Fibrous dysplasia

Different clinical presentation and management of temporal bone fibrous dysplasia in children

Background

Fibrous dysplasia is a slowly progressive benign fibro-osseous disorder that involves one or multiple bones with a unilateral distribution in most cases. It is a lesion of unknown etiology, uncertain pathogenesis, and diverse histopathology. Temporal bone involvement is the least frequently reported type, especially in children.

We reviewed available articles regarding fibrous dysplasia with temporal bone involvement in children and added four patients aged 7 to 17 years who were diagnosed and treated in our institution from 2006 to 2017. The patients’ clinical picture comprised head deformity, external canal stenosis, headache, progressive conductive and/or sensorineural hearing loss, tinnitus, and sudden deafness. Two patients had experienced severe episodic vertigo with nausea and vomiting. Two were referred to us with external canal obstruction and secondary cholesteatoma formation with broad middle ear destruction. One was diagnosed with acute mastoiditis and intracranial complications. Optimal management of fibrous dysplasia is unclear and can be challenging, especially in children. In our two patients with disease expansion and involvement of important structures, surgical treatment was abandoned and a “wait-and-scan” policy was applied. The other two were qualified for surgical treatment. One patient underwent two surgeries: modified lateral petrosectomy (canal left open) with pathological tissue removal, cavity obliteration, and subsequent tympanoplasty. Another patient with extensive destruction of the left temporal bone underwent canal wall down mastoidectomy with perisinus abscess drainage and revision 12 months later. Tympanoplasty was unsatisfactory in both patients because of slow progression of the middle ear pathology. None of our patients underwent pharmacological treatment.

Conclusions

In younger patients, observation and a “wait-and-scan” protocol is relevant until significant function, or cosmetic deficits are obvious. Surgery is not preferred and should be delayed until puberty because fibrous dysplasia has a tendency to stabilize after adolescence. In patients with severe symptoms medical treatment can be implemented, but safety of this treatment in children remain controversial.

Fibrous dysplasia: a systematic review

OBJECTIVES

To evaluate the principal features of fibrous dysplasia (FD) by systematic review (SR) and to compare their frequencies between four global groups.

METHODS

The databases searched were the PubMed interface of Medline and LILACS. Only those reports of FD which occurred in a series in the reporting authors' caseload were considered. All cases were confirmed fibro-osseous lesions histopathologically. The SR-included series must also have included radiographs.

RESULTS

Of the 106 reports considered (including the Hong Kong report), 31 reports and a total of 788 cases were included in the SR. 11 SR-included series were in languages other than English. FD affected both genders equally, but was 50% more prevalent in the maxilla. The mean age at first presentation was 24 years. The decade with the greatest frequency was the second, in which males accounted for 63%. The main symptom in 90% of all SR-included cases was swelling (including deformation of the jaws). Not one SR-included case directly involved the ocular apparatus. All cases displayed buccolingual expansion; all mandibular cases exhibited downward displacement of the lower border of the mandible and almost all maxillary cases involved the maxillary antrum. Only 35% of reports included follow-up; 18% of cases recurred or were reactivated. Not one case displayed sarcomatous change.

CONCLUSIONS

Long-term follow-up of large series that would have revealed the long-term outcomes of FD was lacking. This is necessary because many cases do not burn out at the end of adolescence, as expected of a hamartoma, but are reactivated.

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.

Cranio-facial fibro-osseous dysplasia. A case report and overview of the management of the condition

Fibro-osseous dysplasia is a developmental non familial, benign anomaly of bone development occurring in single or multiple bones, characterised by the replacement of normal bone by fibro-osseous tissue. We describe the case of a fourteen year old boy, which illustrates many of the difficulties confronting surgeons dealing with this uncommon condition. Complete surgical excision was required, before a definitive histological diagnosis could be established. We report the clinical, radiological and pathological features of this unusual case. We review the pathology of the condition and discuss the approaches to surgical management.

Monostotic Fibrous Dysplasia of the Temporal Bone with Associated Lymphadenopathy

Fibrous dysplasia of bone is a benign idiopathic disorder where abnormal fibro-osseous tissue replaces normal bone. The bony abnormalities may be associated with endocrine disorders and abnormal pigmentation of the skin and mucous membranes. Involvement of the temporal bone is a very rare occurrence. We report a case of monostotic fibrous dysplasia of the temporal bone with associated lymphadenopathy. To our knowledge this association has not been previously described in the literature. We also emphasise the need for long term follow up of patients with this condition as cholesteatoma may develop insidiously.

Aggressive fibrous dysplasia of the maxillary sinus

Fibrous dysplasia is usually a slowly progressive, benign disease that develops over several years and presents with deformity or mild symptomatology. Five of 34 patients (ages 4-21 years), who were subsequently diagnosed histologically as having fibrous dysplasia of the maxillary sinus, rapidly developed soft tissue masses of the malar region over a period of less than 4 months with accompanying pain (2 patients) and nasal obstruction and exophthalmos (2 patients). Each was clinically suspected of having a sarcoma; two had been thought to have an "osteofibrosarcoma" on initial biopsy at outside hospitals. After resection, all lesions developed regrowth. At histopathologic examination, both initial and recurrent masses proved to be typical fibrous dysplasia with spicules of woven bone in cellular, sometimes vascular, fibrous tissue. No malignant degeneration was found. On conventional radiography, aggressive fibrous dysplasia produced opacification and expansion of the maxillary sinus and apparent disruption of its wall with an associated soft tissue mass. Computed tomography (CT) demonstrated voluminous heterogeneous masses with "ground glass appearance", calcifications, areas of enhancement, low attenuation, cystic areas, and a thinned, sometimes interrupted, maxillary wall. Despite the aggressive clinical course for both initial and recurrent lesions, the CT findings of a "ground glass" mass with calcifications surrounded by a maxillary sinus wall, even if incomplete, can suggest the diagnosis of aggressive fibrous dysplasia.

Craniofacial fibrous dysplasia

Fibrous dysplasia is a benign localized bone disorder of unknown aetiology in which endocrinopathies, abnormal pigmentation of the skin and mucous membranes may form part of the disease. Five cases involving the facial and cranial bones are described to illustrate the various presentations and radiological appearances including computerized tomography and magnetic resonance imaging. Some of these cases demonstrate that serial radiology may be adequate for diagnosis and management without the necessity for histological confirmation. The place of limited surgical treatment for the craniofacial sites is debated.

Hemorrhage into fibrous dysplasia following minor head injury--effective decompression for the ophthalmic artery and optic nerve

We performed an effective optic canal decompression in a patient with ethmoid and sphenoid fibrous dysplasia and visual impairment following minor head trauma. On admission, the patient's left visual acuity consisted only of light perception, and the left ophthalmic artery was not visible by angiography. A hematoma and fibrous dysplasia tissue in the sphenoid sinus were excised and the left optic canal was decompressed. The vision was markedly improved to an ability to count fingers in the following 2 weeks. The left ophthalmic artery was fully opacified in the postoperative angiogram.

Fibrous dysplasia of the facial bones and mandible

Five cases of fibrous dysplasia isolated to the facial bones and mandible are presented. A review of the clinical and roentgen features of facial fibrous dysplasia are described.

Monostotic fibrous dysplasia of the cranial bones: report of fourteen cases

Polyostotic fibrous dysplasia affects many bones of the skeleton and usually on one side only. In monostotic variety only one bone is affected. The condition which usually starts in early childhood is at first active, gradually becomes quiescent and finally with termination of skeletal growth becomes inactive and ceases to grow. These stages can be seen histologically as well as radiologically. The main feature is increasing calcification of the mass. In half of our cases there was an intracranial mass with signs of raised intracranial or intra-orbital pressure. In all of these cases the mass originated from the base of skull. Those growing from the vault of the skull grew outward. Pathogenesis, diagnosis and treatment are discussed.