Polypoid sinusitis mimicking orbital malignancy

Aggressive Sinonasal Polyposis

Sinonasal polyposis is one of the most common nasal conditions encountered by the otolaryngologist. Trauma, inflammation, allergy, and chemical irritation are all said to play a role in its etiology. While polyps generally behave in a benign noninvasive manner, they can assume a more aggressive course. We recently encountered three cases of histologically benign inflammatory sinonasal polyps which acted in an aggressive manner by eroding bone and invading orbit, pterygomaxillary space, and anterior cranial fossae. After appropriate cranial facial surgical therapy, all three of these patients recovered completely. The mechanism responsible for aggressive clinical behavior in these cases may be related to the formation of multiple, microscopic, intrapolyp mucoceles. Aggressive sinonasal polyposis should be considered when lesions of the paranasal sinus are encountered in clinical practice.

Retrospective assessment of computed tomographic imaging of feline sinonasal disease in 62 cats

Sixty-two cats with sinonasal disease were evaluated with computed tomography. Findings that may lead to a computed tomographic diagnosis of nasal neoplasia versus rhinitis included osteolysis of the paranasal bones, moderate to severe turbinate destruction, lysis of the nasal septum, the presence of a homogenous space occupying mass, and extension of the disease process into the orbit or facial soft tissues. These findings were not pathognomonic for neoplasia and may be associated with severe rhinitis; therefore, nasal biopsy was recommended. When compared with parallel radiographic studies, computed tomography was not more sensitive than radiographs at detecting the presence of nasal cavity abnormalities in cats with referable clinical signs but was more sensitive at localizing these changes and determining the extent of disease.

Radiology of Unilateral Sinonasal Opacification

Two recent cases managed at the University of California San Diego (UCSD) Nasal Dysfunction Clinic are described, with a review of the sinus computed tomography (CT) findings of six common unilateral sinonasal conditions. These include the homogeneous appearance and absence of bony destruction characteristic of unilateral benign polyposis, the focal hyperintensities of fungal sinusitis, the septal bowing seen in inverting papilloma, the involvement of the pterygopalatine fossa by an angiofibroma, the cribiform plate dehiscence associated with an encephalocele/meningocele and the extensive bony destruction characteristic of malignancy, such as epidermoid carcinoma. The clinical appearance and salient sinus CT features may suggest the diagnosis, thereby decreasing the morbidity from invasive tests, such as biopsy of an angiofibroma or an encephalocele, and improving quality resource management.

Inflammatory rheumatism and nasal polyposis

We report five cases of seronegative inflammatory rheumatism associated with nasal polyposis. The patients were four women and one man, mean age 49.5 years (range 42-59 yrs.). Two patients had polyarthralgia predominating in the hands, wrists and knees and two patients had symmetrical acromelic polyarthritis. The fifth patient, a woman, had oligoarticular arthritis. In a single female patient, X-rays showed moderate erosions of both tarsometatarsal bones. The inflammatory syndrome was moderate with mean ESR 23 (12-38) and immunological investigations were negative except for the presence of pANCA (50-200 U) in three patients. HLA-A1, B8, and Bw35 antigens were found in three of the five patients. In all cases, nasal and sinus polyposis (NSP) preceded rheumatism and the joint symptoms were accompanied by worsening of the ENT symptoms. NSP was confirmed by CT scan of the nasal fossae and sinuses. Polyps were surgically removed in four patients and the histology showed neither granuloma nor vasculitis. In four patients the joint symptoms, which responded poorly to nonsteroidal anti-inflammatory drugs (NSAIDs), improved markedly after ENT treatment (surgery and topical steroids) and synthetic antimalarials. The concomitant course of the joint and ENT symptoms suggests there may be a link between inflammatory rheumatism and NSP.

Invasive sinonasal polyps causing ophthalmoplegia, exophthalmos, and visual field loss

In a 20-year-old man with a history of sinonasal polyps, bilateral ophthalmoplegia, exophthalmos, and optic nerve dysfunction developed. Radiologic imaging showed a polypoid mass filling the nose and sinuses, eroding into the pituitary fossa, basal cisterns, and orbits, and compressing the cavernous sinuses. Six months after bilateral maxillary, ethmoid, and sphenoid exploration, ocular motility returned to normal, but there remained mild generalized visual field loss in the right eye. The pathologic specimen showed polypoid respiratory mucosa with acute and chronic inflammation as well as eosinophiles.

Primary liposarcoma of the orbit. Problems in the diagnosis and management of five cases

The clinicopathologic features and the results of diagnostic studies were reviewed in five patients with primary orbital liposarcoma. The major clinical complaints were diplopia and proptosis; visual function was typically well maintained. In three cases, computed tomographic (CT) scans displayed lesions with a central fat density rimmed by a variably radiodense pseudocapsule, leading to the erroneous clinical impression that the lesions were cystic in character. Ultrasonography ruled out a truly cystic tumor by demonstrating internal acoustic interfaces. Magnetic resonance imaging (MRI) in one case showed hyperintense signals in T-1-weighted images, suggesting the presence of fat within the lesional tissue. In the other two cases, CT scans showed reticulated densities accentuating the septa of the orbital fat in the absence of clear-cut circumscription. A potentially useful feature pointing to a neoplasm was bowing of an involved extraocular muscle, which is usually straightened and splinted in either Graves' disease or inflammatory pseudotumor. Histopathologically, two lesions were well-differentiated liposarcomas and three were myxoid liposarcomas, all featuring univacuolar signet ring lipoblasts. Scattered bizarre hyperchromatic mesenchymal cells without prominent lipidization were present in the lesions. None of the patients has experienced regional or distant metastases with follow-ups from onset of 1 to 7 years (mean, 5.2 years); three required orbital exenteration after local recurrence; and two who refused exenteration received only orbital radiotherapy.

Mucin impaction tumor of the paranasal sinuses: a new clinical entity?

A variety of uncommon benign lesions occur in the paranasal sinuses and have been reported to masquerade as carcinomas. Nearly all of such cases have been limited to the frontal, sphenoid, and ethmoid sinuses with an isolated report of maxillary sinus involvement. The classic roentgenologic picture is that of bony destruction. Heretofore described destructive lesions of the maxillary sinus include the mucocele, mucous retention cyst, pseudocyst, pyocele and cholesteatoma. This report deals with a previously undescribed entity, the mucin impaction tumor located in a septate maxillary sinus. This inflammatory, non-neoplastic tumor-like condition, presents as chronic sinusitis with periorbital edema, malar swelling and tenderness. Radiologic examination reveals total destruction of the bony walls of the nose, of the orbital rim and floor and of the maxillary sinus. The importance of recognizing this lesion lies in its benign nature but destructive capabilities. The destruction may possibly be accounted for by its anatomical origin in the septate sinus. Repeated surgical intervention may also serve to predispose or potentiate development of these lesions. Its resolution after adequate surgical extirpation and its place in the differential diagnosis of antral lesions are worthy of emphasis.

Ocular pathology for clinicians. 8. Orbital cellulitis

Orbital cellulitis secondary to sinusitis has been the most common cause of proptosis in children. A case report is presented which emphasizes that the signs and laboratory findings in orbital cellulitis may be confusing, especially when modified by prior antibiotics. When orbital cellulitis is a possibility, adequate antibiotic therapy should be instituted while diagnostic studies are being performed. CT scanning is a new and useful modality for the evaluation of these patients, but cautious and experienced interpretation is essential. In patients who do not respond promptly to appropriate medical therapy, surgical intervention is indicated for drainage and biopsy.