Exploring Sociodemographic Factors in Allergic Fungal Rhinosinusitis in a Northern California Patient Population

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis (CRS) that has previously been associated with younger age and Black patients. However, the role of demographic and socioeconomic factors in AFRS severity remains to be fully elucidated.

OBJECTIVE

The objective of this study was to determine whether demographic and socioeconomic factors are associated with incidence of AFRS, as well as with disease severity in Northern California.

METHODS

A retrospective cohort study was conducted of adult patients with AFRS and CRS from 2010 to 2019. AFRS was determined by the Bent and Kuhn criteria, and severity was assessed by radiographic evidence of cranioorbital invasion and other clinical parameters. Chi-square and t-test were used to assess demographic and socioeconomic differences between AFRS and CRS cohorts, and multivariable logistic regression was used to assess risk factors for severe AFRS.

RESULTS

Black patients represented 26.2% (55/210 patients) of the AFRS group and 4.9% (842/17,300 patients) of the CRS group, with pairwise comparison of race/ethnicity categories showing that the AFRS group had significantly higher proportions of Black race/ethnicity compared with other race/ethnicities (p < 0.01). AFRS and CRS groups differed significantly by age, with mean ages of 48.7 and 51.0 years, respectively (p = 0.04). There were no significant differences in gender, Medicaid status, comorbidities, and socioeconomic status measures. Multivariate logistic regression showed that Black patients had higher odds of having severe AFRS (adjusted odds ratio = 2.29; 95% confidence interval: 1.18-4.45).

CONCLUSION

AFRS has a unique predilection for Black patients, and severe disease is also more likely in this population.

A Real Headache: Intracranial Extension and Epidural Abscess As Complication of Chronic Mucocele

Mucoceles are benign lesions of salivary glands typically originating from the paranasal sinuses. Intracranial extension and superinfection of these lesions are rare but serious complications of chronic mucoceles. Here, we discuss a patient with a known mucocele, initially lost to follow-up, who presented three years later with headache, purulent rhinorrhea, and intracranial extension of his mucocele with development of an epidural abscess. This case highlights the potential complications of chronic, large mucoceles and emphasizes the importance of thorough evaluation in patients with facial abscesses in the setting of known sinus pathology. Any mucocele with signs of superinfection such as purulent rhinorrhea, abscess near the sinuses, or refractory symptoms should warrant cranial imaging. Mucoceles with evidence of intracranial extension require neurosurgical and/or otolaryngologic evaluation for evacuation and debridement to avoid neurologic injury or devastating infection.

Neurofibromatosis Type 1-Associated Malignant Peripheral Nerve Sheath Tumor in the Nasal Cavity

Malignant peripheral nerve sheath tumors (MPNSTs) are rare soft tissue sarcomas, with 50% of cases associated with type 1 neurofibromatosis (NF-1). A 27-year-old male patient was referred to our department with an extended right nasal cavity MPNST. The lesion extended to the skull base, intracranial, parapharyngeal space, and infratemporal fossa. NF-1 was also confirmed by a neurologist. The patient was negative for distant metastases. Due to the tumor's proximity to vital structures, it was decided to treat it with chemotherapy and radiotherapy. Nasal cavity MPNSTs are particularly uncommon, with few reported cases. They should be included in the differential diagnosis of nasal masses or recurrent nosebleeds, particularly in patients with NF-1. Careful follow-up is essential to detect early recurrence, which contributes to a better prognosis.

Fatal Orbital Cellulitis With Intracranial Abscess: A Case Report

Orbital cellulitis is a sight- and life-threatening condition. Prompt diagnosis and immediate intervention are required. We report a case of fatal odontogenic orbital cellulitis complicated with intracranial abscesses in a 55-year-old gentleman. The patient presented with painful swelling of the left eye associated with reduced eye movement, blurry vision, and a headache. There was generalized periodontitis. Initial imaging was suggestive of left eye orbital cellulitis with intracranial abscess, and intensive systemic antibiotic therapy was initiated. After six weeks of antibiotic therapy, there was an improvement in ocular signs and symptoms. However, the patient developed signs of meningism with a persistent fever. Serial brain imaging demonstrated worsening intracranial abscesses. The patient died eight weeks after the initial onset of presentation. This case emphasized that brain abscesses could be a fatal complication of odontogenic orbital cellulitis. A high index of suspicion is important in diagnosing orbital cellulitis and its complications. Early consideration of surgical intervention is necessary in cases not responding to antibiotic therapy.

Pituitary adenoma with cavernous sinus compartment penetration and intracranial extension: surgical anatomy, approach, and outcomes

Objectives

To understand the different characteristics and growth corridors of knosp grade 4 pituitary adenomas (Knosp4PA) with cavernous sinus (CS) compartments penetration and intracranial extension, aiming to improve the safety, effectiveness, and total resection rate of surgery.

Methods

A case series of 120 Knosp4PA patients with 187 invaded compartments were retrospectively reviewed. A novel surgery-relevant grading system was proposed according to the CS penetrating features. The details of approach drafting, risk prediction, and complication avoidance were analyzed and integrated through illustrated cases.

Results

All enrolled tumor was Knosp4PA which was derived from Knosp subgrades 3A(62.5%) and 3B(37.5%). Based on the tumor growth pathway and its relevant features, five subclassifications of intracranial extension(n=98,81.7%) were classified, which derived from the superior (Dolenc's and Oculomotor subtype, 5% and 24.2%), lateral (Parkinson's subtype,18.3%), and posterior (cerebral peduncle and Dorello's subtype, 5.8% and 1.7%) CS compartment penetration. The size of intracranial extension is assessed by Lou's scale proposed here based on preoperative MRI characteristics. Under Lou's scale, the gross total rate (GTR) decreased (82%, 53%, 22%, and 19%) with grades increased (grade 0,1,2,3, respectively), and presents significant difference between the four groups (p=0.000), as well as between single and multiple compartments involved (p=0.001). Preoperative cranial nerve deficits included the optic nerve (53%), oculomotor nerve (24.2%), and abducent nerve (4.2%), with an overall rate of visual function improvement in 68.1%. Postoperative complications of transient diabetes insipidus, cerebrospinal fluid (CSF) leakage, and cranial nerve deficits were 6.7%, 0.8%, and 0%. No new cranial nerve deficits occurred. The mortality rate was 0.8%.

Conclusion

The concept of "penetration" refines the extracavernous growth pattern, and the five intracranial subclassifications help to understand the potential extension corridors, enhancing adequate exposure and targeted resection of Knosp4PA. This grading system may benefit from its predictive and prognostic value, from which a higher GTR rate can be achieved.

Squamous Cell Carcinoma Scalp With Intracranial Extension: Challenging Case of Multidisciplinary Care

Squamous cell carcinoma (SCC) of the scalp is the second most common non-melanoma cancer of the skin. The incidence of squamous cell carcinoma on the scalp is on the rise, but the intracranial extension is rare. Cranial invasion is rare in SCC of the scalp, but when present, it is associated with a poor prognosis. A 62-year-old female presented with complaints of swelling over the back of her scalp for three months, which rapidly increased in size. She also had a throbbing headache, alopecia in that area, and multiple episodes of pustules in that area. On examination, she had an ulceroproliferative lesion measuring 5*5*3 cm with an irregular surface and varying consistency over the occipital area in the midline surrounded by ulcerations and crusted discharge and fixed to the bone. Contrast-enhanced magnetic resonance imaging (MRI) showed an irregular lesion with the destruction of the right parietal and occipital bones involving both inner and outer tables with intracranial and extracranial components, and the lesion was abutting the superior sagittal sinus. The treatment is surgical resection of the tumor with margin clearance. The treatment plan was designed using a multidisciplinary approach with the collaboration of oncosurgery, neurosurgery, and plastic surgery. The patient underwent wide local excision of the tumor with adequate skin and cranial bone clearance. The tumor was found to have infiltrated the dura mater overlying the superior sagittal sinus. The defect was then closed using a vault prosthetic cover and a scalp transposition flap from the left parietal area. This case report intends to highlight the need for a multidisciplinary approach to the proper management of advanced squamous cell carcinoma to decrease the morbidity and mortality in patients.

Dermoid Cyst of Nasal Tip with a Sinus Tract Extending to the Intracranium: A Case Report

Nasal dermoid cysts are rare congenital anomalies that affect one in 20,000 to one in 40,000 individuals. Herein, we report a case of an initially misdiagnosed nasal dermoid cyst with intracranial extension. Among nasal dermoids, the lesion of the nasal tip is considered uncommon. Therefore, this should always be considered as a differential diagnosis of midline nasal masses, and a proper diagnostic approach should be taken.

Nasoethmoidal Schwannoma as a Mimicar of Esthesioneuroblastoma: A Case Report and Literature Review

Nasoethmoidal schwannomas are rare lesions and their presentation with intracranial extension is even rarer. Here, a patient presenting with rhinorrhea, epistaxis, and proptosis of left eye was diagnosed with giant nasoethmoidal schwannoma extending to frontal lobe and orbit, which was managed with bifrontal craniotomy with endoscopic transnasal gross total excision. This being predominantly a benign lesion has good prognosis if total excision is achieved.

Distinct Histopathologic Features of Complicated Sinusitis

BACKGROUND

Sinusitis complicated by intracranial or orbital extension can be life-threatening and require emergent intervention. Histologic features of complicated sinusitis have yet to be determined and may have significant implications for understanding pathophysiology.

METHODS

A structured histopathology report was utilized to analyze sinus tissue extracted during functional endoscopic sinus surgery (FESS). A total of 13 histopathology variables were compared between patients with complicated sinusitis (CS), CRS without nasal polyps (CRSsNP), and CRS with nasal polyps (CRSwNP).

RESULTS

About 24 CS, 149 uncomplicated CRSsNP, and 191 uncomplicated CRSwNP patients were analyzed. Nasal tissue from CS and CRSwNP patients demonstrated similar levels of overall inflammation (66.7% vs. 69.6% with moderate/severe inflammation, P = .466). Relative to CRSsNP, CS patients showed significantly greater overall inflammation (66.7% vs. 41.6%, P = .019). CS patients demonstrated significantly fewer eosinophils per high power field (eos/HPF) and eosinophil aggregates compared to CRSwNP patients (20.8% vs. 70.7% with 5+eos/HPF, P < .0001; 4.2% vs. 33.5%, P < .0001). Relative to CRSsNP patients, CS patients demonstrated enhanced neutrophil infiltration (45.8% vs. 28.0%, P = .011). About 91.7% of CS patients demonstrated a lymphoplasmacytic predominant inflammatory infiltrate, compared to 69.8% of CRSsNP and 62.8% of CRSwNP patients (P < .0001).

CONCLUSION

Significant histopathological differences were evident in patients with CS, CRSsNP, and CRSwNP. CS patients did not perfectly fit either a CRSsNP or CRSwNP profile, underscoring the importance of delineating the histopathological features of CS. This study offers insight into the histologic aspects of CS, providing initial evidence that it is an aggressive neutrophilic inflammatory process.

A Case of Large Intraoral Teratoma with Intracranial Extension: Peri‑Operative Challenges

A 40-day-old female child presented to us with an oral cavity mass, noticed at birth and progressively increasing in size. Preoperative computed tomography revealed intracranial extension of the lesion. Airway management, securing and maintaining invasive vascular access peri-operatively and transport of the patient to MRI suite were the major challenges. Mask ventilation was difficult and successful intubation required three attempts. Otorhinolaryngologists were present in the theatre during induction to perform a tracheostomy if the situation so demanded.

Management of congenital midline nasofrontal dermoid cysts in two identical twins: Case report

Midline dermoid cysts are uncommon lesions that can lead to severe complications when an intracranial extension exists. We report the cases of two twin sisters referred to surgery for removal of the masses and the intracranial extension. They represent an additional example of familial nasal dermoid cysts, providing further support for a genetic basis for the disorder.

Intracranial complications of midline nasal dermoid cysts

BACKGROUND

Nasal dermoid cysts are common tumors in children. Due to anomalies in embryologic development of the nasal complex, sometimes an intracranial extension exists. When these cysts become infected they can lead to meningitis, brain abscess and death.

METHODS

We report the case of a 1.5-year-old girl admitted to the paediatric intensive care unit after infection of a nasal dermoid cyst.

RESULTS

The infant had a spiking fever and epileptic seizures. She was stabilized, intubated and a CT scan showed a subcutaneous mass with an adjacent zone of encephalitis and brain abscess formation. Neurosurgical interventions were necessary to lower intracranial pressure and control infectious spread. After a hospital stay of 69 days the child could be discharged. Due to her young age, irreversible brain damage is expected.

CONCLUSION

Nasal midline dermoid cysts are considered benign swellings. When an intracranial extension exists, infection can lead to deleterious complications. It is important for health care practitioners to be aware of this imminent risk. Suspicion of a nasal midline dermoid cyst should prompt a careful clinical work-up with an ultrasound followed by CT or MRI imaging. The treatment is complete excision to avoid disastrous complications and recurrences.

Diagnostic performance of CT, MRI, and their combined use for the assessment of the direct cranial or intracranial extension of malignant head and neck tumors

BACKGROUND

Preoperative radiological evaluation of the cranial or intracranial extension of malignant head and neck tumors is critical in the planning of curative surgery.

PURPOSE

To assess the diagnostic accuracy of computed tomography (CT) combined with magnetic resonance imaging (MRI), compared to CT or MRI alone in diagnosing the direct cranial or intracranial extension of malignant head and neck tumors, using histopathologic results as the reference standard.

MATERIAL AND METHODS

CT and MRI images in 41 patients with malignant head and neck tumors abutting the skull were retrospectively reviewed. The images were evaluated for the presence or absence of skull invasion (erosion/destruction of the skull), dural invasion (nodular dural enhancement), and brain invasion (enhancing brain lesion with or without brain swelling/edema). The results of the CT alone, MRI alone, and CT combined with MRI were compared with the histopathologic findings.

RESULTS

Of the 41 patients studied, ten had no invasion, eight had skull invasion, 17 had dural invasion, and six had brain invasion by tumor. The sensitivity/specificity/accuracy of CT alone, MRI alone, and CT combined with MRI for diagnosing intracranial extension were 78.0%/100%/94.5%, 85.4%/80.5%/93.9%, and 95.1%/100%/98.8%, respectively. The sensitivity of CT combined with MRI was significantly higher than those of CT alone ( P = 0.0156) and MRI alone ( P = 0.0313).

CONCLUSION

CT combined with MRI is a more sensitive tool for the diagnosis of the direct cranial or intracranial extension of malignant head and neck tumors than CT alone and MRI alone.

Ganglion cyst of the temporomandibular joint with intradural extension: case report

Intracranial extension of temporomandibular joint (TMJ) ganglion cysts is very rare. Two previously reported cases presented clinically due to effects on cranial nerves and had obvious association with the TMJ on imaging. To the authors' knowledge, intracranial extension of a TMJ ganglion cyst presenting with seizures and mimicking a primary brain tumor has not been previously reported. The patient underwent resection of a presumptive primary cystic temporal lobe tumor, but the lesion had histopathological features of a nonneoplastic cyst with a myxoid content. He was followed with serial imaging for 5 years before regrowth of the lesion caused new episodes of seizures requiring a repeat operation, during which the transdural defect was repaired after the adjacent segment of the TMJ was curetted. A thorough review of all imaging studies and the histopathological findings from the repeat operation led to the correct diagnosis of a TMJ ganglion cyst. This case highlights an unusual presentation of this rare lesion, as well as its potential for recurrence. TMJ ganglion cysts should be included in the differential diagnosis of cystic tumors involving the anterior temporal lobe, presenting with or without seizures. Focused imaging evaluation of the TMJ can be helpful to rule out the possible role of associated TMJ lesions.

Idiopathic orbital inflammation with bone destruction and extension into the paranasal sinuses

Idiopathic orbital inflammation developed in the right orbit of a woman in her mid-thirties, causing tearing, photophobia, diplopia, altered depth perception, proptosis, and pain on eye movements. Computed tomography disclosed a mass involving the intraconal and extraconal nasal right orbit, extending to the orbital apex with anterior displacement of the globe, effacement of the medial rectus muscle, portions of the fat plane, and the superior oblique muscle, and bone destruction with extension of the mass through the orbital floor into the superior maxillary sinus and through the lamina papyracea into the ethmoid sinus. Orbital biopsy disclosed dense fibrous connective tissue with numerous lymphocytes and macrophages. Immunohistochemical stains supported a diagnosis of idiopathic inflammatory pseudotumor involving the orbit and sinus mucosa. Treatment with a prednisone taper and a retrobulbar injection of triamcinolone acetonide have relieved her symptoms and diminished her proptosis. This patient highlights the rare potential of idiopathic orbital inflammation to erode though bone into adjacent cranial structures.

[Invasive sinonasal papilloma with intracranial invasion: Case report and bibliographic review]

INTRODUCTION

Inverted papilloma is a locally-aggressive benign neoplasm of the paranasal sinuses with a high potential for recurrence and malignancy. Intracranial extension is infrequent, and dural penetration even more so, typically associated with recurrence of the disease or its degeneration into squamous cell carcinoma.

CLINICAL CASE

A 32-year-old female patient consulted us for an exophytic lesion in her right nostril and exophthalmos, associated with headache, anosmia and dysgeusia. Craniofacial and brain CT and brain MRI demonstrated a lesion in the right nostril, extending into the aerial sinuses, orbital lateral wall and anterior fossa, with osteolysis and intracranial invasion towards the right frontal region. A mass effect and brain compression were noted. A histological diagnosis of inverted papilloma was made initially. Upon later resection of the lesion by double access, with reconstruction of the anterior cranial fossa, a definitive diagnosis was made of inverted papilloma of the Schneiderian type, with areas of atypical transformation in situ. Post-operatively, the patient has had a favorable course, with full upper airway patency and neither complications nor signs of recurrence after four years of follow-up.

CONCLUSIONS

Intracranial invasion of this pathology is extremely uncommon. When it exists, the tumor has a high potential for local recurrence. Consequently, complete excision of the lesion determines the patient's prognosis.

A Frontal Giant Intradiploic Giant Pearl (Epidermoid Cyst) With Intracranial and Extracranial Extension: A Rare Entity

Craniofacial epidermoid cysts are rare tumors representing 0.2%-1% of all the intracranial tumors. Intradiploic variants account for 25% of these cysts. These cysts are benign, slow-growing, congenital tumors derived from ectodermal remnants misplaced during embryogenesis. Mean age at presentation of these lesions is 40 years; epidermoid cysts are typically asymptomatic (Toglia JU, Netsky MG, Alexander E Jr. Epithelial (epidermoid) tumors of the cranium. Their common nature and pathogenesis. J Neurosurg 1965;23:384-93). Giant extradural epidermoid cysts with profound deformation of the brain and extensive lytic skull lesions may allow a normal life without any significant neurological deficits. Computed tomography scan and magnetic resonance imaging play an important role in the diagnosis of the lesion and management protocol. Histologically, epidermoid cysts are lined by stratified squamous epithelium and are filled with anucleatic keratin (Hao S, Tang J, Wu Z, Zhang L, Zhang J, Wang Z. Natural malignant transformation of an intracranial epidermoid cyst. J Formos Med Assoc 2010;109:390-6). Complete removal of the cyst along with its capsule is the treatment of choice. Recurrences of intradiploic epidermoid cyst have been reported. Here, we report a case of 14-year-old girl presenting with a giant frontal intradiploic epidermoid cyst with an intracranial and extracranial extension without any neurological deficits. Bifrontal craniotomy was performed and cyst was excised in toto.

Frontal Mucocele Mimicking a Frontal Subcutaneous Tumor

Mucoceles are chronic, expanding, mucosa lined pathology of the paranasal sinuses. Frontal mucocele usually presents with the visual complaints such as diplopia, diminution of vision, visual field defect, ptosis, orbital swelling, retro-orbital pain, displacement of eye globe, and proptosis. Very rarely, it can be present as a subcutaneous swelling. This article presents a 58-year-old male patient presenting with an asymptomatic periorbital swelling and a painless forehead mass of 3 years duration. There was a partial ptosis, and an elongated, soft, subcutaneous mass over the forehead. Surgical excision of the mass confirmed the diagnosis of a mucocele. Postoperatively, the patient was asymptomatic. A subcutaneous soft-tissue mass may be the presenting complaint of a frontal mucocele. Careful examination of the surrounding skin may suggest the diagnosis of sinus-related disease and thus direct appropriate investigations.

Midline Craniofacial Masses in Children

Nasal dermoids, encephaloceles, and gliomas are rare congenital lesions that result from improper embryologic development. The differentiation between them and a firm understanding of their pathology is necessary to avoid unnecessary complications. In view of their potential intracranial connection, prompt diagnosis and treatment are paramount. The authors review the embryology, diagnoses, radiologic work-up, surgical management, and complications of these midline craniofacial masses in children.

Mucoepidermoid Carcinoma of Palatal Minor Salivary Glands with Intracranial Extension: A Case Report and Literature Review

Mucoepidermoid carcinoma (MEC) is one of the most common malignant tumors of both major and minor salivary glands. Although there are reports of parotid MEC tumors extending intracranially via the facial nerve, intracranial extension from MEC originating from minor salivary glands in the palate has not previously been reported. This report presents a case of MEC arising from the minor salivary glands of the palate and extending into the middle fossa via the foramen rotundum with perineural invasion of the maxillary division of the trigeminal nerve. The patient received surgical intervention via a combined otolaryngology and neurosurgery approach to achieve gross total resection of the tumor. This was followed by adjuvant radiotherapy. The epidemiology, histopathology, and treatment of MEC originating from salivary glands are discussed.

Esthesioneuroblastoma with intracranial extension: A non-surgical approach

Esthesioneuroblastoma is a rare tumor arising from the olfactory mucosa of upper respiratory tract. The primary modality of treatment has been surgery with craniofacial resection followed by post-operative radiotherapy. There are only a few reported cases of non-surgical approaches. We report a case of esthesioneuroblastoma with intracranial extension treated with Vincristine, Adriamycin, Cyclophosphamide, Ifosfamide, Etoposide protocol followed by radiation with 5 years of follow-up. This is the first reported case using this chemotherapy schedule.

Inverted Sinonasal Papilloma Masquerading as a Malignancy - Report of an Unusual Case

Inverted sinonasal papilloma (ISP) is a benign epithelial neoplasm arising from the Schneiderian membrane. We report a case of ISP in a 50-year-old male that clinically presented as a polypoid mass in the nasal cavity. Imaging studies revealed it to be an aggressive lesion showing intracranial extension. On histopathological examination of the excised specimen, a diagnosis of ISP was arrived at. However, an extensive sampling of the tissue revealed no evidence of any malignant transformation. Taking into account the suggested viral aetiology for such lesions and the aggressiveness observed in this case, human papillomavirus (HPV) profiling was done but it turned out to be negative. Only one other case of inverted sinonasal papilloma arising from the nasal cavity and involving the brain has been reported in the literature to date. Considering the alarming clinical course in spite of its benign nature, it is important for the pathologist and surgeon to be well informed about this lesion.

Multiple myeloma with intracranial extension and bilateral renal infiltration: A case report and review of the literature

Multiple myeloma (MM) is a rare hematological malignancy, characterized by uncontrolled proliferation of plasma cells in the bone marrow. MM is usually confined to the bone marrow, however, it may occasionally infiltrate other tissues, which is known as extramedullary plasmacytoma (EMP). The majority of EMPs involve the head and neck region, although different anatomical sites, including the gastrointestinal tract, central nervous system, thyroid gland and breast may also be affected. The simultaneous presentation of EMP in the kidney and head is rare, presenting diagnostic challenges due to its unusual location and non-specific or absent symptoms. To the best of our knowledge, no case of extramedullary plasmacytoma presenting with simultaneous renal and intracranial infiltration has been reported in the literature thus far. However, the present study reports a case of primary renal and intracranial extramedullary plasmacytoma in a 76-year-old male patient. The patient presented with a swelling over the right side of the forehead, which had slowly increased in size prior to hospital admission. The swelling was associated with dizziness and weakness, without bone pain. Contrast magnetic resonance imaging suggested an osteolytic skull lesion with intracranial extension. Abdominal enhanced computed tomography scanning revealed a large tumor mass extending around and into the kidneys. Immunohistochemical examination of the renal tumor biopsy, and blood and serum samples, as well as immunoelectrophoresis of serum proteins, resulted in a diagnosis of EMP being proposed. Therefore, the patient was administered with two cycles of cyclophosphamide and thalidomide in combination with dexamethasone. Follow-up imaging performed 4 months later revealed almost complete disappearance of the intracranial tumor mass and renal infiltration. The current study also presented a review of the literature. This study revealed that EMPs may co-exist with MM or present as the main symptom of MM. The diagnosis of an EMP is complex and requires radiological, hematological, biochemical and histological investigation. At present, no guidelines for EMP treatment have been established and thus, treatment options include surgery, chemotherapy and radiotherapy, either alone or in combination. We hypothesize that combined treatment may provide the best patient outcome.

Calvarium and dura mater as delayed sites of distant metastasis from papillary thyroid carcinoma

Background

Skull calvarium and dura mater are rare sites of distant metastasis, and mostly have been reported in lung, breast, and prostate malignancies. However, the calvarial and dural metastases from papillary thyroid cancer (PTC) are rare entities and pose diagnostic and therapeutic challenges. To date, only seven cases of calvarial metastasis with intracranial extension from PTC have been reported in literature. However, true dural metastasis from PTC has not yet been reported.

Case presentation

A 65-year-old Saudi woman presented with 6 months history of painful posterior scalp lump, 7 years after initial diagnosis of PTC. Computed tomography and magnetic resonance imaging showed occipitoparietal calvarial lesion with massive intracranial extension. Another para-sagittal lesion was found at the top of corpus callosum mimicking a meningioma. Histopathology of para-sagittal lesion and the biopsy of calvarial mass confirmed the diagnosis of metastatic PTC. After surgical resection, residual tumors were treated with postoperative intensity-modulated radiation therapy. At 13 months of follow-up, patient was alive and without any signs of recurrence.

Conclusion

Calvarial and dural metastases from PTC are extremely rare clinical entities. Surgical resection followed by postoperative radiotherapy is the treatment of choice. However, for such cases, multidisciplinary approach can prolong the treatment outcome and survival.

Primary Ewing's sarcoma of the sinonasal tract, eroding the ethmoid and sphenoid sinus with intracranial extension: A rare case report

Ewing's sarcoma (ES) is an aggressive tumour that may present with skeletal and extraskeletal forms. The extraskeletal form is rarely encountered in the head and neck region and is extremely rare in the sinonasal tract. This is the case report of a ES of the ethmoid sinus with intracranial and orbital extension in a 33-year-old male patient who presented with anosmia, epistaxis, reduction of visual acuity in the left eye and headache. On otorhinolaryngological clinical examination and biopsy via flexible endoscope, the lesion was misdiagnosed as ethmoid sinus carcinoma. The subsequent magnetic resonance imaging (MRI) of the brain revealed a large mass (6×7 cm) eroding the ethmoid and sphenoid sinuses, extending beyond the orbits and occupying the anterior cranial fossa with a maximum extension of ~5 cm. The patient underwent surgical resection and the microscopic examination of the specimen established the diagnosis of ES (immunohistochemically positive for CD99, neuron-specific enolase, CD56, synaptophysin, pancytokeratin, low-molecular weight cytokeratins and vimentin. The periodic acid Schiff stain exhibited strong intracytoplasmic block positivity and fluorescence in situ hybridization revealed a t(22;11) translocation. First-line chemotherapy was administered for 3 cycles; however, on restaging MRI, local disease progression was diagnosed. The patient received radiotherapy and second-line chemotherapy for 6 cycles. At 15 months after the diagnosis, the patient remains recurrence-free and maintains a good functional status and quality of life.

A giant frontoethmoid mucocele with intracranial extension

Mucoceles are mucus-containing cysts lined by epithelium. Although benign, they may show expansive growth and remain undiagnosed until symptoms due to compression of surrounding structures arise. We report a rare case of frontoethmoid mucocele with intracranial extension in an 80-year-old woman with complaints of headache, right diplopia and proptosis. A right frontoorbital craniotomy was performed, and a mucocele in the frontal sinus extending into the frontal lobe and orbit was totally removed. The patient was successfully treated without any complication. The two-year follow-up results were satisfactory. Magnetic resonance imaging excluded any recurrence of the mucocele. Combined intranasal and transcranial approach is necessary to treat giant frontoetmoid mucoceles with intracranial extension.

Usefulness of 11C-methionine positron emission tomography for detecting intracranial ameloblastic carcinoma: A case report

Ameloblastic carcinoma, secondary type, is an extremely rare odontogenic malignant tumor. The present study reports the case of a 58-year-old male with ameloblastic carcinoma that extended into the intracranial space close to the internal carotid artery. Surgical excision was performed, as headaches were being caused via compression by the mass. Small remnants of the tumor remained surrounding the internal carotid artery following surgical resection. Although the remnant tissue was not detected on magnetic resonance imaging or 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET), it was clearly visualized on ¹¹C-methionine PET in the early post-operative follow-up period. No neurological deficits were exhibited during the follow-up period, and ¹¹C-methionine PET was able to detect the remnant lesion distribution in the intracranial space. The current study presents a rare case of ameloblastic carcinoma that extended into the intracranial space. In addition, several diagnostic imaging tools were compared in order to determine the most suitable imaging modality. At present, the patient is continuing a therapeutic course of radiation and evident mass reduction has been observed. However, the therapeutic effects are currently under consideration. To the best of our knowledge, this is the first study on the effectiveness of using ¹¹C-methionine PET for detecting ameloblastic carcinoma with intracranial extension.

Pigmented villonodular synovitis of the temporomandibular joint with intracranial extension: A case series and systematic review

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder of the synovial membrane. PVNS generally affects large joints but occasionally involves the temporomandibular joint (TMJ), with occasional extension into the middle cranial fossa. The purpose of this study was to report our experience with PVNS along with a focused literature review.

METHODS

Patients with PVNS of the TMJ treated at the University of California - San Francisco from 2007 to 2013 were reviewed. A PubMed search was performed to identify additional cases.

RESULTS

Five patients underwent surgical resection, with 1 recurrence at 61 months. A literature review identified 58 patients, 19 of which had intracranial involvement. Interestingly, intracranial extension was more common in men. Intracranial extension was not associated with an increased rate of recurrence.

CONCLUSION

PVNS of the TMJ is a rare entity associated with excellent outcomes, even with intracranial extension. Management should consist of maximal resection, with radiotherapy reserved for extensive or recurrent lesions.