Slow-growing mass and expansive swelling in the maxilla

Abstract

CLINICAL PRESENTATIONA 40-year-old white man was referred to the oralmedicine clinic with the chief complaint of pressure inthe region from where the right maxillary first molarhad been extracted. The patient presented with diffuseswelling of the right maxilla that had persisted throughthe past year and had worsened during the 6 monthspreceding his admission to our clinic. The patient hadalso experienced trauma to the maxillary right centralincisor, which required endodontic treatment. The pa-tient was a woodworker, and his medical history wasnot informative. He reported a history of smoking,regular alcohol consumption, and occasional use ofmarijuana.Extraoral examination revealed fixed cervical lymphnodes that were enlarged and asymptomatic on palpa-tion. The right side of his face was slightly asymmetricwithout inflammation of the skin. Intraoral examinationrevealed a swelling with undefined borders, measuringapproximately 6.0 5.5 3.2 cm. The lesion extendedfrom the right upper incisor to the right second molar,was firm on palpation, and caused cortical plateexpansion, as well as displacement and mobility of theright maxillary premolars. The color and surface of thecovering mucosa were clinically normal except forsome red punctate areas that drained blood underpressure. Further, the maxillary right central incisor,which required endodontic treatment, showed coronaldiscoloration, suggesting pulp necrosis (Figures 1Aand 1B).A panoramic radiograph showed an ill-definedradiolucency in the region of the first right maxillarymolar, opacification of the antrum, and disruption of itsfloor. In addition, a well-defined radiolucency of 3 cmdiameter with sclerotic margins was present in theanterior region of the maxilla, consistent with aradicular cyst (Figure 2). A periapical radiographrevealed radiolucency with borders that had a moth-eaten appearance in the region of the first molar. Thelesion involved the periradicular portions of the adja-cent teeth, which presented no signs of dental rootresorption (Figure 3).DIFFERENTIAL DIAGNOSISThe clinical presentation, radiographic findings, andthe vitality of all the adjacent teeth excluded thepresence of inflammatory lesions. An expansiveintraosseous mass causing tooth displacement andbone destruction suggested an aggressive neoplasticprocess. Therefore, we considered squamous cellcarcinoma of the maxillary sinus, malignant salivarygland tumor (e.g., adenoid cystic carcinoma, mucoe-pidermoid carcinoma) and lymphoma as the maindifferential diagnoses. Further, the presence of abenign, locally aggressive odontogenic tumor, suchas a keratocystic odontogenic tumor (KOT) or amyxoma, was possible. Non-neoplastic lesions, suchas a central giant cell lesion or an aneurysmal bonecyst, could also display the features of this patient’slesion.A swelling with aggressive behavior suggested thepossibility of a malignancy that originated in themaxillary sinus. Among those tumors, squamous cellcarcinoma of the maxillary sinus (SCCMS) is one of themost frequent. Although its symptoms are nonspecific,the most common manifestation is facial swelling, fol-lowed by epistaxis and nasal obstruction that resemblesinusitis.