Chondroblastic Osteosarcoma of Nasal Bone: Report of a Rare Case

Primary Care Evaluation of the Nose and Paranasal Sinuses

There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods. A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies. The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies. Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

On the basis of strong research evidence, the pathogenesis of sinusitis involves 3 key factors: sinusostia obstruction, ciliary dysfunction, and thickening of sinus secretions. On the basis of studies of the microbiology of otitis media, H influenzae is playing an increasingly important role in the etiology of sinusitis, exceeding that of S pneumoniae in some areas, and b-lactamase production by H influenzae is increasing in respiratory isolates in the United States. On the basis of some research evidence and consensus,the presentation of acute bacterial sinusitis conforms to 1 of 3 predicable patterns; persistent, severe, and worsening symptoms. On the basis of some research evidence and consensus,the diagnosis of sinusitis should be made by applying strict clinical criteria. This approach will select children with upper respiratory infection symptoms who are most likely to benefit from an antibiotic. On the basis of some research evidence and consensus,imaging is not indicated routinely in the diagnosis of sinusitis. Computed tomography or magnetic resonance imaging provides useful information when complications of sinusitis are suspected. On the basis of some research evidence and consensus,amoxicillin-clavulanate should be considered asa first-line agent for the treatment of sinusitis.

Chronic Rhinosinusitis

Pleomorphic adenoma is very rare in the sinonasal region, with the most common localization on the nasal septum, followed by lateral nasal wall. In the case presented, a 72-year-old woman was complaining of the right sided nasal obstruction without any other symptoms. The symptom started a year before and increased progressively. Anterior rhinoscopy revealed a mucosa-covered, smooth-surfaced, soft, polypoid, pale, grayish-pink in color mass in the right nasal cavity, approximately 2x2 cm in size. Nasal endoscopy showed the mass to have a broad base on the lateral nasal wall. Computerized tomography scan showed a homogeneous, solid soft tissue mass, 25x18x12 mm in size, which was attached to the lateral nasal wall, behind the nasal vestibule, just in front of the inferior turbinate. Endonasal endoscopic complete tumor excision was performed, during which some spillage of the tumor occurred. Histology diagnosis was pleomorphic adenoma of minor salivary glands. The patient was followed up on regular basis and had no tumor recurrence in the 6th postoperative year. Intranasal pleomorphic adenoma arising from the lateral nasal wall in front of the inferior turbinate is extremely rare, so the presented case is probably the first ever published.

What are the indications for the use of computed tomography before septoplasty?

In 1863, the term “odontoma” was introduced by Paul Broca which he described as a tumor formed by overgrowth of transitory or complete dental tissue. The World Health Organization classified them under mixed benign odontogenic tumors because of their origin from epithelial and mesenchymal cells, exhibiting different structures of dental tissue (enamel, dentin, cementum and pulp).1 There are two distinct types: compound and complex. Compound odontoma is composed of all odontogenic tissue in an orderly fashion resulting in many teeth-like structures but with no morphological resemblance to normal teeth, whereas a complex odontoma appears as an irregular mass with no similarity even to rudimentary teeth.2,3,4
 The pathogenesis of odontomas has not been completely established, although the most accepted etiology is related to trauma, infection, growth pressure, and genetic mutations in one or more genes that cause disturbances in the mechanism controlling tooth development.1,5
 Patients with compound odontoma are often asymptomatic. It is usually detected on routine radiography upon examination of an unerrupted tooth.6 Odontomas can occur anywhere in the jaws and are usually found associated with or within the alveolar process.7 However, the presence of an odontoma in the maxillary sinus is very rare.
 We present a female patient with a compound odontoma in the maxillary sinus, initially managed as nasal vestibulitis with maxillary sinusitis.
 
 CASE REPORT
 A 63-year-old woman from Cavite City, Philippines consulted in our institution due to perception of foul odor. Six weeks prior to admission, she experienced right alar pain, facial fullness and swelling with associated undocumented fever. She consulted an ENT specialist and was diagnosed with nasal vestibulitis with maxillary sinusitis. She was given cefixime 200mg, one tablet twice a day and Metronidazole 500mg, one tablet every six hours for seven days.
 Five weeks prior to admission, despite resolution of the nasal and maxillary swelling and pain, she started to perceive a foul odor. There was no associated nasal congestion and nasal discharge, fever, no nasal itchiness nor frequent sneezing. Her physician requested an orthopantomogram hat revealed a suspicious mass and haziness in the right maxillary sinus and an impacted tooth in the left maxillary sinus. (Figure 1) She was advised surgery but opted for a second opinion.
 2 weeks prior to admission, still with perception of foul odor, she consulted another ENT specialist and was given co-amoxiclav 625mg, one tablet every eight hours. A CT scan of the paranasal sinuses revealed mucoperiosteal thickening and calcific density within the opacified right maxillary sinus. (Figure 2 A, B) The patient was advised surgery.
 The patient had pulmonary tuberculosis in 1983 but was treated for six months. She does not recall having any un-erupted teeth and claimed that her previous dental extractions were unremarkable. She had a family history of bronchial asthma and colon cancer. She did not drink alcoholic beverages but she previously smoked for 1 pack-year.
 Anterior rhinoscopy revealed scant clear mucoid discharge in both nasal cavities, noncongested and nonhyperemic turbinates, and no intranasal mass. She was edentulous, with no facial mass or swelling. The rest of the examination was unremarkable.
 With an assessment of a right maxillary mass (odontogenic tumor versus foreign body) with right maxillary sinusitis, and an impacted tooth in the left maxilla she underwent a Caldwell-Luc procedure. Antrotomy was performed through the canine fossa via a gingivolabial incision overlying the anterior maxillary wall. Thick clear mucous was seen oozing out and eventually drained and suctioned out. (Figure 3) A 2 cm x 2 cm x 2.1 cm ovoid, whitish to tan colored hard mass partially covered by black fragments was carefully extracted. (Figure 4) Irrigation of the maxillary sinus was performed using normal saline solution and the natural maxillary ostium was widened. The incision was closed with interrupted mattress sutures using chromic 3.0 and the mass was submitted for histopathological analysis.
 Microscopic sections revealed misshapen teeth or denticles with a coordinated pattern of calcification such as enamel, dentin and cementum. (Figure 5 A - C) The final histopathologic report was a compound odontoma of the right maxillary sinus.
 The postoperative follow-up was satisfactory. Our patient developed no oro-antral fistula and showed no signs of maxillary sinusitis and the perception of foul odor resolved.
 
 DISCUSSION
 Odontoma is a generally asymptomatic, slowly progressing tumor that may pass unnoticed. It is usually detected by routine radiograph. This may be associated with un-erupted tooth, mainly the mandibular third molar, followed by the upper canine and upper central incisor. The prevalence of odontoma associated with impacted canine is 1.5 %.8 The maxillary sinus is a frequent site for pathologies of odontogenic origin because of its close anatomical relationship with teeth and periodontal tissues. This makes a frequent but not a common site for inflammatory diseases as well as neoplastic lesions.6 The patient initially presented with right alar pain and right facial swelling. She did not recall having an un-erupted tooth and claimed that her previous dental extractions were unremarkable. After treatment, the pain and swelling resolved but she started to perceive a malodorous smell. Commonly, clinicians arrive at the diagnosis of sinusitis when failure of its resolution despite antibiotic treatment prompts warning bells that warrant further radiographic investigation. The radiographic appearance of odontoma is almost always diagnostic3 as in the presented case. Panoramic and periapical images usually show well-defined borders of a similar density to calcified dental tissue, having a ground-glass appearance, and a radiopaque mass occupying the affected maxillary sinus.9 This was evident in the patient's panoramic radiograph. 
 Additional radiographic evaluation with computed tomography was necessary to determine the extension and features of the lesion because periapical and panoramic images do not provide complete visualization of the maxillofacial complex. CT scans serve as a guide not only for evaluation of the lesion itself, but also for localization of associated pathology and proper treatment planning.10 In this case, the computed tomography scan of the paranasal sinuses revealed mucoperiosteal thickening and calcific density within the opacified right maxillary sinus, suggesting odontogenic origin with concomitant maxillary sinusitis. 
 Due to its asymptomatic course, it can be surmised that the patient might have had the asymptomatic compound odontoma for a long time. The mass in her maxillary sinus was seen freely floating in her CT scan. It may be hypothesized that obstruction by the odontoma could have altered the ventilation and drainage of the maxillary sinus, causing the symptoms of the patient. Cabov, et al. reported that odontomas in the maxillary sinus may also cause pain, facial asymmetry and chronic congestion of the sinus.11
 Management for this case was surgical removal of the mass with drainage of trapped mucus as well as medical treatment of the maxillary sinus infection. The Caldwell-Luc procedure was the favored approach to this case because it offered easy access to the mass that could not be extracted trans-nasally because of its size and solid nature. Restoring the drainage of the maxillary sinus was also essential and this was done by widening the natural maxillary sinus ostium. 
 The histological characteristics of the mass extracted from the patient consisted of denticles with a coordinated pattern of calcification such as enamel, dentin and cementum, compatible with a compound odontoma.
 The rarity of odontomas makes them easy to miss should a radiographic examination not have been done. Despite their being usually asymptomatic, our patient had chronic perception of foul odor that was bothersome and frustrating. A clinician relying on medical history and physical examination alone could not have arrived at the correct diagnosis. In this case, it was shown that radiographic imaging was very crucial in catching a hidden and rare tumor.

Introduction Rhinolithiasis is a clinical symptom caused by rhinoliths (1). Today, the incidence of rhinolith in adults is low. Rhinoliths result from mineralization of an endogenous or exogenous nidus and usually develop within the nasal cavity (1). They are a mixture of 10% organic substances and 90% inorganic material incorporated into the lesion from nasal secretions (2). Exogenous rhinoliths are more common and are usually formed due to concretions around impacted foreign bodies (3), whereas endogenous rhinoliths develop spontaneously with deposition of mineral around accumulated secretions (3). The presence of rhinoliths can cause unilateral nasal symptoms, like nasal discomfort or obstruction with or without foul-smelling discharge. The severity of the symptoms depends upon the size of the rhinolith. Longterm complications for rhinoliths include nasal polyps, atrophic rhinitis, septal perforation (4) and oroantral fistula (5). Diagnosis is established via medical history, anterior rhinoscopy, and nasal endoscopy and is confirmed with radiological imaging (2). Clinical Presentation and Intervention Case 1 A 41-year-old Malay man presented with a history of intermittent right foul-smelling nasal discharge and nasal blockage for 6 weeks. It was not associated with pain and facial swelling. He denied a history of frequent running nose and blocked nose prior to the onset of the current illness. He also denied any history of putting a foreign body inside the nostril during childhood. Nasal examination using a 0-degree scope revealed an irregular hard mass and friable mucosa situated at the inferior meatus. No mucopurulent was discharge seen. The postnasal space was normal. The oral cavity and neck examination was normal. Computed tomography of the paranasal sinuses showed widening of the right nasal space with a soft tissue mass seen in the right nasal cavity (Figure 1). The adjacent inferior turbinate was thickened. He underwent an examination under general anesthesia. Intraoperatively, there were multiple stony hard masses in the right nasal cavity (Figure 2). Upon removal of the rhinolith, the area became widened. The post-operative recovery was uneventful. The histopathological examination showed calculus tissue. Biopsy from the right inferior turbinate and right inferior meatus showed moderate chronic inflammation. There is no evidence to suggest malignancy. 148

Cocaine-induced midline destructive lesions: clinical, radiographic, histopathologic, and serologic features and their differentiation from Wegener granulomatosis.

Dear Editor,
 
 Papillomas are primary benign epithelial neoplasms producing finger–like projections that typically cover fibrous stalks.1 The term Inverted Papilloma (IP) describes the endophytic projection of epithelium into the stroma. Also known as Schneiderian papillomas, IPs predominantly affect males in the 6th decade.2 They usually arise from the lateral nasal wall and seldom involve the frontal or sphenoid sinuses.2 The frequency of IP on the nasal septum is even less.3 We report a case of IP of the nasal septum and the role of endoscopic resection of the IP without any sign of recurrence.
 
 CASE REPORT
 A 52-year-old man who was a chronic smoker and worked as a cook presented with a 1-year history of progressively worsening unilateral nasal blockage and hyposmia. Rigid nasoendoscopy revealed a reddish grape-like mass filling the right nasal cavity. The mass extended posteriorly to the posterior nasal space and crossed to the left side and had a broad-based attachment to the posterosuperior part of the nasal septum. Computed tomography (CT) scan showed a heterogeneously-enhanced soft tissue density mass in the right nasal cavity and a soft tissue density in the right ethmoid and sphenoid sinus most likely representing retained secretions. The patient underwent endoscopic excision of the mass using Integrated Power Console (IPC®) system coupled to Straightshot® M4 microdebrider (Medtronic, Minneapolis MN, USA) under general anaesthesia. After induction, each nostril was packed with five rayon neuro-patties (Ray-cot®, American Surgical Company, Lynn MA, USA) soaked with 2mls cocaine 10%, 2mls adrenaline 1:1000 and 6mls of water, carefully placed along the septum, floor and turbinate region. This method reduces the bleeding significantly and prevents blood from impairing the endoscopic view. During the operation, a septal perforation was found at the origin of the mass. No further removal of nasal septum was performed. Histopathological examination (HPE) confirmed the diagnosis of Inverted Papilloma. He has been under our follow-up for the past 5 years and remains well and symptom-free with no evidence of recurrence detected on endoscopic examination. 
 DISCUSSION
 Inverted Papilloma (IP) poses many clinical, pathological and even management challenges. There are various surgical techniques advocated for treating IP. Radical transfacial approaches like lateral rhinotomy, minimally invasive endoscopic techniques and even midfacial degloving procedures are among some of the surgical techniques advocated.4 Most authors agree that complete surgical removal is the hallmark in treating IP.1, 2, 4, 5 Traditionally, en bloc excision of the lateral nasal wall via lateral rhinotomy approach is the standard surgical option for IP arising from the lateral nasal wall. This approach provides good access to the tumor. Despite achieving complete surgical removal, IP tends to recur.1 Recurrence rates of IP when treated surgically are as high as 71%.2 Persistent disease is unacceptable especially with the possibility of malignant transformation.1, 2 It is reported that malignancy in IP is particularly high at 10 to 15%.1
 
 With regard IP of the nasal septum, Lawson et al. in 1995 reported 5 of 112 IP patients (4%) with isolated septal lesions that were treated by septectomy.6 Our patient underwent transnasal endoscopic resection of the tumor without further need of posterior septectomy. The tumor was removed using a microdebrider. Using the microdebrider for septal surgery usually involves a lateral (PNS and nasal cavity) to medial (septum) process, and posterior inferior to anterior superior shaving technique, also minimizes blood from impairing the endoscopic view. Any visible tumor at the margins was also removed. Unlike conventional polypectomy, complete removal of the tumor and sterilization of the margins is the hallmark in treating IP. Removal of IP without sterilization of the margins should be avoided. Sterilization of the margin is not necessarily by microdebrider only; other authors have reported debulking tumor completely and sterilizing the margins and underlying bone using a diamond burr.5
 
 Transnasal endoscopic surgery avoided aggressive surgery and facial scarring in this patient. We observed no evidence of recurrence on follow up to date using this method. Although this tumor has the ability to destroy bone, tends to recur, and is associated with malignancy, we demonstrated that transnasal endoscopic resection of IP limited to nasal septum may be safely performed without the need for further septectomy. However, we do not advocate this technique in cases of large tumor or when malignancy is suspected. Endoscopic surgery would not adequately visualize the whole tumor and risk recurrence of tumor.2 Larger series and better study design are required to support our observation and establish an acceptable and safe technique indicated for IP on the nasal septum. 

Background:Olfactory neuroblastoma (ONB) is a rare malignant neuroectodermal tumor of the nasal cavity. Mixed olfactory neuroblastoma which contains areas of divergent differentiation is even rare. Till date, only 4 cases of mixed olfactory neuroblastomas have been reported.Case Description:We report the case of a 46-year-old male who presented with the chief complaints of nasal bleeding and nasal obstruction since 4 months. Radiological imaging was suggestive of a large heterogeneous mass in the left superior nasal cavity with extensions into bilateral maxillary, ethmoidal, and sphenoidal sinuses, as well as into the anterior cranial fossa. Bifrontal osteoplastic craniotomy and excision of the intracranial part of the tumor from above and transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below was done. Postoperative radiological imaging was suggestive of gross complete excision of the mass. Histopathological diagnosis was “mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV.” On immunohistochemistry, the tumor cells were positive for neuron specific enolase (NSE), synaptophysin, chromogranin, and CD56 and peripherally for S100. Because of personal reasons, the patient did not take adjuvant radiotherapy. He presented again after 2 months with a full blown recurrence of esthesioneuroblastoma with similar extensions as before. The patient is now planned for salvage surgery followed by adjuvant chemoradiation.Conclusion:We report the 5th case in the world of mixed olfactory neuroblastoma-carcinoma with squamous and glandular differentiation. From an analysis of the findings in the 5 reported cases of mixed olfactory neuroblastomas, one might infer that a separate subcategory of ONB, i.e., mixed ONB, should be considered because mixed ONBs have an aggressive behavior, high rates of recurrence, and these tumors should be treated aggressively by multimodality treatment.

Background Topical nasal decongestant sprays are used commonly in routine otolaryngology practice to reduce the symptoms of nasal airway obstruction (NAO) through vasoconstriction, thereby reducing the bulk of vasoerectile tissue and increasing nasal airflow. Such tissue is found predominantly on the lateral wall of the nose within the inferior turbinates (ITs), but recent evidence suggests that it may also be found medially within the nasal septal swell body (SSB). Objective To determine whether isolated topical decongestion of the medial nasal wall, targeting the SSB, is as effective as isolated decongestion of the lateral nasal wall, targeting the IT, in maximizing nasal patency. Methods A double-blinded, randomized controlled, crossover study was performed investigating the effect of decongestion of the lateral nasal wall or septum in isolation on nasal airflow. Isolated decongestion was performed by placing a cottonoid, soaked in oxymetazoline and attached to a silastic sheet, into the nasal cavity randomly facing either the septum or lateral nasal wall, bilaterally. Anterior rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow (PNIF), and subjective patient-reported outcomes (Sinonasal Outcome Test (SNOT-22) and Nasal Obstruction Symptom Evaluation (NOSE) scores) were recorded at baseline and postdecongestion. Decongestion of the alternate site was then performed at a later date. Results A total of 20 healthy volunteers (30% females, mean age 26.6 ± 3.8 years) were recruited. Improvements in nasal obstruction and SNOT-22 scores were found following decongestion of the septum compared with baseline (mean difference: 0.82, t = 2.32, P = .04; mean difference: 3.30, t = 2.50, P = .04, respectively). Improvements in mean inspiratory flow, minimal cross-sectional area, volume, and PNIF were also demonstrated. Conclusion This study suggests that the SSB contains erectile tissue that responds to topical decongestant therapy in a similar manner to IT tissue. The SSB may represent a novel target in surgery for NAO.

A 9 years old girl, presented with longstanding, left sided nasal obstruction and serosanguinous nasal discharge. She had been experiencing nasal obstruction and intermittent epistaxis for one year already. Her past medical history was otherwise unremarkable. The patient on anterior rhinoscopy, a bulge was detected, arising from the left nasal wall and impinging on the septum. The computed tomography (CT) examination was performed on a spiral scanner. The CT scan obtained following intravenous contrast administration revealed a large, inhomogeneously enhancing mass in the left maxillary sinus and nasal cavity (Figure 1,2&3). The nasal turbinates and the medial wall of the maxillary sinus had been eroded by the mass. There was also a bony remodeling in the anterior wall of the maxillary sinus. Because of the suspicion of sinonasal cancer, a biopsy was taken to obtain tissue from the nasal cavity and maxillary sinus. However, the biopsy revealed multiple submucosal dilated vessels filled with blood, fibrin deposition and organized thrombi stain for fungal organism negative, findings consistent with hemangioma. The microscopic examination showed dilated sinusoidal vascular channels in the stroma lining with an interconnecting fibrous wall covered with flat endothelium. The Lumina of these spaces were filled with blood. The histologic features were most compatible with cavernous hemangioma (Figure 4). On follow up, patient improvement regarding nasal obstruction and less nasal bleeding.

Aim to develop a new method of endonasal augmentation of the alveolar process of the upper jaw to reduce postoperative risks.
 Material and methods. The study involved 10 patients during the period of December, 2019, and June, 2021. The examination methods were: computed tomography of the nose and paranasal sinuses, upper and lower jaw, and video-endoscopy of the nasal cavity. The patients received the indonasal sinus inlay with the use of allogenic bone chips.
 Results. The surgical access through the lower nasal passage, under the lower nasal concha, allows to expose the maxillary sinus floor with preservation of mucous membrane integrity and to fill in the space between them with the allogenic bone material. Formation of a bone window in the lateral nasal wall using a piezotome prevents the rupture of the sinus mucous membrane. A bony fragment of the lateral nasal cavity wall transferred into the cavity of the maxillary sinus as one block with the mucosa creates additional protection for the Schneiderian membrane. Allogenic material introduced by endonasal method is substituted by the own organotypic tissue, restoring the lost volume of the maxillary sinus alveolar process.
 Conclusion. The endonasal method of alveolar augmentation may be used in clinical practice as an alternative to the classic methods.

In clinical practice, lateral nasal wall collapse during forced inspiration is widely regarded as a sign of nasal obstruction or criterion indicating nasal valve surgery. This study aims to evaluate the relationship between the degree of lateral nasal wall collapse and subjective nasal obstruction. In addition, factors related to lateral nasal wall collapse were also investigated. In this study, lateral nasal wall collapse is determined by the degree of lateral nasal wall triangle (LNWT) area reduction on frontal view during forced inspiration compared to quiet inspiration. LNWT area ratio of the patient and control groups was compared. The relationship between the lateral nasal wall collapse and clinical factors including symptom scores, nasal valve angles, skin thickness were evaluated. The average LNWT area ratio of the patient (n = 24) and control groups (n = 27) was 0.96 and 0.83 respectively (P = .001). Symptom score (NOSE and VAS) is not related to the degree of lateral nasal wall collapse. Moreover, nasal valve angle and skin thickness were also not related to the degree of lateral nasal wall collapse. In 14 of the 19 patients, the more obstructed side corresponded to the side of narrower nasal valve angle, and 5 were not. Lateral nasal wall collapse is not related to a patients' nasal obstruction.