Fibrous dysplasia of the sphenoid sinus and skull base presents in an adult with localized temporal headache

Fibrous dysplasia (FD) of the sphenoidal sinus is a rare disease, especially during adulthood. We report a case of FD of the right sphenoidal sinus in an adult male patient who presented with nonspecific symptoms limited to headache localized to the right temporal area and to the inferior orbital rim of both sides. Magnetic resonance imaging revealed a dense mass that occupied the entire right sphenoidal sinus and skull base with typical ground-glass opacification and bony sclerosis of the whole sphenoidal wall. The diagnosis of FD was confirmed on pathological examination of a biopsy taken through sphenotomy. The patient underwent a subcranial craniotomy for tumor resection. After more than 4 years of follow-up, the patient was disease-free. On the basis of these clinical features, it is important to consider sphenoidal FD in both young and adult patients complaining of an unexplained headache, because it may present unusually with headache localized to the temporal region or the inferior orbital rim.     

Bilateral subpontic osseous hyperplasia. A case report

A case of osseous hyperplasia under the pontics of fixed partial dentures in right and left mandibular first molar regions is presented. Radiographs showed hemispherical radio-opacities on the alveolar ridges. Histologic examination revealed the lesions were composed of a dense mass of mature bone with well-developed lamellae and haversian systems, viable osteocytes in lacunae and a few marrow spaces filled with loose fibrous connective tissue. The review of the literature showed osseous hyperplasia under the pontic of a fixed partial denture has been seen only in the mandibular molar or premolar regions, but no conclusion about its etiology was made.     

Frontal sinus fractures: computed tomography evaluation of sinus obliteration with lyophilized cartilage.

Allogenic lyophilized cartilage has been proven clinically to be a reliable material for obliteration of the frontal sinus without the limitations of donor site morbidity and the prolongation of the operation time produced by autogenic grafting. The long-term behaviour of the implanted material is of paramount importance for the success of the obliterative technique. This survey included 51 trauma patients on whom obliteration of the frontal sinus with lyophilized cartilage was performed. The fate of the lyophilized cartilage graft was evaluated from computed tomography imaging of the obliterated frontal sinus. No radiological sign of mucocele formation or inflammatory disease was noted. Bone density measurement of the obliterated sinus and the adjacent trabecular bone was calculated. The patient population was distributed into four groups (0-2, 2-4, 4-6, > 6 years) according the postobliterative time. The bone density of the implanted lyophilized cartilage was accentuated from group 1 to group 4 when compared with the bone density of the trabecular bone. This shows the long-term tendency of lyophilized cartilage graft to osseous substitution.     

Case challenge. Chronic maxillary inflammation

A 30-year old male was referred by a dental practitioner to the Department of Oral Radiology at the University of Lund, Sweden, for a radiological evaluation of chronic symptoms of inflammation on the right side of the maxilla. According to the patient, at age 12 he had surgery to remove a non-erupted maxillary right second premolar. Postoperatively, a draining sinus tract appeared on the buccal aspect of the alveolar process. Thirteen years later, at age 25, surgery was again performed and the sinus tract reappeared. Intermittent discharge of exudate from the sinus tract occurred since the second surgery. Clinical and radiological examinations were conducted prior to a third surgery. The clinical examination revealed pus draining from the tract located on the buccal aspect of the alveolar process between the right maxillary first molar and first premolar. The radiological examination included periapical radiographs of the right maxillary first premolar and canine, a panoramic radiograph, and frontal tomograms of the maxillary right premolar area.     

Frontal parosteal lipoma

Parosteal lipoma of the head and neck is very rare, and there is no reported case of parosteal lipoma in the frontal region. We present the case of frontal parosteal lipoma in a 20-year-old man who was referred for a forehead mass causing a cosmetic problem. Computed tomography revealed an osseous projection with cortical irregularity and soft tissue enlargement. Excision of the lesion revealed a 7 x 4.5-cm lobulated, encapsulated, yellow tan mass. Histopathologic examination revealed mature adipose tissue, and pathologic diagnosis of lipoma was made. Here, we present the first case of parosteal lipoma in the frontal region.     

Ossification of the frontal sinus in juvenile minipigs following water jet application.

BACKGROUND: Obliteration of the frontal sinus is a generally accepted management for patients with severe craniofacial trauma in whom the sinus cannot be repaired or adequately drained. Effective obliteration requires complete removal of mucosa, sufficient filling of the sinus cavity as well as effective occlusion of the nasofrontal duct. The use of various filling materials for sinus obliteration has been described and include autologous fat, bone, muscle and lyophilized cartilage. MATERIAL AND METHODS: In order to appreciate the advantages of the water-jet scalpel an animal study in 10 juvenile (4 months old) and 10 adult (18 months) minipigs was performed. In 5 juvenile and 5 adult animals the frontal sinus mucosa was removed using the water jet, while in the others bone curettes were used. No occlusion of the frontonasal duct was carried out and no filling material was implanted. All animals were followed-up for 40 days. After sacrifice, radiological, histological and computerized histomorphometrical examinations were carried out. RESULTS: Removal of the mucosa from the sinus was simplified when using the water jet. Previous studies have shown that the selected tissue structures were less traumatized when compared with conventional surgical techniques. In young animals (only) and exclusively following the use of a water-jet scalpel osseous occlusion of the frontal sinus was found at follow-up. Histomorphometric findings revealed a significant increase of bone formation in the frontal sinus area of these animals. CONCLUSION: Based on these experimental results in a small series of juvenile minipigs the water-jet technique is a faster and less traumatic technique (less blood loss) for osteoplastic surgery of the frontal sinus. Further long-term studies are needed to evaluate the possibilities for applying this technique in post-traumatic craniofacial surgery in man.     

Cemento-ossifying fibroma of the ethmoidal sinus in a child presenting with isolated pain in the nasal region

The authors present a case of a previously healthy 8-year-old girl who presented with pain on the right side of the nose (bony part) radiating to the frontal and temporal regions. Physical examination was normal, whereas magnetic resonance imaging (MRI) of the facial region revealed a tumor limited to the right ethmoidal sinus with a small extension to the medial wall and the upper part of the nasal septum. The tumor was removed by using a 5-degree nasoscope and sent for pathologic examination, which revealed a cemento-ossifying fibroma of the ethmoidal sinus. This is a rare condition, and MRI is a valuable tool in its detection because results of physical examination may be normal in patients reporting nasal pain. According to the World Health Organization classification, this tumor is a variant of cementifying fibromas, which represent a subgroup of cementomas, fibro-osseous lesions containing cementum. Cementifying fibromas are rare tumors. They are usually small, asymptomatic lesions, but although benign, they can develop into aggressive, expansible masses.     

Closed treatment of frontal sinus fracture with percutaneous screw reduction

Fractures of the frontal sinus are a relatively common injury presenting to trauma units that deal with craniofacial injuries. Approximately one third of frontal sinus fractures affect the anterior wall alone, with two thirds involving the anterior wall, posterior wall, or frontonasal duct. Isolated posterior wall defects are exceedingly rare. Frontal sinus fracture management is still controversial and involves preserving function when feasible or obliterating the sinus and duct, depending on the fracture pattern. In the standard treatment modality of frontal sinus fractures, repair is best performed by way of a coronal approach, which offers excellent access. Most of the frontal sinus fractures deserve this attentive surgical manipulation to prevent late sequelae of infection or mucocele formation. In this article, we present a case of isolated depressed anterior wall fracture of the frontal sinus that was treated by closed reduction to avoid coronal incision. Anterior wall fracture of the right frontal sinus was diagnosed with preoperative evaluation of three-dimensional CT of a 34-year-old male patient with maxillofacial trauma. The anterior wall fracture was reduced by traction of two percutaneously applied screws to the depressed fragments. Accurate reduction was obtained, and neither recurrent displacement nor infection was observed during the follow-up period of 3 months. The screws were removed in the clinical setting without difficulty. Although percutaneous reduction of noncomminuted anterior wall frontal sinus fractures has limited indications, it has its own advantages over open techniques. This method is a less-invasive technique and can be performed without problem in selected cases. Our technique is not suitable for complex fractures of the frontal sinus.     

Synchronous multicentric bilateral sinonasal inverted papilloma and frontal sinus osteoma

Inverted papilloma is generally considered a benign unilateral sinonasal tumor. Its synchronous bilateral multicentric occurrence is extremely rare. A 22-year-old male patient presented with stage III inverted papilloma involving both ethmoid sinuses, both frontal sinuses, and cribriform area. The patient also had a large osteoma emanating from the basal part of the frontal sinus septum, which completely obstructed both nasofrontal recesses, leaving no communication between the sinuses and the nasal cavity. The frontal sinus septum was intact, so there was no communication between the 2 sides either. Following the era of aggressive surgical approaches dominated by lateral rhinotomy and medial maxillectomy, the advent of endoscopic techniques has dramatically improved visualization of sinus chambers and nasal cavity, resulting in lower morbidity and similar results to those achieved with open surgical procedures. In our patient, the concomitant presence of a huge frontal sinus osteoma posed an unacceptable risk for endoscopic resection due to the possible residual disease in the nasofrontal recess regions. Surgical resection remains the mainstay treatment and should be tailored in accordance with the localization and spread of disease. The surgeon should be ready to use different surgical approaches and, if intraoperatively needed, to modify them accordingly.     

Nasofrontal heterotopic ossification following lymphangioma resection

Heterotopic ossification (HO) is the formation of mature lamellar bone in soft tissues. Heterotopic ossification can occur locally following surgical trauma, most commonly after total hip arthroplasty. Periosteal stripping, organizing hematoma, and extensive soft tissue dissection have been associated with subsequent HO. Craniomaxillofacial HO is rare and almost always associated with injury to the muscles of mastication. We present a report of biopsy-established HO of the cranium. An 18-month-old boy presented with a soft, compressible mass in the forehead midline, which did not extend intracranially on computed tomography scan. Surgical exploration revealed a poorly marginated lymphangioma infiltrating the periosteum of the nasofrontal region. This was debulked to restore nasofrontal contour. Two months postoperatively, after minor accidental trauma, the patient developed a subperiosteal hematoma that was evacuated in the clinic. Eight months postoperatively, the patient returned with a visible nasofrontal prominence overlying a firm immobile mass. Computed tomography scan revealed a 3-cm horn-like osseous structure extending inferiorly from the frontal bone across the nasofrontal junction. The bony mass was resected via a coronal approach and confirmed as HO with hematopoietically active marrow.     

Intracranial spread of a giant frontal mucocele: case report

A giant mucocele eroded both the anterior and posterior wall of the frontal sinus and infiltrated the dura mater. Its extracranial growth caused a frontal bony prominence. The tumour and part of the dura were resected. A 12 x 6cm defect in the dura was repaired with a freeze-dried patch. A split-thickness bone graft from the right parietal region was used to repair the anterior frontal bony defect. The result one year later was satisfactory. Spiral computed tomography with thr ee-dimensional reconstructions excluded any recurrence of the tumour and showed good integration of bone grafts.     

Solitary plasmacytoma of the maxilla--a case report and review of the literature

Plasma cell neoplasms have been classified as multiple myeloma, solitary plasmacytoma, and extramedullary plasmacytoma. The solitary plasmacytoma of the maxilla is a rare condition that focuses solely on myelomatous tissue and is not disseminated to other parts of the skeleton. Some lesions appear to be benign and do not recur after complete removal, while others are locally invasive. The dense plasma cell infiltration that commonly is associated with inflammatory lesions within the oral tissues makes diagnosing plasmacytoma at this site problematic. This article presents a case of solitary plasmacytoma in the maxilla. Radiographic examination revealed an osteolytic lesion over the right maxillary bone, invading the maxillary sinus. A CT scan showed that the tumor mass occupied the right maxillary sinus and the lateral wall of the nasal cavity. The tumor cells were composed of densely packed, round, polygonal cell structures that were scattered in relatively sparse stoma. The neoplastic cells had a large, single eccentric nucleus, resembling typical plasma cells. The clinical, histopathological, and radiological features of solitary plasmacytoma are discussed.     

Reconstruction of Large Cranial Defect with Alloplastic Material (Bone Cement-Cold Cure Polymethyl-Methacrylate Resin)

A 40-years-old male patient reported to our department with a chief complaint of persistent palatal fluid discharge and large depressed forehead defect. He gave a history of trauma 20 months back due to head on collision to electric pole and underwent surgery twice for open reduction and fixation of facial skeletal fractures. After 9 months of surgery again a third surgery was performed for the removal of frontal bone due to infection and osteomyelitis at the same site. Extra-oral examination revealed a large fronto-cranial defect extending from superior border of frontal bone to supra-orbital margins bilaterally in length, and from frontal right lateral to frontal left lateral side in width, measuring 8.0 cm in length, 10.5 cm in width and 1.5 to 2.0 cm in depth. Intra-oral sinus fluid discharge was from left posterior palatal region. Preoperative CT was taken and reconstruction of fronto-cranial defect was successfully performed with bone cement. Alloplastic implant reconstruction achieved an excellent esthetic result without any complications.     

Outer table craniotomy for frontal sinus mucocele

Variants of the external osteoplastic flap procedure or endoscopy have been used to approach the frontal sinus mucocele. The authors introduce a modified external approach for radical resection of the mucocele. Using the bicoronal skin incision, the skin flap exposed the right upper orbital rim. The outer table craniotomy was then performed to expose the frontal sinus cavity while carefully preserving the inner table, with radical removal of the mucocele mucosa. The sinus cavity was irrigated with hyper-oxide solution to ensure adequate destruction of possible residual mucosa. The fascia of the frontalis muscle was split, with one part placed into the mucocele cavity to plug the nasofrontal duct. The advantages of the procedures for mucocele removal include clear visualization of the frontal sinus for radical resection of the mucosa, preservation of the inner table avoiding dura manipulation, prevention of central nervous system infection, possibly lower rates of recurrence, prevention of mucosal ingrowth by plugging of the nasofrontal ducts with fascia, and favorable cosmetic outcome. The disadvantages are more intensive surgery comparable to the endoscopic approaches and execution difficulties when the frontal mucocele is small. Additional clinical studies are needed to evaluate the efficiency and safety of this procedure.     

Use of ultrafast computed tomography in dental surgery: a case report

Abstract - A case of a transdental fixation planned on the basis of ultrafast computed tomography is reported. This method allows to gain an insight in the osseous structures required for the operative procedure. Ultrafast computed tomography is superior to the convential radiographs in obtaining accurate information about the vertical bone supply and the extension of the facial osseous sinus wall. A set of axial CT-images with an extension of 3 mm was acquired in the region of the alveolar bone. By means of frontal reconstructions and data processing methods the thickness of the bone layer in transverse direction was accurately determined. The calculated bone thickness allowed to anchor a transdental self-tapping titanium screw.     

Maxillary Sinusitis Caused by Dental Implants Extending into the Maxillary Sinus and the Nasal Cavities

This report describes the case of a patient who underwent osseointegrated dental implant placement. The implants were misplaced inside the nasal fossae and in the right maxillary sinus, causing chronic purulent sinusitis. CT scan without contrast showed signs of right maxillary sinusitis and confirmed the misplacement of four dental implants that surfaced into the nasal cavities. The imaging also revealed the presence of another implant that emerged inside the maxillary sinus. The patient underwent functional endoscopic sinus surgery with complete symptom remission at the long‐term follow‐up. We propose that sinusitis caused by protrusion of implants and by sinus floor lift procedures could share common physiopathological patterns and predisposing factors.     

Unilateral bony ankylosis of the temporomandibular joint in a case of ankylosing spondylitis

Background

Ankylosing spondylitis (AS) is a chronic inflammatory disease with multiple articular and para-articular involvement that has a predilection for the axial skeleton. In spite of its high prevalence, ankylosis secondary to AS is a rare condition.

Case report

A 31-year-old male diagnosed with AS was referred for computed tomography (CT) of the temporomandibular joint (TMJ) due to severe mouth opening limitation. The patient had a 16-year medical history of AS and sought assistance due to TMJ pain and incapacity to open his mouth.

Results

Previous bony scintigraphy revealed involvement of the spine, sacroiliac joints, right knee, and left TMJ. Magnetic resonance imaging revealed erosion of the left condyle and posterior slope of the articular eminence, and a mass of heterogeneous signal intensity between these structures. The left condyle also presented sclerosis/edema of the bone marrow and the disk could not be identified. Sagittal and coronal CT images showed moderate alterations of the TMJ on the right side. On the left side, the images displayed markedly eroded condyle and mandibular fossa, and a bony mass resulting in ankylosis of the osseous components of the joint.

Conclusion

TMJ ankylosis in AS patients is rare and very few reports have presented imaging features of the condition through advanced diagnostic techniques.     

An unusual case of dental infection by Pseudomonas aeruginosa causing a brain abscess: case report

A brain abscess may result when dental infection reaches the brain through contiguous anatomic cavities such as the maxillary sinus, the ethmoid sinus and the orbital cavity. It is an important complication and should be treated aggressively. Such treatment would include the excision of the etiological factor, drainage and adjuvant antibiotic therapy. The present case concerns a 23 year old woman who presented at the General Hospital of Nova Iguaçu with complaints of pain in the right side of the face and was diagnosed with acute sinusitis. Antibiotics and analgesics were prescribed to treat the disease. However, after 10 days, she returned to the emergency room, presenting with proptosis of the right eyeball, subconjunctival haemorrhage, ophthalmoplegia and intense pain in the right orbit, in addition to headaches. After computed tomography was performed, she was diagnosed with a brain abscess in the frontal lobe with the involvement of the maxillary right first molar, the maxillary sinus, the ethmoid sinus and the orbital cavity. With culturing of the secretion, the growth of Pseudomonas aeruginosa colonies was evident. Treatment consisted of a craniotomy to drain the brain abscess, a Caldwell–Luc procedure to drain the right maxillary sinus, dental extraction and aggressive antibiotic therapy. After 6 weeks, the patient was discharged with no neurological sequelae.     

Experimental study of the frontal sinus development on Goettingen miniature pigs

According to the literature, the development of the frontal sinus cavity is a result of the active immigration of cells from the ethmoidal complex into the os frontale. This migration theory is in contrast to the operative outcome of Apert's syndrome patients, after fronto-orbital advancement. When a fronto-orbital advancement at the age of a few months is performed in these patients while the frontal suture is yet closed, a sinus developed even the distance between nasal root and frontal bone bing up to 2 cm.In order to study the development of the frontal sinus, an animal study on 12 five-week-old infant Goettingen minipigs (GMP) was conducted, which did not have any clinical or histological signs of a frontal sinus development to investigate the development of the frontal sinus in "orthotopically" transplanted frontal bone with an open frontal suture. A comparison was made to a control group.The macro- and microscopical comparison with a control group revealed that the orthotopical transplants in the occipital bone developed epithelium-lined sinus, beginning from the thirty-fifth week.Based on these histomorphological results, a development scheme for the genesis of the sinus frontalis as a model were drawn.     

Cystic Shape Cemento-Ossifying Fibroma of Ethmoid Sinus

Cemento-ossifying fibromas are a group of rarely occurring benign tumours, developing from the periodontal membrane and varying considerably in appearance and in the progress of the disease. Their common feature is higher or lower production of cemental tissue. In most cases the tumours are small because their cementoma mature quickly and become inactive, which causes the tumour to stop growing. They develop most frequently in the mandible and also in the maxilla. Other sites, such as paranasal cavities, soft tissues and bones of the head, are extremely rare. The case of a cemento-fibrosing tumour with psammoma infiltrations, developing from the ethmoid sinus in a nine-year-old girl is reported. Due to frontal headaches and sight defects as well as impaired vision on the right side, NMR was done, which showed a mucocele of the front and rear ethmoid with destruction of the orbital wall and a breakthrough into the orbit. The right maxillary sinus showed a visible retention and a thickened mucous membrane. A rhinoscopy revealed a ball-shaped spherical mass in the medial nasal meatus, which was defined as concha bullosa. An endoscopic examination showed that the tumour protruded in front of the medium nasal concha into the right nasal cavity, softened the ethmoid roof, penetrated toward the base of the skull, adhered and pushed the orbit. It was removed by FESS technique, and PHD revealed subsequently that it was not a mucocele but a cemento-ossifying fibroma.Key words: Fibroma, Cementoma, Ethmoid Sinus, Mucous Membrane, Turbinates