Rhinology

The role of MMP-2, MMP-9, and TIMP-1 in the pathogenesis of nasal polyps: Immunohistochemical assessment at eight different levels in the epithelial, subepithelial, and deep layers of the mucosa

April 27, 2015     Nuray Bayar Muluk, MD; Osman Kürşat Arikan, MD; Pınar Atasoy, MD; Rahmi Kiliç, MD; Eda Tuna Yalçinozan, MD
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Abstract

We conducted a prospective study to investigate the role of matrix metalloproteinase-2 (MMP-2), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) in the pathogenesis of nasal polyps. Our study group consisted of 24 patients-21 men and 3 women, aged 23 to 70 years (mean: 45.97 ± 11.60)-with nasal polyposis who underwent functional endoscopic sinus surgery. For comparison purposes, we assembled a control group of 11 patients-6 men and 5 women, aged 18 to 56 years (mean: 29.90 ± 14.22)-without nasal polyps who underwent septoplasty and/or rhinoplasty. We analyzed 36 polyp specimens obtained from the study group (10 from the nasal cavity, 10 from the maxillary sinus, and 16 from the ethmoid sinus) and 11 tissue specimens from the control group (each control provided 1 specimen from the inferior turbinate). We then calculated the mean number of these cells in the epithelium, subepithelial layer of the lamina propria, and the deep paraglandular layer of the mucosa. In general, we found that MMP-2, MMP-9, and TIMP-1 values were higher in the nasal polyp group. These differences became less so as patients' ages and the duration of polyps increased. We conclude that the most important role that MMP-2 plays in polyp growth may be in terms of perivascular localization and an increase in vascular permeability, which causes inflammatory cell migration and edema in the extracellular matrix. An increase in MMP-2 in glandular tissue may lead to hydrolysis of tissue matrix components. The degraded extracellular matrix may result in fibrosis of the polyps. An increase of MMP-9 in the apical part of the epithelium in the polypoid tissue of the nasal cavity, maxillary sinus, and ethmoid sinus may facilitate the epithelial and endothelial cell migration that is observed during polyp development and growth.

Sinonasal undifferentiated carcinoma as a third primary neoplasm: A case report and review of the literature

April 27, 2015     John J. Chi, MD; Michael D. Feldman, MD; James N. Palmer, MD
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Abstract

A 71-year-old man with a history of a pituitary prolactinoma and metastatic pancreatic carcinoma presented with epistaxis, visual changes, bilateral ophthalmoplegia, involuntary closure of the left eye, and ptosis of the right eye. The patient was found to have a soft-tissue mass in the posterior nasal cavity with extension through the floor of the sella turcica, the sphenoid sinuses, cavernous sinuses, and suprasellar region. The patient was subsequently taken to the operating room. Intraoperative frozen section of the sinonasal mass demonstrated carcinoma. The final pathology of the mass revealed sinonasal undifferentiated carcinoma (SNUC)-the patient's second skull base lesion and third primary neoplasm. SNUC is a rare neoplasm of the sinonasal cavities that rapidly progresses from symptom onset to mortality in the presence of aggressive multidimensional therapies. Given its poor prognosis and possibly devastating treatments, an open discussion of treatment options between physicians and the patient is of the utmost importance. Although SNUC is rare, it is important that practicing otolaryngologists, neurosurgeons, and skull base surgeons be familiar with this disease process-especially when caring for patients with a history of a benign skull base neoplasm and concern for possible recurrence, as was the case in this report.

Conidiobolus coronatus granuloma of the right inferior turbinate: A rare presentation

April 27, 2015     Saurabh Varshney, MBBS, MS; Pratima Gupta, MBBS, MD; Sampan Singh Bist, MBBS, MS; Sanjeev Bhagat, MBBS, MS
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Abstract

Fungal infections are common in tropical countries such as India. Very few clinical cases caused by the Entomophthorales Zygomycetes have been reported. Rhinofacial infection is a rare form of zygomycosis in humans, and only limited information regarding optimal treatment is available. We report here a rare case of rhinofacial Conidiobolus coronatus infection in a previously healthy 18-year-old man who presented with a fungal granuloma of the right inferior turbinate and face. Diagnosis was confirmed by microbiologic culture from a tissue biopsy. The infection was successfully treated with surgery and itraconazole therapy for 12 months. The clinical presentation and treatment of this rare, chronic, indolent form of fungal infection are highlighted in this article.

Schneiderian papilloma of the sinonasal tract

April 27, 2015     Lester D.R. Thompson, MD
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The overall clinical presentation of Schneiderian papillomas is quite nonspecific, with nasal obstruction, polyps, headache, epistaxis, and rhinorrhea the most common symptoms.

Large Haller cell mucocele leading to maxillary sinusitis

April 27, 2015     Jae-Hoon Lee, MD
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Paranasal sinus mucoceles are epithelial-lined cystic lesions containing mucus or mucopurulent fluid. Symptoms vary depending on the location of the mucocele.

Prophylactic antibiotic therapy for fractures of the maxillary sinus

April 27, 2015     Robert S. Schmidt, MD; Kelley M. Dodson, MD; Richard A. Goldman, MD
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Abstract

We conducted a study to examine the incidence of acute sinusitis following maxillary sinus fractures, as well as the impact of antibiotics in the postinjury period. Fifty patients who presented to our institution with a fracture of the maxillary sinus were prospectively randomized to receive either a nasal saline spray and a 3-day course of antibiotics (either amoxicillin/clavulanate or levofloxacin) or nasal saline alone; there were 25 patients in each group. After a minimum of 3 days, all patients were assessed for acute sinusitis. Follow-up data were available on 17 patients (a total of 21 fractured sinuses) in the antibiotic group (68%) and 14 patients (17 fractured sinuses) in the control group (56%). The groups were balanced in terms of demographics, location of fractures, mechanism of fracture, and time to follow-up. After 3 days, 95.23% of the fractured sinuses in the antibiotic group and 88.23% of the fractured sinuses in the control group exhibited signs or symptoms consistent with or suggestive of acute sinusitis. Very few sinuses in either group showed no evidence of sinusitis: only 1 in the antibiotic group (4.76%) and 2 in the control group (11.76%); this difference was not significant (p = 0.5768). We conclude that while the clinical rate of acute sinusitis after maxillary sinus fractures is high, a 3-day course of antibiotics is not effective in preventing its symptoms in the postinjury period.

Frontal recess polyp extending to the posterior choana-a frontal recess-choanal polyp

April 27, 2015     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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Frontal recess-choanal polyps, as found in the case described in this report, are rare.

Maxillary sinus cyst containing a bone chip

March 2, 2015     Jae-Hoon Lee, MD
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If bone fragments in the sinus can be removed, the patient's prognosis is usually excellent.

Septic arthritis: A unique complication of nasal septal abscess

March 2, 2015     Steven M. Olsen, MD; Cody A. Koch, MD, PhD; Dale C. Ekbom, MD
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Abstract

Nasal septal abscesses (NSAs) occur between the muco-perichondrium and the nasal septum. They most often arise when an untreated septal hematoma becomes infected. The most commonly reported sequela is a loss of septal cartilage support, which can result in a nasal deformity. Other sequelae include potentially life-threatening conditions such as meningitis, cavernous sinus thrombosis, brain abscess, and subarachnoid empyema. We report the case of a 17-year-old boy who developed an NSA after he had been struck in the face with a basketball. He presented to his primary care physician 5 days after the injury and again the next day, but his condition was not correctly diagnosed. Finally, 7 days after his injury, he presented to an emergency department with more serious symptoms, and he was correctly diagnosed with NSA. He was admitted to the intensive care unit, and he remained hospitalized for 6 days. Among the abscess sequelae he experienced was septic arthritis, which has heretofore not been reported as a complication of NSA. He responded well to appropriate treatment, although he lost a considerable amount of septal cartilage. He was discharged home on intravenous antibiotic therapy, and his condition improved. Reconstruction of the nasal septum will likely need to be pursued in the future.

Basaloid squamous cell carcinoma of the sinonasal tract with metastasis to the liver: A case report and literature review

February 2, 2015     Boon Ping Toe, FRCR(Lond); Norlisah Ramli, FRCR(Lond); Sze Yin Lam, MRad(Mal); Kum Thong Wong, FRCPath(Lond); Narayanan Prepageran, FRCS(Edin)
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Abstract

Basaloid squamous cell carcinoma (BSCC) is a rare subtype of squamous cell carcinoma. To date, only 95 cases of sinonasal BSCC have been reported in the English-language literature, and they account for 5% of all cases of head and neck BSCC. We describe what we believe is only the second reported case of a sinonasal tract BSCC that metastasized to the liver. The patient was a 36-year-old woman who presented with right-sided nasal obstruction and a foul-smelling discharge. Clinical examination and imaging identified a large lobulated enhancing mass in the right nasal cavity. Following excision of the mass, the patient was scheduled for radiotherapy. However, before it could be administered, follow-up imaging detected a metastasis to the liver and lung, and the patient was switched to chemotherapy. Initially, she responded well clinically, but at 5 months postoperatively, a follow-up CT showed an increasing metastatic presence in the liver and bone. The patient died of her disease 1 year after surgery.

Primary thyroid-like papillary adenocarcinoma of the nasal septum: A case report

February 2, 2015     Kerem Ozturk, MD; Rasit Midilli, MD; Ali Veral, MD; Yesim Ertan, MD; Bulent Karci, MD
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Abstract

Primary thyroid-like papillary adenocarcinomas are extremely rare neoplasms that generally originate in the nasopharynx. We report the case of a 24-year-old woman who was diagnosed with a thyroid-like papillary adenocarcinoma that originated in the nasal septum. The tumor was surgically removed, and the patient showed no evidence of local recurrence during 4 years of follow-up.

Palliative endoscopic surgery for sinonasal metastases: A case report and literature review

February 2, 2015     Jason M. Roberts, MD; Christopher Brook, MD; Steven Parnes, MD
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Abstract

Cancer metastatic to the paranasal sinuses often presents with ophthalmologic and facial deformities, as well as sinonasal complaints. These diminutive tumors are difficult to effectively treat, often leading to poor quality of life. Although breast cancer is a common cancer affecting more than 150,000 women each year,1 rarely is metastatic breast cancer found within the sinuses. We report our palliative treatment approach and outcomes of a 40-year-old patient with breast cancer metastatic to the paranasal sinuses. While providing a better understanding of this tumor's metastasis through a review of the literature, our report describes the role of palliative surgery for metastases to the paranasal sinuses.

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