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Val-Bernal JF, Martino M, Castaneda-Curto N, García-Triana M, Teigeiro-Núñez V. Cholesterol granuloma in an antrochoanal polyp. A rare lesion in children. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 51:262-266. [PMID: 30269780 DOI: 10.1016/j.patol.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/09/2018] [Accepted: 03/25/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- José-Fernando Val-Bernal
- Pathology Unit, Medical and Surgical Sciences Department, University of Cantabria and IDIVAL Research Institute, Santander, Spain.
| | - María Martino
- Anatomical Pathology Service, Marqués de Valdecilla University Hospital, Medical Faculty, University of Cantabria and IDIVAL Research Institute, Santander, Spain
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Han BH, Choi IS. A Case of Cholesterol Granuloma of Maxillary Sinus Misdiagnosed as Odontogenic Cyst. JOURNAL OF RHINOLOGY 2018. [DOI: 10.18787/jr.2018.25.2.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Byung Hyun Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Inje University of College of Medicine, Ilsan Paik Hospital, Ilsan, Korea
| | - Ick Soo Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Inje University of College of Medicine, Ilsan Paik Hospital, Ilsan, Korea
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Cholesterol granuloma of the frontal sinus: a case report. Case Rep Otolaryngol 2012; 2012:515986. [PMID: 23150840 PMCID: PMC3488387 DOI: 10.1155/2012/515986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 10/10/2012] [Indexed: 11/17/2022] Open
Abstract
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.
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Durgam A, Batra PS. Paranasal sinus cholesterol granuloma: systematic review of diagnostic and management aspects. Int Forum Allergy Rhinol 2012; 3:242-7. [PMID: 23044766 DOI: 10.1002/alr.21093] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 07/07/2012] [Accepted: 07/17/2012] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Aditya Durgam
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Cassano M, Pennella A, Taranto FD, Limosani P, Simone M. Cholesterol granuloma of the maxillary sinus in a young patient with associated neurosurgical pathology. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.pedex.2008.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Karaky AA, Sawair FA, Baqain ZH, Hassona Y, Khraisat A. Cholesterol granuloma of the maxillary sinus encountered during floor augmentation procedure: A case report. Clin Implant Dent Relat Res 2009; 12:249-53. [PMID: 19438963 DOI: 10.1111/j.1708-8208.2009.00151.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ashraf Abu Karaky
- Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology and Periodontology, The University of Jordan, Amman, Jordan.
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Nakagawa T, Asato R, Ito J. Cholesterol granuloma of the posterior ethmoid sinus mimicking meningocele. Acta Otolaryngol 2007:47-50. [PMID: 17453444 DOI: 10.1080/03655230601066744] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Takayuki Nakagawa
- Department of Otolaryngology, Head and Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Chao TK. Cholesterol granuloma of the maxillary sinus. Eur Arch Otorhinolaryngol 2006; 263:592-7. [PMID: 16506040 DOI: 10.1007/s00405-006-0015-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Accepted: 09/09/2005] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Ting-Kuang Chao
- Department of Otolaryngology, Far Eastern Memorial Hospital, 21, Sec. 2, Nan-Ya S Rd., Pan-Chiao, Taipei, Taiwan.
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Jackler RK, Cho M. A new theory to explain the genesis of petrous apex cholesterol granuloma. Otol Neurotol 2003; 24:96-106; discussion 106. [PMID: 12544037 DOI: 10.1097/00129492-200301000-00020] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To propose a new hypothesis that attempts to explain the pathogenesis of petrous apex cholesterol granuloma (PA CG). CLASSIC OBSTRUCTION-VACUUM HYPOTHESIS: PA CGs form when mucosal swelling blocks the circuitous pneumatic pathways to the apical air cells. Trapped gas resorption results in a vacuum that triggers bleeding, and CG forms through anaerobic breakdown of blood products. PROBLEMS WITH THE CLASSIC (OBSTRUCTION-VACUUM) HYPOTHESIS: Impaired ventilation of mucosa-lined pneumatic tracts in the middle ear, mastoid, paranasal sinuses, and lung are very common, but CG is rare. The extraordinary levels of temporal bone pneumatization typically observed in PA CG cases is indicative of excellent ventilation and freedom from inflammatory mucosal disease. Were under pressure due to gas absorption alone sufficient to trigger hemorrhage, CG ought to be frequent in otitis media with effusion. PATIENTS The opposite PA of 13 patients with PA CG compared with 31 highly pneumatic PAs in patients undergoing imagery for non-otologic reasons. MAIN OUTCOME MEASURE The nature of the bony partition, as seen on computed tomography, between the PA air cell system and the adjacent marrow compartment. RESULTS 4 of 13 PAs with CGs on the opposite side showed deficient septation between air cells and marrow, whereas this was not observed in any of the 31 extensively pneumatized normal ears. NEW HYPOTHESIS (EXPOSED MARROW): As cellular tracts penetrate the apex during young adulthood, budding mucosa invades and replaces hematopoietic marrow. The bony interface becomes deficient, with coaptation of richly vascular marrow and the mucosal air cell lining. Hemorrhage from the exposed marrow coagulates within the mucosal cells and occludes outflow pathways. Sustained hemorrhage from exposed marrow elements provides the engine responsible for the progressive cyst expansion. As the cyst expands, bone erosion increases the surface area of exposed marrow along the cyst wall. This exposed marrow theory explains the unique proclivity of the healthy and well-pneumatized PA to form a CG.
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Affiliation(s)
- Robert K Jackler
- Department of Otolaryngology, Head and Neck Surgery, University of California San Francisco, 94143-0342, USA.
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Ochiai H, Yamakawa Y, Fukushima T, Nakano S, Wakisaka S. Large cholesterol granuloma arising from the frontal sinus--case report. Neurol Med Chir (Tokyo) 2001; 41:283-7. [PMID: 11396310 DOI: 10.2176/nmc.41.283] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 59-year-old male presented with a large cholesterol granuloma arising from the frontal sinus manifesting as a large, fluctuated, soft mass in his brow, compressing left eye. Skull radiography showed dilation of the frontal sinus. Computed tomography and magnetic resonance imaging revealed a cystic mass extending into the left orbit and anterior cranial fossa. Gross inspection at the frontal craniotomy showed mucinous, dark green fluid intermingled with shining material. The histological diagnosis was cholesterol granuloma with epithelial lining. Large cholesterol granuloma with facial deformity is always associated with bone and cosmetic problems. Wide opening of the frontal sinus followed by cyst wall removal and plastic repair of the skull is necessary.
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Affiliation(s)
- H Ochiai
- Department of Neurosurgery, Miyazaki Medical College, Miyazaki
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Kunt T, Ozturkcan S, Egilmez R. Cholesterol granuloma of the maxillary sinus: six cases from the same region. J Laryngol Otol 1998; 112:65-8. [PMID: 9538449 DOI: 10.1017/s002221510013991x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It is common to find cholesterol granuloma in the mastoid antrum and air cells of the temporal bone, but it is very rare in paranasal sinuses. In the development of this pathology, the key factor is the presence of a closed cavity containing exudate and blood. Six cases of cholesterol granuloma of the maxillary sinus are presented from six years' study in our hospital. According to the main symptoms, clinical findings, and radiological appearance (except the destruction of the antrum wall in some patients), the pathology was similar to chronic maxillary sinusitis. All the patients were treated with radical operative techniques. In this study, we reviewed the literature and our cases, and could not detect any findings to explain why this pathology had occurred frequently in our district. We strongly recommend that investigations should be carried out on all specimens obtained from paranasal sinus surgery, because the cholesterol granuloma in the maxillary antrum could be mistaken for chronic sinusitis.
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Affiliation(s)
- T Kunt
- Department of Otolaryngology, Cumhuriyet University, Medical School Hospital, Sívas, Turkey
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Affiliation(s)
- S C Marks
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
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Abstract
A 35-year-old male complained of recurring headache and nasal obstruction over a 4-year period. A Caldwell-Luc operation was subsequently performed on the left maxillary sinus and a greenish appearing material was removed. Microscopic examination of the tissue specimen showed a granulomatous tissue with typical cholesterol clefts and inflammatory changes consistent with chronic sinusitis. This entity is presented and reviewed.
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Affiliation(s)
- G Erpek
- Department of Otolaryngology, Inönü University Medical School, Malatya, Turkey
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Rath-Wolfson L, Talmi YP, Halpern M, Levit I, Zohar Y, Gal R. Cholesterol granulomas of the maxillary sinus presenting with nasal obstruction. Otolaryngol Head Neck Surg 1993; 109:956-8. [PMID: 8247581 DOI: 10.1177/019459989310900530] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- L Rath-Wolfson
- Department of Pathology, Golda Meir Medical Center, Petah-Tikvah, Israel
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Abstract
Cholesterol granuloma of the orbital bones is a rare but readily recognizable clinical and radiologic entity usually affecting men. Twenty-seven patients are reported, and in all except one, the frontal bone in the region of the lacrimal fossa was involved. These lesions produced an area of osteolysis in the frontal bone with expansion into the extraperiosteal space of the lacrimal fossa, causing fullness of the upper lid and proptosis. The granuloma always remained extraperiosteal and was composed of a granulomatous reaction surrounding cholesterol crystals and altered blood. It is postulated that cholesterol granuloma occurs because of hemorrhage into the diploe of the bone. Extraperiosteal surgical removal cured all patients. Some previous reports have failed to identify the true nature of this lesion and confused its nomenclature.
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Affiliation(s)
- A A McNab
- Orbital Clinic, Moorfields Eye Hospital, London, England
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Abstract
Cholesterol granulomata of the middle ear occasionally accompany chronic middle-ear diseases with diminished ventilation. In the paranasal sinuses, especially in the frontal sinus, they have occasionally been mentioned in the literature. Disordered ventilation and impaired drainage are decisive pathogenic factors in the causation of cholesterol granuloma. Views remain divided on the source of the cholesterol and on the importance of bleeding in the development of cholesterol granuloma. Two patients with a cholesterol granuloma of the frontal sinus are presented and discussed.
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Affiliation(s)
- S Bütler
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital, St. Gallen, Switzerland
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Abstract
The cholesterol granuloma is a particular form of granulation tissue developing as part of a variety of tissue reactions, Cholesterol granuloma is not related to cholesteatoma which may be regarded as an epidermoid cyst of the middle ear or temporal bone. Cholesterol granulomas are rarely associated with such cases (Friedmann, 1976; Gherini et al., 1985). Microscopically, the cholesterol granuloma consists of dense masses of cholesterol crystals which appear as clefts. They are surrounded by foreign body giant cells, foam cells, plasma cells and lymphocytes. There is frequently some fresh blood and some blood pigment (Wilhelm, 1977; Beales, 1979; Gibb, 1979). It seems probable that inflammation and prolonged obstruction of a bony cavity that is normally aerated, are the main ways in which cholesterol is concentrated in the paranasal sinuses. It could be expected to be relatively frequent in the maxillary and frontal sinus, but only a few cases have been reported in the literature and only nine cases affecting the maxillary sinus have been published over the last 22 years (Milton and Bickerton, 1986). We have recently found a cholesterol granuloma arising in the maxillary antrum.
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Affiliation(s)
- H A Gunes
- Department of Pathology, Medical School, Cumhuriyet University, Sivas, Turkey
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Abstract
Cholesterol granuloma in sites other than the ear may present to many different specialties. Diagnosis is rarely suspected pre-operatively, and depends on the finding of a characteristic histological picture. It is generally considered that malaeration with haemorrhage into a cavity which is normally aerated is the primary event in the development of this condition. Nine cases of cholesterol granuloma affecting the maxillary sinus are described, together with the radiological appearances in some cases. The main differential diagnosis in these cases were mucoceles of the maxillary antrum, cysts arising within the sinus, or cysts of dental origin, and in those cases showing expansion or erosion of the maxillary sinus, malignant disease. The results of treatment are discussed.
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