Differential Diagnosis of Necrotizing Sinonasal Lesions

Granulomatosis with polyangiitis or its mimic? A case report

Differentiation between granulomatosis with polyangiitis (GPA) limited to the upper airways and cocaine-induced midline destructive lesion (CIMDL) may be particularly difficult because of their common histopathologic features and antineutrophil cytoplasmic antibody (ANCA) profiles. We herein present a case involving a young woman with an initial diagnosis of GPA based on upper and lower airway manifestations and constitutional symptoms, histopathologic evidence of granulomas, a positive cytoplasmic ANCA indirect immunofluorescent test result, and proteinase 3 positivity by enzyme-linked immunosorbent assay (ELISA). CIMDL was confirmed based on the appearance of a hard palate perforation, positivity for methylecgonine on urine toxicology, a positive perinuclear ANCA indirect immunofluorescent test result, and subsequent human neutrophil elastase (HNE) ANCA positivity by ELISA. Finally, based on the coexistence of CIMDL, constitutional symptoms, and lower airway manifestations, the diagnosis was modified to cocaine-induced GPA mimic. Urine toxicology for cocaine and HNE ELISA are indicated in young patients with GPA who develop limited airway disease to check for the presence of CIMDL and cocaine-/levamisole-induced ANCA-associated vasculitis. Continued abstinence from cocaine is the first-choice therapy for both CIMDL and cocaine-induced GPA mimic.

An Unusual Case of Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type Masquerading as Dacryocystitis and Sinusitis

Extranodal natural killer (NK)/T-cell lymphoma, nasal type (NNKTL) is a rare and highly aggressive non-Hodgkin lymphoma originating from NK or γδ T cells infected by Epstein-Barr virus (EBV). In the United States, NNKTL is usually noted in people of Asian or Hispanic descent. Natural killer/T-cell lymphoma, nasal type commonly involves the upper aerodigestive tract, including the nasopharynx, nasal cavity, Waldeyer's ring, and oropharynx. Extensive local destruction and invasion has been noted, especially of the paranasal sinuses, hard palate, and central nervous system; involvement of the nasolacrimal duct with dacryocystitis is yet to be reported. We report a rare case of a Hispanic man with extranodal NNKTL masquerading as persistent dacryocystitis and necrotizing sinusitis unresponsive to antibiotics and surgical intervention. An extensive background of necrosis and inflammation was noted on pathology, and additional analysis with immunohistochemistry and in situ hybridization after repeat biopsy were necessary for accurate diagnosis.

A case of COVID-19-related necrotic nasal ulceration

We are reporting a case of a COVID-19-related necrotic nasal ulcer. All other common etiologies were excluded after a full round of investigations. Even though COVID-19 has been known to cause skin ulcers via different mechanisms, this is the first nasal ulcer to be reported in the current literature.

Two Cases of Herpes Virus Infection of Nose Mimicking Acute Invasive Fungal Infection in Immunocompromised Hosts

Various invasive fungal infections can occur in immunocompromised hosts, and an acute invasive fungal infection (AIFI) can be fatal. Because of its high mortality rate, AIFI must be quickly diagnosed and treated, such as anti-fungal agents or surgical debridement. In an immunocompromised host, nasal herpes simplex infection, usually caused by herpes simplex virus (HSV) type-1, can have various clinical manifestations, some of which can mimic AIFI. However, the management of acute viral infection differs significantly from invasive fungal infections of the nose. A fast and accurate differential diagnosis is mandatory because a delay in the disease-specific treatment of acute invasive infections can lead to mortality. This report describes two immunocompromised patients with mucosal and skin lesions around the nose. We provide clinical clues when mucosal lesions of the nasal cavity and skin lesions around the nose develop in immunocompromised hosts.

Necrotizing Bacterial Rhinitis in an Immunocompromised Patient

Specific bacterial infections can cause rapid necrosis of the nasal mucosa in immunocompromised patients, mimicking an invasive fungal infection. The exclusion of the latter is a priority because rapid deterioration and death may ensue within hours to days. The time lag between investigations and final diagnosis warrants empiric administration of Amphotericin B but patients are exposed to significant side effects. Histopathology and culture of the nasal tissues provide the necessary diagnostic clues to avoid inappropriate treatment.

Differential diagnosis of sinonasal extranodal NK/T cell lymphoma and diffuse large B cell lymphoma on MRI

Purpose

To evaluate whether imaging features on conventional magnetic resonance imaging (MRI) can differentiate sinonasal extranodal natural killer/T cell lymphomas (ENKTL) from diffuse large B cell lymphoma (DLBCL).

Methods

Consecutively, pathology-proven 59 patients with ENKTL and 27 patients with DLBCL in the sinonasal region were included in this study. Imaging features included tumor side, location, margin, pre-contrast T1 and T2 signal intensity and homogeneity, post-contrast enhancement degree and homogeneity, septal enhancement pattern, internal necrosis, mass effect, and adjacent involvements. These imaging features for each ENKTL or DLBCL on total 86 MRI scans were indicated independently by two experienced head and neck radiologists. The MRI-based performance in differential diagnosis of the two types of lymphomas was evaluated by multivariate logistic regression analysis.

Results

All ENKTLs were located in the nasal cavity, with ill-defined margin, heterogeneous signal intensity, internal necrosis, marked enhancement of solid component on MRI, whereas DLBCLs were more often located in the paranasal sinuses, with MR homogenous intensity, mild enhancement, septal enhancement pattern, and intracranial or orbital involvements (all P < 0.05). Using a combination of location, internal necrosis and septal enhancement pattern of the tumor in multivariate logistic regression analysis, sensitivity, specificity, and accuracy in differential diagnosis of ENKTL and DLBCL were 100%, 79.4%, and 91.9%, respectively, for radiologist 1, and were 98.3%, 81.5%, and 93.0%, respectively, for radiologist 2.

Conclusion

MRI can effectively differentiate ENKTL from DLBCL in the sinonasal region with a high diagnostic accuracy.

Coagulase-negative staphylococci (CoNS) as a significant etiological factor of laryngological infections: a review

This review article shows that coagulase-negative staphylococci (CoNS) are widely responsible for laryngological diseases. General characteristics of CoNS infections are shown in the introduction, and the pathogenicity in terms of virulence determinants, biofilm formation and genetic regulation mechanisms of these bacteria is presented in the first part of the paper to better display the virulence potential of staphylococci. The PubMed search keywords were as follows: CoNS and: nares infections, nasal polyps, rhinosinusitis, necrosing sinusitis, periprosthetic joint infection, pharyngitis, osteomyelitis of skull and neck bones, tonsillitis and recurrent tonsillitis. A list of laryngological infections and those related to skull and neck bones was presented with descriptions of the following diseases: rhinosinusitis, necrotizing sinusitis, nasal polyps, nares and nasal skin infections, periprosthetic joint infections, osteomyelitis, pharyngitis, and tonsillitis. Species identification and diagnostic problems challenging for diagnosticians are presented. Concluding remarks regarding the presence of CoNS in humans and their distribution, particularly under the effect of facilitating factors, are mentioned.

Intranasal tissue necrosis associated with opioid abuse: Case report and systematic review

OBJECTIVE

Opioid abuse is a common disorder affecting over 2 million Americans. Intranasal tissue necrosis is a previously described sequela of nasal opioid inhalation, with a similar presentation to invasive fungal rhinosinusitis (IFRS). The goal of this case report and systematic review is to evaluate the evidence supporting this uncommon disease, with qualitative analysis of the presentation, management and treatment outcomes.

DATA SOURCES

MEDLINE, EMBASE, Google Scholar, Scopus, and Web of Science.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting intranasal mucosal injury associated with prescription opioid abuse. Primary outcomes included clinical presentation, treatment strategies, and outcomes.

RESULTS

Systematic review identified 61 patients for qualitative analysis. Common clinical features include facial pain without a history of chronic sinusitis or known immunodeficiency. Diagnostic nasal endoscopy revealed superficial debris with underlying tissue necrosis, consistent with a preliminary diagnosis of IFRS. Characteristic pathologic findings include mucosal ulceration with an overlying acellular substrate, often with polarizable material. Fungal colonization is often reported, with several accounts of angiocentric invasion in immunocompetent patients. Complete symptom resolution is expected following surgical debridement with cessation of intranasal opioid inhalation, with 89% of identified patients experiencing a complete resolution of disease.

CONCLUSION

Intranasal opioid abuse is a prevalent condition associated with chronic pain and tissue necrosis that is clinically concerning for invasive fungal disease. Whereas IFRS must be excluded, even in patients without known immunodeficiency, complete resolution of symptoms can be expected following surgical debridement with cessation of opioid abuse. Laryngoscope, 1767-1771, 2018.

Invasive fungal sinusitis: treatment of the orbit

PURPOSE OF REVIEW

To summarize diagnostic techniques for invasive fungal rhinosinusitis and provide a review of treatment options once disease has spread to the orbit.

RECENT FINDINGS

Improved imaging criteria, polymerase chain reaction and other serologic tests show promise in advancing our ability to accurately diagnose invasive fungal disease. Currently, there exists three treatment options for infected orbital tissue: exenteration, conservative debridement and transcutaneous retrobulbar injection of amphotericin B. Exenteration, the most frequently reported intervention, has not been proven to enhance survival. Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are increasingly considered reasonable first-line options.

SUMMARY

Although investigative tools are improving, invasive fungal rhinosinusitis can still pose a diagnostic challenge. No one treatment option for the orbit has been proven superior to another. Therefore, it is justified to initiate therapy by prioritizing less morbid procedures. If deterioration is continually noted, more invasive interventions can then be employed. The treatment algorithm established at our institution is provided.

Inflammatory and Infectious Lesions of the Sinonasal Tract

The sinonasal tract is frequently affected by nonneoplastic inflammatory diseases. Inflammatory lesions of the sinonasal tract can be divided into 3 main categories: chronic rhinosinusitis, which encompasses a heterogeneous group of entities, all of which result in mucosal inflammation with or without polyps-eosinophils; infectious diseases; and autoimmune diseases and vasculitides, which can result in midline necrosis and facial deformities. This article reviews the common inflammatory lesions of the sinonasal tract with emphasis on infectious diseases, vasculitis, iatrogenic, and diseases of unknown cause. Many of these lesions can result in midline destruction and result in facial deformity.

Pathology of Fungal Rhinosinusitis: A Review

Fungal rhinosinusitis (FRS) comprises a spectrum of disease processes that vary in clinical presentation, histologic appearances, and biological significance. FRS can be acute or chronic and is most commonly classified as non-invasive or invasive based on whether fungi have invaded into tissue. This manuscript will review the pathologic classification of FRS.