Spontaneous CSF Rhinorrhea Our Experience

Cerebrospinal fluid (CSF) leak occurs due to an abnormal communication between the subarachnoid space and sinonasal tract. We reported a retrospective case series of five patients of spontaneous CSF rhinorrhea. These patients were undergone successful repair with a single transnasal endoscopic procedure. This is seen in anterior part of the cribriform plate of middle aged obese females. HRCT paranasal sinus (1 mm cuts) was an effective modality of investigation in our study with ancillary investigations been CT cisternography. Endoscopic repair of CSF rhinorrhea carries a high success rate with very low morbidity rate.     

Nasion Swelling as the Presenting Symptom of Lung Adenocarcinoma

Metastasis to the paranasal sinuses from lung cancer is extremely rare. Here, we reported a patient of lung adenocarcinoma presenting with nasion swelling because of metastasis to the paranasal sinuses. A review of the literature from 1966 to 2008 yielded another 15 patients. Adenocarcinoma was the most commonly encountered histologic subtype, and modern combination chemotherapy was probably the most effective treatment modality. Headache, visual disturbance, facial mass, and facial pain were the symptoms frequently associated with paranasal sinus metastasis; however, all of them were nonspecific for a metastatic tumor. A thorough history taking, ear, nose, and throat examination, and laboratory investigations are of paramount importance to achieve a correct diagnosis.     

Importance of CT Scan of Paranasal Sinuses in the Evaluation of the Anatomical Findings in Patients Suffering from Sinonasal Polyposis

Sinonasal polyps are benign lesions arising from nose and/or sinuses mucosa. Paranasal sinuses computed tomogram (CT) scan are important for functional endoscopic sinus surgery (FESS) as their information assist the surgeon in pre-operative planning. This study aimed to show importance of CT scan in evaluation of anatomical variations to prove a correlation with disease process and extent of disease in sinonasal polyposis patients. A study was done from Sept, 2010 to Sept, 2011 with 33 patients presenting with nasal polyps. All recruited patients, after thorough history, general examination and thorough ENT examination, were examined by nasal endoscopy and sinus CT scans. All scans were carried out using a 3 mm thickness in axial and coronal planes with sagittal reconstruction. An analysis was then carried out to see anatomical variations and disease extent in CT scans. Maxillary sinus was the most commonly and most severely affected sinus, while the sphenoid sinus was the least involved sinus. Ostiomeatal complex (OMC) was found to be blocked in 84.85 % cases. There were few anatomic variations (57.58 %) found as hypertrophied uncinate process (30.30 %), septal deviation (21.21 %), skull base type-2, Concha bullosa, Haller’s cell, Paradoxical middle turbinate, Onodi cell, pneumatized crista galli and dehiscent skull base. Hyperdense and heterogeneous opacification in paranasal sinuses was seen in 12.12 % patients. Importance of CT scans is to know anatomical variations as etiology, fungal etiology, to know extent of polyposis and anatomical variations to prevent complications during FESS and Navigation sinus surgery.     

Adénocarcinome de bas grade des fosses nasales : à propos d’un cas

Low-grade sinonasal adenocarcinomas are uncommon and recently described entities. Its histologic diagnosis is challenging. This tumour is characterized by a tendency to local invasion, and rare distant metastases. Well treated, the prognosis is excellent. We describe a case of low-grade nasal cavity adenocarcinoma and discuss the anatomoclinical, therapeutic and evolutionary characteristics of this malignant tumour. A 54-year-old female patient presented with a 10 years history of right-sided nasal obstruction and recurrent epistaxis. On examination the patient had a large, firm mass in the right nasal cavity. Endoscopic sinonasal surgery was performed. The lesion was found to originate from the posteriolateral wall of the right nasal cavity. Histopathology analysis identified a low-grade sinonasal adenocarcinoma. Upon follow-up 4 years after surgery, the patient exhibited no clinical evidence of recurrence. Low-grade sinonasal adenocarcinomas are poorly defined neoplasms, accounting for 4 to 20% of all sinonasal malignancies. The nasal cavity is the most frequently involved site. Low-grade sinonasal adenocarcinomas pose a diagnostic challenge for the pathologist because they must be distinguished from benign tumours, especially adenomas. The primary treatment of sinonasal adenocarcinoma is complete surgical excision.     

Gastrointestinal Stromal Tumor Masquerading as a Spontaneous Rectal Hematoma

A 78-year-old Caucasian male with a history of atrial fibrillation and anticoagulation with warfarin presented with a change in bowel habits and weight loss. A computed tomography (CT) scan showed a 3.5 cm rectal mass. After biopsy with colonoscopy and endoscopic ultrasonography, the rectal mass was highly suspicious for rectal hematoma. When the rectal mass did not resolve after 1 month of follow-up, surgery showed the patient to have a rectal gastrointestinal stromal tumor. He is being treated with imatinib and follow-up CT scans. This case illustrates the importance of a high level of suspicion for a gastrointestinal stromal tumor when a rectal mass is found.     

Role of F.E.S.S. in chronic sinusitis

Functional endoscopic sinus surgery (FESS) is a new and exciting treatment for chronic sinus disease. A prospective study of 50 patients undergoing FESS was undertaken at the department of Otolaryngology, Dayanand Medical College & Hospital, Ludhiana. Parameters studied included patient symptoms, medical history, medical therapy, radiologic findings, complications and postoperative symptoms. 62% of our patients had sinonasal polypi (ethmoidal polypi 56%, antrochoanal polypi 6%) while 38% had chronic sinusitis. Osteomeatal complex involvement (88%) was the most common preoperative CT scan findings. All the cases were subsequently suhjected to functional endoscopic sinus surgery, studied for post-operative complications and 82% of the patients achieved improvement in preoperative symptoms. It was concluded that FESS is a highly successful treatment for chronic sinus disease.     

Nasal Endoscopy Versus Other Diagnostic Tools in Sinonasal Diseases

Sinonasal endoscopy is an essential part of the rhinologic examination performed by otolaryngologists in the evaluation of sinonasal disease. The use of the endoscopes has been popularized with the advent of endoscopic sinus surgery. To evaluate the role of nasal endoscopy as primary examination in the early and accurate diagnosis of sinonasal diseases in comparison to other diagnostic tools in rhinology. A retrospective and prospective study was carried out on 200 patients with clinical evidence of sinonasal diseases. They were evaluated with anterior rhinoscopy, nasal endoscopy and CT paranasal sinus. The level of agreement between anterior rhinoscopy and nasal endoscopy was substantial for deviated nasal septum, inferior turbinate hypertrophy and polyp (0.735, 0.712 and 0.709, respectively), but moderate for middle turbinate hypertrophy (0.418). The results of endoscopy and CT comparison among 80 patients, whose symptoms warranted CT, indicated that although for most of the findings, there was almost perfect to substantial level of agreement between the results of the two methods, five patients had normal CT imaging report, while they demonstrated early polyps during endoscopic evaluation. Also, CT missed 4 cases of deviated nasal septum. Diagnostic nasal endoscopy proved a better technique to detect various sinonasal pathologies as well as anatomical variations, which are otherwise missed on Computed Tomography or inaccessible on anterior rhinoscopy especially in the key area comprising the ostiomeatal complex. We reinforce the fact that it should be viewed as an essential part of a complete examination of the nose and sinuses.     

鼻腔鼻窦肌上皮癌的生物学行为及诊治

目的 提高临床医生对鼻腔鼻窦肌上皮癌的认识。方法 回顾性分析我科近期收治的两例鼻腔鼻窦肌上皮癌临床资料，并复习文献。结果 1例为女性，47岁；1例为男性，54岁。临床表现为鼻塞、鼻腔暗红色肿物。鼻窦CT示鼻腔占位性病变。术前病理及免疫组化(S-100蛋白、平滑肌动蛋白、细胞角蛋白、波形蛋白等呈阳性染色)确诊“肌上皮癌”。两例均行鼻侧切开鼻腔肿瘤切除术，例1术后5月出现颈淋巴结转移，术后11月死于全身骨及肝转移。例2术后8月死于肺转移。结论 鼻腔鼻窦肌上皮癌极为罕见，迄今为止，仅8例报道。综合文献，该瘤具有生长迅速、广泛侵犯周围组织、颈部淋巴结转移率高、血行转移率高、治疗后易复发、预后差等特点。诊断依赖病理及免疫组化。治疗以根治性手术为主，对于cNO的患者,应行分区性颈淋巴结清扫术。     

Head and neck tumors other than squamous cell carcinoma

PURPOSE OF REVIEW: This review deals with classification and treatment of some rare nonsquamous cell carcinomas of the head and neck. RECENT FINDINGS: Paranasal sinus tumor classification is under evaluation. Contrary to the past, the recent tendency is to build stage classifications on prognostic factors that mainly reflect limitations for adequate surgery, and not simply on dimensional criteria, which are more frequently used in TNM. Among sinonasal tract tumors new pathologic entities have been described. So far, little is known about their natural history and about the need to use pathologic classification to differentiate treatment. Recent advances in radiotherapeutic techniques, such as intensity-modulated radiotherapy, will probably have an impact on future treatment of paranasal sinus tumors. Several molecular targets (c-kit, HER-2/neu, androgen receptors) have been identified in salivary gland cancer. It is interesting to note that among different histotypes there is a trend toward a consistent expression of specific markers in specific cancers, suggesting a possible implication of them in the disease histogenesis. Not surprisingly these findings prompted clinical research with molecular targeted drugs. SUMMARY: Nonsquamous cell carcinomas of the head and neck are rare neoplasms. A multidisciplinary team treatment plan is needed, in particular for skull base-located tumors. Salivary gland cancer displays several molecular targets that need to be investigated further.     

Sinonasal adenoid cystic carcinoma: the M. D. Anderson Cancer Center experience

BACKGROUND: Adenoid cystic carcinoma of the sinonasal tract is a rare cancer that accounts for 10% of all malignancies at this site. The objective of the current study was to evaluate prognostic factors, treatment outcomes, recurrence patterns, and survival rates for sinonasal adenoid cystic carcinoma. METHODS: A retrospective chart review was performed at an academic tertiary referral center. Between 1990 and 2004, 105 patients were evaluated for adenoid cystic carcinoma of the sinonasal tract at a single institution. Demographics, presentation, anatomic site, Tumor, Lymph Node, Metastasis (TNM) classification, pathology, treatment, recurrences, and survival were evaluated. RESULTS: One hundred five patients with adenoid cystic carcinoma were evaluated, including 58 women and 47 men. Their median age was 50 years, and the mean follow-up was 47 months. The maxillary sinus (47%) and the nasal cavity (30%) were the most common primary tumor sites. The majority of patients presented with T3/T4 (76.7%), N0 (98%), M0 (97%) disease. Eighty-four percent of patients underwent surgery and received postoperative radiation as treatment for their primary disease. The local recurrence rate was 30%, and the distant metastases rate was 38%. The 5-year overall survival and disease specific survival rates were 62.9% and 70.9%, respectively. CONCLUSIONS: Adenoid cystic carcinoma of the paranasal sinuses is a rare disease, and the ideal treatment paradigm has yet to be defined. The current data suggested that surgical resection with postoperative radiation therapy offers durable local control and compares favorably with historic data. Although local recurrences develop in a significant percentage of patients, survival from this disease exceeds that of other sinonasal malignancies.     

Giant Ethmoid Mucocele Presenting as an Orbital Mass

Mucocele is a benign and expansile cystic lesion lined with respiratory mucosa of pseudo stratified columnar epithelium. Mucocele most commonly produces bone destruction within the paranasal sinuses. It mostly involves the frontal sinus followed by ethmoid and rarely sphenoid and maxillary sinuses. We report a case of giant ethmoid mucocele who presented with history of progressive unilateral protrusion of eye since 5 years. CT scan revealed a large mucocele of the ethmoid sinus with orbital extension on the same side. He was successfully treated with endoscopic sinus surgery.     

Management of paranasal sinus malignancy

Opinion statement Malignancies of the nasal cavity and paranasal sinuses represent a wide spectrum of histologies, tissues of origin, and anatomic primary sites. The inherent difficulty in generalizing treatment approaches is obvious, given the numerous variables associated with the broadly-based term, paranasal sinus malignancy (PNSCa). Nevertheless, the majority of epithelial and salivary malignancies of this region (ie, squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, sinonasal undifferentiated carcinoma, and esthesioneuroblastoma) require surgical intervention as part of any treatment regimen. Recent trends have broadened the indications for chemotherapeutic and radiotherapeutic options in the management of advanced PNSCa. Nonepithelial malignancies, including the wide variety of sarcomas arising in this region, most commonly require multimodality treatment including chemotherapy, radiation, and/or surgery for definitive treatment. Moreover, the proximity of the nasal cavity and paranasal sinuses to structures including the orbit, dura, brain, cranial nerves, and carotid arteries mandates careful radiologic and neurologic evaluations throughout the course of the disease. Surgical advances now permit complex tumor removal and reconstruction surrounding these structures resulting in functional and cosmetic improvements when compared to earlier techniques. However, additional clinical trials are necessary to systematically evaluate the locoregional control, organ-preservation strategies, and survival related to the variety of treatments currently available.     

鼻内镜下鼻腔鼻窦内翻性乳头状瘤切除术

目的探讨经鼻内窥镜鼻腔鼻窦内翻性乳头状瘤切除术和鼻内镜联合鼻侧切开鼻腔鼻窦内翻性乳头状瘤切除术的疗效。方法26例鼻腔鼻窦内翻性乳头状瘤病例中,22例行经鼻内窥镜鼻腔鼻窦内翻性乳头状瘤切除术,4例行鼻内镜联合鼻侧切开鼻腔鼻窦内翻性乳头状瘤切除术。结果术后随访9~60个月。1例术后30个月复发,其它25例未见复发,全部病例无并发症发生。结论经鼻内窥镜鼻腔鼻窦内翻性乳头状瘤切除术适用于较局限的病变,而对广泛病变则应采用鼻内镜联合鼻侧切开术,术后鼻内镜定期复查可早期发现肿瘤复发并处理。     

Inferior Turbinate osteoma — rare cause of nasal obstruction

Osteomas are common benign tumors of the paranasal sinus, with a predilection for the frontal sinus. We report a rare case of inferior turbinate osteoma in a 54 year old lady. The osteoma was resected completely by endoscopic sinus surgery and the patient was relieved of symptoms.     

Impact of Anatomical and Radiological Findings for Consideration of Functional Endoscopic Sinus Surgery

Endoscopic sinus surgery is being done more accurately and with better diagnosis and planning with the help of high resolution CT scan. It has played an invaluable role in the delineation of the sinonasal pathology and anatomic variations preoperatively. To correlate the CT scan findings with endoscopic findings with respect to anatomical variants and pathology and evaluation of its impact on surgical planning. A prospective study conducted on 300 patients who presented to the ENT out patient department with sinonasal diseases and underwent Functional endoscopic sinus surgery. There is a need to evaluate and correlate the findings to deduce the extent of relations CT findings have to that of findings observed during endoscopy as they really affect the surgical planning and outcomes.     

Sinonasal neuro endocrine carcinoma extending into orbit — a case report

Small Cell Neuroendocrine Carcinomas of the Sinonasal tract are extremely uncommon and distinct neoplasms with aggressive clinical behavior. They have similar morphological and immunohistochemical features to those of small cell carcinomas of the lung. They should be distinguished from Olfactory Neuroblastomas. We report a case of this rare entity. A 46-year-old woman presented with a history of injury to the right eye with facial pain and proptosis as the primary symptoms. Later she developed nasal stuffiness. C.T. Scan revealed a space occupying lesion in the right nostril extending into ethmoid sinus and orbit. Functional endoscopic sinus surgery was done with decompression of the orbit. The biopsy material was obtained from ethmoid sinus and orbit. Histopathological examination of the biopsy specimen along with Immunohistochemical stains confirmed a Small Cell Neuroendocrine Carcinoma. Patient was treated with Radiotherapy and chemotherapy and responded well.     

Antrolith in the maxillary sinus: an unusual complication of endoscopic sinus surgery

Antrolith of the paranasal sinuses are rare entity which are usually asymptomatic, caused by calcification of a nidus and are detected incidentally on radiological examinations. We report a case which presented to us with features of pansinusitis six months after endoscopic sinus surgery. Radiological examination revealed a discrete bony density in the maxillary sinus blocking the ostiomeatal complex. The bony mass was removed endoscopically from the maxillary sinus with drainage of discharge and debris from the sinuses. Histopathological examination revealed an antrolith with bony nidus and calcium deposited around it. We present the imaging and review the present world literature on this rare complication of endoscopic sinus surgery.     

鼻内镜下手术治疗侵及眼眶的鼻腔鼻窦肿瘤

目的： 探讨鼻内镜下手术治疗侵及眼眶的鼻腔鼻窦肿瘤的安全性、临床效果和术式的选择。方法:回顾性分析15例在鼻内镜下行切除手术治疗的侵及眼眶的良性和早期恶性鼻腔鼻窦肿瘤患者的临床资料、手术方法、并发症及治疗预后。结果:全部病例中,11例单纯经鼻内镜下切除肿瘤,4例经鼻腔和鼻外切口双径路手术治疗,其中 1例侵袭性大B细胞淋巴瘤患者术后出现下睑外翻,经治疗后好转;1例鼻腔鼻窦骨瘤患者于鼻内镜下全切骨瘤,术后出现患侧内眦外移;4例良性骨源性病变患者行鼻内镜下病变部分切除术,其余病例均彻底切除肿瘤而无明显并发症,随访6~36月未见复发。结论:鼻内镜下手术治疗侵及眼眶的鼻腔鼻窦肿瘤有其独特的优势,在鼻内镜下单纯经鼻腔或内镜辅助经鼻腔和鼻外切口双径路手术治疗可以取得比较好的临床预后。     

Three cases of colonic-type adenocarcinoma in the head and neck region with positive CEA

Adenocarcinoma arising in the head and neck region is found very rarely. Recently, we have experienced 3 cases of papillary adenocarcinoma (2 of paranasal sinus and 1 of epipharyngeal origin) with a histological similarity to colon cancer. Histochemical study of CEA by the PAP method was positive in all 3 cases, and this resembled colon cancer with respect to the tumor marker. Adenocarcinoma of the colonic type in the head and neck region should be further investigated for tumor characterization including the significance of positive CEA, as this tumor might be regarded as usual adenocarcinoma so far.     

Evaluation of P53, P63, P21, P27, Ki-67 in Paranasal Sinus Squamous Cell Carcinoma and Inverted Papilloma

Using a molecular genetic approach, we try to confirm the molecular alterations of inverted papilloma and clarify its status as a putative precursor lesion of sinonasal squamous cell carcinoma. To better understand its genetics, we investigated the immunohistochemical protein expression patterns of cell-cycle-regulators p53, p63, p21, p27 and proliferation marker Ki-67 in 22 inverted papilloma and 9 squamous cell carcinoma of the sinonasal tract. Significantly elevated levels of p53 and p63 in squamous cell carcinoma of sinonasal tract compared with inverted papilloma were revealed. Ki-67-stained neoplastic cell nuclei were found in a significantly higher percentage of squamous cell carcinoma of sinonasal tract than in inverted papilloma, whereas no variation of p21 and p27 expression was identified. This work first examined the immunohistochemical overexpression of p63 in sinonasal inverted papilloma and squamous cell carcinoma. In conclusion, this is a first study shedding light on the expression of p63 in tumors of paranasal sinuses.