Malignant paraganglioma of frontoethmoidal region

Nonchromaffin paragangliomas are unusual tumours arising from widely distributed paraganglionic tissues probably of neural crest origin. In the head and neck region they are usually seen as carotid body or jugulotympanic tumours. Other rarely reported sites in the head and neck region are the orbit, nose and larynx. This report deals with a case of sinonasal paraganglioma which was initially treated with surgery and radiotherapy. Twenty two years later the tumour recurred and showed a rapid growth due to malignant transformation which we believe is late effect of radiotherapy. The clinical features, histopathology and role of radiotherapy in sinonasal paragangliomas together with a review of the medical literature have been discussed.

ras gene mutations in ethmoid sinus adenocarcinoma: prognostic implications

BACKGROUND

The presence of mutations of the 3 ras proto-oncogenes in 31 cases of ethmoid sinus adenocarcinoma, an uncommon tumor type epidemiologically related to professional exposure to wood dust, was studied.

METHODS

The authors studied 31 patients with ethmoid sinus adenocarcinoma. The polymerase chain reaction was used to amplify ras specific sequences of DNA isolated from paraffin embedded tumor samples. ras point mutations were subsequently detected with mutation specific oligonucleotide probes.

RESULTS

H-ras was found to be mutated in 5 cases (16%). It is noteworthy that all of these mutations were identical and consisted of a G-for-T transversion at the second base of codon 12. H-ras mutations were related to a worse prognosis, with shorter tumor free survival (P = 0.04) and overall survival (P = 0.008). T classification was a significant clinical factor related to survival (P = 0.01 for disease free survival and P = 0.006 for overall survival). The prognostic value of H-ras mutation was consistent after adjustment for T classification. H-ras mutations showed no association with patients' previous exposure to wood dust. K-ras was found to be transformed in a single case; this was the only patient in the series to develop lymph node metastases. In this case, both the nasal tumor and the lymph nodes showed the GAT-for-GGT mutation at codon 12 of K-ras. No activation of the N-ras gene was detected.

CONCLUSIONS

The presence of H-ras point mutations defines a subgroup of patients with ethmoid sinus adenocarcinomas for whom the prognosis is very poor. The finding that all of these mutations are identical emphasizes the peculiarity of this type of tumor.

Histopathological findings in equine sinonasal disorders

Biopsies collected from 79 referred cases of equine sinonasal disease, including 27 horses with primary sinusitis, 10 with secondary dental sinusitis, 19 with sinus cysts, 11 with progressive ethmoid haematomata (PEH), 4 with false nostril epidermal inclusion cysts, 4 with sinonasal polyps, 3 with sinonasal mycosis and from 2 control animals were examined histologically. Observations were made on epithelial type and integrity, cellular inflammatory response, fibroplasia and presence of potential pathogens. Chronic inflammatory changes including mucosal thickening, ulceration and significant fibroplasia, were found in the sinus mucosa with most sinus disorders, similar to those found in human chronic sinusitis. Bacteria were variably present on sinusitis mucosae but their aetiological significance was unclear. The presence of apparently irreversible changes including fibroplasia in some of these sinusitis cases may explain their poor or delayed response to treatment. Sinus cysts had histological similarities to human mucocoeles. Progressive ethmoid haematomata showed recent and older haemorrhage, as did sinus cysts (and occasionally some chronic sinusitis sections), but support for a common aetiology between sinus cysts and PEH was absent.

[Exophthalmos and blindness disclosing an ethmoidal-maxillary malignant non-Hodgkin's T-cell lymphoma. Apropos of a case]

BACKGROUND

We report a case of non-Hodgkin's malignant lymphoma of the cervicofacial region revealed by unilateral exophthalmos and blindness, an unusual mode of expression.

CASE REPORT

A 40-year-old man with a 4-month history of diabetes mellitus had suffered from exophthalmos and blindness of the right eye for 20 years. Physical examination showed a homolateral hemifacial tumefaction and ophthalmoplegia. The right ocular fundus showed papillar edema and non-proliferative diabetic retinopathy. The left eye was normal. The otolaryngology explorations revealed a voluminous tumor in the anterior nasal cavity and in the cavum. Two biopsies were performed. Histology reported non-Hodgkin's T-cell lymphoma. Orbitocerebral and cervicofacial computed tomography visualized the aggressive ethmoidomaxillary extension with intraorbital and intracranial involvement. Chemotherapy (CHOP) combined with radiotherapy led to tumor regression and involution of the exophthalmos. Diagnostic difficulties, management and prognosis are discussed.

[Fronto-naso-ethmoido-sphenoido-maxillo-orbital mucocele with ophthalmologic presentation]

PURPOSE

We present a case of a large mucocele pressing the orbit forward and compared our findings with those reported by others.

CASE REPORT

A 23-year-old woman was examined for an inflammatory tumor of the internal canthus. She had a 6/10 vision loss of the left eye, diplopia, and non-axial exophthalmos. CT scan and magnetic resonance imaging evidenced a huge sinus mucocele behind the orbit. Surgery using the paralateronasal approach was performed. Pathology confirmed the diagnosis of mucocele.

DISCUSSION

Ophthalmic complications of mucoceles result from tumor growth leading to compressive optic neuropathy or even compression of the chiasma. A sinus mucocele should be suspected upon indirect clinical signs and lead to neuroradiological explorations. Magnetic resonance imaging reveals iso- or high signals on T1-weighted sequences and high signal on T2-weighted sequences. MRI evidences intracranial or orbital extension. CT scan reveal the degree of bone erosion. Prognosis is favorable after surgical treatment. It is important to correctly diagnose mucocele on the basis of clinical and neuroradiological findings in order to propose early surgery and prevent permanent visual loss by compressive optic neuropathy.

Pneumatocele of the orbit

PURPOSE

To describe an uncommon sinus condition that can cause proptosis.

METHODS

Intermittent unilateral proptosis and diplopia developed in a 29-year-old man. Computed tomography showed an enlarged frontal sinus with erosion of the floor of the sinus and air in the orbit.

RESULTS

Endoscopic ethmoidectomy and frontal sinusotomy corrected an outlet check valve of the nasal frontal duct and eliminated the proptosis.

CONCLUSION

Pneumatocele of the orbit is an uncommon cause of proptosis and diplopia and can be corrected with endoscopic sinus surgery.

Ethmoid sinus osteoma presenting as epiphora and orbital cellulitis: case report and literature review

Paranasal sinus osteoma is a slow-growing, benign, encapsulated bony tumor that may be commonly asymptomatic, being detected incidentally in 1% of plain sinus radiographs or in 3% of sinus computerized tomographic scans. In a patient presenting with orbital cellulitis and epiphora, computed tomography disclosed a large osteoma of the ethmoid sinus. Excision of the osteoma allowed recovery of vision, return of extraocular muscle function, and resolution of choroidal folds. Proptosis, diplopia, and visual loss are other frequent presenting signs of paranasal osteomas. Epidemiology, diagnosis, treatment, and pathologic findings in paranasal sinus osteoma are reviewed.

Mucocele in an orbitoethmoidal (Haller's) cell (accidentally combined with acute contralateral dacryocystitis)

Haller's cells--according to recent terminology now called orbitoethmoidal cells (OEC)--are defined as anterior or posterior ethmoidal cells that have developed into the orbital floor. They can be excessively pneumatized and thus contribute to obstruction of the ostiomeatal complex area. We present the case of a 42 year old white male, who was admitted for treatment of an acute dacryocystitis on the right side. The CT scan revealed moderate sinusitis of the right ethmoid and maxillary sinuses and coincidentally a mucocele in an OEC on the left side. An endoscopic dacryocystorhinostomy on the right and a revision of the mucocele on the left side were performed in the same sitting. We consider both indications--stenosis of the nasolacrimal duct as well as mucoceles rewarding indications for endoscopic surgery. An external approach to the nasolacrimal duct in this case would have been problematic, as the external skin and soft tissue covering the duct already showed severe inflammatory changes. The operation of the up until that time asymptomatic mucocele was of prophylactic character. To our knowledge this is the first report of a mucocele developing in an OEC in the literature.

Extended endoscopic frontal sinus surgery to interrupted nasofrontal communication caused by scarring of the anterior ethmoid: long-term results

OBJECTIVE

To examine the long-term results of extended endoscopic frontal sinus surgery, including removal of the floor of the frontal sinus (Draf type II procedure) and the median drainage operation (Draf type III procedure or modified Lothrop procedure), for obstructive frontal sinusitis caused by postoperative scar formation, with the emphasis on the long-term success of the median drainage procedure.

DESIGN

Retrospective review of 22 consecutive cases of extended endonasal frontal sinus surgery in patients with obstructive frontal sinusitis caused by postoperative scarring.

SETTING

The procedures were performed at a private surgicenter in Japan.

PATIENTS

Twenty-two patients (15 males and 7 females) ranging in age from 14 to 61 years. All patients had scar formation in the anterior ethmoid, either with or without middle turbinate lateralization or ethmoiditis. Three patients underwent Draf type II procedure followed by Draf type III procedure because of surgical failure of the type II procedure.

MAIN OUTCOME MEASURES

Restoration of communication to the frontal sinus was evaluated by computed tomography. All patients were examined at least 12 months after surgery or stent removal.

RESULTS

Of the 16 patients who underwent the type III procedure, in 14 (88%) the patency of the opening to the frontal sinus and an aerated sinus were confirmed. Of 12 sides in 9 patients who underwent Draf type III procedure, 5 sides (42%) were also confirmed as "cured."

CONCLUSIONS

The median drainage operation (Draf type III procedure) on the frontal sinus showed excellent long-term results compared with the type II procedure. Extended endoscopic frontal sinus surgery, particularly the median drainage procedure, is useful in the functional treatment of obstructive frontal sinusitis caused by postoperative scarring.

Pneumocephalus associated with ethmoidal sinus osteoma--case report

A 35-year-old female suffered sudden onset of severe headache upon blowing her nose. No rhinorrhea or signs of meningeal irritation were noted. Computed tomography (CT) with bone windows clearly delineated a bony mass in the right ethmoid sinus, extending into the orbit and intracranially. Conventional CT demonstrated multiple air bubbles in the cisterns and around the mass in the right frontal skull base, suggesting that the mass was associated with entry of the air bubbles into the cranial cavity. T1- and T2-weighted magnetic resonance (MR) imaging showed a low-signal lesion that appeared to be an osteoma but did not show any air bubbles. Through a wide bilateral frontal craniotomy, the cauliflower-like osteoma was found to be protruding intracranially through the skull base and the overlying dura mater. The osteoma was removed, and the dural defect was covered with a fascia graft. Histological examination confirmed that the lesion was an osteoma. The operative procedure resolved the problem of air entry. CT is superior to MR imaging for diagnosing pneumocephalus, by providing a better assessment of bony destruction and better detection of small amounts of intracranial air.

Comparison of CT and MRI features in sinusitis

OBJECTIVE

To correlate the features of inflammatory changes in the paranasal sinuses on magnetic resonance imaging (MRI) with computed tomography (CT).

METHODS AND PATIENTS

One hundred and fourteen patients with histologically proven nasopharyngeal carcinoma (NPC) were staged with both CT and MRI. All CT and MRI images of patients with mucosal thickening but no tumour involvement of the sinuses were retrospectively analysed.

RESULTS

There were inflammatory changes in 36 maxillary, 21 sphenoid and 16 ethmoid sinuses. These changes include mucosal thickening, retention cysts, retained secretions, inspissated secretions and dystrophic calcification. MRI is superior to CT in separating thickened mucosa, retained secretions and retentions cysts.

CONCLUSION

It is important to appreciate CT changes of sinusitis and the corresponding spectrum of MRI features.

Intradural extension of mucocele complicating frontoethmoid sinus osteoma: case report

BACKGROUND

Osteomas of the paranasal sinus are often asymptomatic and are sometimes complicated by mucoceles, but intradural extension of such a mucocele has rarely been reported.

CASE DESCRIPTION

This 67-year-old man with complaint of headache was diagnosed as having an intradural extension of a mucocele complicating an osteoma of the frontoethmoid sinus. A right frontobasal craniotomy was performed and a mucocele in the frontal sinus extending into the frontal lobe through two dural defects and the osteoma was removed completely. The patient was successfully treated without recurrence.

CONCLUSION

The importance of radical surgery for such lesions and the relationship between osteomas and mucoceles are discussed.

A case of self-inflicted intraorbital injury: wooden foreign body introduced into the ethmoidal sinus

A patient with an intraorbital wooden foreign body is presented. A 43-year-old schizophrenic male patient purposely introduced a twig through his left medial canthus and into the orbital cavity 6 months before presentation. Magnetic resonance imaging showed a well-delineated intraorbital object that partially penetrated the ethmoidal sinus through the medial orbital wall. Under general anesthesia, a 55-mm-long and 6-mm-diameter twig was removed through an incision along the sulcus palpebromalaris. Thick capsule formation around the foreign body, fibrosis of the adjacent tissues, and severe infection were observed. Diagnosis and management of intraorbital foreign bodies are discussed.

Chondromyxoid fibroma of the ethmoid sinus

Only a small proportion of cases of this rare neoplasm occur in the skull. We present an unusually extensive tumour in a young man.

Diagnostic imaging in two cases of recurrent maxillary ameloblastoma: comparative evaluation of plain radiographs, CT and MR images

We report detailed clinical and imaging findings of two patients with recurrent maxillary ameloblastoma. In one patient the recurrent tumour presented at follow-up examination 5 years after the initial operation. The other patients had a far advanced recurrent tumour with maxillary destruction extending into the adjacent normal structures including the infratemporal fossa, infraorbital fissure, masticator space and the left ethmoid sinus. The findings on conventional radiography including panoramic, posteroanterior and Waters' projection, and the findings of computed tomography (CT) and magnetic resonance (MR) imaging were evaluated using the following three variables: artefact degradation, lesion detectability, and conspicuity. The results suggested that MR imaging was the best imaging method for visualization of the tumours, followed by contrast enhanced CT. These two cases show that maxillary ameloblastoma can be difficult to control when it extends to the adjacent normal structures after destroying the maxilla. MR imaging was essential to establish the exact extent of the advanced maxillary ameloblastoma.

[Relationship between anatomic variations of nasal sinus and chronic sinusitis]

OBJECTIVE

To understand the etiology of chronic sinusitis.

METHODS

Ninety-one coronal CT scans of chronic sinusitis were analysed with mutimedia software developed by the authors. Sinus CT images were scanned into multimedia computer and the subtle anatomic structures such as pneumatization of the middle turbinate, agger nasi cell, Haller's cell, septal deformity, maxillary sinus hypoplasia, abnormality of uncinate process and ethmoid bulla and so on were measured. The results were analysed by the statistical software SPSS.

RESULTS

The penumatization rate of total or inferior part of middle turbinate correlated positively to the inflammation of anterior ethmoid and maxillary sinuses. Compared with patients with normal frontal sinuses, the vertical diameters of agger nasi cells of patients with frontal sinusitis were larger(11.70 +/- 5.50 mm and 8.54 +/- 3.67 mm respectively, P < 0.01). Compared with patients with normal maxillary sinuses, the Haller's cells of patients with maxillary sinusitis were larger (77.8% and 33.3%, P < 0.05) and the amount of inflammatory Haller's cells of the latter was more abundant than that of the former(91.6 +/- 17.8 mm2 and 41.6 +/- 12.6 mm2, respectively, P < 0.05). The deviation of uncinate process was one of the factors of maxillary sinusitis. The sizes of ethmoid bullae increased with the soft tissue thickening in anterior ethmoid sinus, the large ethmoid bulla may cause anterior ethmoid sinusitis.

CONCLUSION

Some anatomic variations may play a role in chronic sinusitis.

Benign fibroosseous lesions involving the skull base, paranasal sinuses, and nasal cavity. Report of two cases

The authors report two patients with benign fibroosseous lesions involving the center of the skull base: a 15-year-old boy with repetitive meningitis and pneumocephalus and a 11-year-old boy with nasal obstruction and headache. The clinical diagnoses were ossifying fibroma and aneurysmal bone cyst, respectively. Lesions in both patients extended to the nasal cavity, the sphenoid and posterior ethmoid sinuses, and the skull base, where the planum sphenoidale, the sella turcica, the upper two-thirds of the clivus, and the medial portion of the middle cranial base were involved. The lesions were totally removed using an anterior craniofacial approach. Characteristics of these lesions and the surgical approach are discussed.

Pneumo-orbital cyst after orbital fracture repair

PURPOSE

To report a case of a respiratory epithelial-lined, air-filled orbital cyst as a late complication of orbital fracture repair.

METHOD

Case report.

RESULTS

Recurrent episodes of diplopia and hyperophthalmia developed secondary to pneumatic inflation of a respiratory epithelial-lined orbital cyst 6 months after orbital fracture repair. This cyst remained in communication with an ethmoidal air cell and became inflated during pressurization of the ethmoid sinus. Removal of the cyst and orbital implant was curative.

CONCLUSION

Air-filled, respiratory epithelial-lined orbital cyst is a rare cause of episodic diplopia and globe displacement after orbital trauma.

Extracranial repair of cerebrospinal fluid rhinorrhoea

BACKGROUND

Extracranial techniques, which have none of the inherent morbidity associated with intracranial techniques, can successfully repair rhinological cerebrospinal fluid (CSF) fistulas.

METHODS

A series of five consecutive adult patients with persistent rhinological CSF fistulas were reviewed retrospectively.

RESULTS

The success rate for initial closure was 60%. On the second operation both failures were successfully repaired.

CONCLUSIONS

The external approach is a safe, successful, alternative approach for the surgical repair of rhinological CSF fistulas.

Sino-orbital giant cell reparative granuloma

An otherwise healthy, 9-year-old boy had gradual onset of a mass deformity in the region of the left medial canthus with resulting superior and lateral globe displacement. Radiographic evaluation demonstrated an osteolytic, expansile lesion involving the bones of the ethmoid and maxillary sinuses. Combined anterior orbitotomy and nasal endoscopic surgical resection revealed additional involvement of the nasolacrimal sac wall. Histopathology was consistent with a giant cell reparative granuloma. The authors know of 15 case reports of sino-orbital giant cell reparative granulomas with ophthalmic manifestations; only 3 of these appeared in the ophthalmology literature. This case appears unique in that extension of the abnormal tissue into the nasolacrimal sac wall was demonstrated.

[Psammomatoid ossifying fibroma]

OBJECTIVE

To clarify the histopathological, clinical behavior biological characterics and the relationship among the psammomatoid ossifying fibroma (POF), ossifying fibroma and fibrous dysplasia of bone.

METHODS

Thirty-one cases of POF in the ear and sinonasal region were studied retrospectively. The sections, clinicopathological records from June, 1956 to November, 1996 were reviewed. The reticulum fiber and Masson's stain and alkaline phosphatase immunostain were done in 10 cases, Vimentin, Desmin, EMA and smooth actin immunohistochemical stain were done in 5 cases. One case was studied by transmission electron microscope.

RESULTS

The specimens were broken tissue with the sand-like felling, eleven specimens with intact thin shell consisted of bone tissue were used to study the changes in the area between tumor and normal bone. Histopathologically they were rich in mesenchymal tumor cells and a lot of calcifying psammomatoid-like osteoid and a few of calcified bodies similar to those described by Shafer, and the bony trabecula was not found in the center of the tumor. In addition, three zones were noted at the junction of normal bone and tumor, namely, the normal bone-reactive proliferative bone-tumor. In some cases, the reactive bony proliferation may be not marked. The normal bone adjacent to the tumor may be absorbed and disappeared, and were then replaced by the tumor, and finally led to tumor tissue invasion into the soft tissue, but the infiltration appearance is not present.

CONCLUSION

POF is the slowly growing benign tumor and is different from ossifying fibroma and fibrous dysplasia of bone.

[Fungal sinusitis. Report of four cases]

Fungal sinusitis has a nonspecific clinical presentation, is refractory to standard medical treatment and may produce expansion and erosion of the sinus wall. Various factors have been implicated in the development of fungal sinusitis: anatomical factors in the osteomeatal complex, tissular hypoxia, traumatic factors, massive exposure to fungal spores, allergy and immunosuppression. Our study of four cases diagnosed in the department included the clinical, pathological, and radiological features of fungal sinusitis. Five forms are described. Bacterial infection often occurs. The diagnosis of fungal sinusitis requires a high level of clinical and pathological suspicion. Before surgery, fungal sinusitis is suggested by the clinical and radiological features, and is confirmed by histological study. Culture of the tissue sometimes leads to identification of the fungus. Surgical removal of the infection is the main treatment for every form of fungal sinusitis.

The multidisciplinary management of psammomatoid ossifying fibroma of the orbit

OBJECTIVE

To discuss the multidisciplinary management of psammomatoid ossifying fibroma (POF) of the orbit and to clarify the clinicopathologic terminology.

DESIGN

The authors present a cohort of cases of POF involving the frontal and ethmoid sinuses and the orbit and discuss the nomenclature and literature.

PARTICIPANTS

Three patients with POF and their treatment are discussed.

INTERVENTION

Patients were worked up and treated by a multidisciplinary team using imaging studies and histopathologic analysis. Reconstruction, if necessary, was carried out at the time of excision or in a second-stage procedure.

MAIN OUTCOME MEASURES

In each case, the lesion was completely excised and has not recurred.

RESULTS

The diagnosis of POF was made in each case, and the patient underwent successful resection of the tumor.

CONCLUSION

The authors' experience suggests that a multidisciplinary approach, including a radiologist, pathologist, neurosurgeon, otolaryngologist, craniofacial surgeon, and orbital specialist, may be useful in the evaluation and management of these lesions.

Acute sinusitis in the rabbit model: histologic analysis

OBJECTIVES

Characterize the histology of the rhinogenic model of sinusitis and compare this with existing models of sinusitis.

STUDY DESIGN

Prospective controlled trial in animals.

METHODS

New Zealand white rabbits were implanted with a synthetic sponge, which was then impregnated with Streptococcus pneumoniae bacteria. After a specified time the animals were sacrificed, and whole-mount sectioning of both the infected and noninfected sinuses was performed. The sinuses were carefully examined for evidence of inflammatory changes.

RESULTS

This model produced a sinus infection that is characterized by luminal exudates of neutrophils and eosinophils, mucosal infiltration with lymphocytes and plasma cells, and epithelial degeneration. In addition, discrete lymphoid follicles were identified in both the implanted and nonimplanted sides that in the implanted sides appear to hypertrophy and liberate leukocytes into the sinus lumen. Other areas were observed where luminal exudates seem to act on and degrade mucosa that has little or no underlying inflammation. In severely infected sinuses submucosal vacuole formation with overlying granulation tissue was observed.

CONCLUSIONS

The rhinogenic model of sinusitis demonstrates features typical of other known models of sinusitis. In addition, there appear to be unique features of this model, specifically the identification of discrete lymphoid aggregates, which suggest that this model has the potential to be valuable for the study of the immune response of the sinuses.