Abstract
Primary sinonasal lymphomas are a rare type of non-Hodgkin lymphoma (NHL) with an overall incidence of about 1% of all head and neck cancers. Diffuse large B-cell lymphoma (DLBCL) is the most common type of NHL and it most commonly occurs in elderly men. The diagnosis of such a lymphoma is difficult because of its varied presentation, which usually occurs late after a significant mass effect has taken place. Symptoms vary significantly, from simply nasal obstruction or epistaxis to varied cranial neuropathies or the confusion seen with central nervous system (CNS) spread. Patients may present with a large orbital mass and proptosis. Therefore, emphasis should be placed on earlier detection by using appropriate imaging modalities to reveal such masses. A biopsy is necessary to confirm the diagnosis. The prognosis is scored by the International Prognostic Index. Staging scans with whole-body computed tomography (CT) with contrast and positron emission tomography-fluorodeoxyglucose (PET-FDG) are required to determine other areas of involvement. Treatment is with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) with the case-dependent use of intrathecal chemoprophylaxis (methotrexate) to prevent CNS spread. Here, we present a case series of two patients who were found to have a primary sinonasal lymphoma of the DLBCL type. In both cases, the presenting symptoms were vague. A high index of suspicion is required to diagnose NHL early on, which portends the best chance of a successful outcome. This article seeks to emphasize the role of including primary sinonasal lymphoma as a differential in the presentation of unrelenting cranial neuropathies or facial mass.
Highlights
We present a case of a 76-year-old male with a past medical history most significant for myasthenia gravis, rheumatoid arthritis, coronary artery disease (CAD) s/p percutaneous coronary intervention (PCI), type 2 diabetes, and atrial fibrillation on anticoagulation, who presented to the emergency department (ED) for severe left hip pain and blurred vision
non-Hodgkin lymphoma (NHL) should be included in the differential diagnosis of soft tissue tumors of the sinonasal
NHL should be included in the differential diagnosis of soft tissue tumors of the sinonasal tract, especially in the age group of 60 to 70
Summary
Videofluoroscopy showed severe pharyngeal phase dysphagia, absence of anterior hyoid movement, reduced tongue retraction, reduced laryngeal elevation, and absent epiglottic inversion She was admitted to the neurology service due to the progressive involvement of multiple cranial nerves (CN), including bilateral VI (with right greater than left) and left V, VII, VIII, IX, X. CT head showed a mass involving the left masticator space and pterygopalatine foramen with the destruction of the left pterygoid and extension into the posterior superior aspect of the left maxillary sinus as well as the posterior left nasal choana (Figure 4). Stained sections were from a biopsy of case two The patient was started on R-CHOP therapy for a total of five months She underwent six cycles of R-CHOP (rituximab 375 mg/m2 IV, cyclophosphamide 750 mg/m2, vincristine 2 mg IV, doxorubicin 50 mg/m2) along with intrathecal methotrexate (total of three doses each at 12 mg). High power; B: Malignant cells with high nuclear to cytoplasmic ratio; C: CD20 positive; D: Immunostain Bcl-6 positive; E: CD3 + T-cell infiltration
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