Extraorbital Skull Base Idiopathic Pseudotumor

Diagnosis and Treatment of Inflammatory Pseudotumor with Lower Cranial Nerve Neuropathy by Endoscopic Endonasal Approach: A Systematic Review

Inflammatory pseudotumor (IPT) is a non-neoplastic condition of unknown etiology. IPT with lower cranial nerve (CN IX, X, XI, XII) neuropathies is extremely rare. In this study, we systematically reviewed all previously reported cases regarding the management of IPT with lower cranial nerve neuropathies. We searched the PubMed/MEDLINE database for reports related to IPT with lower cranial nerve neuropathies. A total of six papers with 10 cases met the inclusion criteria (mean age 51.6 years, 70% male). The mean follow-up period was 15.4 months (range: 1–60 months). The most frequent treatment was corticosteroids alone (60%), followed by surgery alone (20%), and multimodal treatment (20%). Corticosteroid therapy was associated with an excellent (100%) response rate at 6 months of follow-up, and half of the patients were in complete remission after 9 months. Both cases who received surgery had persistent neurological deficits. Immediate complete remission of neurological symptoms and resolution on imaging after decompression surgery via an endoscopic endonasal approach (EEA) with corticosteroids was demonstrated in our representative case. This review suggests that EEA is a preferred method for diagnosis and treatment, a promising approach associated with favorable outcomes, and a viable first-line treatment for selected cases, followed by multimodal therapy.

Inflammatory Pseudotumor in the Parapharyngeal Space: Is It Possible to Diagnose by Exclusion?

Inflammatory pseudotumor (IP) is a rare pathologic condition that easily can be confounded with malignancy. The clinical presentation depends on the site of occurrence and the radiological or laboratory findings are not specific. Diagnosis can be established only with histology. We report a case of a 64-year-old woman with IP in an uncommon localization, the parapharyngeal space extending to skull base. Although the diagnosis was not certain after histopathological examination, broad diagnostic workup helped to exclude malignancy or bacterial infection and led to diagnosis of an IP by exclusion. We observed a good clinical and radiological regression of symptoms after administration of oral immunosuppressants, confirming the immunological mechanism of the disease.

Idiopathic Orbital Inflammation Associated With Necrotizing Scleritis and Temporal Bone Inflammation

The authors present a case of aggressive idiopathic orbital inflammation producing necrotizing scleritis along with synchronous tumefactive fibroinflammatory lesion of the temporal bone. A young woman with no medical history presented with sectoral scleritis and mildly reduced vision. Response to initial treatment, which included topical and systemic corticosteroids, as well as systemic nonsteroidal anti-inflammatory drugs, was limited. Over the following months, signs of orbital inflammation developed, including ptosis, proptosis, and limited extraocular motility. MRI revealed both orbital and ipsilateral temporal bone masses. An orbital biopsy was performed revealing a mixed inflammatory infiltrate, whereas a biopsy of the temporal bone mass revealed a tumefactive fibroinflammatory lesion. Biopsy showed no histopathologic evidence of infection nor neoplasm. The patient eventually responded to treatment with systemic prednisone, azathioprine, and rituximab.

Sinonasal and ventral skull base inflammatory pseudotumor: a systematic review

OBJECTIVES/HYPOTHESIS

Inflammatory pseudotumor is a benign idiopathic inflammatory process often misdiagnosed as an infection or neoplasm. This review analyzes all reported cases of sinonasal and ventral skull base inflammatory pseudotumor to date, and provides a framework for evaluation and management of this uncommon condition.

DATA SOURCES

MEDLINE/PubMed database.

REVIEW METHODS

A search for articles related to sinonasal and ventral skull base inflammatory pseudotumor, along with bibliographies of those articles, was performed. Demographics, presentation, radiographic findings, treatment, follow-up, and outcome were analyzed.

RESULTS

Thirty-three articles were reviewed, including a total of 87 patients. The most common presenting symptom was vision change (58.6%). Sinonasal and ventral skull base inflammatory pseudotumor was found in the cavernous sinus in 46.0% of cases. The lesion appeared isointense (66.7% of cases) and homogeneously enhancing on T1-weighted magnetic resonance imaging (MRI), whereas it appeared hypointense on T2-weighted MRI in 90.7% of cases. Inflammatory pseudotumor appeared hyperdense on computed tomography in 78.9% of cases. Histopathological analysis of biopsied specimens revealed presence of inflammatory cells (94.4%) and fibrosis (80.3%). Corticosteroids alone were the most common treatment modality (55.2%), resulting in disease-free patients in 22.9% of cases over a median follow-up period of 17.6 months. Surgical management alone was uncommon (8.0%), but showed high success rate (57.1%).

CONCLUSION

This review is the most comprehensive analysis of sinonasal and ventral skull base inflammatory pseudotumor to date. Radiologic findings and histopathological analysis are essential for diagnosis. Corticosteroids are the most common treatment modality. Surgery, although uncommon, appears to be an efficacious treatment modality.

Inflammatory pseudotumor of the nasopharynx with spread along the trigeminal nerve

Inflammatory pseudotumor of the nasopharynx is a rare diagnosis that is often misinterpreted as carcinoma or lymphoma. It has been referred to as a tumefactive fibroinflammatory lesion, idiopathic pseudotumor, and fibrosing inflammatory pseudotumor. We present a rare case of a 40-year-old African American female from Kenya with inflammatory pseudotumor of the nasopharynx with perineural spread of disease along the trigeminal nerve to discuss the diagnosis and treatment of such an uncommon entity.

Aggressive inflammatory pseudotumor of the mandible

Inflammatory pseudotumor (IP) is a nongranulomatous inflammatory process with no apparent local or systemic cause. The distinction between IP and malignant tumor is of great clinical importance. The incidence of IP in the head and neck region is very low. Inflammatory pseudotumor is a distinct pathological entity rarely found in the jaw bones. A rare case of aggressive IP of the mandible is presented along with its clinicopathologic features and surgical management.

Extraorbital pseudotumor of the petrous apex: biopsy via a transnasal endoscopic approach

Extraorbital idiopathic pseudotumors of the skull base are very uncommon. We report the case of a 50-year-old woman who presented with left ophthalmoplegia and vision loss. Imaging studies revealed an enhancing lesion involving the left petrous apex and cavernous sinus. A transnasal endoscopic approach was used to obtain a biopsy of the left petrous apex. Pathology identified the lesion as an idiopathic pseudotumor. The patient was treated with high-dose steroids and steroid-sparing immunomodulators, and she experienced a significant improvement. To the best of our knowledge, this is the first reported case of a transnasal endoscopic approach to a biopsy of a pseudotumor involving the petrous apex. We discuss the features of this case, and we review the literature on this condition.

Progressive tumefactive fibroinflammatory lesion of the infratemporal fossa treated by radiation therapy

Tumefactive fibroinflammatory lesion (TFIL) is a rare benign tumor in the head and neck region. We present a case of a 40-year-old female with a benign but progressive lesion of the infratemporal fossa, which was diagnosed as TFIL. Patient responded briefly to a course of steroid treatment but eventually showed progression and was unresponsive to further steroids. She was then treated with external beam radiation to a dose of 60 Gy in 30 fractions. After radiation a slow, gradual decrease in tumor size was noted over the course of years and she is free of disease after more than 11 years of follow-up. The major long-term side effect this patient developed was an expected unilateral radiation-induced retinopathy, due to the close proximity of the lesion to the orbit. The dilemma of treatment of benign disease with radiation with potential long-term complications is discussed and a review of the literature on TFIL is presented.

Inflammatory Pseudotumor of the Skull Base

INTRODUCTION: Inflammatory pseudotumor is an idiopathic, non-neoplastic mass lesion with few cases reported in the literature involving only the skull base and related structures. Imaging of skull-base pseudotumors shows characteristics similar to that of nasopharyngeal carcinoma and lymphoma, thereby requiring a biopsy to exclude malignancy. Surgical versus medical management relates to the location of the mass, the extent of bony invasion, and the involvement of corresponding anatomic structures.

METHODS: A retrospective chart review of patients diagnosed with inflammatory pseudotumor of the skull base from a single tertiary care institution over a five-year period.

RESULTS: Five cases of skull-base pseudotumor have been identified and followed from one to four years. In our clinical experience, maintenance oral corticosteroids have proven effective in improving symptoms and significantly reducing radiologic tumor dimensions.

CONCLUSION: Inflammatory pseudotumor of the skull base is a challenging diagnosis due to its occult anatomic location, vague associated symptoms, and nonspecific histology. Low-dose oral corticosteroids are often very effective in management.

Imaging of nasopharyngeal inflammatory pseudotumours: differential from nasopharyngeal carcinoma

The purpose of this study was to describe the MRI findings of inflammatory pseudotumours (IPTs) involving the nasopharynx and to differentiate IPTs from nasopharyngeal carcinoma (NPC). The medical records and imaging studies of 7 patients (6 men, 1 woman; age range, 32-71 years; mean age, 52.4+/-18 years) with IPT involving the nasopharynx were reviewed retrospectively. The MRI findings were compared with those of seven patients with advanced NPC with skull base invasion. All patients with IPT involving the nasopharynx presented with single or multiple cranial neuropathies; six reported pain; and four patients had a recent history of otitis media. Three were initially misdiagnosed as having NPC according to MRI findings, and all underwent nasopharyngeal biopsy to exclude malignancy. 7/7 (100%) patients received systemic corticosteroid treatment; 7/7 (100%) showed initial rapid resolution of clinical symptoms or radiographical findings; 3/7 (42.9%) had resolution of all signs and symptoms; 3/7 (42.9%) still have limited residual symptoms; and 1/7 (14.3%) suffered recurrence 3 years after remission. The characteristic MR findings of IPT include an infiltrative growth pattern, minimal to mild mass effect, hypointensity on T(2) weighted images, and moderate homogeneous enhancement after contrast administration. Intact nasopharyngeal mucosa, internal carotid artery encasement and narrowing, extensive pachymeningeal thickening and a relative paucity of associated neck lymphadenopathy are additional MR findings that favour the diagnosis of IPT rather than NPC. In conclusion, IPT involving the nasopharynx has characteristic MR findings which, together with clinical and laboratory presentations, are helpful in differentiating IPT from malignant tumours, especially NPC.