Sinus Biopsy Research Articles

Computed Tomography Imaging Measurement for Safer Cavernous Sinus Biopsy.

The aim of this study was to measure the relative location between foramen ovale and internal carotid artery. The results can guide surgeons to avoid damaging internal carotid artery in cavernous sinus biopsy. One hundred twenty people (73 men and 47 women) were involved in this study anonymously. Five parameters of both sides were measured on 2 planes. This study provides data for safer cavernous sinus biopsy.

Rhino-orbital Mucormycosis: Clinical Findings and Treatment Outcomes of Four Cases.

In this case report, we present the clinical findings and therapeutic outcomes of four rhino-orbital mucormycosis patients. The four patients (1 female, 3 male; age range, 55-77 years) all had diabetes mellitus and two also had chronic renal failure. All patients exhibited proptosis, sinusitis, and dark-colored lesions on the nasopharynx and/or hard palate; three patients had ipsilateral peripheral facial paralysis. Visual acuity was no light perception in the two patients with severe orbital involvement and 0.8 in two patients with limited orbital involvement. Histopathological examination of the hard palate, nasopharynx or sinus biopsy revealed typical Mucor hyphae. Systemic liposomal amphotericin B was initiated in all patients. The patients with limited ocular involvement received amphotericin B both intravenously and by local irrigation; both patients had complete recovery. The other two patients underwent orbital exenteration; one patient died after declining systemic treatment postoperatively. Rapid diagnosis and treatment are important for the survival of rhino-orbital mucormycosis patients. With orbital involvement, surgical debridement and systemic and local treatment with antifungal agents may help avoid mutilating surgery like exenteration.

From Polyuria to Renal Mass: An Unexpected Link

From Polyuria to Renal Mass: An Unexpected Link

Modification of endoscopic medial maxillectomy: a novel approach for inverted papilloma of the maxillary sinus.

To describe modification to endoscopic medial maxillectomy for treating extensive Krouse stage II or III inverted papilloma of the nasal and maxillary sinus. Ten patients with inverted papilloma arising from the nasoantral area underwent diagnostic nasal endoscopy, contrast-enhanced computed tomography scanning of the paranasal sinus and pre-operative biopsy of the nasal mass. They were all managed using endoscopic medial maxillectomy and followed up for seven months to three years without recurrence. Most patients were aged 41-60 years at presentation, and most were male. Presenting symptoms were nasal obstruction, mass in the nasal cavity and epistaxis. In each case, computed tomography imaging showed a mass involving the nasal cavity and maxillary sinus, with bony remodelling. The endoscopic medial maxillectomy approach was modified by making an incision in the pyriform aperture and removing part of the anterolateral wall of the maxilla bone en bloc. Modified endoscopic medial maxillectomy providing full access to the maxillary and ethmoid sinuses is described in detail. This effective, reproducible technique is associated with reduced operative time and morbidity.

Wegener’s Granulomatosis Presenting With an Isolated Paranasal Sinus Involvement in a Child

©2014 Turkish League Against Rheumatism. All rights reserved. Wegener’s granulomatosis (WG) is mostly seen in adults with ages between 20 and 50 without a sex predilection. It is a necrotizing granulomatous vasculitis mostly affecting the lungs (95%), paranasal sinuses (90%), kidneys (85%), nose or nasopharynx (65%), and joints (65%) accordingly.1-4 It is rarely seen in children.5,6 Childhood WG has many common findings with those of adult disease, especially respiratory tract and renal involvement. However, the disorder has a female predominance in children and less frequently involves joints and paranasal sinuses.7 Paranasal and thorax computed tomography (CT) can be used to support the diagnosis.8,9 The definite diagnosis is based on the presence of necrotizing granulomatous vasculitis in pulmonary, renal or paranasal sinus biopsy specimens.5 Here we report a previously healthy boy who presented with facial edema, a history of recurrent upper respiratory tract infection and recurrent sinusitis without any other complaints and findings, and who was later on diagnosed as having WG limited to the maxillary sinuses, without other systemic involvement.

Extranodal Natural Killer/T-cell Lymphoma, Nasal Type, of the Orbit Mimicking Recurrent Orbital Cellulitis

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, is a rare type of lymphoma that is endemic to East Asia and parts of Central and South America. Most patients present with nasal obstruction, sinusitis, ulcer, and epistaxis due to a destructive mass involving the midline facial tissues. The patient visited our clinic approximately 1 year ago; she had right-sided orbital swelling and pain. The patient was sent to the department of ear, nose, and throat (ENT), and computed tomographic scan was performed. Computed tomographic imaging showed a soft tissue density in the right frontal, maxillary, and ethmoidal sinus and demonstrated fungal sinusitis in the right maxillary sinus. Then, she underwent the operation at ENT; her symptoms seemed to have disappeared. After 6 months, however, she had visited our clinic again because of a left-sided orbital cellulitis that seemed to be similar to the previous right-sided symptoms 1 year ago. She received treatments immediately and the operation again at ENT. In addition, a biopsy of left ethmoid sinus tissue was performed. The biopsy result revealed "chronic inflammation." However, unfortunately, the patient had a relapse of almost the same symptoms in a month. An excisional biopsy was performed for histopathologic diagnosis again. The left ethmoid sinus biopsy results were consistent with extranodal NK/T-cell lymphoma, nasal type. The patient then transferred her care to the department of internal medicine for chemotherapy. The authors demonstrate how the progressive-staging extranodal NK/T-cell lymphoma can present in a similar fashion as a recurrent orbital cellulitis.

Metastatic Basal cell carcinoma accompanying gorlin syndrome.

Gorlin-Goltz syndrome or basal cell nevus syndrome is an autosomal dominant syndrome characterized by skeletal anomalies, numerous cysts observed in the jaw, and multiple basal cell carcinoma of the skin, which may be accompanied by falx cerebri calcification. Basal cell carcinoma is the most commonly skin tumor with slow clinical course and low metastatic potential. Its concomitance with Gorlin syndrome, resulting from a mutation in a tumor suppressor gene, may substantially change morbidity and mortality. A 66-year-old male patient with a history of recurrent basal cell carcinoma was presented with exophthalmus in the left eye and the lesions localized in the left lateral orbita and left zygomatic area. His physical examination revealed hearing loss, gapped teeth, highly arched palate, and frontal prominence. Left orbital mass, cystic masses at frontal and ethmoidal sinuses, and multiple pulmonary nodules were detected at CT scans. Basal cell carcinoma was diagnosed from biopsy of ethmoid sinus. Based on the clinical and typical radiological characteristics (falx cerebri calcification, bifid costa, and odontogenic cysts), the patient was diagnosed with metastatic skin basal cell carcinoma accompanied by Gorlin syndrome. Our case is a basal cell carcinoma with aggressive course accompanying a rarely seen syndrome.

A case of neurosarcoidosis with labyrinthine involvement.

Sarcoidosis is a chronic granulomatous disease of unknown aetiology, which may involve any organ system. It most commonly occurs in adults with childhood involvement being rare. Central nervous system involvement is seen in up to 25% and typically involves meningeal disease resulting in multiple cranial neuropathies. Other common clinical findings include seizures, headache, dementia, and pituitary dysfunction. Imaging plays a central role in the diagnosis with typical findings including pachymeningeal and leptomeningeal enhancing lesions. Other imaging findings include lacunar and major territory infarcts, hypothalamic and infundibular thickening, hydrocephalus, and cranial nerve enhancement. We present a case of an eight-year-old male patient with progressive headache, visual disturbance, unilateral sensory hearing loss, and multiple cranial neuropathies. Imaging findings demonstrated the classic pachymeningeal and leptomeningeal enhancement along much of the skull base, as well as enhancement of the right and left second and eighth cranial nerves. Extensive inflammatory changes were noted in the temporal bones and paranasal sinuses. There was also enhancement of the right and left labyrinths. Sinus biopsy confirmed sarcoidosis. We present the first case to our knowledge of sarcoid labyrinthitis.

A RARE CAUSE OF HEADACHE–THE IMPORTANCE OF A TISSUE DIAGNOSIS AND PERSEVERANCE

A 64 year old diabetic hypertensive milkman presented in September 2011 with 4 months progressive constant right frontotemporal retro–orbital pain. It was worse at night affecting sleep with slight right...

Differential Expression of Adhesion Molecules by Sinonasal Fibroblasts among Control and Chronic Rhinosinusitis Patients

Chronic rhinosinusitis (CRS) is characterized by inflammatory cell migration into sinus tissue with resultant inflammation fueled by a milieu of cytokines. Fibroblasts may contribute to inflammation through expression of leukocyte adhesion molecules such as vascular cell adhesion molecule (VCAM) and intercellular adhesion molecule (ICAM). VCAM attracts eosinophils and mast cells contributing to Th2 skewing, and ICAM attracts neutrophils and to a lesser degree, eosinophils, and contributes to mixed Th1/Th2 skewing. The purpose of this study was to compare sinus fibroblast adhesion molecule expression ex vivo among CRS subtypes and in vitro after cytokine stimulation. Sinus biopsy specimens were taken from control patients (n = 13), CRS without nasal polyposis (CRSsNP, n = 6), and CRS with nasal polyposis (CRSwNP, n = 15). ex vivo levels of VCAM and ICAM were measured by flow cytometry from single cell suspensions of tissue biopsy specimens. Changes in VCAM and ICAM expression to cytokine exposure were assessed using in vitro cultured sinonasal fibroblasts treated with tumor necrosis factor (TNF)-α, interleukin (IL)-4, or interferon (IFN)-γ. ex vivo VCAM expression was lowest in controls, higher in CRSsNP, and highest in CRSwNP. in vitro stimulation with TNF-α and IL-4, but not IFN-γ, increased VCAM among CRSsNP, while expression in CRSwNP remained elevated with all treatments except IFN-γ. ex vivo ICAM expression was elevated in both CRS subtypes. in vitro stimulation with TNF-α and IFN-γ, but not IL-4, increased ICAM expression in all patients with the largest effects among the CRSsNP subgroup. Sinonasal fibroblast expression of adhesion molecules in sinusitis varies by disease state and is selectively influenced by exposure to inflammatory cytokines.

Selection of the antifungal agent decides prognosis of invasive aspergillosis: case report of a successful outcome with voriconazole

Invasive aspergillosis is a rare disease and is often misdiagnosed. The clinical course is quite aggressive and it is a potentially fatal disease. We report a case of invasive aspergillosis involving the dura mater and optic nerves which was successfully treated with voriconazole, even though the patient had residual monocular blindness. An 86-year-old Japanese man complained of developing loss of vision in his left eye while taking oral fluconazole prescribed by an otolaryngologist for mycosis of the left maxillary sinus. He was referred to our hospital. At the first visit, he already had no light perception in the left eye, with decreased ocular motility in all directions and orbital apex syndrome. His corrected distance visual acuity (CDVA) in the right eye was 20/25 with enlargement of Mariotte's blind spot. Magnetic resonance imaging revealed inflammation around both optic nerves that also involved the dura mater. His antifungal therapy was changed to intravenous voriconazole. Although his right CDVA temporarily declined to 20/50, it improved to 20/16 by 10months after the initiation of treatment. Maxillary sinus biopsy detected Aspergillus. Invasive aspergillosis progresses rapidly and aggressively. The present case highlights the importance of early diagnosis and selection of an appropriate antifungal agent.

Unilateral non-Hodgkin's lymphoma of the frontal sinus presenting as Pott's puffy tumour

Malignant lymphoma of the paranasal sinuses and nasal cavity is very rare and can mimic those of infectious, non-lymphomatous neoplastic and granulomatous process in their initial presentation, thus delaying its diagnosis. This report describes a case of unilateral frontal sinus B-cell lymphoma presenting as Pott's puffy tumour. Key features to differentiate the two conditions are discussed. A 61-year-old woman presented with 4 weeks history of a gradually enlarging right-sided forehead swelling, which was smooth and firm with no tenderness, fluctuation or overlying skin changes.Initial computed tomography (CT) of the paranasal sinuses revealed a mildly opacified right frontal sinus with an overlying soft tissue swelling. A repeat CT scan one week later showed evidence of osteomyelitis of the medial wall of the right frontal bone and orbit, suggesting diagnosis of Pott's puffy tumour. A third CT scan was performed as the swelling continued to enlarge despite antibiotics, which demonstrated a collection over the frontal sinus. No pus was found from a frontal sinus trephine. Histopathologic analysis of the frontal sinus biopsy showed diffuse large B cell lymphoma. The patient was treated successfully with 6 cycles of chemotherapy. In conclusion, it is not easy to differentiate Pott's puffy tumour from frontal sinus lymphoma at their initial presentation. With clearer understanding of both conditions, we can raise the index of suspicion among clinicians of the possibility of frontal sinus lymphoma even when evidence of osteomyelitis is present, therefore prompting earlier tissue biopsies for confirmation of diagnosis.

Primary Ciliary Dyskinesia With Central Pair Agenesis

The etiology of bronchiectasis is undetermined in one half of adults. Consideration of primary ciliary dyskinesia (PCD), a diagnosis made in childhood, may not occur in adults without dextrocardia. A 37-year-old man with recurrent sinusitis, cough, and sputum production was noted to have bronchiectasis on chest computed tomography. A work-up for tuberculosis, human immunodeficiency syndrome infection, cystic fibrosis, α-1 antitrypsin deficiency, and collagen vascular disease was negative. There was no family history of chronic lung disease but the mother and father were distant relatives. A maxillary sinus biopsy was performed to rule out PCD and it came back positive with central pair agenesis on transmission electron microscopy. PCD with central pair agenesis does not occur with dextrocardia and has never been clinically described in an adult. Definitive diagnosis requires ciliary biopsy and cross-sectional examination with electron microscopy. All adults with idiopathic bronchiectasis should be considered for ciliary biopsy.

Monocular Vision Loss and Headache in a 60-Year-Old Liver Transplant Patient

Monocular Vision Loss and Headache in a 60-Year-Old Liver Transplant Patient

Occam’s razor reveals a hidden Churg-Strauss syndrome

Abstract A 28 year-old caucasian lady, with nine years of uncontrolled bronchial asthma, rhinosinusitis and mild upper limb paresthesia, came to our attention to be followed for coeliac disease (CD). She had a biopsy performed elsewhere which proved the diagnosis five years before. Since there was no clinical improvement on a strict gluten-free diet, we re-evaluated the slides of her duodenal biopsies and we found an overestimation of the duodenal lesions due to the wrong orientation of the specimens. Moreover, she had never had positive CD-related antibodies and she was negative for DQ2/DQ8 MHC Class II heterodimers. Months later, she referred she was suffering from diffuse joint pain, epistaxis and a substantial weight loss. A few days later she was hospitalized because of a sudden onset of dyspnea, peripheral edema and pleural effusion. Her echocardiogram showed global left ventricular hypokenesia with an ejection fraction of 24%. The patient was discharged with a diagnosis of dilated cardiomyopathy and NYHA Class II. After a large spectrum of haematological exams, the diagnosis of Churg Strauss Syndrome (CSS), a rare multisystemic small-vessel necrotizing vasculitis, was confirmed by the presence of four/five out of six diagnostic American College of Rheumatology classification criteria (Asthma, Eosinophilia >10%, Neuropathy, Non-fixed pulmonary infiltrates, Paranasal sinus abnormality and Biopsy containing a blood vessel with extravascular eosinophils). Our patient had been under-diagnosed by pulmonologist and by gastroenterologists although she presented the criteria required for CSS diagnosis. Our case report emphasizes that often seemingly unrelated symptoms can be caused by a single rare clinical complex.

Use of the Venner™ A.P. Advance™ video laryngoscope for biopsy examination of the base of the tongue

Biopsy specimens taken from the base of the tongue can be non-diagnostic, because of errors in sampling and tissue samples that are too small or superficial. The Venner™ A.P. Advance™ video laryngoscope (Intavent Direct, Maidenhead, UK) is an anaesthetic laryngoscope designed for use in patients with a difficult airway. We present a pilot study that compares video laryngoscope-assisted biopsy examination of the base of the tongue with the standard technique using a surgical laryngoscope. The video laryngoscope gives a wide view of the base of the tongue and the ability to use sinus biopsy forceps, which can take larger and deeper specimens.

Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients

The cavernous sinus and surrounding regions-specifically the Meckel cave, posterior sector of the cavernous sinus itself, and the upper part of the petroclival region-are the location of a large variety of lesions that require individual consideration regarding treatment strategy. These regions may be reached for biopsy by a percutaneous needle inserted through the foramen ovale. The aim of this retrospective study was to evaluate the diagnostic accuracy of percutaneous biopsy in a consecutive series of 50 patients referred for surgery between 1991 and 2010. Seven biopsies (14%) were unproductive and 43 (86%) were productive, among which 28 lesions subsequently underwent histopathological examination during a second (open) surgery. To evaluate the diagnostic accuracy of the procedure, results from surgery were compared with those from the biopsy. Sensitivity of the percutaneous biopsy was 0.83 (95% CI 0.52-0.98), specificity was 1 (95% CI 0.79-1), and κ coefficient was 0.81. Because of its valuable diagnostic accuracy, percutaneous biopsy of the cavernous sinus and surrounding regions should be performed in patients with parasellar masses when neuroimaging does not provide sufficient information of a histopathological nature. This procedure would enable patients to obtain the most appropriate therapy, such as resective surgery, corticosteroids, chemotherapy, radiotherapy, or radiosurgery.

Human Bocavirus DNA in Paranasal Sinus Mucosa

Human Bocavirus DNA in Paranasal Sinus Mucosa

Actinomyces and Nocardia infections in chronic granulomatous disease

Objective:Chronic granulomatous disease (CGD) is an inherited disorder of the Nicotinamide adenine dinucleotide phosphate reduced oxidase complex characterized by recurrent bacterial and fungal infections. Disseminated infection by combination of opportunistic agents is being increasingly reported in CGD patients. We presented in the retrospective review of medical records, the etiology, presentation, clinical characteristics the infections detected, predisposing condition and outcome of nocardiosis and actinomycosis involved in a group of pediatric patients diagnosed with CGD.Materials and Methods:The clinical presentation of CGD-related infections was reviewed retrospectively from the medical records of all 12 patients with CGD. We studied respectively 12 patients between 2001 and 2008, and we analyzed two pediatric patients with CGD who acquired Nocardia and Actinomyces infections, and their clinical and microbiological characteristics were described. The material for investigations was collected from scrapings, crusts, pus from subcutaneous abscesses or exudation from sinus tracts, surgical debridement, and biopsy specimens. The microbiological diagnosis was determined by biochemical tests, histology, microscopy, and culture of clinical samples.Results:The medical records of 12 diagnosed CGD patients with suspected nocardiosis or actinomycosis were reviewed. One patient was diagnosed with actinomycosis and one patient with nocardiosis. Patients consisted of seven males and five females with ranging ages of 3 to 18 years. Nocardiosis and actinomycosis isolated in the two patients were confirmed by histology and culture methods. Neutrophil oxidative burst were absent (NBT=0) in both patients. The most common manifestations of CGD due to fungal infections, actinomycosis, and nocardiosis were osteomyelitis (42.8%), pulmonary infections (28.6%), lymphadenopathy (14.3%), and skin involvement (14.3%) during their illness.Conclusion:Nocardiosis and actinomycosis in children indicate the need for evaluation for an underlying immunological deficiency. Early diagnosis remains critical for decreased morbidity and occasional mortality. Physicians caring for patients with CGD should maintain a high index of suspicion for nocardiosis and actinomycosis especially if work up for TB and fungal infections are negative.

Langerhans/Dendritic Cell Sarcoma Arising From Hairy Cell Leukemia

Abstract Introduction Langerhans/dendridic cell sarcomas (L/DCS) are rare neoplasms that have rarely been reported to originate from malignant lymphomas. Tumor course can vary from spontaneous regression to aggressive disease. Biphasic progression of hairy cell leukemia to L/DCS has not been previously reported. We describe a case of L/DCS resulting from HCL. Case Report A 66-year-old female, diagnosed in 2000 with HCL (World Health Organization criteria), confirmed by bone marrow biopsy (BMB) and flow cytometry. Flow cytometric evaluation demonstrated a monotypic B-cell population that expressed the classic hairy cell markers CD11c, CD22, CD25, and CD103). The patient was treated with cladribine. After first relapse in 2003, the patient was again treated with cladribine followed by rituximab × 6. After second relapse in 2006, the patient was treated with rituximab × 6. In 2008, splenectomy was performed for massive splenomegaly and showed features of HCL, although the phenotype was not entirely classic at this point. BMB showed a monotypic B-cell population. The patient presented with a left pyriform sinus mass 5 months later that underwent biopsy. Based on histologic and immunophenotypic findings, the tumor was classified as a Langerhans cell sarcoma (expression S100 and CD1a; negative for specific B- and T- cell markers and CD30). Identical clonal immunoglobulin gene rearrangements were identified by polymerase chain reaction (PCR) from the 2003 BMB and pyriform sinus biopsy, which suggests that both the HCL and LCS developed from the same precursor cells. Furthermore, there were similar genetic changes between the 2 tumors, which further supported a clonal relationship between the 2 tumors. The patient was treated with gemcitabine × 3 plus docetaxel. Within 3 months the clinical course was complicated by pancytopenia. In addition, computed tomography showed progression of disease with enlarging mediastinal lymphadenopathy, new pulmonary lesions and retroperitoneal lymphadenopathy. Conclusion This case shows the importance of the biopsy when lesions arise in uncommon areas in patients with HCL. It has been postulated that therapeutic agents might play a role in the development of these tumors. This patient received multiple treatments for HCL. Whether L/DCS in this clinical setting is related to therapy or due to other mechanisms requires further study. While clinical data is limited, our case shows the development of progressive L/DCS in a patient with HCL.