Fibrous dysplasia of the paranasal sinuses

Scedosporium apiospermum invasive sinusitis presenting as extradural abscess

INTRODUCTION

Chronic invasive fungal rhinosinusitis (CIFR) is a rare entity generally observed in immunodepressed subjects. The pathogen most frequently identified is Aspergillus spp. Imaging generally reveals invasive pseudoneoplastic features. We report a case of Scedosporium apiospermum (S. apiospermum) CIFR with an atypical clinical and radiological presentation.

CASE REPORT

A 72-year-old immunocompetent man presented with chronic headache, neck pain and bilateral limitation of lateral gaze. Imaging revealed an isolated left sphenoidal lesion with marked bone changes and an extradural abscess over the clivus. Large endoscopic sphenoidotomy with type II rhinopharyngectomy was performed and the diagnosis of S. apiospermum CIFR was based on histological examination and fungal culture. The patient refused all medical treatment and did not present any signs of recurrence after 1 year of follow-up.

DISCUSSION

S. apiospermum is a fungal species rarely isolated in CIFR. The present case was revealed by an atypical clinical presentation including isolated sphenoidal infection complicated by bilateral abducens nerve paralysis and extradural abscess. Imaging was also unusual, revealing features of fibrous dysplasia or bacterial osteomyelitis rather than the typical pseudoneoplastic appearance. The patient was successfully treated by surgery alone, which may therefore be sufficient treatment in immunocompetent subjects.

Sinonasal disease in polyostotic fibrous dysplasia and McCune-Albright Syndrome

OBJECTIVES/HYPOTHESIS

To characterize the spectrum, symptoms, progression, and effects of endocrine dysfunction on sinonasal disease in polyostotic fibrous dysplasia (PFD) and McCune-Albright Syndrome (MAS).

STUDY DESIGN

Retrospective review.

METHODS

A prospectively followed cohort of subjects with PFD/MAS underwent a comprehensive evaluation that included otolaryngologic and endocrine evaluation, and imaging studies. Head and facial computed tomography scans were analyzed, and the degree of fibrous dysplasia (FD) was graded using a modified Lund-MacKay scale. Those followed for >4 years were analyzed for progression.

RESULTS

A total of 106 patients meeting inclusion criteria were identified with craniofacial FD. A majority (92%) demonstrated sinonasal involvement. There were significant positive correlations between the sinonasal FD scale score and chronic congestion, hyposmia, growth hormone excess, and hyperthyroidism (P < .05 for all). Significant correlations were not found for headache/facial pain or recurrent/chronic sinusitis. Thirty-one subjects met the criteria for longitudinal analysis (follow-up mean, 6.3 years; range, 4.4-9 years). Those who demonstrated disease progression were significantly younger than those who did not (mean age, 11 vs. 25 years). Progression after age of 13 years was uncommon (n = 3) and minimal. Concomitant endocrinopathy or bisphosphonate use did not have any significant effect on progression of disease.

CONCLUSIONS

Sinonasal involvement of fibrous dysplasia in PFD/MAS is common. Symptoms are usually few and mild, and disease progression occurs primarily in young subjects. Concomitant endocrinopathy is associated with disease severity, but not progression.

[Current imaging of nasal sinuses]

Depending on the problems, CT or MRI should be used in the differential diagnosis of conditions affecting the nasal sinuses. In particular, when chronic sinusitis is present, computed tomography should be performed before surgery to ascertain the condition of the bones. In most cases spiral CT with a decidedly lowered tube voltage and power (MAS product) is now used for this purpose. This means that the patient is exposed to about 70% less radiation than in other CT investigations. To avoid artefacts attributable to dental fillings, whenever possible the spiral should be tilted in such a way that the dental artefacts are not within the mass imaged. When an isotropic voxel is selected secondary reformatting is possible with no loss of quality. Diagnostic MRI should include both T1- and T2-weighted sequences before and after the administration of contrast agent. For the differential diagnosis of a space-occupying tumour coronal cuts about 2 mm apart are advised, whether the spiral or the conventional technique is used. A T2-weighted and fat-suppressed sequence or a STIR (short tau inversion recovery) sequence can also be helpful in the recognition and visualization of lymph nodes. If orbital involvement seems possible it is advisable to use a T1-weighted and fat-suppressed sequence in the coronal plane in addition to check this.

Endoscopic surgery for fibrous dysplasia of the sinonasal tract in pediatric patients

Fibrous dysplasia (FD) is a non-neoplastic, expansile lesion of unknown origin. In about one-fourth of cases this disorder affects the head and neck area, where the mandible and maxilla are the most frequently involved sites. Its localization to the ethmoid is a rare event. Since the disease slowly progresses, its management is delayed until significant clinical symptoms or non-well-tolerated aesthetic deformities are present. When required, surgery is the treatment of choice. Several external procedures have been used to manage the lesion, but recently, more conservative transnasal approaches have been proposed. We report the history of a 6-year-old boy with fibrous dysplasia of the ethmoid labyrinth that underwent successful transnasal endoscopic removal. Furthermore, an analysis of the literature is presented with particular emphasis on clinical picture, diagnosis, and treatment of this rare illness.

Monostotic fibrous dysplasia originating from ethmoid bone: treatment with endoscopic approach

We present a case of monostotic fibrous dysplasia of the ethmoidal sinus in an 11-year-old boy. This condition is of interest to the otorhinolaryngologist because of the difficulty of differential diagnosis and treatment. This tumorlike growth was not restricted to the right ethmoidal sinus, but also compressed the orbit and the globe. Endoscopic and transnasal removal of the mass with a drill was performed under general anesthesia. No residual tumor was observed 6 months later.

Transnasal endoscopic surgery for the treatment of fibrous dysplasia of maxillary sinus associated to aneurysmal bone cyst in a 5-year-old child

Fibrous dysplasia (FD) and aneurysmal bone cyst involving the facial skeleton are rare but their synchronous association in other parts of the body is well-known. The most common treatment for these lesions has been based on surgical resection using an external approach. Only recently has the endonasal endoscopic approach been utilized for the partial or complete removal of these lesions. In this report, we attempt to outline the effectiveness of the endonasal endoscopic approach for the treatment of a 5-year-old child affected by a fibrous dysplasia associated with an aneurysmal bone cyst of the right maxillary.

Fibrous dysplasia with cystic appearance in maxillary sinus

Fibrous dysplasia (FD) in the paranasal sinuses is uncommon, and its management may be difficult. We report the case of a 25-year-old female with FD exhibiting a cystic appearance in the maxillary sinus. The patient had been complaining of facial swelling for few years. Imagery study showed a cystic lesion and dense bone changes in the maxillary bone. Inferior meatal antrostomy with a nasal endoscope failed to confirm a histological diagnosis. After a 3-year follow-up, the degree of facial swelling was unchanged, and the patient underwent middle meatal antrostomy and was diagnosed with FD.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.