Partial Removal of Orbital Tumor in Rosai-Dorfman Disease

BACKGROUND

Rosai-Dorfman disease is a rare idiopathic histiocytic proliferation disorder that typically presents with painless cervical lymphadenopathy. We report our experience with the management of a case of Rosai-Dorfman disease with compressive optic neuropathy.

CASE

Rosai-Dorfman disease involving the bilateral orbital and paranasal sinuses was diagnosed in a 14-year-old boy. Diagnosis was based on the characteristic histopathologic features of sinus histiocytosis, composed of large, round S-100 protein-positive histiocytes with striking emperipolesis. The boy received chemotherapy to resolve the bilateral proptosis and compressive optic neuropathy in the right eye, but this treatment failed. Orbital debulking surgery using the Lynch approach was performed.

OBSERVATIONS

Corneal exposure was resolved and visual acuity recovered from 14/20 to 20/20 after partial removal of the tumor mass. There were no complications after surgery. During the 22 months of follow-up, orbital tumor masses redeveloped to cause lagophthalmos again, but did not cause visual impairment.

CONCLUSIONS

Rosai-Dorfman disease is a rare disorder, especially in Asia. The disease is usually chronic with spontaneous remission and is refractory to treatment. Partial removal of tumor masses is a workable way to improve visual acuity and correct corneal exposure. Before carrying out this procedure, we discussed with the parents of the patient the potential complications that might follow surgery and secured their permission before proceeding further.

[Unusual nasal clinical entities]

Three cases of rare entities in nasal pathology are reported. Two of them are high-grade lymphomas (T/NK type), with nasal blockage as the first symptom. Clinical course and treatment response are described. The third case refers to an infrequent benign nasal entity called angiocentric eosinophilic fibrosis. Its aetiology and management remains rather uncertain nowadays.

Expression of IL-12 and T helper cell 1 cytokines in the fluid of paranasal sinus mucoceles

OBJECTIVE

The objective of this study was to assess the expression of regulatory cytokines and T helper cell (Th)1/Th2 cytokines in paranasal sinus mucoceles.

MATERIALS AND METHODS

Fluid samples of 12 paranasal sinus mucoceles were assessed by enzyme-linked immunosorbent assay for concentrations of regulatory cytokines (interleukin [IL]-10 and IL-12), Th1 cytokines (IL-2 and interferon gamma), and Th2 cytokines (IL-4 and IL-5).

RESULTS

IL-12 was detected in all samples, whereas IL-10 was detected in only one case. The concentration of IL-12 tended to correlate with that of interferon gamma and was significantly and positively correlated with that of IL-2.

CONCLUSIONS

Th1 cytokines and the Th1 regulatory cytokine IL-12, but not IL-10, potentially play a key role in the pathogenesis of paranasal sinus mucoceles. Together with our recent report showing that lipopolysaccharide is highly detected in mucocele fluid, the data from this study suggest that the Th1 response induced by lipopolysaccharide may affect the immunological inflammation in the epithelium of paranasal sinus mucoceles.

Characterization of oxidative pathways in chronic rhinosinusitis and sinonasal polyposis

BACKGROUND

Eosinophils are a characteristic inflammatory cell infiltrate in both chronic rhinosinusitis (CRS) and sinonasal polyposis (SNP). The posttranslational modifications, 3-bromo-tyrosine (Br-Tyr) and 3-chloro-tyrosine (Cl-Tyr), serve as specific molecular markers for production of brominating and chlorinating oxidants, respectively, by the eosinophil peroxidase and myeloperoxidase systems of leukocytes. The aim of this study was to identify mechanisms of oxidative protein modifications in sinonasal mucosa of CRS and SNP patients by measuring Br-Tyr, Cl-Tyr, and alternative molecular markers of distinct oxidative pathways.

METHODS

Levels of Br-Tyr; Cl-Tyr; di-Tyrosine (di-Tyr), a specific oxidative cross-link; ortho-tyrosine (o-Tyr) and meta-tyrosine (m-Tyr), markers for protein modification by hydroxyl radical-like oxidants; and nitro-tyrosine (NO2-Tyr), a stable product of nitric oxide (NO)-derived oxidants, were measured in anterior ethmoid mucosa tissue from CRS and SNP patients, as well as in middle turbinate mucosa from normal volunteers, using tandem mass spectrometry.

RESULTS

Tissue levels of Br-Tyr were significantly higher in the CRS group compared with the control group (797 micromol/mol versus 515 micromol/mol tyrosine, p < 0.015), but no differences were detected for Cl-Tyr, di-Tyr, m-Tyr, o-Tyr, and NO2-Tyr. Tissue levels of both Br-Tyr and di-Tyr were significantly higher in the SNP group compared with the control group (879 micromol/mol versus 515 micromol/mol, p < 0.005; 5090 micromol/mol versus 1700 micromol/mol, p < 0.024, respectively), but no differences were detected for Cl-Tyr, m-Tyr, o-Tyr, and NO2-Tyr.

CONCLUSION

Br-Tyr, a molecular footprint predominantly formed by eosinophil peroxidase-catalyzed tissue damage, may serve as an objective index of CRS and SNP disease activity.

MR spectroscopy in sinus mucocele: N-acetyl mimics of brain N-acetylaspartate

We describe MR spectroscopy in 2 patients with frontal sinus mucoceles that showed a dominant metabolite peak at 2.0-ppm chemical shift, simulating N-acetylaspartate (NAA) of normal neuronal tissue. In vitro analysis of postsurgical mucocele samples confirmed that the signal at 2.0 ppm was arising from the methyl moiety of an N-acetyl compound. This is probably caused by N-acetylgalactosamine or N-acetylglucosamine, which are glycoproteins found in normal respiratory mucus produced by the paranasal sinus epithelium.

Voriconazole brain tissue levels in rhinocerebral aspergillosis in a successfully treated young woman

Invasive aspergillosis of the central nervous system has a mortality rate exceeding 90%. We describe a 29-year-old woman with a medical history of chronic polyarthritis who developed a proven rhinocerebral Aspergillus fumigatus infection refractory to first-line treatment with liposomal amphotericin B. The patient responded successfully to salvage combination treatment with voriconazole and caspofungin. Furthermore, for the first time, voriconazole levels in an intracerebral abscess were measured in this patient undergoing voriconazole oral therapy.

[Cholesterol granuloma in paranasal sinus. An unfrequent pseudotumor in maxillary sinuses]

The cholesterol granuloma is well known in the middle ear, in the mastoid antrum and the air cells of temporal bone, mostly related to a chronic infectious process. There are other localizations such as the pleura, lung, pericardium, kidneys, arterial wall, nerves, brain, testicles, lymphatic ganglion and in the paranasals sinuses. Its localization in the mediofacial area is very unfrequent, having only been described 44 cases up to the year 2002. We present a 42 year-old patient, who required surgical treatment because of a increase in the volume of area her left facial of one month's old. It resulted to be secundary to an expansion of the maxilar sinus, such as seen on the computerized tomography carried out on the patient. The diagnosis was cholesterol granuloma, performed, through the anatomo-pathology study. We review the litterature on this subject and analyse the possible etiologic cause of this lesion, its clinic, diagnostic methodology and treatment.

Nasal chondromesenchymal hamartoma: report of a case and review of the literature

The sinonasal region is the site of several hamartomatous lesions, the majority of which are mesenchymal, with vascular hamartomas predominating. The occurrence of hamartomas in the nasal cavity of infants and children is especially rare. Nasal chondromesenchymal hamartoma (NCMH) is a rare lesion of the intranasal sinuses generally diagnosed in the newborn period, with the eldest reported patient presenting at 16 years of age. This neoplasm is composed of mesenchymal-stromal and chondroid tissue in varying proportions. It is felt to be analogous to the mesenchymal hamartoma of the chest wall, a lesion of similar histology generally involving the ribs and chest wall of neonates. To the best of our knowledge, only 14 cases of NCMH have been reported to date. We report a case of NCMH in an 11-year-old boy.

Current value of nasal nitric oxide measurement in rhinology

PURPOSE OF REVIEW

Since the first description of nitric oxide in the exhaled breath of humans by Gustafsson et al., there has been enormous interest in the study of nitric oxide and its role in the nose and paranasal sinuses. The aim of this review is to present the current knowledge about nasal NO: its physiology, novel methods of detection and measurement, and implications in sinonasal disease, focusing on the recent data from the literature.

RECENT FINDINGS

Nitric oxide production is known to be produced in the nose at the apical tip of the ciliated respiratory mucosa. A new study has localized nitric oxide production in the pericytes and osteocytes of nasal turbinates. Studies have also discovered the efficacy of offline measurement techniques showing high correlation between standard online measurements with offline techniques. In an interesting study examining the influence of maxillary ostium size and nasal nitric oxide levels, decreased nitric oxide levels found with larger size ostia may eventually influence our approach to sinus surgery.

SUMMARY

Nasal nitric oxide has been an ever-increasing topic of interest to both the allergist and the head and neck surgeon. The recent advances in the study of nasal nitric oxide as it relates to sinonasal disease and nasal physiology are discussed and important new findings are highlighted.

Effect of clarithromycin on nuclear factor-kappa B and transforming growth factor-beta in chronic rhinosinusitis

OBJECTIVES

Long-term, low-dose macrolide therapy is effective in the treatment of chronic rhinosinusitis. It is believed that macrolide antibiotics produce this benefit through an anti-inflammatory effect. In this study, the effect of clarithromycin treatment on the expression of transforming growth factor (TGF)-beta and the key pro-inflammatory nuclear transcription factor, NF-kappa B, was examined in vitro and in vivo.

STUDY DESIGN AND METHODS

In vitro: nasal mucosa was obtained from 10 patients with chronic sinusitis and was cultured for 24 hours in the presence of clarithromycin or control. Cellular expression of TGF-beta and NF-kappa B was determined by immunohistochemistry. In vivo: 10 patients with chronic rhinosinusitis were treated for 3 months with clarithromycin. Nasal mucosal biopsies were taken pre- and posttreatment. Cellular expression of TGF-beta and NF-kappa B was again determined by immunohistochemistry.

RESULTS

Clarithromycin, when applied to nasal biopsies in vitro, reduced cellular expression of TGF-beta and NF-kappa B. Nasal biopsies taken before and after clarithromycin treatment showed no differences in cellular expression of NF-kappa B or TGF-beta.

CONCLUSION

Clarithromycin can reduce cellular expression of TGF-beta and NF-kappa B when applied in vitro, but its action during clinical therapy is less clear. Clarithromycin is capable of inhibiting pro-inflammatory cytokines in vitro, and reductions of TGF-beta and NF-kappa B may represent additional mechanisms by which macrolides reduce inflammation in chronic airway disease. Discrepancies between the actions of clarithromycin on nasal biopsies in vitro and after clinical therapy warrant further investigation.

Sinonasal adenocarcinoma: evidence for histogenetic divergence of the enteric and nonenteric phenotypes

Adenocarcinomas of nonsalivary origin represent approximately 10% to 20% of all sinonasal malignancies and are characterized by varying histopathologic features and uncertain histogenesis. To better understand the histogenesis and phenotypic heterogeneity of these tumors, we performed immunohistochemical analyses for cytokeratin (CK) 7 and CK20 on 12 primary sinonasal adenocarcinomas (SNACs) representing the histopathologic spectrum of these tumors, adjacent normal mucosa, and 2 metastatic adenocarcinomas from colonic primaries. The demographic and clinicopathologic characteristics of our cohort were similar to those in previously published series. Our results indicate that histologically normal respiratory-type epithelium and submucosal seromucous glands show restricted reactivity to CK7. Epithelial metaplasia of surface epithelium associated with enteric SNACs was accompanied by a conversion from CK7 positivity to CK20 positivity. All primary enteric-type carcinomas and the 2 colonic metastases were reactive to CK20, but all nonenteric-type tumors were negative for CK20 (P=0.003) and positive for CK7. In some of the enteric types, coexpression of CK7 and CK20 was noted. We conclude that (1) nonenteric-type (seromucinous) adenocarcinoma may originate directly from surface respiratory-type epithelium or from seromucous glands, (2) metaplastic transformation of surface respiratory to enteric-type epithelium precedes the development of enteric adenocarcinoma, and (3) coordinate analyses of CK7 and CK20 reactivity may aid the differential diagnosis of adenocarcinoma in the sinonasal tract.

The role of leukotriene inhibitors in allergic rhinitis and paranasal sinusitis

Leukotrienes (LTs) have been known in the field of immunology since the 1930s. At that time they were referred to as the slow reacting substance of anaphylaxis. However, they were not characterised until the 1980s, when they were noted to be formed during the breakdown of arachidonic acid (AA) by the enzyme 5-lipoxygenase (5-LO). There are five types of LT: LTA(4), LTB(4), LTC(4), LTD(4) and LTE(4). LTs are so called because the molecules were originally isolated from leukocytes and their carbon backbones contain 3 double bonds in series (a trion). This structural information provided the key to the oxidative pathway of lipometabolism, known as the 5-LO pathway. LTs are classified as inflammatory mediators. They are produced by a number of cell types, particularly mast cells, eosinophils, basophils, macrophages and monocytes. With the identification disorders associated with inflammatory pathways, such as asthma, allergic rhinitis and paranasal sinusitis, the LTs have been implicated in the pathogenesis of these conditions and have become targets for therapeutic modulation. In this review we will look at the biological effects of LTs, how they are formed, their role in asthma patients, the first therapeutic use of LT inhibitors and finally LTs with reference to the paranasal sinus areas.

Nitric oxide in the nasal airway: a new dimension in otorhinolaryngology

The discovery that the gas nitric oxide (NO) is an important signaling molecule in the cardiovascular system earned its Nobel prize in 1998. NO has since been found to play important roles in a variety of physiologic and pathophysiologic processes in the body including vasoregulation, hemostasis, neurotransmission, immune defense, and respiration. The surprisingly high concentrations of NO in the nasal airway and paranasal sinuses has important implications for the field of otorhinolaryngology. NO provides a first-line defense against micro-organisms through its antiviral and antimicrobial activity and by its upregulation of ciliary motility. Nasal treatments such as polypectomy, sinus surgery, removal of hypertrophic adenoids and tonsils, and treatment of allergic rhinitis may alter NO output and, therefore, the microbial colonization of the upper airways. Nasal surgery aimed at relieving nasal obstruction may do the same but would also be expected to improve pulmonary function in patients with asthma and upper airway obstruction. NO output rises in a number of conditions associated with chronic airway inflammation, but not all of them. Concentrations are increased in asthma, allergic rhinitis, and viral respiratory infections, but reduced in sinusitis, cystic fibrosis, primary ciliary dysfunction, chronic cough, and after exposure to tobacco and alcohol. Therefore, NO, similar to several other inflammatory mediators, probably subserves different functions as local conditions dictate. At present, it seems that the measurement of NO in the upper airway may prove valuable as a simple, noninvasive diagnostic marker of airway pathologies. The objective of this review is to highlight some aspects of the origin, physiology, and functions of upper airway NO, and to discuss the particular methodological problems that result from the complex anatomy.

Peroxynitrite formation in the orbit of diabetics with rhinocerebral mucormycosis

OBJECTIVE

To evaluate whether an intact respiratory burst exists within the orbit of diabetics with rhinocerebral mucormycosis.

METHODS

Immunohistochemical detection of nitrotyrosine in the orbital tissue of diabetics requiring exenteration due to rhinocerebral mucormycosis. Nitrotyrosine is the stable product of the nitration of tyrosine residues by peroxynitrite. Peroxynitrite is a potent oxidant produced by the combination of superoxide and nitric oxide during the respiratory burst.

RESULTS

Four specimens were analyzed. All showed focal areas of specific staining against nitrotyrosine of the walls and internal structures of fungal organisms.

CONCLUSIONS

An intact respiratory burst is present in the orbit of diabetics during infection with rhinocerebral mucormycosis. Possible mechanisms of peroxynitrite's microbicidal effects and reasons for a deficiency in diabetics are discussed.

Nasal nitric oxide concentration in paranasal sinus inflammatory diseases

In normal upper airways, nitric oxide is generated by the paranasal sinus epithelium and then diffuses into the nasal cavities. This study examined whether or not nasal NO concentration is affected by paranasal sinus inflammatory diseases. The influence of obstruction (nasal polyposis) and/or inflammation (allergy or chronic sinusitis) of the paranasal sinuses on nasal NO concentration was evaluated in nasal allergic (n=7 patients) or nonallergic (n=20) polyposis, nonallergic chronic sinusitis (n=10) and Kartagener's syndrome (n=6) and compared with control subjects (n=42). A score of alteration of the paranasal sinus (number of altered and occluded sinuses) was determined by a computed tomography scan. The nasal NO concentration in nasal nonallergic polyposis (150+/-20 parts per billion (ppb)) was significantly decreased compared with both controls (223+/-6 ppb, p=0.01) and polyposis with allergy (272+/-28 ppb, p<0.0001). In each group, the nasal NO concentration was inversely correlated with the extent of tomodensitometric alteration of the paranasal sinuses. In Kartagener's syndrome, the nasal NO concentration (14+/-2 ppb) was drastically decreased compared with all other groups, despite the presence of open paranasal sinuses. Thus, the nasal NO concentration in patients with nasal polyposis appeared to be dependent on both the allergic status and the degree of obstruction of the paranasal sinuses.

Inhaled and exhaled nitric oxide

Inhaled nitric oxide (NO) is used to treat various cardiopulmonary disorders associated with pulmonary hypertension. The rationale is based on the fact that NO, given by inhalation, only dilates those pulmonary vessels that perfuse well-ventilated lung units. As a result, pulmonary gas exchange is improved while pulmonary vascular resistance is reduced and pulmonary blood flow is increased. Inhaled NO has been successfully applied to treat persistent pulmonary hypertension of the newborn, reducing the need for extracorporeal life support. Although pulmonary hypertension and altered vasoreactivity contribute to profound hypoxaemia in adult and paediatric acute respiratory distress syndrome (ARDS), the benefit of inhaled NO still remains to be established in patients with ARDS. ARDS is a complex response of the lung to direct or indirect insults, leading to pulmonary vasoconstriction and various inflammatory responses. Recent randomized trials suggest that inhaled NO only causes a transient improvement in oxygenation. Whether this effect is important in the long-term management of ARDS remains to be established. NO, measured in the exhaled breath, is an elegant and non-invasive means to monitor inflammation of the upper and lower respiratory tract. In the normal upper airways, the bulk of exhaled NO originates from the paranasal sinuses. Exhaled NO is increased in nasal allergy and decreased in cystic fibrosis, nasal polyposis and chronic sinusitis. That NO production is increased in asthmatic airways is also well established. However, several questions still need to be addressed, in particular evaluation of the sensitivity and specificity of the measurement techniques, and assessment of the bronchodilator action of endogenous NO.

High nitric oxide production in human paranasal sinuses

Nitric oxide (NO) is present in air derived from the nasal airways. However, the precise origin and physiological role of airway-derived NO are unknown. We report that NO in humans is produced by epithelial cells in the paranasal sinuses and is present in sinus air in very high concentrations, close to the highest permissible atmospheric pollution levels. In immunohistochemical and mRNA in situ hybridization studies we show that an NO synthase most closely resembling the inducible isoform is constitutively expressed apically in sinus epithelium. In contrast, only weak NO synthase activity was found in the epithelium of the nasal cavity. Our findings, together with the well-known bacteriostatic effects of NO, suggest a role for NO in the maintenance of sterility in the human paranasal sinuses.

Primary localized amyloidosis of the nose and paranasal sinuses. A case report with immunohistochemical observations and a review of the literature

Primary localized amyloidosis of the nose and nasopharynx is a rare disease. We present a case and review seven additional cases from the English literature. The ages of the patients ranged from 8 to 86 years; there was no sex predominance. Symptoms were nasal obstruction, epistaxis, and impaired hearing. Physical examination revealed a nasal mass or glue ears. The lesions were composed of amyloid and chronic inflammatory cells, mainly plasma cells. Ours is the first case of nasal amyloidosis in which the type of amyloid was determined immunohistochemically to be amyloid light chain (AL) lambda. The main treatment was surgical. Recurrences developed. Determination of the biochemical nature of this amyloid clarified its pathogenesis and may influence treatment. Amyloidosis should be considered in the differential diagnosis of nasal obstruction, epistaxis, and glue ears, even in the pediatric age group.

Chronically obstructed sinonasal secretions: observations on T1 and T2 shortening

Clinically assessed chronic proteinacious sinonasal secretions usually have long T1 and T2 relaxation times reflecting their high water content. However, in some cases variable combinations of short and long T1 and T2 relaxation times are found. To study the causes of these findings, the magnetic resonance (MR) images of 41 patients with surgically proved, chronically obstructed sinonasal secretions were studied. The relative signal intensities on both T1- and T2-weighted sequences of the sinus specimens were correlated with the gross viscosity of the specimens at surgery. Ten specimens were collected that were not contaminated with either blood or saline. UV spectrophotometric analysis of four of these samples excluded the presence of methemoglobin. Total protein content was determined in five samples, and in vitro T1 and T2 values were measured in one sample. These T1 and T2 relaxation times were accurately predicted with use of a standard pure lysozyme protein solution with the same concentration as the specimen. In addition, the observed T1- and T2-weighted signal intensities on the 41 MR images were predicted from an analysis of pure protein solutions. This study concludes that the primary causes of the variable T1 and T2 relaxation times of chronic sinonasal secretions are the macromolecular protein concentration, the amount of free water, and the specimen viscosity. Furthermore, an orderly and predictable transition of these signal intensities occurs over time.

Cholesterol crystals in the temporal bone and the paranasal sinuses

In order to study the manifestation and genesis of cholesterol deposits in the temporal bone and the paranasal sinuses, 137 temporal bones and 3 paranasal sinuses with deposits were examined. For histological study, 1036 specimens were obtained from temporal bones, and 16 specimens were obtained from paranasal sinuses. Several stages of a progressive foreign body reaction, including the appearance of histiocytes, granuloma formation and the development of granulation into scar tissue, were observed depending on the size and form of the crystals. Many large deposits were found in the temporal bones of patients with chronic non-suppurative lesions. Blue eardrum and hemotympanum were seen in the last stage of this foreign body reaction in these patients. Small deposits were found in the temporal bones and the paranasal sinuses of patients with chronic suppurative lesions. Most of these deposits were found in the obstructed parts. The pathogenesis of the cholesterol deposits is suspected to be fatty degeneration of the connective tissue.

[Study of mucins of two sinus mucoceles (author's transl)]

Glycoproteins were isolated in the contents of two sinus mucoceles by ionic exchange and gel filtration chromatography. These glycoproteins are of the mucin-type and characterized by their richness in carbohydrate, a low amino acid content with a strong proportion of hydroxy amino acids. However, they differ largely by their peptide axis, the length of the carbohydrate chain and their acidity, which is in relation with the presence of sialic acid residue and of sulfate groups. The least acidic mucins are the richest in sialic acid residue and in threonine but have the shortest carbohydrate chains while the most acidic are rich in sulfate, richer in serine and have longer carbohydrate chains. The wall of these two mucoceles has only one type of cell capable of synthetizing the glycoproteins: the epithelium goblet cells revealed by the PAS and the alcian blue at different pH. Glandular formations have never been found in the chorion.

Acidic glycosaminoglycans in the ground substance in paranasal sinus diseases

Acidic glycosaminoglycans (AGAG) in the normal maxillary sinus mucosae were analysed by electrophoretic separation and densitometric quantitation, and then compared with those in chronic maxillary sinusitis, nasal polyps and maxillary sinus cancer. The total amount of AGAG in the edematous maxillary sinusitis and nasal polyps increased significantly. Both increases were almost twice as large as the normal content. When the changes of each AGAG in the total amount were compared with the normal content, chondroitin sulfate A and C showed the most conspicuous increase, chondroitin sulfate B was rather stable and hyaluronic acid showed a roughly twofold increase, in all the tissues examined. The ratio of %hyaluronic acid divided by %chondroitin sllfate B increased the most in maxillary sinus cancer.