cavity. Moreover, maneuvers should be gentle, and scratching violently the nasal septum should be avoided. The distance between the entrance of the nose and the posterior wall of the nasopharynx is 8-10 cm in adults and 6-7 cm in children³⁰. A quick medical history, with a focus on previous surgeries in the nose, presence of nasal septal deviation, encephaloceles, meningoceles, idiopathic intracranial hypertension, or coagulopathies could also prevent adverse events. If there is a high risk of complication, alternative specimen collection techniques, such as oropharyngeal or anterior nasal swabbing, could be chosen.

Sinonasal LCH are rare benign vascular lesions appearing as red well-circumscribed masses in the nasal cavity. This is the first presentation of an LCH after continuous self-tests for COVID-19 with an anterior nasal swab. Healthcare professionals should be aware that screening tests with nasal or nasopharyngeal swabs are not free from complications. When testing, the swab should be advanced in a plane parallel to the floor of the nasal cavity and its angle from that plane should not exceed 30°.