Cholesterol granuloma of the maxillary sinus presenting as sinonasal polyp

Cholesterol granuloma is usually found in chronic middle ear diseases. However, it rarely occurs in the sinonasal regions and only a few case reports can be found in the literature. The etiology of sinonasal cholesterol granuloma is not yet known, and the clinical manifestations are nonspecific. Most patients presented with nasal discharge. Our patient is the only reported case presenting with nasal obstruction and facial pain. Here we present a patient with cholesterol granuloma of the maxillary sinus with a nasal polyp, whose clinical, imaging, and histological characteristics were unique. The tumor was excised via the transnasal endoscopic sinus approach without recurrence after 3 years of follow-up.     

Cholesterol granuloma of the maxillary sinus

Cholesterol granuloma (CG) of the maxillary sinus is very rare. In this study, the searching of the literature was performed with the keywords of cholesterol granuloma and maxillary sinus. All retrieved literature were reviewed throughout to identify and analyze all individual characteristics. Two additional cases in our hospital were also included. The result showed that, in the overall 37 cases, the ratio of male to female was about 3:1. Caucasian (14/37) and Turkish (10/37) were reported more frequently. CG of maxillary sinus had an opposite sex predilection compared with the fungus balls of the maxillary sinus. In addition, the comorbidity of these two diseases was found only in one patient in the literature. These results suggested that the different mechanisms other than poor aeration of the maxillary sinus played a role in the formation of CG of maxillary sinus. The diagnosis for CG of the maxillary sinus before operation is difficult, but the clear golden yellow rhinorrhea and hemorrhagic signs may provide a good diagnostic evidence. The symptoms were vague and about half of the patients presented with non-specific symptoms. Therefore, it seemed reasonable that CG of the maxillary sinus was under diagnosed in the clinical practice. Treatment consists of complete excision via Caldwell–Luc or endoscopic approach and provides a good prognosis. Bilateral involvements are rare but possible in this disease entity.     

Cholesterol granuloma of the frontal sinus

It is common to see cholesterol granuloma in the mastoid air cells, less common in the orbit, and uncommon in the paranasal sinuses. Cholesterol granuloma is thought to be due to an interruption to normal aeration with impaired lymphatic drainage, resulting in a closed cavity where it may form. These expanding cysts cause bone destruction and compression of the surrounding structures that lead to clinical symptoms. Diagnosis and management of cholesterol granuloma cysts can be challenging. Magnetic resonance imaging (MRI) and computed tomographic (CT) scans are usually diagnostic. We present a rare case of cholesterol granuloma in the frontal sinus, few cases have been reported in the literature.     

Cholesterol granuloma of the posterior ethmoid sinus mimicking meningocele

Cholesterol granuloma is usually associated with chronic middle ear disease, less common in the orbit, and rare in the paranasal sinus. Cholesterol granuloma is thought to be initiated by hemorrhage, impaired drainage, and interruption of aeration. Here we report a case of cholesterol granuloma arising in the posterior ethmoid sinus mimicking meningocele. Magnetic resonance imaging is useful for differential diagnosis, and endoscopic surgery is effective for the management of cholesterol granuloma arising in the ethomoid sinus.     

Cholesterol granuloma of the maxillary sinus resembling an invasive,destructive tumor

The case of a maxillary sinus cholesterol granuloma posing as a malignant tumor is presented. The patient was referred to the authors clinic with symptoms typical of maxillary sinusitis, but physical examination suggested the presence of neoplasm. Radiology also resulted in confusing, tumor-like pictures. Histological examination of a preoperative tissue sample identified the process as a cholesterol granuloma, which was removed by a classic Caldwell-Luc operation. The patient has been symptom free since the operation. The pathogenesis of cholesterol granuloma is described, and the problems of establishing a diagnosis without preoperative histology are discussed.     

Cholesterol granuloma of the maxillary antrum

A case of cholesterol granuloma of the maxillary antrum is presented, the eighth reported case in the ENT literature. It is postulated that a maxillary antral cholesterol granuloma could be associated with obstruction of the antral ostia, hemorrhage into polypoidal mucosal disease or that an antral cyst may have developed a cholesterol granuloma in its walls as a result of cholesterol precipitation. A review of the literature on cholesterol granuloma suggests that it is a condition which arises in a closed space with poor ventilation or drainage, with long-standing inflammation with effusion or hemorrhage contributing to the formation of free cholesterol crystals derived from tissue or blood breakdown products. The foreign body granuloma produced in this way is then self-perpetuating and requires complete removal for cure rather than a simple drainage procedure.     

上颌窦胆固醇肉芽肿5例分析

目的：探讨上颌窦胆固醇肉芽肿的病因、发病机制以及治疗方法。方法：所有患者均行上颌窦根治术。结果：所有患者均病理诊断为鼻窦胆固醇肉芽肿,随访2个月～12年,均未见复发。结论：本病病因为高血脂症,含气腔通气受阻,引流障碍。确诊需要病理检查,治疗上应对高脂血症进行干预与治疗,手术可以根治。     

上颌窦胆固醇肉芽肿(附2例报告)

为探讨胆固醇肉芽肿形成的机理，报告２例发生于上颌窦的胆固醇肉芽肿。该病的常见症状是鼻阻塞，严重者可引起骨质破坏。其病因可能源于上颌窦窦口阻塞、粘膜息肉样病变内部出血或上颌窦囊肿瘤壁内胆固醇沉积。文献复习表明：窦腔通气不良，长期的炎症渗出或出血可导致胆固醇肉芽肿的形成。治疗主要是行上颌窦根治术，以达到永久治愈的目的。     

Cholesterol granuloma of the paranasal sinuses

Cholesterol granulomata of the middle ear occasionally accompany chronic middle-ear diseases with diminished ventilation. In the paranasal sinuses, especially in the frontal sinus, they have occasionally been mentioned in the literature. Disordered ventilation and impaired drainage are decisive pathogenic factors in the causation of cholesterol granuloma. Views remain divided on the source of the cholesterol and on the importance of bleeding in the development of cholesterol granuloma. Two patients with a cholesterol granuloma of the frontal sinus are presented and discussed.     

Cholesterol granuloma and aspergilloma of the maxillary sinus

Cholesterol granuloma (CG) of the paranasal sinuses is rare. The proposed mechanisms of initiation are haemorrhage, impaired drainage and obstruction of ventilation. To the best of our knowledge, association of CG with a specific infection has not been described before. We have recently observed CG and aspergilloma of Aspergillus flavus type from the left maxillary sinus of a 58-year-old male patient presenting with nasal obstruction, headache and postnasal discharge. Any causative relationship between the two findings is obscure. The suspected mechanisms underlying aspergilloma and CG of the paranasal sinuses seems similar, since there is obstruction of ventilation and drainage. The cholesterol accumulation cannot be attributed to cellular components or breakdown products of the aspergillus as the major sterol of the plasma membranes of fungi is ergosterol, not cholesterol. Received: 15 February 2000 / Accepted: 31 October 2000     

The ultrastructure of cholesterol granuloma of the middle ear: an electron microscope study.

The ultrastructure of giant cells in cholesterol granuloma is described, with particular reference to their role in the absorption of cholesterol needles. Cholesterol is a highly resistant substance in its crystalline form and it is confirmed that the giant cells are endowed with endoplasmic structures and organelles and are partly crowded with lysosomes, as evidence of the active role of the giant cells in the absorption and removal of cholesterol formed in the granuloma from blood, mucus or necrotic material.     

鼻窦胆固醇肉芽肿24例

目的探讨鼻窦胆固醇肉芽肿患者的病因、发病机理以及治疗方法。方法回顾性总结分析1996年3月至2003年3月经手术和病理证实的24例鼻窦胆固醇肉芽肿患者的临床资料。结果24例患者中，术前诊断为慢性鼻窦炎10例，鼻窦黏液囊肿8例，鼻息肉或出血坏死性鼻息肉5例，考虑可能为胆固醇肉芽肿者仅l例。主要症状有鼻塞(20／24)、鼻漏(18／24)、嗅觉减退(10／24)、头痛(7／24)、眼眶痛(5／24)、复视(2／24)等。鼻窦CT及MRI提示为慢性鼻窦炎、鼻窦囊肿以及鼻息肉和(或)黏膜息肉样变。所有病例均因保守治疗无效而采取外科手术治疗，即鼻内镜术或Caldwell-Luc术，仅l例行鼻侧切开术。23例手术效果良好，随访1年以上无复发；仅l例Caldwell-Luc术后2年复发，再次行鼻内镜术，术后3年未复发。结论鼻窦胆固醇肉芽肿的病因主要有三：含气腔通气受阻、引流障碍、含气腔出血。鼻窦胆固醇肉芽肿似乎与鼻窦慢性炎性疾病关系密切，尤其是鼻窦黏液囊肿。术式的选择应根据病变范围和程度来决定，其原则是彻底清除病变，保持鼻窦通畅引流。     

Lethal midline granuloma, An anatomoclinical study apropos of 3 cases

In Midline malignant granuloma, a clinical entity characterized by necrotic ulcerations of the upper respiratory tract, two different histological features can be observed. The first one, called "idiopathic" granuloma, looks like simple granulation tissue and remains a strictly localized disease. In the second type (midline malignant reticulosis or histiocytosis), the granulation tissue contains atypical histiocytic cells. The 3 cases reported here belong to this last group. The early lesions were located in the nose (2 cases) or in the maxillary sinus (1 case). The histological analysis showed in all cases 20 to 40% of atypical histiocytes associated with other "inflammatory" cells. Radiotherapy was used in association with chemotherapy or surgery in the treatment. One patient is still alive at 3 years. We have no follow-up data for another patient. The third patient died after 18 months. An autopsy demonstrated multifocal visceral involvement by atypical histiocytes (malignant histiocytic lymphoma). The histogenesis of this disease, in light of histoenzymological and ultrastructural findings, and its possible relationship to lymphomatoid granulomatosis are discussed.     

Cholesterol granuloma in thyroglossal cysts: a clinicopathological study

Thyroglossal duct cyst (TDC) is a congenital anomaly caused by retention of epithelial remnants from the descent of the thyroid gland during embryological development. Cholesterol granuloma represents a granulomatous reaction to precipitates of cholesterol crystals in tissue, usually related to middle-ear disease. The association of TDC with cholesterol granuloma has hardly been reported. This study describes five patients with TDC and cholesterol granuloma over a 16-year-period. The treatment consisted of excision of the TDC and the mid-portion of the hyoid bone and excision of a core of tissue between the hyoid bone and the foramen cecum (Sistrunk procedure). We speculate that the pathogenesis of cholesterol granuloma in TDC resembles that in the paranasal sinuses, as both sites provide a closed, poorly ventilated hollow structure with slow drainage. Our five patients accounted for 13% of all patients with TDC treated in our center during the same period, indicating that cholesterol granuloma in TDC may not be as rare as previously thought.     

Cholesterol granulomas in antrochoanal polyps: a clinicopathologic study

The purpose of this study was to investigate antrochoanal polyps with cholesterol granuloma (CG), which is a granulomatous reaction to cholesterol crystals that has been precipitated in the tissue. It is usually associated with chronic middle ear disease, common in the mastoid air cells, less common in the orbit and rarely found in the paranasal sinuses. The aim of this study was to analyze the etiology and pathological findings of antrochoanal polyps associated with cholesterol granuloma. This is a retrospective study of five cases of antrochoanal polyp with cholesterol granuloma, (four males and one female between 15 and 77 years of age) who presented with nasal obstruction, rhinorhea and snoring. The cases were clinically and histologically reviewed. Four patients were treated endoscopically and one by intranasal polypectomy without endoscope. There was no recurrence during the follow-up between 24 to 36 months (mean 31.2 months). Five uncommon cases with antrochoanal polyp with cholesterol granuloma are presented. The cholesterol granulomas consist of fibrous granulation tissue containing cholesterol crystals with surrounding foreign body giant cells. The pathogenesis of antrochoanal polyp with cholesterol granuloma is unclear, and further investigations are needed.     

Cholesterol granuloma of the maxillary and frontal sinuses

5 cases of cholesterol granuloma are described, 3 within the maxillary sinuses and 2 within the frontal sinuses. The lesions arise from the mucosa and can be recognized on plain films and tomograms of the sinus as opacity, sometimes resembling a mucocele. Radical operation seems to give absolute cure without any recurrence. The pathogenesis is hemorrhage and/or filtration. The closed cavities of the paranasal sinuses provide favorable conditions for cholesterol to become dissociated from the lipoprotein complex and to precipitate and to give rise to a granulomatous reaction.     

Inflammatory pseudotumour (plasma cell granuloma) arising in the maxillary sinus

CONCLUSIONS: Inflammatory pseudotumours in the maxillary sinus may present as malignant tumours and manifest locally aggressive features characteristic of such tumours. Despite their locally destructive features, they pursue a benign course after local excision. OBJECTIVE: Inflammatory pseudotumour (plasma cell granuloma) is an uncommon non-neoplastic lesion comprising a proliferation of spindle myofibroblasts and chronic inflammatory cells. Despite its benign histopathological nature, it may exhibit aggressive behaviour that is yet to be characterized in the head and neck area. MATERIAL AND METHODS: We present the cases of two adult patients with inflammatory pseudotumour arising from the maxillary sinus. Immunohistochemistry and polymerase chain reaction for immunoglobulin from tissue sections were performed to confirm the polyclonality of the infiltrating plasma cells. RESULTS: CT and MRI disclosed expansive soft masses eroding surrounding soft and bony tissues. Histopathologically, the lesions were unencapsulated and composed of numerous plasma cells, histiocytes and spindle cells with minimal nuclear pleomorphism.     

Inflammatory pseudotumour (plasma cell granuloma) arising in the maxillary sinus

Conclusions. Inflammatory pseudotumours in the maxillary sinus may present as malignant tumours and manifest locally aggressive features characteristic of such tumours. Despite their locally destructive features, they pursue a benign course after local excision. Objective. Inflammatory pseudotumour (plasma cell granuloma) is an uncommon non-neoplastic lesion comprising a proliferation of spindle myofibroblasts and chronic inflammatory cells. Despite its benign histopathological nature, it may exhibit aggressive behaviour that is yet to be characterized in the head and neck area. Material and methods. We present the cases of two adult patients with inflammatory pseudotumour arising from the maxillary sinus. Immunohistochemistry and polymerase chain reaction for immunoglobulin from tissue sections were performed to confirm the polyclonality of the infiltrating plasma cells. Results. CT and MRI disclosed expansive soft masses eroding surrounding soft and bony tissues. Histopathologically, the lesions were unencapsulated and composed of numerous plasma cells, histiocytes and spindle cells with minimal nuclear pleomorphism.     

Cholesterol granuloma of the petrous apex

Cholesterol granuloma of the petrous apex is caused by a foreign body response to cholesterol crystals. This condition has infrequently been described, but it can prove to be highly destructive. Obstruction of drainage, with failure of ventilation of a normally aerated space and subsequent hemorrhage, yields blood breakdown products which liberate cholesterol. Osteitis, bone erosion, and bone resorption have all been reported, but major bone destruction is rare. It should always be considered by otologists and skull base surgeons when evaluating lesions of the petrous apex. This article reviews the more common causes of primary lesions of the petrous apex, with special emphasis on the clinical findings, pathophysiology, and surgical considerations in cholesterol granuloma. Two pertinent case histories are included.     

Radiology of the paranasal sinuses in nonhealing granulomas of the nose

Radiology of the paranasal sinuses in non-healing granulomas of the nose The few accounts of the radiographic features in the nose and sinuses of Wegener's granulomatosis and lethal midline granuloma have involved small numbers. This paper reviews these changes in 20 cases of Wegener's granulomatosis and 7 cases of lethal midline granuloma. Fifteen cases of Wegener's granulomatosis showed either negative or non-specific changes on plain sinus views. In the remaining 5 cases some evidence of bone destruction was seen. The range of changes was much greater in lethal midline granuloma. The radiographic changes varied from normal appearances (1 case) through generalized soft tissue opacity (3 cases), to massive destruction of the nasal bones and sinus walls (3 cases). The difference in radiological pattern in Wegener's and lethal midline granuloma would seem to be one of degree only.