Cholesterol granuloma of the maxillary sinus

Cholesterol Granuloma of the Maxillary Sinus-A Case Report and Literature Review

Cholesterol Granulomas of the Maxillary Sinus, considered an unusual presentation at this anatomical site. Over last 2 decades, only few cases are reported in the literature (English) and no available comprehensive reviews or studies on this entity. Herein in this article we present a comprehensive literature review of the available reports of 16 cases along with reporting a new case which we managed, aided with its histopathological pictures. This review article can be a reference for practitioners in the field of otorhinolaryngology who may encounter these cases. Also, it attracts the attention to consider this pathology among the differential diagnoses of nasal masses. Moreover, including a described pathological imaging may help young pathologist to identify this pathology.

Endoscopic Removal of Huge Cholesterol Granuloma in the Maxillary Sinus Confused With Odontogenic Keratocyst

Cholesterol granuloma is a foreign body reaction to the deposition of cholesterol crystals, usually found in association to chronic middle ear diseases, being highly uncommon in the paranasal sinuses. Furthermore, a huge and aggressive cholesterol granuloma involving the maxillary sinus, hard palate, buccal space, and maxillary alveolus is extremely rare and has not been reported previously. This article reports a case of huge cholesterol granuloma in the maxillary sinus confused with an expansile odontogenic keratocyst, which was treated successfully via transnasal endoscopic approach.

Cholesterol granuloma in an antrochoanal polyp. A rare lesion in children

Antrochoanal polyps (ACPs) are an infrequent clinical entity. Cholesterol granulomas (CGs) are commonly associated with chronic middle ear disease but are rare in the paranasal sinuses. We describe a case of a 10-year-old girl with a concomitant CG in an ACP which was surgically excised by nasosinusal endoscopic surgery. To our knowledge, there are only five previously published cases of CGs in ACPs and of these, only two were pediatric cases. We describe a third case in the youngest patient yet reported. Increased intrasinus pressure may affect venous and lymphatic drainage, leading to hemorrhages with hemolysis and deposition of cholesterol crystals and their esters initiating the formation of granulomas in the polyp. In addition, the insufficient lymphatic drainage prevents the complete elimination of lipids, contributing to the formation of cholesterol granulomas. The treatment and the outcome of an ACP associated with a CG are the same as for usual ACPs.

Cholesterol Granuloma Associated with Otitis Media and Destruction of the Tympanic Bulla in a Dog

An 8-year-old, male neutered Irish Setter was presented with a 2-week history of pain upon opening the mouth and chronic otitis externa. Computed tomography examination revealed destruction of the left tympanic bulla with a soft-tissue density within the remains of the tympanic cavity. Cytology of aspirates collected from tissue adjacent to the tympanic bulla revealed suppurative inflammation and bacteria. A ventral bulla osteotomy was performed. Histopathology of granulation tissue within the remains of the tympanic cavity was diagnostic of cholesterol granuloma.

Calcifying odontogenic cyst: a rare report of a nonneoplastic variant associated with cholesterol granuloma

AIM

To report a case of a non-neoplastic variant of calcifying odontogenic cyst (COC) with the lining epithelium showing ameloblastomatous proliferation and capsule exhibiting features of a cholesterol granuloma. The importance of delineating this histologic variant from unicystic ameloblastoma and the formation of cholesterol granuloma in this variant is discussed.

BACKGROUND

Calcifying odontogenic cyst is a developmental jaw cyst, which presents itself as both the neoplastic and the non-neoplastic forms. The ameloblastomatous variant of COC is often mistaken for unicystic ameloblastoma and treated aggressively.

CASE REPORT

A 68-year-old female who presented with a cystic enlargement of the posterior mandible on the right side was suggestive of unicystic ameloblastoma based on radiography and initial biopsy report. Microscopic examination of the excision specimen, however, was fitting in favor of calcifying odontogenic cyst with ameloblastomatous proliferation.

CONCLUSION

Identifying the non-neoplastic ameloblastomatous variant of COC from a cystic ameloblastoma is crucial as the treatment of the two lesions vary considerably.

CLINICAL SIGNIFICANCE

This case emphasizes the need for thorough examination of the entire surgical specimen before arriving at an appropriate diagnosis.

Cholesterol granuloma of the frontal sinus: a case report

Cholesterol granulomas are common in the mastoid antrum and air cells of the temporal bone. In the paranasal sinuses, especially in the frontal sinus, they have occasionally been mentioned in the literature. The pathogenesis is unknown, but the majority of the authors support the concept of airway obstruction in the cells well pneumatised of temporal bone and paranasal sinuses. The authors report a case of cholesterol granuloma of the frontal sinus treated with radical surgical techniques, and they also recommend an endoscopic approach to frontal sinus to restore or enlarge the nose-frontal canal and promote drainage and ventilation of the frontal sinus.

Paranasal sinus cholesterol granuloma: systematic review of diagnostic and management aspects

BACKGROUND

Cholesterol granuloma (CG) is an expansile, cystic lesion most commonly observed in the temporal bone. CG is rarely encountered in the paranasal sinuses. Given its paucity in this region, the diagnostic and management aspects remain to be elucidated.

METHODS

Systematic review of the literature yielded 66 cases reported as individual data in 37 articles; an additional 69 cases were reported as aggregate data in 5 case series.

RESULTS

The mean age of the 135 patients was 43.8 years, with a male:female ratio of 5.6:1. The most common presenting symptoms were orbital (66%), followed by headaches (19.3%). The most common location for CG was the frontal sinus (60%), followed by maxillary (34.1%) and ethmoid (3.7%) sinuses. Computed tomography (CT) imaging was used in 84 patients (63.3%), with bone erosion being noted in 80% of cases. Magnetic resonance imaging (MRI) was reported in only 9 cases (6.7%); high signal on T1- and T2-weighted images was evident in 77.8% and 66.7%, of cases respectively. Surgical data was available on 65 cases; drainage was achieved by open and endoscopic techniques in 52 (80%) and 13 (20%) cases, respectively. Primary symptom improvement and CG cavity patency was achieved in 92% of cases at a mean follow-up of 34.5 months.

CONCLUSION

Paranasal sinus CG is most commonly observed in middle-aged males, arises in the frontal sinus, and typically presents with orbital symptoms. Both open and endoscopic techniques can be used with high success rate. The present study represents the first attempt in the literature to construct a clinical profile of this rare entity.

Cholesterol granuloma presenting as a mass obstructing the external ear canal

BACKGROUND

Cholesterol granuloma (CG) may involve the middle ear, the mastoid bone and the petrous apex. However, CG presenting as a mass obstructing the external ear canal (EEC) is relatively rare and it can be a diagnostic challenge.

CASE PRESENTATION

We report a case of a CG occupying the mastoid antrum and presenting as a mass into the EEC. Temporal bone computerized tomography showed a soft tissue mass which eroded the posterior-superior bony wall of the EEC. On magnetic resonance imaging, the mass revealed a high signal on both T1 and T2-weighted images. The CG was removed by a mastoidectomy procedure and the histopathologic report confirmed the diagnosis of CG. A type III tympanoplasty was performed.

CONCLUSIONS

The postoperative course was uneventful.

Granulomatous disorders of the nose and paranasal sinuses

PURPOSE OF REVIEW

To review granulomatous findings in sinus and nasal tissue as part of a diagnostic indicator of various disease states, focusing on the role of further testing and evaluation to clarify this diagnosis as well as the implications for patient care.

RECENT FINDINGS

Inflammatory and infectious diseases as well as neoplasms, cocaine abuse and trauma may have rhinosinus granulomatous findings as part of the disease state. The need for careful histopathologic evaluation as well as the pitfalls and caveats of laboratory testing will be reviewed in this paper. Some infections such as invasive fungal rhinosinusitis and rhinoscleroma may have a chronic granulomatous course, which may require extensive surgical and pharmacologic treatment. Treatment options for Wegener's granulomatosis have shown a lack of effect of etanercept, but hopeful alternatives to prolonged cyclophosphamide use include methotrexate and leflunomide. Cocaine-induced midline destructive lesions unfortunately have a high prevalence of cytoplasmic antineutrophil cytoplasmic antibodies, limiting this test's usefulness in distinguishing this disorder from Wegener's granulomatosis.

SUMMARY

The otorhinolaryngologist must be aware of the differential diagnosis of these chronic inflammatory states to formulate an optimal course of evaluation and longitudinal management for these patients.

Cholesterol granuloma of the maxillary sinus encountered during floor augmentation procedure: A case report

BACKGROUND

Cholesterol granuloma (CG) is a foreign-body reaction to the deposition of cholesterol crystals. Its occurrence in the paranasal sinuses is very rare.

PURPOSE

This report describes a new case of maxillary sinus CG discovered incidentally during sinus-floor augmentation for dental implant placement in a 60-year-old female patient.

MATERIALS AND METHODS

The preoperative clinical and radiological examinations revealed a normal maxillary antrum with no evidence of sinus pathology. After lateral osteotomy, a dark-green, viscous soft tissue mass appeared through the thin mucous membrane inside the sinus. Enucleation and curettage of the sinus contents including the sinus membrane were performed for histopathologic analysis. The augmentation and implant placement procedures were postponed.

RESULTS

Histopathologic analysis showed several fragments of granulation tissue containing diffuse cholesterol clefts surrounded by mixed chronic inflammatory cell infiltrate including plasma cells and lymphocytes. These features were compatible with the diagnosis of CG. The patient was followed up for 3 months after the first procedure, and a second attempt of sinus augmentation and dental implant insertion was then carried out. The inserted dental implants were followed up for 6 months without any complications.

CONCLUSIONS

CG of maxillary sinus can be an incidental finding. For this reason, the final diagnosis can only be achieved after examination of the material under the microscope.

Cholesterol granuloma of the maxillary sinus

Cholesterol granuloma (CG) is a foreign body reaction to the deposition of cholesterol crystals, usually found in association to chronic middle ear diseases, being highly uncommon in the paranasal sinuses. This article reports a case of CG in the maxillary sinus of a 22-year-old man, manifesting as a swelling on the right maxilla associated with pain and nasal obstruction. Computed tomography (CT) imaging showed complete opacification of the right maxillary sinus with cortical bone expansion and destruction. Incisional biopsy showed a solid mass filling the sinus and histological examination showed foreign body reaction to cholesterol crystals. The microscopic findings associated to tooth vitality, CT images and absence of a cavity during the surgical procedure were compatible with the diagnosis of CG of the maxillary sinus. Complete surgical excision of the mass under general anesthesia was suggested, but the patient did not return to conclude the treatment. CG must be included in differential diagnosis of diseases that cause opacification on the paranasal sinuses, especially sinusitis, and cystic and tumoral lesions.

Cholesterol granuloma in thyroglossal cysts: a clinicopathological study

Thyroglossal duct cyst (TDC) is a congenital anomaly caused by retention of epithelial remnants from the descent of the thyroid gland during embryological development. Cholesterol granuloma represents a granulomatous reaction to precipitates of cholesterol crystals in tissue, usually related to middle-ear disease. The association of TDC with cholesterol granuloma has hardly been reported. This study describes five patients with TDC and cholesterol granuloma over a 16-year-period. The treatment consisted of excision of the TDC and the mid-portion of the hyoid bone and excision of a core of tissue between the hyoid bone and the foramen cecum (Sistrunk procedure). We speculate that the pathogenesis of cholesterol granuloma in TDC resembles that in the paranasal sinuses, as both sites provide a closed, poorly ventilated hollow structure with slow drainage. Our five patients accounted for 13% of all patients with TDC treated in our center during the same period, indicating that cholesterol granuloma in TDC may not be as rare as previously thought.

Presence of cholesterol granuloma in the maxillary and ethmoid sinuses

INTRODUCTION

Although cholesterol granuloma associated with chronic middle ear disease is shown to be common in the mastoid antrum and air cells of the temporal bone (Leon et al., Arch Pathol Lab Med 126:217-219, 2002), its presence in the maxillary and ethmoid sinuses is rarely encountered. There are few cases reported regarding the incidence of cholesterol granuloma in these sinuses (Ko et al., Am J Otoryngol 27:370-372, 2006).

CASE

Here, we report a case of concomitant cholesterol granuloma in the maxillary and ethmoid sinuses of a 33-year-old man who underwent surgical excision.

DISCUSSION

Histopathological examination of the removed specimen revealed fragments of respiratory mucosa with cholesterol clefts surrounded by multinucleated foreign-body giant cells.

Unilateral paranasal sinus diseases: analysis of the clinical characteristics, diagnosis, pathology, and computed tomography findings

CONCLUSION

This study observed a much higher percentage of unilateral sinus pathology than reported in the literature. Comprehensive evaluations of patient age, presenting symptoms, nasoendoscopy examination, and computed tomography (CT) findings help in the diagnosis of unilateral sinus disease. Nevertheless, histological confirmation remains obligatory for diagnosis.

OBJECTIVES

To evaluate the clinical features, diagnosis, pathology, and CT findings in patients who had undergone sinus surgery for unilateral sinus diseases.

PATIENTS AND METHODS

Among 524 patients who had undergone sinus surgery, patients with unilateral sinus opacification on the preoperative CT scans were selected. Data were collected from the medical records and CT findings were evaluated.

RESULTS

Unilateral sinus opacification was identified in 121 (23.1%) patients. Male gender was predominant and the greatest number of patients had chronic rhinosinusitis. The mean age was oldest for fungus ball and youngest for antrochoanal polyp. Purulent discharge and foul odor were the common presenting symptoms under inflammatory conditions, while frequent epistaxis and cheek swelling were the main symptoms in neoplastic diseases. Calcifications were observed only in patients with fungus ball, while bony destruction was detected in both benign and malignant tumors. Punch biopsy performed in the office offered accurate histopathologic diagnosis in 94.3% of the patients.

[Cholesterol granuloma]

AIM OF THE STUDY

We report 2 cases (52 and 29-year-old men) of CG in the petrous apex we treated in 2004-2006. We also review the literature and discus the mechanism of development of CG and the treatment of this lesion.

MATERIAL AND METHODS

Cholesterol granuloma (CG) is a chronic inflammatory process with associated foreign body reaction to hemorrhage-related cholesterol crystals. Although CG is found in various organs the temporal bone is the most common site of detection. Numerous ethiopathological hypotheses have been proposed but most authorities support the concept of air cell tract blockage in well pneumatized petrous apex. Obstruction of the air cells leads to rupture of blood vessels and hemorrhage. Red blood cell degradation into cholesterol crystals produces a foreign body giant-cell reaction with progressive accumulation of typical brownish glistening fluid. Clinically, this lesion can produce sensorineural hearing loss, tinnitus, hemifacial spasm, facial numbness and trigeminal neuralgia. Cholesteatoma is the main lesion to distinguish from CG. On MRI studies, CG appears with a high signal on both T1- and T2-weighted sequences, cholesteatoma appear bright only on T2-weighted ones. Goal of the surgery is to create a drainage and ventilation of the affected area to prevent recurrence. Several alternative approaches to the petrous apex have been described.

RESULTS

12-18 months follow up shows no clinical signs of recurrence.

Free cholesterol in atherosclerotic plaques: where does it come from?

PURPOSE OF REVIEW

Free cholesterol in plaques is an emerging contributing factor to lesion instability and, until recently, apoptosis of lipid-laden macrophages was considered the major source of free cholesterol. The validity of this concept is beginning to be challenged since there is recent evidence of erythrocyte membrane-derived cholesterol in plaques. Therefore, intraplaque hemorrhage may not be a passive event, as once considered as studies continue to support the relationship of intraplaque hemorrhage and necrotic core expansion.

RECENT FINDINGS

The association of intraplaque hemorrhage, accumulated free cholesterol, and necrotic core expansion is beginning to unfold and recent MRI studies suggest the value of intraplaque hemorrhage as a predictor of recurrent cerebrovascular events. The amount of erythrocyte membrane-derived cholesterol is also suggested to be a measure of lesion vulnerability in acute coronary syndromes. Recent inhibitors studies of vascular permeability factors further emphasize the importance of intraplaque hemorrhage in plaque progression. Finally, DNA microarray analysis is starting to reveal key molecules involved in the accumulation of free cholesterol that are selectively induced in high-risk plaques.

SUMMARY

These recent findings emphasize the importance of intraplaque hemorrhage as a contributor of free cholesterol in plaques and point to its provocative role in lesion destabilization.

Elimination of Neoangiogenesis for Plaque Stabilization

Emerging data suggest that intraplaque hemorrhage is critical in promoting atherosclerotic lesion instability. Because red blood cell membranes are a rich source of free cholesterol and accumulated red blood cells within plaques promote inflammation, intraplaque hemorrhage is associated with expansion of the necrotic core. Plaque hemorrhage results from the development of immature neointimal vasa vasorum. Therefore, it is proposed that molecular therapies designed to eliminate pathologic neovascularization within developing lesions will interrupt the process of hemorrhage and decrease the rate of necrotic core expansion. The elimination of intraplaque neovascularization would involve targeting of pre-existing and new vessel development. The concept of vascular regression has met some success in other neovascular-dependent diseases, including macular degeneration and malignancies. The efficacy of this novel approach is dependent on gaining critical knowledge of the environment required to support development and maturation of the vasa vasorum within varying plaque types. A multitargeted approach involving selective local antiangiogenic agents should contribute to prevention of plaque progression and its clinical consequences.

Cholesterol granuloma of the posterior ethmoid sinus mimicking meningocele

Cholesterol granuloma is usually associated with chronic middle ear disease, less common in the orbit, and rare in the paranasal sinus. Cholesterol granuloma is thought to be initiated by hemorrhage, impaired drainage, and interruption of aeration. Here we report a case of cholesterol granuloma arising in the posterior ethmoid sinus mimicking meningocele. Magnetic resonance imaging is useful for differential diagnosis, and endoscopic surgery is effective for the management of cholesterol granuloma arising in the ethomoid sinus.

Cholesterol granuloma of maxillary sinus

The cholesterol granuloma is a particular form of granulation tissue developing as part of a variety of tissue reactions. It is usually associated with chronic middle ear disease and is common in the mastoid antrum of temporal bone. Cholesterol granuloma is rare in maxillary antrum. A case is reported of cholesterol granuloma in the maxillary sinus of a 42-year-old man, with the unique feature that the soft tissue lesion is enclosed by thick bone, entirely within the sinus.

Cholesterol granuloma of the maxillary sinus

Cholesterol granuloma (CG) of the maxillary sinus is very rare. In this study, the searching of the literature was performed with the keywords of cholesterol granuloma and maxillary sinus. All retrieved literature were reviewed throughout to identify and analyze all individual characteristics. Two additional cases in our hospital were also included. The result showed that, in the overall 37 cases, the ratio of male to female was about 3:1. Caucasian (14/37) and Turkish (10/37) were reported more frequently. CG of maxillary sinus had an opposite sex predilection compared with the fungus balls of the maxillary sinus. In addition, the comorbidity of these two diseases was found only in one patient in the literature. These results suggested that the different mechanisms other than poor aeration of the maxillary sinus played a role in the formation of CG of maxillary sinus. The diagnosis for CG of the maxillary sinus before operation is difficult, but the clear golden yellow rhinorrhea and hemorrhagic signs may provide a good diagnostic evidence. The symptoms were vague and about half of the patients presented with non-specific symptoms. Therefore, it seemed reasonable that CG of the maxillary sinus was under diagnosed in the clinical practice. Treatment consists of complete excision via Caldwell-Luc or endoscopic approach and provides a good prognosis. Bilateral involvements are rare but possible in this disease entity.

Atherosclerotic plaque progression and vulnerability to rupture: angiogenesis as a source of intraplaque hemorrhage

Observational studies of necrotic core progression identify intraplaque hemorrhage as a critical factor in atherosclerotic plaque growth and destabilization. The rapid accumulation of erythrocyte membranes causes an abrupt change in plaque substrate characterized by increased free cholesterol within the lipid core and excessive macrophage infiltration. Neoangiogenesis is associated closely with plaque progression, and microvascular incompetence is a likely source of intraplaque hemorrhage. Intimal neovascularization is predominantly thought to arise from the adventitia, where there are a plethora of pre-existing vasa vasorum. In lesions that have early necrotic cores, the majority of vessels invading from the adventitia occur at specific sites of medial wall disruption. A breech in the medial wall likely facilitates the rapid in-growth of microvessels from the adventitia, and exposure to an atherosclerotic environment stimulates abnormal vascular development characterized by disorganized branching and immature endothelial tubes with "leaky" imperfect linings. This network of immature blood vessels is a viable source of intraplaque hemorrhage providing erythrocyte-derived phospholipids and free cholesterol. The rapid change in plaque substrate caused by the excessive accumulation of erythrocytes may promote the transition from a stable to an unstable lesion. This review discusses the potential role of intraplaque vasa vasorum in lesion instability as it relates to plaque rupture.

Cholesterol granulomas in antrochoanal polyps: a clinicopathologic study

The purpose of this study was to investigate antrochoanal polyps with cholesterol granuloma (CG), which is a granulomatous reaction to cholesterol crystals that has been precipitated in the tissue. It is usually associated with chronic middle ear disease, common in the mastoid air cells, less common in the orbit and rarely found in the paranasal sinuses. The aim of this study was to analyze the etiology and pathological findings of antrochoanal polyps associated with cholesterol granuloma. This is a retrospective study of five cases of antrochoanal polyp with cholesterol granuloma, (four males and one female between 15 and 77 years of age) who presented with nasal obstruction, rhinorhea and snoring. The cases were clinically and histologically reviewed. Four patients were treated endoscopically and one by intranasal polypectomy without endoscope. There was no recurrence during the follow-up between 24 to 36 months (mean 31.2 months). Five uncommon cases with antrochoanal polyp with cholesterol granuloma are presented. The cholesterol granulomas consist of fibrous granulation tissue containing cholesterol crystals with surrounding foreign body giant cells. The pathogenesis of antrochoanal polyp with cholesterol granuloma is unclear, and further investigations are needed.

Orbitofrontal cholesterol granuloma

Cholesterol granuloma of the orbital bones is a rare but readily recognisable condition. It is an osteolytic lesion with a granulomatous reaction surrounding cholesterol crystals, old haemorrhage and a fibrous capsule. There is a male preponderance and it usually occurs in young or middle-aged men. It is treatable with drainage and curettage via an orbitotomy, and craniotomy or wide bone removal is almost never required. Six cases of this condition were reviewed to highlight the typical clinical presentation, computed tomography and magnetic resonance results, and surgical management.

Diagnosis and pathology of unilateral maxillary sinus opacification with or without evidence of contralateral disease

OBJECTIVE

Determine the diagnostic criteria and etiology of complete unilateral maxillary sinus opacification.

METHODS

A prospective analysis was performed on patients presenting to a tertiary care rhinology practice with complaints of chronic rhinosinusitis or acute exacerbation. Sixty-four consecutive patients were identified with unilateral maxillary sinus opacification on computed tomography (CT) scan after at least a 3-week medical therapy for rhinosinusitis. The study population comprised 30 men and 34 women with a mean age of 47.0 years. All patients completed a symptom score questionnaire, received nasal endoscopy, and CT imaging. Patient symptoms and endoscopic and radiographic findings were analyzed to determine patterns related to final diagnosis.

RESULTS

All 64 patients underwent functional endoscopic sinus surgery. Each surgical specimen was sent for pathologic confirmation of the diagnosis. Sixteen mucoceles, 12 cases of nasal polyposis, 27 cases of acute or chronic sinusitis, 7 cases of inverting papilloma, and 2 cases of mycetoma were identified. Endoscopic and radiographic appearances were correlated with each disease process.

CONCLUSION

Unilateral maxillary sinus opacification is a relatively common finding. Early identification of inverting papillomas and mucoceles may avoid delay in surgical intervention, whereas acute/chronic rhinosinusitis and nasal polyposis can initially be managed medically. Careful history, endoscopic examination, and radiographic studies can often determine the responsible disease process.

Intraplaque hemorrhage and progression of coronary atheroma

BACKGROUND

Intraplaque hemorrhage is common in advanced coronary atherosclerotic lesions. The relation between hemorrhage and the vulnerability of plaque to disruption may involve the accumulation of free cholesterol from erythrocyte membranes.

METHODS

We stained multiple coronary lesions from 24 randomly selected patients who had died suddenly of coronary causes with an antibody against glycophorin A (a protein specific to erythrocytes that facilitates anion exchange) and Mallory's stain for iron (hemosiderin), markers of previous intraplaque hemorrhage. Coronary lesions were classified as lesions with pathologic intimal thickening, fibrous-cap atheromas with cores in an early or late stage of necrosis, or thin-cap fibrous atheromas (vulnerable plaques). The arterial response to plaque hemorrhage was further defined in a rabbit model of atherosclerosis.

RESULTS

Only traces of glycophorin A and iron were found in lesions with pathologic intimal thickening or fibrous-cap atheromas with cores in an early stage of necrosis. In contrast, fibroatheromas with cores in a late stage of necrosis or thin caps had a marked increase in glycophorin A in regions of cholesterol clefts surrounded by iron deposits. Larger amounts of both glycophorin A and iron were associated with larger necrotic cores and greater macrophage infiltration. Rabbit lesions with induced intramural hemorrhage consistently showed cholesterol crystals with erythrocyte fragments, foam cells, and iron deposits. In contrast, control lesions from the same animals had a marked reduction in macrophages and lipid content.

CONCLUSIONS

By contributing to the deposition of free cholesterol, macrophage infiltration, and enlargement of the necrotic core, the accumulation of erythrocyte membranes within an atherosclerotic plaque may represent a potent atherogenic stimulus. These factors may increase the risk of plaque destabilization.

Endoscopic sinus surgery in cases of cholesterol granuloma of the maxillary sinus

Cholesterol granuloma is usually associated with middle ear disease and is very rare in the paranasal sinuses. We report a case of cholesterol granuloma originating in the maxillary sinus of a 52-year-old female. Endoscopic sinus surgery was performed on the left maxillary sinus, and the cholesterol granuloma was successfully removed by the middle meatal antrostomy. Light microscopic examination showed granulomatous tissue with typical cholesterol clefts, multinucleated foreign body giant cells, small areas of hemorrhage, hemosiderin-laden macrophages and plasma cells. We also describe the details of the endoscopic surgical techniques employed in the treatment of this disorder.