Mucosal Melanoma Presenting As Epistaxis
Amber Berry, D.O. PGY2 AOCOO-HNS Mid-Year Conference September 2013

• 53 y.o. female who presents to the ER for

• 53 y.o. female who presents to the ER for epistaxis.
• ER resident attempts topical adrenaline and silver nitrate cautery
 no success. Hemostasis achieved with
RhinoRocket; patient sent home.
• Patient returns to ER for bleeding around RhinoRocket.
Floseal and Arixtra attempted with persistent bleeding.
ENT called.
• Packed with Merocel and sent home.
• Patient follows up in the office 3 days later requesting packing removal. Active nasal bleeding during visit occurs, and packing is maintained. Patient sent to ER for management of her blood pressure and anxiety.

• She returns to the office one month later for active epistaxis. A small polypoid change near the middle turbinate was noted on exam. The area was cauterized and a small specimen submitted to pathology.
• Pathology: mucosa of the right nostril; melanoma, indeterminate type

• Review the etiology, basic features and treatment approaches for mucosal melanoma
• Suggest patient characteristics or specific case situations in which less common causes of epistaxis should be thoroughly evaluated/considered.

• Melanoma:
• May arise in respiratory, alimentary and genitourinary mucosal epithelium (all contain melanocytes)
• Rare, account for 1-2% of melanomas
• Majority found in H&N
• 50% reported cases within the nasal cavity
• Nasopharynx
• Oral cavity
• Oropharynx
• Paranasal sinuses

• No clear risk factors
• Most common presenting symptom: nasal obstruction
• May be asymptomatic until advanced stage
• More aggressive
• Melanosis may be absent
• Five year survival:10-
45%

• Work up:
• Includes endoscopic inspection
• CT/MRI of primary site
• CT/PET to assess lymph node involvement or distant mets
• Staging differs from cutaneous melanoma!

• Wide local excision: mainstay of therapy
• Radiation therapy
• Primary modality
• Adjuvant therapy
• ? Role for SLNB
• Systemic therapy
• adjuvant chemotherapy
• Targeted therapy
• Imatinib mesylate
(inhbits KIT)
• Anti-CTLA4: ipilimumab

Approach to Epistaxis

• Trauma
• Idiopathic
• Inflammatory
• Neoplastic
• Vascular
• Iatrogenic
• Structural
• Drugs
• Hematological
• Environmental
• Organ Failure
• Other

• Refractory to “typical” interventions
• Recurrences that do no resolve spontaneously or with minimal self-tx
• A severe episode
• Patient’s with a high risk history
• When the story “just doesn’t add up”

• Refractory to “typical” interventions
• Recurrences that do no resolve spontaneously or with minimal self-tx
• A severe episode
• Patient’s with a high risk history
• When the story “just doesn’t add up”

References:
Johnson, J. and C. Rosen. Mucosal Melanoma. Bailey’s Otolaryngology Head and Neck Surgery, Fifth Edition. LWW. (2):1742.
Carvajal, R, et al. “Mucosal Melanoma” Wolter’s Kluwer Health . Obtained online July 2013.
Hobbs, C. and L. Pope. “Epistaxis: An Update on Current Management”
Postgraduate Medical Journal 2005 89:955, 309-314.
Gattuso, P, et al. “Sinonasal Melanoma.” Differential Diagnosis in Surgical
Pathology. Obtained online from Expert Consult July 2013.
Seetharamu, N, et al. “Mucosal Melanomas: A Case-Based Review of the
Literature.” Oncologist . 2010 July, 15 (7) 772-781.