Rhinology

Meningeal carcinomatosis in undifferentiated nasopharyngeal carcinoma: A case report

July 13, 2014     Daniel M. Cushman, MD; German Giese, MD; Panta Rouhani, MD, PhD, MPH
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Abstract

Meningeal carcinomatosis is the tumoral invasion of the leptomeninges. It is caused by the spread of malignant cells throughout the subarachnoid space, which produces signs and symptoms due to multifocal involvement. Cranial nerve symptoms are the most common focal findings. The diagnosis is usually made by imaging and/or cytology. Head and neck cancers are the cause of approximately 2% of all cases of meningeal carcinomatosis; in very rare cases, they are caused by a nasopharyngeal carcinoma. We report a case of meningeal carcinomatosis that was caused by a recurrence of undifferentiated nasopharyngeal carcinoma. The patient, a 60-year-old woman, experienced no focal neurologic symptoms and exhibited no radiologic evidence of meningeal involvement. We also review the literature on meningeal carcinomatosis secondary to nasopharyngeal carcinoma.

Endoscopic view of osteogenesis imperfecta of the maxilla

June 8, 2014     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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Osseous lesions in the maxilla can represent ossifying fibroma, fibrous dysplasia, amelogenesis imperfecta, or osteogenesis imperfecta.

Metastatic hepatocellular carcinoma presenting as a sphenoid sinus mass and meningeal carcinomatosis

June 8, 2014     Hilwati Hashim, MBBCh, MRad; Kartini Rahmat, MBBS, MRad; Yang Faridah Abdul Aziz, MBBS, MRad; Patricia Ann Chandran, MD, MPath
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Abstract

We report the case of a 30-year-old woman who was referred to us for evaluation of a 2-week history of fever, headache, vomiting, bilateral ptosis, and blurred vision. Imaging obtained by the referring institution had identified a sphenoid sinus mass and diffuse meningeal infiltration, which was thought to represent an infective process. We subsequently identified the mass as a metastatic hepatocellular carcinoma (HCC). The patient was placed under palliative care, and she died 1 month later. Metastases to the sphenoid sinus from any primary source are very rare, and they are generally not considered in the radiologic differential diagnosis. HCC is known to metastasize to the lung, lymph nodes, and musculoskeletal system; again, reported cases of metastasis to the sphenoid sinus are rare. Indeed, our review of the English-language literature found only 6 previously reported cases of sinonasal metastasis of a primary HCC. A diagnosis of a sinonasal metastasis is more difficult in a patient who has no previous diagnosis of a primary malignancy. In presenting this case, our aim is to remind readers of this possibility.

An abnormal sigmoid sinus with a dire clinical implication

June 8, 2014     Perianan Puraviappan, MS(ORL); Naryanan Prepageran, FRCS Ed; Cheng Ai Ong, MS(ORL); Raffique Abd Karim, MS(ORL); Omkara Rubini Lingham, MS(ORL); Rajagopalan Raman, MS(ORL)
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In reviewing CT scans before surgery, the location of the sigmoid sinus should always be noted.

Nasal vestibule schwannoma: Report of a rare case

June 8, 2014     Ismail Fadzilah, MSurg(ORL-HNS); Husain Salina, MSurg(ORL-HNS); Baharudin Khairuzzana, MSurg(ORL-HNS); Omar Rahmat, MSurg(ORL-HNS); SHA Primuharsa Putra, MSurg(ORL-HNS)
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Abstract

Schwannomas of the nasal cavity and paranasal sinuses are quite rare, especially in the nasal vestibule. We report the case of a 61-year-old woman who presented with a 2-month history of progressively worsening right-sided epistaxis and nasal blockage. Rigid nasoendoscopy showed a mobile, smooth, globular mass occupying the right nasal vestibule. The mass arose from the lateral nasal wall and impinged on the anterior part of the middle turbinate posteriorly. Computed tomography of the paranasal sinuses showed a 3.8 x 1.7-cm enhancing mass in the right nostril. The mass obliterated the nasal cavity and caused mild deviation of the septum. The preoperative histopathologic examination showed positivity for vimentin and S-100 protein, suggesting a diagnosis of schwannoma. The patient underwent an intranasal laser-assisted excision biopsy. The histopathologic examination confirmed the diagnosis of schwannoma. Postoperative recovery was uneventful, and no recurrence was seen in the follow-up period.

Nasal valve surgery: Assessment of quality of life with the Glasgow Benefit Inventory

May 7, 2014     Jaiganesh Manickavasagam, MRCS(Edin), DOHNS(Lond); Smeeta Wong, MRCS; Veronika Varabei, MBBS; Ullas Raghavan, FRCS(ORL)
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Abstract

We used the 18-question Glasgow Benefit Inventory (GBI) to conduct a retrospective assessment of quality of life following nasal valve surgery. We telephoned 53 patients who had undergone open rhinoplasty for the treatment of nasal valve collapse over a 2-year period. A total of 39 patients-24 men and 15 women, aged 20 to 50 years (mean: 38)-agreed to participate and answer the questions. Follow-up ranged from 3 to 12 months (mean: 8). The spectrum of possible GBI scores ranges from -100 (maximum negative outcome) to 0 (no change) to +100 (maximum benefit); in our group, the median total score was +56 (interquartile range: +32 to +90.5) and the overall total score was +58. The three subscale components of the GBI-general benefit, physical benefit, and social benefit-were analyzed individually; the respective median scores were +46 (+21 to +71), +67 (+25 to +91.5), and +50 (+17 to +100), and the respective overall scores were +60, +59, and +50. Based on these findings, we conclude that nasal valve surgery significantly improves quality of life.

Endoscopic view of a concha bullosa of the inferior nasal turbinate

May 7, 2014     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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Pneumatization of the inferior turbinate, or concha bullosa of the inferior turbinate, is clinically significant when it causes persistent nasal airway obstruction.

Anatomic measurements of the anterior and posterior ethmoid arteries in cadaveric heads using endoscopic sinus instrumentation

May 7, 2014     Zeeshan S. Aziz, MD; Ninef E. Zaya, MD; Richard M. Bass, MD
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Abstract

The challenges of endoscopic sinus surgery lie in the complexity of the anatomy of the nasal vault and side walls and the proximity to critical structures. Additionally, operating in a three-dimensional space while relying on a two-dimensional image for surgical navigation can be a disorienting task. Successful sinus surgery relies on the surgeon having a clear understanding of the anatomy and relationships within the operative field. We performed a study of 8 adult cadaveric heads to better elucidate the location of the ethmoid arteries in relation to an accessible external landmark, the nasal sill. Sinus endoscopy was performed on the heads to identify and measure the distance from the nasal sill to the anterior and posterior ethmoid arteries. We found that the distance from the nasal sill to the anterior ethmoid artery was approximately 6.0 cm, and the distance to the posterior ethmoid artery was approximately 6.7 cm. The interarterial distance was approximately 1.2 cm. With a better understanding of these vessels, surgeons will be better able to avoid them during surgery and thereby minimize the risk of excessive intraoperative bleeding and perioperative orbital hematoma.

Rhinotopic therapy for refractory chronic rhinosinusitis: A study of 20 cases

May 7, 2014     Alan H. Shikani, MD, FACS; Karim A. Chahine, MD; Mohannad A. Alqudah, MD
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Abstract

The management of refractory chronic rhinosinusitis (CRS) after endoscopic sinus surgery is complex and challenging. We conducted a prospective clinical pilot study to evaluate the effectiveness of a rhinotopic protocol for the treatment of refractory CRS. Our study population was made up of 20 patients-8 men and 12 women, aged 31 to 76 years (mean: 50.1)-who were treated in our tertiary care rhinology fellowship training program. The rhinotopic protocol consisted of twice-daily saline rinses, each of which was followed by the administration of a nebulized corticosteroid and then a nebulized antibiotic. This regimen was administered for 6 weeks. Thereafter, patients underwent a once-weekly endoscopic sinus debridement followed by topical intrasinus installation of a corticosteroid and antibiotic. The duration of follow-up was 24 weeks, and thus the total study duration was 30 weeks. Treatment outcomes were based on Lund-Kennedy symptom scores and Lund-Kennedy endoscopic appearance scores. We found a 56% improvement in the mean symptom score after 3 weeks of therapy and 77% after 6 weeks. Subsequent follow-up revealed 90% improvement 4 weeks following the completion of therapy and 95% at 8 weeks post-therapy. Thereafter, we saw a small decrease in improvement: 73% at 16 weeks of follow-up and 65% at 24 weeks. Analysis of endoscopic appearance scores revealed a 55% improvement at 3 weeks of therapy and 84% at 6 weeks. The same general pattern emerged during follow-up, with 94% improvement 4 weeks after the cessation of therapy, 96% at 8 weeks, 76% at 16 weeks, and 75% at 24 weeks. Sinus cultures performed 4 weeks after the cessation of therapy found no growth in 13 patients (65%), normal respiratory flora in 5 patients (25%), a persistent pathogen in 1 patient (5%), and the emergence of a new pathogen in another (5%). Analysis of symptom scores and endoscopic appearance scores revealed that the rhinotopic protocol resulted in statistically significant improvement (p < 0.001) throughout the treatment period and follow-up period, although the improvement gradually declined over time. We therefore conclude that a rhinotopic protocol can be an effective treatment for refractory CRS.

Aggressive inflammatory pseudotumor of the maxillary sinus and orbit

March 18, 2014     Sheldon Chong, MBBS, MS(ORL-HNS); Carren S.L. Teh, MBBS, MS(ORL-HNS); Shashinder Singh, MBBS, FRACS; Mun Kein Seong, MBBS, MPath; Subrayan Viswaraja, MBBS, FRCS(Edin), FRCOphth(UK)
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Abstract

Inflammatory pseudotumor (IPT) is a rare, locally aggressive, benign neoplasm of unknown etiology. It is uncommon in the head and neck region, particularly in the paranasal sinuses. We present an unusual case of IPT of the maxillary sinus and orbit in a 27-year-old woman who presented with cheek swelling, right orbital swelling, double vision, and associated fever and trismus. Computed tomography identified a mass with radiologic features suggestive of a malignancy of the maxillary sinus and orbit; the mass extended into the infratemporal fossa, parapharyngeal space, anterior antral wall, and surrounding soft tissue. A diagnosis of IPT was established on the basis of histologic and immunohistochemical analysis, which identified a proliferation of bland spindle cells and a mixed inflammatory cell infiltrate. Despite its aggressive appearance, IPT is associated with a good prognosis. Our patient was treated successfully with a combination of surgery, steroid therapy, and methotrexate. Chemotherapeutic agents are generally reserved for recalcitrant cases.

Schwannoma of the nasal septum: An unusual finding

March 18, 2014     Shruti Dhingra, MS, DNB; Jaimanti Bakshi, MS, DNB; Satyawati Mohindra, MS, DNB
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Abstract

Schwannomas of the nasal cavity are rare benign tumors, and those that arise from the nasal septum are even rarer. When they do occur, they usually become symptomatic early because of the close confines of the nasal cavity. We describe a case of nasal septal schwannoma that was noteworthy in that the patient-a 28-year-old woman-waited 8 months after the onset of symptoms to seek medical care. Her symptoms included complete right-sided nasal obstruction, occasional epistaxis, and hemifacial pain. The tumor was completely removed via an endoscopic approach. We discuss the clinical presentation, differential diagnosis, and treatment of this rarely encountered neoplasm.

Endoscopic modified Lothrop approach for the excision of bilateral frontal sinus tumors

March 18, 2014     Jiun Fong Thong, MRCS; Deyali Chatterjee, MD; Siew Yoong Hwang, FRCS
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Abstract

We describe the use of an endoscopic modified Lothrop approach for clearance of an extensive sinonasal-type hemangiopericytoma of the nasal cavity and paranasal sinuses with bilateral frontal sinus involvement in a 44-year-old woman. The modified Lothrop approach is conventionally used to treat sinusitis, but with some slight modifications to the technique, it can also be used for tumor excision.

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