title: Occult renal cell carcinoma manifesting with epistaxis in a woman: a case report.
abstract: BACKGROUND
  Metastatic disease in the sinonasal region occurs rarely and the primary site may be elusive. This case highlights the possibility of an occult renal tumor manifesting with nasal symptoms and the risk of severe bleeding following nasal biopsy.
  
  
  METHODS
  We report the case of a 79-year-old Caucasian woman who presented with a six-week history of intermittent left-sided nosebleeds. She was fit, without previous surgery or anticoagulation. Nasal endoscopy and computed tomography showed a hemorrhagic mass occupying her left ethmoid cells and middle meatus. After a highly hemorrhagic biopsy, the lesion was histologically confirmed as clear cell carcinoma. Screening revealed a right kidney mass with widespread metastases. Palliative radiotherapy to the sinonasal metastasis and systemic treatment rendered her free of symptoms nine months after initial presentation.
  
  
  CONCLUSIONS
  General practitioners and ear, nose and throat (ENT) doctors are very often confronted with epistaxis. A small minority of patients with epistaxis show a primary or metastatic nasal mass. Detection of the origin of secondary sinonasal masses requires a high index of suspicion and examination of infraclavicular sites by a multidisciplinary team. Renal cell carcinoma metastases are prone to severe bleeding during any surgical intervention, therefore, preoperative embolization is recommended. Resection or radiotherapy to the sinonasal metastasis of renal origin is justified in order to prevent recurrent nosebleeds.
authors.affiliation: ENT Department, Conquest Hospital, The Ridge, St Leonards-on-Sea, East Sussex, TN37 7RD, UK. drfirbas@hotmail.com.
authors.forename: Georgios
authors.initials: G
authors.lastname: Fyrmpas
authors.forename: Ade
authors.initials: A
authors.lastname: Adeniyi
authors.forename: Simon
authors.initials: S
authors.lastname: Baer