Introduction and Context
Nasal cavity and paranasal sinus masses are common clinical findings, ranging from benign inflammatory polyps to rare but aggressive malignancies. Mistakes in the initial evaluation—missed imaging, inappropriate or blind biopsy, or inadequate pathology workup—can delay diagnosis, cause complications, or misdirect treatment. To address these issues, a multidisciplinary expert panel published a consensus statement in JAMA Otolaryngology—Head & Neck Surgery (London et al., 2026) with 23 proposed recommendations for the evaluation and workup of sinonasal masses. This article synthesizes the core guidance, highlights what changed or was emphasized compared with prior practice patterns, and translates the recommendations into actionable steps for clinicians.
Why this consensus now? Advances in imaging, endoscopic techniques, and tumor molecular diagnostics, plus recognition of frequent diagnostic pitfalls, made an updated, multidisciplinary approach necessary. The consensus was developed following a systematic literature review (1990–2025) and a modified Delphi process involving otolaryngologists (general, rhinology, head and neck), neurosurgery, and medical oncology from North America and the UK.
Key reference sources that informed the consensus include the consensus statement itself (London et al., 2026), the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020), established staging systems (Lund–Mackay and AJCC), and specialty guidance such as NCCN head and neck cancer pathways.
New Guideline Highlights
Major themes and practical takeaways from the consensus:
– Triage by risk: Not every nasal mass needs the same pathway—stratify patients by red-flag features (unilateral symptoms, recurrent epistaxis, rapid growth, cranial neuropathy, bony erosion on imaging) to determine urgency and extent of workup.
– Imaging-first in high-risk presentations: For unilateral or suspicious masses, cross-sectional imaging (CT and/or MRI) should usually be obtained before attempting a tissue biopsy to define anatomy, assess skull-base or orbital involvement, and detect highly vascular lesions.
– Selective in-office biopsy: Office endoscopic biopsy is appropriate for many lesions but should be avoided when imaging suggests intracranial extension, encephalocele, or a vascular tumor—specialty referral is required first.
– Close clinic—pathology partnership: Provide radiologic images and clinical context to pathologists. For uncommon histologies consider centralized review and molecular testing (e.g., NUT, SMARCB1/INI1, IDH2 alterations) because these findings alter treatment.
– Special populations: Pediatric adolescent males (juvenile nasopharyngeal angiofibroma) and immunocompromised patients require tailored approaches—imaging and subspecialty referral before invasive procedures.
Updated Recommendations and Key Changes
Compared with prior informal practice patterns and earlier position papers, the consensus emphasized three changes:
1) Imaging before biopsy in higher-risk cases. Previously, some clinicians performed immediate in-office biopsy of any accessible nasal lesion. The new consensus specifies risk features that should trigger pre-biopsy imaging.
2) Formal encouragement of multidisciplinary review. The statement formalizes routing of suspicious cases to tumor boards or multidisciplinary clinics early in the workup.
3) Broader application of targeted molecular testing. Whereas traditional pathology relied mainly on morphology and limited immunostains, experts now recommend molecular tests for select high-grade or poorly differentiated sinonasal tumors because targeted therapies and prognosis may hinge on molecular subtype.
Table: Quick comparison of previous practice vs. current consensus (summary)
– Previous: Routine in-office biopsy for most accessible lesions. | Consensus: Reserve pre-biopsy imaging for unilateral/suspicious lesions.
– Previous: Variable communication between clinicians and pathologists. | Consensus: Strong recommendation to send imaging and clinical notes with specimens.
– Previous: Molecular testing rarely performed. | Consensus: Recommend molecular testing for select tumor types (UCS, NUT carcinoma, SMARCB1-deficient tumors).
Referenced evidence driving these updates includes case series documenting complications from blind biopsy of encephaloceles or vascular tumors, improved sensitivity of combined CT/MRI for defining skull-base involvement, and growing literature on molecularly defined sinonasal neoplasms that affect management.
Topic-by-Topic Recommendations
General principles
– Take a focused history: onset and laterality of obstruction, epistaxis, facial pain, anosmia, visual changes, neurologic symptoms, prior sinus surgery or trauma, immunosuppression, and age/sex (adolescents—JNA suspicion).
– Perform office nasal endoscopy (rigid or flexible) for characterization: site of origin, surface features (ulceration, necrosis), bleeding, and mucosal changes.
When to image
– Indications for cross-sectional imaging before biopsy (consensus):
– Unilateral nasal mass, especially if progressive or recurrent.
– New or recurrent significant epistaxis.
– Signs suggesting skull-base, orbital, or intracranial extension (visual change, cranial neuropathy, severe headaches).
– Suspected congenital herniation (encephalocele) or CSF leak.
– Pediatric patients with nasopharyngeal or posterior nasal masses (to evaluate for JNA).
– Imaging modalities:
– Non-contrast CT of the paranasal sinuses: best for bone detail, erosion, and surgical planning.
– Contrast-enhanced MRI: best for soft tissue delineation, perineural/intracranial extension, and differentiating tumor from secretions or inflammation.
– CT angiography or formal angiography: when a hypervascular tumor (e.g., juvenile nasopharyngeal angiofibroma or highly vascular malignancy) is suspected; angiography may be combined with preoperative embolization planning.
– PET-CT: reserved for staging when malignancy is confirmed or strongly suspected.
Biopsy strategy
– Office biopsy is appropriate for many exophytic or accessible lesions without red-flag imaging features. Use topical and local anesthesia and obtain adequate tissue for histology and ancillary testing.
– Avoid biopsy and refer urgently when the lesion appears pulsatile, cystic in the skull base region, or imaging suggests intracranial communication, as biopsy risks CSF leak or catastrophic hemorrhage.
– For suspected vascular tumors (e.g., JNA), do not biopsy; refer to a specialist for angiography/embolization and planned surgical biopsy or resection.
Pathology and tissue handling
– Always send adequate, fresh tissue when possible, and include clinical history and imaging with the specimen. Small curettage fragments can be non-diagnostic; aim for core/endoscopic forceps biopsies that preserve architecture.
– Recommended pathology workflow:
– Routine H&E and a basic immunohistochemical panel tailored to morphology.
– Reflex ancillary testing for poorly differentiated tumors: cytokeratins, p40/p63, S100, SOX10, desmin, myogenin, cytokeratin 5/6, synaptophysin, chromogranin, INI1 (SMARCB1), NUT immunostain, and molecular tests (as indicated).
– Send rare or ambiguous cases to specialized head and neck or tertiary pathology centers for a second opinion.
– Consider molecular testing for:
– NUT midline carcinoma (NUTM1 rearrangement) in undifferentiated midline tumors.
– SMARCB1-deficient carcinomas (INI1 loss) or SMARCA4 alterations.
– IDH2 mutations in sinonasal undifferentiated carcinomas where actionable targets or prognostic information exist.
Staging and additional workup if malignancy is suspected or confirmed
– Use AJCC staging for nasal cavity and paranasal sinus tumors (AJCC 8th edition) and follow NCCN guidelines for baseline staging workup, which typically includes chest imaging and consideration of PET-CT for high-grade tumors.
– Multidisciplinary tumor board review is recommended before definitive therapy planning; include head and neck surgery, radiation oncology, medical oncology, radiology, and pathology.
Follow-up and surveillance
– Benign lesions (e.g., inflammatory polyps): manage and surveil per chronic rhinosinusitis guidelines (e.g., EPOS 2020). Surveillance intervals depend on recurrence risk and symptoms.
– Malignancy: follow NCCN surveillance schedules—typically frequent surveillance in the first two years then at increasing intervals, with imaging guided by initial stage, histology, and symptoms.
Special populations and red flags
– Pediatric/adolescent with posterior nasal mass: high suspicion for juvenile nasopharyngeal angiofibroma; obtain imaging prior to any invasive attempt and refer to an experienced center.
– Immunocompromised patients: consider invasive fungal disease in the differential; fungal masses may progress rapidly and require urgent imaging and combined medical-surgical management.
– Pregnancy: minimize radiation—if imaging is necessary, MRI without gadolinium is preferred when feasible; CT may be used when clinical urgency outweighs risk and shielding is applied.
Expert Commentary and Insights
The consensus panel included 25 experts across relevant specialties and regions. Their collective views produced strong agreement on many points but also identified areas of debate:
– Imaging-first vs. biopsy-first: While most experts supported pre-biopsy imaging for unilateral/suspicious masses, a minority emphasized that straightforward, clearly inflammatory polypoid lesions in low-risk patients may be safely sampled in-office without prior imaging. The compromise: use clear clinical criteria to avoid unnecessary imaging while protecting against missed aggressive disease.
– Role of molecular testing: Experts endorsed targeted molecular testing selectively, recognizing both the value for prognosis/therapy and the realities of cost and tissue availability. Many advocated centralized testing for rare tumors.
– Accessibility and resource constraints: The panel acknowledged global variability in access to MRI, angiography, and specialized pathology—recommendations were framed to be adaptable when resources are limited, emphasizing safe referral when advanced diagnostics are unavailable locally.
– One statement in the original set failed to reach consensus—illustrating where evidence remains thin: specifically, the routine use of preoperative embolization for all highly vascular-appearing sinonasal malignancies. Some surgeons favor embolization for symptom control and decreased blood loss; others reserve it for selected histologies and planned resections.
Practical Implications for Clinicians
How to apply these recommendations in daily practice:
– Triage quickly: Use a brief checklist at initial visit for red flags (unilateral, epistaxis, rapid growth, neurologic/visual signs). If any present, arrange expedited imaging and ENT referral.
– Communicate: When sending a biopsy, include endoscopy images or detailed description and CT/MRI if available. This improves pathology diagnostic yield.
– Plan biopsies: When in doubt, obtain imaging before tissue sampling. For suspected vascular or skull-base lesions, involve subspecialists and avoid blind procedures.
– Build pathways: Practices with head and neck oncology exposure should create fast-track multidisciplinary review for suspicious sinonasal masses to shorten time to definitive diagnosis and treatment.
Practical vignette
John, a 58-year-old man, presents with 3 months of progressive left-sided nasal obstruction and two recent episodes of significant unilateral epistaxis. On endoscopy, a friable mass is seen in the left nasal cavity. Following the consensus recommendations: urgent CT sinus (bone detail) and contrast MRI (soft tissue and skull-base evaluation) were ordered before biopsy. Imaging revealed a mass eroding the medial wall of the maxillary sinus with suspicious orbital extension. The patient was referred to a head and neck tumor board; an endoscopic-guided biopsy in the OR yielded tissue for histology and molecular studies, which permitted coordinated surgical and adjuvant therapy planning. This pathway minimized risk of bleeding and ensured prompt staging and multidisciplinary management.
References
– London NR, Chiu J, Akhave NS, Choby G, Dubin MG, Fortune DS, Gray ST, Grayson JW, Hanna EY, Hanna GJ, Holbrook EH, Hopkins C, Lechner M, Lund VJ, McKean E, Mydlarz WK, Reh DD, Sanusi O, Stewart MG, Su SY, Wang EW, Wang MB, Witterick I, Kuan EC, Geltzeiler M. Multidisciplinary Consensus Statement for Appropriate Evaluation and Workup of Sinonasal Masses. JAMA Otolaryngol Head Neck Surg. 2026 Jul 1;152(7):714-721. PMID: 42207510.
– Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology. 2020 Feb;58(Suppl S29):1-464.
– Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology. 1993 Dec;31(4):183-184.
– Krouse JH. Endoscopic Management of Inverted Papilloma: A Staging System and Treatment Algorithm. Otolaryngol Head Neck Surg. 2000 Dec;122(4):451-459.
– National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers. Version 2.2024. Available at: https://www.nccn.org (accessed 2026).
– Amin MB, Edge SB, Greene FL, et al. AJCC Cancer Staging Manual. 8th ed. Springer; 2017.
(Readers are encouraged to consult the full London et al. 2026 consensus statement for the detailed 23 recommendations and the specific wording used by the expert panel.)
Closing
The 2026 multidisciplinary consensus provides a pragmatic, patient-safety–focused framework for evaluating sinonasal masses. Its core message: use risk stratification to guide the need for imaging, biopsy, and subspecialty involvement; ensure robust clinic–pathology–radiology communication; and apply molecular testing selectively for tumors where it changes management. Adopting these recommendations should reduce preventable complications, shorten diagnostic delays, and improve care coordination for patients with sinonasal masses.
