Eosinophilic granuloma of the head and neck: CT and MRI features in three cases

Isolated adult lymphadenopathy: a rare presentation of Langerhans cell histiocytosis

INTRO

Langerhans cell histiocytosis (LCH) is a rare disease involving the proliferation of histiocytes in one or more organ systems. The presentation of LCH is more common in the pediatric population and rarely occurs within the adult population. Isolated lymph node involvement is an extremely rare presentation of the disease. The authors present a case of isolated lymph node LCH in an otherwise healthy adult female and discuss management strategies for these unusual findings.

METHODS

A case report of a patient at a tertiary care facility in June 2014 is discussed.

RESULTS/DISCUSSION

The diagnosis, clinical course, and management strategies for isolated adult LCH are discussed and reviewed.

CONCLUSION

Langerhans cell histiocytosis rarely presents with isolated lymph node involvement in adults. Management and surveillance algorithms are discussed in this unusual case of seemingly benign lymphadenopathy.

Incidence of non-infectious ‘acute mastoiditis’ in children

Objective:

The temporal bone may be the first involved site in cases of systemic disease, and may even present with acute, mastoiditis-like symptomatology. This study aimed to evaluate the incidence of such non-infectious ‘acute mastoiditis’ in children.

Materials and methods:

Retrospective chart review of 73 children admitted to a tertiary referral centre for acute mastoiditis.

Results:

In 71 cases (97.3 per cent), an infectious basis was identified. In the majority of cases (33 of 73; 45 per cent), the responsible bacteria was Streptococcus pneumoniae. However, histopathological studies revealed a non-infectious underlying disease (myelocytic leukaemia or Langerhans' cell histiocytosis) in two atypical cases (2.7 per cent).

Conclusion:

‘Acute mastoiditis’ of non-infectious aetiology is a rare but real threat for children, and a challenging diagnosis for otologists. A non-infectious basis should be suspected in every atypical, persistent or recurrent case of acute mastoiditis.

Giant-cell tumors of the sphenoid bone in four children: radiological, clinical, and pathological findings

We report the clinical pathological and radiological findings of giant cell tumor of the sphenoid bone in four children aged 10 to 16 years. The most common clinical finding was headache, followed by cranial nerve abnormalities. The computed tomographic findings of giant cell tumor consist of a lytic defect, sharply margmated with no sclerosis associated with an expansile, homogeneous mass (isodense with muscle). In the differential diagnosis, the lesion most similar to giant cell tumor is giant cell granuloma. The different histopathological features of the two lesions are discussed, along with other lesions, in the differential diagnosis. The magnetic resonance features consist of a mass with low signal intensities on T(1) and T(2) weighted images associated with moderate enhancement after introduction of gadolinium.

Diagnosis of Langerhans cell histiocytosis on fine needle aspiration cytology: a case report and review of the cytology literature

A case of multifocal Langerhans cell histiocytosis in a two-year-old child is presented where fine needle aspiration was helpful in achieving a rapid and accurate diagnosis in an appropriate clinical and radiological setting. This can avoid unnecessary biopsy and guide the management especially where access to histopathology is limited. The highly characteristic common and rare cytological features are highlighted with focus on differential diagnoses and causes of pitfalls.

Causes of facial swelling in pediatric patients: correlation of clinical and radiologic findings

Facial swelling is a common clinical problem in pediatric patients. The causes of swelling are diverse, and knowledge of the typical clinical and imaging manifestations and the most common sites of occurrence of these conditions is needed to formulate a differential diagnosis. The general clinical manifestations may be classified into the following four groups: (a) acute swelling with inflammation, (b) nonprogressive swelling, (c) slowly progressive swelling, and (d) rapidly progressive swelling. Conditions that may account for acute swelling accompanied by inflammation include lymphadenitis, sinusitis, odontogenic infection, and abscess. Contrast-enhanced computed tomography is the modality of choice for detection of abscesses requiring surgical drainage. Nonprogressive midfacial swelling is suggestive of a congenital anomaly (eg, a cephalocele, nasal glioma, or nasal dermoid or epidermoid cyst). Slowly progressive swelling may indicate the presence of a neurofibroma, hemangioma, lymphangioma, vascular malformation, or pseudocyst, or of fibrous dysplasia. The differential diagnosis for rapidly progressive facial swelling in association with cranial nerve deficits should include rhabdomyosarcoma, Langerhans cell histiocytosis, Ewing sarcoma, osteogenic sarcoma, and metastatic neuroblastoma.

Solitary Langerhans-cell histiocytosis of the clivus and sphenoid sinus with parasellar and petrous extensions: case report and a review of literature

BACKGROUND

In Langerhans-cell histiocytosis, there occurs an uncontrolled clonal proliferation of dendritic cells that have Langerhans cell like characteristics. In this report, a unique case of a solitary, skull base Langerhans-cell histiocytosis (LCH) is described.

CASE DESCRIPTION

A 15-year-old boy presented with raised intracranial pressure, decreased visual acuity, bilateral abducent nerve palsy, and 25% hypoesthesia in all three divisions of the right trigeminal nerve. He had normal strength but with a left-sided upper and lower limb hypertonia and hyper-reflexia and an upgoing plantar reflex. The magnetic resonance (MR) imaging revealed a heterogeneously iso-to hyperintense lesion of the clivus and the sphenoid sinus, extending to the right cavernous sinus to encase the right cavernous internal carotid artery segment, and also involving the right petrous apex and the extradural space in the prepontine region. The lesion was brilliantly enhancing on contrast. An extended frontobasal approach was used to excise the lesion. Following surgery, the residual parasellar and the right petrous apex tumor was treated with a low dose radiation therapy. At follow-up after 1.5 years, there was significant clinical improvement and the computed tomographic scan showed no residual lesion.

CONCLUSION

A review of the literature reveals that this is only the second reported case of a spheno-clival LCH. An additional feature includes extensions into the parasellar as well as the petrous apex regions. Despite the extensive spread, the surgical excision with low dose radiation therapy was successful in providing complete resolution of the tumor.

Langerhans' cell histiocytosis with bilateral temporal bone involvement

BACKGROUND

Langerhans' cell histiocytosis (LCH) is a rare disease with variable clinical appearance. The etiology of LCH remains unclear to date. It is currently believed that clonal accumulation and proliferation of CD1a-positive Langerhans' cells are causative.

METHODS

A 2-year-old boy presented with hypacusis and disturbance of balance. Auditory brainstem-evoked responses (ABRs) revealed severe bilateral labyrinthine hearing loss. Magnetic resonance imaging (MRI) showed inflammatory changes with bone erosion in both temporal bones including labyrinthine systems and mastoid processes.

RESULTS

During bilateral surgical exploration, fragile slightly yellowish tissue with necrotic areas was found that turned out to be LCH on histology. Chemotherapy with vinblastine and prednisone was subsequently initiated, leading to continuing complete remission.

CONCLUSIONS

The initial presentation of LCH with bilateral temporal bone involvement is a very rare condition. The signs and symptoms of otologic histiocytosis can mimic those of acute and chronic infectious ear disease. Only a surgically obtained biopsy leads to definitive diagnosis and appropriate therapy.

Eosinophilic granuloma of the bilateral temporal bone

An unusual presentation of eosinophilic granuloma (EG) of the bilateral temporal bone in a 2-year-old male child is discussed with the literature review. Involvement of the temporal bone is relatively uncommon and otorrhea or symptoms resembling mastoiditis are nonspecific. This rare condition should be kept in mind in differential diagnosis of otitis media refractory to medical therapy.

A case of calvarial eosinophilic granuloma with rapid expansion and wide skull invasion: immunohistochemical analysis of Ki-67

A 15-year-old male visited our neurological service with progressive occipitalgia. Computed tomography showed an osteolytic lesion at the occipital cranium, which grew rapidly during a month. Magnetic resonance imaging showed the lesion as low intensity on T1- and high intensity on T2-weighted images. The mass was soft and successfully removed with surrounding cranium. Histological examination revealed an eosinophilic granuloma with wide skull invasion. Immunohistochemical analysis on the specimen disclosed Ki-67 expression with labeling index of 6.2%. Relatively high proliferative activity in the present case indicates that the local replication of Langerhans' cells as well as inflammatory response contributes to the expansion of calvarial eosinophilic granuloma. This is the first report demonstrating the result of Ki-67 expression on calvarial eosinophilic granuloma.

Langerhans histiocytosis of temporal bone: role of magnetic resonance imaging

Langerhans cell histiocytosis (LCH) may involve nearly every organ of the body. In children, head and neck involvement has been reported in as many as 82% of patients. Sites of head and neck involvement include skull, temporal bone, orbit, mandible, maxilla and cervical nodes. In addition, patients may have coexisting central nervous system (CNS) involvement adjacent to, or remote from, osseous lesions. Magnetic resonance imaging (MRI) of the temporal bone in patients with LCH is ideal for evaluating the extracranial extent of the soft-tissue mass and is complementary to computed tomography (CT) in the assessment of osseous erosion. MRI is superb in the evaluation of intracranial extension, usually into the middle cranial fossa, and of patency of adjacent vascular structures. It is the imaging modality of choice to evaluate patients with suspected CNS involvement of LCH, which includes lesions of the infundibulum, cerebrum, cerebellum, and extra-axial spaces.

Magnetic resonance imaging of calvarial eosinophilic granuloma with pericranial soft tissue reaction--case report

A 4-year-old girl presented with an eosinophilic granuloma in the cranial vault. Magnetic resonance (MR) imaging showed the mass as slightly low intensity on T1- and high intensity on T2-weighted images. The pericranial soft tissue was densely enhanced after gadolinium-diethylenetriaminepenta-acetic acid infusion. The mass was soft and successfully removed. Histological examination disclosed Langerhans' cell histiocytosis. MR imaging is useful for the diagnosis of calvarial eosinophilic granuloma with soft tissue involvement.

Langerhans' cell histiocytosis of the temporal bone in pediatric patients: imaging and follow-up

OBJECTIVE

The purpose of this study was to review the initial clinical and radiologic manifestations and the follow-up of pediatric patients with Langerhans' cell histiocytosis affecting the temporal bone.

MATERIALS AND METHODS

We retrospectively studied 14 patients with Langerhans' cell histiocytosis affecting the temporal bone. All patients were examined initially and sequentially with CT. In six patients, MR imaging was also done.

RESULTS

Temporal bone involvement was the initial form of presentation in 12 patients. In eight patients, temporal bone involvement presented as an isolated manifestation, and in four it was associated with multisystemic involvement. In the remaining two patients, temporal bone involvement appeared during the course of the Langerhans' cell histiocytosis. Bilateral involvement was seen in four patients. In two patients, the temporal bone was affected only at the petrous apex. CT showed destruction of bone in all 14 patients and an associated soft-tissue homogeneous mass after injection of i.v. contrast material in 12 patients. CT showed a heterogeneous appearance of the soft-tissue mass in two patients. The average period of follow-up was 5 years. In seven of the 14 patients, the disease had a satisfactory evolution in which the bony lesions of the temporal bone reossified and remodeled over the course of a year.

CONCLUSION

In Langerhans' cell histiocytosis, involvement of the temporal bone is usually seen on radiographs as extensive lytic lesions associated with soft-tissue masses. The lesions that remit show early disappearance of the soft-tissue mass, followed by reossification and remodeling of the involved bone. Patients with limited initial involvement of the temporal bone have a better prognosis on long-term follow-up than do patients with the multisystemic form.

Presentation and diagnosis of unilateral maxillary swelling in children

Facial asymmetry secondary to pathologic processes involving the maxillary sinus and its surrounding structures presents a challenge for the clinician. An organized approach to evaluate these patients is essential in order to differentiate inflammatory sinus pathology from disease processes primarily involving the surrounding maxilla, parotid gland, orbital contents, and dental structures. In addition to a thorough history and physical examination, appropriate imaging studies must be obtained to localize the pathologic processes and develop a meaningful differential diagnosis. Once this is accomplished, specific treatment modalities can be developed. Representative cases will be presented to illustrate this organized approach to unilateral maxillary swelling, including soft tissue and osseous masses, fibro-osseous lesions, osseous cysts and inflammatory lesions.

The role of radiology in the diagnosis and follow-up of Langerhans cell histiocytosis

Diagnostic imaging plays a major role in the management of patients with Langerhans cell histiocytosis. Plain radiography depicts most lesions. Nuclear scintigraphy may detect additional areas of bone involvement, but its routine use is controversial. Ultrasonography may be used to evaluate the abdomen for evidence of solid organ involvement. CT and MR imaging are often of great value in clarifying and delineating findings seen on plain radiographs and other imaging modalities. Ultimately, the choice of imaging study depends on the patient's clinical presentation and the body part affected.

Eosinophilic granuloma of the clivus: case report, follow-up of two previously reported cases, and review of the literature on cranial base eosinophilic granuloma

OBJECTIVE AND IMPORTANCE

To our knowledge, this is the first reported case of the use of stereotactic radiotherapy for an eosinophilic granuloma (EG) of the clivus. We report follow-up information on two previously reported cases and suggest a management plan for this rare lesion.

CLINICAL PRESENTATION

We report the case of a 4.5-year-old boy who presented with a complete abducens palsy on the right with an associated head turn. A computed tomographic scan of his head revealed a lytic lesion on that side, and magnetic resonance imaging showed the mass to be of low intensity on T1-weighted images and of high intensity on T2-weighted images with heterogeneous enhancement.

INTERVENTION

A transnasal stereotactic biopsy was performed, revealing an EG. The patient was treated with stereotactic radiotherapy, and he became symptom-free with radiographic resolution of his lesion. Reviewing the literature, we found 13 series with 87 cases of EG in the petrous portion of the temporal bone. EG in the cranial base occurring outside of the temporal bone or in the temporal bone and extending intracranially is, however, quite rare, with only nine other cases reported, two of them clival.

CONCLUSION

These findings suggest a classification schema in which cranial base EG lesions be grouped with either the more common extracranial petrous temporal bone lesions or the very rare intracranial lesions. Although there are few cases in the literature, treatment results indicate that clival EG, and perhaps all intracranial cranial base EGs, be treated by a biopsy alone, followed by surgery or stereotactic radiotherapy if there is an incomplete resolution of the symptoms or if there is a recurrence.