A multidisciplinary expert panel developed consensus-driven recommendations for the evaluation and workup of sinonasal masses, with guidance focused on avoiding biopsy and management pitfalls that may complicate diagnosis and treatment.
In a multidisciplinary consensus statement, researchers used a modified Delphi process informed by a systematic review of English-language guidelines, systematic reviews, and consensus statements published from 1990 to 2025 in the PubMed database. The panel included 25 physicians from the United States, United Kingdom, and Canada representing rhinology, head and neck surgery, comprehensive otolaryngology, neurosurgery, and medical oncology. The group evaluated 23 statements addressing initial evaluation, biopsy, imaging, pathologic assessment, multidisciplinary coordination and treatment decision-making regarding sinonasal masses.
According to the researchers, 20 of the statements reached consensus during the initial voting round, and two additional statements achieved consensus following revision. One statement regarding clinical trial enrollment did not ultimately reach consensus.
The panel agreed that physicians evaluating patients with unilateral nasal obstruction, epistaxis, cranial neuropathy, facial numbness, or visual disturbances should maintain suspicion for sinonasal malignancy and perform comprehensive nasal endoscopy that includes visualization of the nasal cavity, middle meatus, sphenoethmoid recess, and nasopharynx to reduce the likelihood of overlooked lesions.
Among the strongest biopsy recommendations was one focused on avoiding complete excisional biopsy without permanent pathologic diagnosis. The researchers noted that removal of the visible tumor before definitive diagnosis may obscure the tumor attachment site, complicate margin assessment, and limit future oncologic management options.
The panel also recommended preserving the tumor pedicle or attachment site during biopsy procedures and identified endoscopic endonasal biopsy as the preferred tissue-sampling approach when feasible because of its minimally invasive nature and lower risk of soft-tissue seeding.
Office-based biopsy should be considered appropriate only for accessible masses that are not highly vascular and in settings where epistaxis can be controlled, the researchers stated. The panel advised against office biopsy of vascular-appearing unilateral nasal masses in adolescent male patients because of the possibility that the mass is a juvenile nasal angiofibroma.
Additional recommendations addressed lesions associated with procedural risk. The researchers recommended imaging prior to biopsy when encephalocele is suspected and advised high-resolution magnetic resonance imaging (MRI) with and without contrast for sinonasal masses with bony destruction on computed tomography ( CT) or suspected extension beyond the sinonasal cavity.
Among patients with diagnosed sinonasal malignancy, the expert panel supported imaging of the neck, chest, abdomen, and pelvis to evaluate metastatic disease, including CT or positron emission tomography (PET)-CT.
Pathology recommendations included review by pathologists with sinonasal expertise and consideration of second-opinion review or additional molecular studies when diagnosis or tumor behavior is uncertain. The panel also reached consensus that permanent tissue diagnosis should be available prior to treatment planning involving the resection of vital structures or procedures associated with substantial morbidity, including dural resection or orbital exenteration.
One recommendation narrowly missed consensus. Although several panelists supported clinical trial enrollment when available, some noted that access may be limited because of geography, resource availability, and the rarity of sinonasal malignancy.
The researchers acknowledged several limitations, including the reliance on expert opinion and possible expert-selection bias. They also noted that implementation may be more difficult in settings with limited access to MRI, PET-CT, subspecialty pathology review, or high-volume referral centers.
“This multidisciplinary expert consensus statement can guide physicians and medical practitioners in adopting the proper evaluation and workup of nasal masses, helping them to avoid common pitfalls, optimize management practices, and ultimately improve patient outcomes,” wrote lead study author Nyall R. London Jr, MD, PhD, of the Departments of Otolaryngology Head and Neck Surgery, Neurosurgery, and Oncology at the Johns Hopkins University School of Medicine, and colleagues.
The study was supported in part by the Intramural Research Program of the National Institutes of Health. Full disclosures of the study authors can be found in the study.
