A giant prolactinoma with nasopharyngeal extension presenting with nasal blockage and epistaxis.

To cite: Sahoo JP, Kamalanathan S, Parida PK, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014208811 DESCRIPTION A 35-year-old woman presented to the ear, nose and throat outpatient department with headache and a blocked left-sided nasal canal with epistaxis for 2 years. Medical history revealed secondary amenorrhoea for the past 19 years with regression of secondary sexual characteristics with no galactorrhoea. Physical and ophthalmological examinations were within normal limits. Nasal examination revealed a left-sided choanal mass. As the mass was bleeding on palpation, imaging was advised prior to performing a biopsy. MRI of the head showed a sellar and infra-sellar mass extending into the nasopharynx (figure 1). The patient was then referred to the endocrinologist for further hormonal investigation. Her serum prolactin was very high— 7443 mg/L (N<20). Other pituitary hormones were within normal limits. A final diagnosis of giant prolactinoma was made and the patient was prescribed cabergoline 0.25 mg twice per week with the associated risks explained in advance. Prolactinomas account for 57% of pituitary tumours. Female patients with prolactinoma typically present with menstrual irregularities and galactorrhoea; however, galactorrhoea may be absent in patients with severe hypogonadism, as seen in our present case. Giant prolactinoma presenting with nasal blockage and epistaxis is rare in the current literature. Cabergoline (a dopamine receptor agonist) is the first-line treatment for these patients, with endoscopic trans-spheroidal surgery and radiosurgery as secondary alternatives. However, surgery may be considered upfront if the patient presents with visual compromise. The present case highlights the importance of considering pituitary adenoma and in particular giant prolactinoma as part of the differential diagnosis for choanal masses.