Case Presentation: A 79-year-old male with metastatic prostate cancer status post multiple systemic agents presented with recurrent episodes of epistaxis with associated anemia and fatigue. The patient had a pertinent history of multifactorial CKD stage III. He was diagnosed with a left nasal polyp which required polypectomy. Despite removal of the polyp, the patient continued to experience epistaxis with progressive fatigue which prompted multiple emergent evaluations. Upon presentation routine labs revealed the patient to be recurrently anemic with hemoglobin level of 6.2 g/dl. Patient underwent a CT Maxillofacial which showed soft tissue changes of left nasal cavity extending into nasopharynx and abnormal soft tissue extension into left pterygopalatine fossa. Pathology obtained during polypectomy revealed the polyp to be malignant. As per pathology, the tumor cells were positive for NKX3.1 and androgen receptor, while negative for PSA, CK7, p63 and SOX10. The polyp was diagnosed as metastatic deposit resulting from prostatic adenocarcinoma. Definitive hemostasis was achieved only after emergent radiation therapy and angioembolization of the distal left internal maxillary artery. The patient’s clinical condition improved following a blood transfusion and no further episodes of epistaxis were endured.

Discussion: One percent of malignant tumors of the nose and paranasal sinuses are metastatic in nature. Common manifestations of a solitary metastatic deposit of the nasal cavity or paranasal sinuses include epistaxis (70%), nasal obstruction and facial pain. Definitive diagnosis requires biopsy with histological examination. Cancers which metastasize to the sinonasal cavity include renal cell (54%), breast (40%), thyroid, colon, and prostate (<1%). Prognosis is poor due to the associated widespread disseminated disease. Although androgen deprivation treatment can provide improvement in survival of early prostate cancer, most patients with paranasal sinus metastases suffer from castration-resistant prostate cancer. Radical surgery has proven to be ineffective and leads to increased morbidity. Palliative radiation therapy is the mainstay of treatment with the most profound relief in symptoms and improvement in quality of life.

Conclusions: In patients with refractory epistaxis, this case demonstrates that despite being an extremely rare diagnosis, sinonasal metastasis should be considered in the differential. Early detection of sinonasal metastasis could lead to optimal palliation of symptoms and overall improvement of associated morbidity. This case serves to raise awareness amongst hospitalists that not all cases of epistaxis are benign.