Sinus Biopsy Research Articles

The Bell's Toll

A 70-year-old man presented complaining of lid and facial drooping and facial numbness, which progressed over several months. Magnetic resonance imaging of the head showed an enlarged right cavernous sinus. His past medical history was remarkable to squamous cell carcinoma of the face. The patient underwent a craniotomy with biopsy of the cavernous sinus that confirmed malignancy. High index of suspicion in a patient that presents facial drooping and/or numbness should alert ophthalmologists about the occurrence of perineural spread of a previous malignant lesion of the skin.

Fungal infections of the central nervous system in HIV-negative patients: Experience from a tertiary referral center of South India

Objective:To describe the clinical, radiological, and cerebrovascular fluid (CSF) findings and the outcome of microbiologically or histopathologically proven fungal infections of the central nervous system (CNS) in HIV-negative patients.Methodology and Results:We identified definite cases of CNS mycosis by screening the medical records of our institute for the period 2000–2008. The clinical and imaging details and the outcome were abstracted from the medical records and entered in a structured proforma. There were 12 patients with CNS mycosis (i.e., 2.7% of all CNS infections treated in this hospital); six (50%) had cryptococcal infection, three (25%) had mucormycosis, and two had unclassified fungal infection. Four (33%) of them had diabetes as a predisposing factor. The common presentations were meningoencephalitis (58%) and polycranial neuritis (41%). Magnetic resonance imaging revealed hydrocephalus in 41% and meningeal enhancement in 25%, as well as some unusual findings such as subdural hematoma in the bulbocervical region, carpeting lesion of the base of the skull, and enhancing lesion in the cerebellopontine angle. The CSF showed pleocytosis (66%), hypoglycorrhachia (83%), and elevated protein levels (100%). The diagnosis was confirmed by meningocortical biopsy (in three cases), paranasal sinus biopsy (in four cases), CSF culture (in three cases), India ink preparation (in four cases), or by cryptococcal polysaccharide antigen test (in three cases). Out of the ten patients for whom follow-up details were available, six patients recovered with antifungal medications (amphotericin B, 1 mg/kg/day for the minimum period of 6 weeks) and/or surgical treatment. Four patients expired (only one of them had received antifungal therapy).Conclusions:Most patients with CNS mycosis recover with appropriate therapy, but the diagnosis and management of these rare infections remains a challenge to clinicians.

Primary Malignant Myoepithelioma of the Left Maxillary Sinus: A Case Report

We describe the case of a 41-year-old woman who presented with a malignant myoepithelioma (MME) in her left maxillary sinus. Exploratory biopsy of the left maxillary sinus was performed and pathological examination demonstrated that the tumour was positive for calponin and cytokeratin 14, which are indicative of MME. Lateral rhinotomy and left total maxillectomy were undertaken and the patient received radiotherapy and chemotherapy post-surgery. Primary recurrence and metastasis to the left angle of the mandible occurred 9 months after the surgery. The patient died of cachexia 13 months after the surgery.

Craniofacial dematiaceous fungal infection

A 48-year-old man with no history of immunosuppressive illness presented with generalised facial ulceration and crusting throughout the lower and middle face (Fig. 1). He had previously had a Curvularia infection of the left turbinate. After an endoscopic examination of the maxillary sinus and incisional biopsy of the facial skin, extensive debridement, and treatment with itraconazole 600 mg daily, orally for four weeks he was considerably better. Curvularia is a saprobic dematiaceous mould that is often associated with human infections of the paranasal sinus, skin, and soft tissue. Antifungal treatment with itraconazole has been reported to be successful.

Isolated inflammatory sphenoiditis with multiple unilateral cranial nerve palsies

Isolated sphenoidits is a rare entity that often presents with vague, non-specific symptoms. We present the case of a 36-year-old Middle Eastern man, who developed headache and a painful right eye. A diagnosis of acute sphenoiditis was made. Shortly afterwards, he developed diplopia due to isolated abducent nerve involvement. Within two months, the extent of cranial nerve involvement had increased to include cranial nerves II, III, and V. Subsequently, this was treated by functional endoscopic sinus surgical drainage and biopsy. Histology revealed inflammatory changes. The patient made a dramatic recovery post-operatively, with resolution in all symptoms.

Paranasal sinus inflammation and non-specific orbital inflammatory syndrome: an uncommon association

The aim of this study is to present a series of patients with orbital inflammatory symptoms associated with significant paranasal sinus inflammation, and to discuss the diagnostic and management modalities. A retrospective, non-comparative, interventional case series of all patients diagnosed with orbital inflammatory syndrome and significant sinus inflammation, seen at two Orbital Units between January 1999 and October 2005. The clinical records of all patients were reviewed. Of 91 cases diagnosed with non-specific orbital inflammatory syndrome, six (6.6%, four males, two females mean age 51+/-17 years) had significant sinus inflammation. Symptoms and signs were periorbital swelling and erythema, proptosis, globe displacement and ocular motility restrictions with diplopia. On imaging, there was extraocular muscle enlargement and/or orbital fat haziness, as well as almost complete ipsilateral maxillary sinus opacification with varying degrees of opacification of adjacent sinuses. Sinus biopsy in four cases showed a non-specific inflammatory reaction. Treatment with steroids alone (four cases) or a combination of oral antibiotics and systemic steroids (two cases) resulted in resolution of signs and symptoms within 24-72 h. One case of recurrence was noted during a mean follow-up period of 9 months (range, 3-24 months), and this responded well to oral steroids. Although uncommon, paranasal sinusitis can be associated with a non-specific orbital inflammatory syndrome. When an infectious etiology is excluded, systemic steroids may play a major role in the management of these patients and result in prompt resolution of orbital signs and symptoms.

Diagnostic challenge of zygomycosis in compromised hosts

Rhinocerebral zygomycosis was classically associated with diabetes and diabetic ketoacidosis in the past. In recent years, hematological malignancies and immunocompromised states have become increasingly more frequent underlying conditions for patients with pulmonary and disseminated zygomycosis. In this study we identified 37 patients with a histopathologic diagnosis of zygomycosis and 21 patients with a positive culture for zygomycetes seen at the National Taiwan University Hospital, Taipei, during 1986-2003. Of these, 39 cases with probable or proven invasive zygomycosis were included in these studies. The major underlying diseases were immunocompromised states (74%), and diabetes mellitus (26%). The frequency of zygomycosis in immunocompromised hosts increased from 1.86 during 1986-1991 to 4.13 per 100,000 discharges during 1998-2003. Rhinocerebral involvement was the most common site (74%). An antemortem diagnosis by sinus biopsy was made in 93.1%. Immunocompromised patients were more likely to be younger than diabetics, to have an onset during hospitalization, a positive culture and a postmortem diagnosis. They were less likely than patients with diabetes to receive surgery and more likely to die in the hospital (p < 0.05). Of the 29 patients with invasive rhinocerebral zygomycosis, cerebral involvement (adjusted odds ratio [OR]: 31.7, 95% confidence interval [CI]: 2.4-426.8, p = 0.009) and positive cultures (adjusted OR: 23.8, 95% CI: 1.7-338.6, p = 0.019) were associated with in-hospital mortality by multivariate analysis. Hematological disease and steroid use have become the most important predisposing factors for zygomycosis. Aggressive diagnostic approaches, effective antifungal therapy and surgical debridement are essential for a successful outcome.

直腸癌の蝶形骨洞転移例

Metastatic carcinoma of the sphenoid sinus is rare, and that from rectal carcinoma is extremely rare. We describe a case of metastatic sphenoid carcinoma from the rectum. A 49-year-old female visited an ophthalmologic clinic complaining of eye dysmobility and double vision. Tumor of the sphenoid sinus was detected by MRI. She had a past history of rectal carcinoma resected 3 years earlier. She was referred to our hospital from the clinic and biopsy of the sphenoid sinus was performed by intranasal endoscopy. Histologic examination highly suggested that sphenoid sinus adenocarcinoma had metastasized from the rectum. Though radiotherapy and chemotherapy were performed, she died of sphenoid sinus carcinoma about eleven months later.

Successful treatment of relapsed PTLD with YT-90/anti-CD20 radioimmunotherapy

Background: Posttransplant lymphoproliferative disease (PTLD), is a major cause of morbidity and mortality following lung transplantation, responsible for 4% of mortality after 30 days post-transplant in pediatric recipients. Chemotherapy related mortality in thoracic organ recipients is reported from 30–70%. Therefore, initial treatment is usually reduced immunosuppression and anti-CD20 monoclonal antibody (rituximab). Rituximab is well tolerated and achieves a 60–70% response rate. However, rituximab refractory relapse may occur, requiring the use of chemotherapy. The Zevalin therapeutic protocol (ZTP), including radioimmunotherapy with a Yttrium-90 tagged anti-CD20 antibody (ibritumomab tiuxetan; Zevalin), is a minimally toxic, effective therapy for relapsed or refractory low grade, follicular, or transformed B-cell nonHodgkin’s lymphoma (NHL). We found no published reports of radioimmunotherapy for PTLD. We report the successful use of ZTP in a 16-yr-old bilateral cadaveric lung transplant recipient. Abdominal PTLD was diagnosed 8 months post-transplant. Remission was achieved with reduced immunosuppression and rituximab. Relapse occurred 28 months posttransplant. Procedures: Relapsed CD20 positive, monomorphic B-cell PTLD was diagnosed by biopsy of sinus and esophagus. The patient received 1 dose of rituximab and reduced immunosuppression, with some improvement in symptoms. Once available, she received ZTP, including 0.3 mCi/kg Yt-90 ibritumomab tiuxetan. Efficacy was monitored with PET, CT and endoscopic biopsies (GI and lung). The anticipated hypogammaglobulinemia has been treated with IVIG. Results: Treatment with ZTP resulted in a complete remission without evidence of graft dysfunction. At 8 months post-treatment, there was no evidence of recurrent PTLD. There has been no significant infection. Conclusions: In our patient, ZTP was effective treatment of relapsed PTLD. Although further study is needed to confirm this observation, minimal toxicity makes ZTP an attractive alternative to chemotherapy for relapsed or rituximab refractory PTLD.

Malignant lymphoma in the cavernous sinus with bilateral total ophthalmoplegia and tonic pupils

A 58-year-old man presents with bilateral total ophthalmoplegia caused by malignant lymphoma in the cavernous sinuses. He reported right retrobulbar pain and diplopia; however, corticosteroid therapy was not effective. After admission, right total ophthalmoplegia progressed to bilateral involvement within a few days. From biopsy of the ethmoidal sinus and axillary lymph nodes, non-Hodgkin's lymphoma was diagnosed. Chemotherapy was started immediately, and non-Hodgkin's lymphoma was completely remitted within 3 months. Bilateral total ophthalmoplegia also improved; however, tonic pupils became prominent in both eyes. Paraneoplastic effects of non-Hodgkin's lymphoma may be responsible for the tonic pupils.

A propósito de un caso: linfoma no hodgkin de hipofaringe en paciente con infección por vih. remisión sin tratamiento específico para el linfoma

Non-Hodgkin's lymphomas (NHL) are common in HIV patients, although it is rare for primary lymphomas to develop in the larynx or hypopharynx. We present the case of a patient that was diagnosed of a high degree NHL, following a biopsy of the piriform sinus' lesion, taker by direct laryngoscopy. Simultaneously he was diagnosed as HIV. The interest of this paper is the total remission of the lymphoma seen after specific HIV treatment only.

Efficacy of a 5-day course of telithromycin in the treatment of acute maxillary sinusitis caused by drug-resistant Streptococcus pneumoniae

Efficacy of a 5-day course of telithromycin in the treatment of acute maxillary sinusitis caused by drug-resistant Streptococcus pneumoniae

Rhinovirus RNA in the maxillary sinus epithelium of adult patients with acute sinusitis.

We used in situ hybridization for the detection of rhinovirus in maxillary sinus biopsy specimens obtained from 14 adult patients with acute sinusitis. In 7 specimens, rhinovirus RNA could be demonstrated in the maxillary sinus epithelium, thereby confirming the etiology of rhinovirus and the clinical suspicion of acute sinusitis.

Study of ethmoid sinus involvement in multibacillary leprosy.

The nasal mucosal involvement in lepromatous leprosy is well recognized. Currently interest has centred around the involvement of paranasal sinuses in leprosy. They act as a reservoir and constant source of reinfection to the nasal mucosa. In the present prospective study 25 untreated patients with multi-bacillary leprosy were included. Clinical examination, computed tomography (CT) scan of paranasal sinuses, ethmoid sinus endoscopy and biopsy were carried out in all patients, to investigate the involvement of the paranasal sinuses in leprosy. Ethmoid sinus involvement was noted in 20 patients on CT scan. Bilateral involvement was more common (65 per cent). Anterior ethmoids were more commonly affected (65 per cent). On ethmoid sinus endoscopy abnormal mucosa was noted in 17 patients (68 per cent). Ethmoid sinus biopsy was confirmative in 16 patients (64 per cent). Statistically significant correlation was found between CT findings, sinus endoscopy and sinus biopsy findings.

Comparison of inflammatory cell profile and Th2 cytokine expression in the ethmoid sinuses, maxillary sinuses, and turbinates of atopic subjects with chronic sinusitis

Chronic sinusitis is a common disease characterized by persistent inflammation of the sinus mucosa. This study was undertaken to investigate immunopathologic findings in biopsy specimens from the ethmoid sinuses, maxillary sinuses, and inferior nasal turbinates of 14 allergic subjects with chronic sinusitis. The composition of the inflammatory infiltrate in the three tissue sites was examined by immunocytochemistry with anti-CD3 (total T cells), anti-CD4 (helper T cells), anti-CD8 (suppressor T cells), anti-MBP (eosinophils), antitryptase (mast cells), and antichymase (mast cells) antibodies. These revealed a significant increase in the T-cell helper/suppressor ratio and eosinophils in the ethmoid sinus mucosa compared with those in the maxillary sinus mucosa and the inferior turbinate. Eosinophil numbers were also higher in the maxillary sinus than in the inferior turbinate. Mast cells were present in significantly higher numbers in the ethmoid sinus and inferior turbinate biopsy sections than in the maxillary sinus. With antisense, radiolabeled riboprobes, we used in situ hybridization to examine the expression of interleukin-4 and interleukin-5 transcripts. The density of cells expressing interleukin-4 transcripts was significantly higher in the inferior turbinate biopsy sections than in those from the ethmoid and maxillary sinuses. In addition, the number of interleukin-4 mRNA–positive cells was higher in the ethmoid than in the maxillary sinus mucosa. The density of interleukin-5 mRNA–positive cells was significantly higher in the ethmoid and maxillary sinuses than in the inferior turbinate. The results of this study indicate (1) a more intense inflammatory response in the ethmoid sinus than in the maxillary sinus and inferior turbinate in allergic chronic sinusitis and (2) different inflammatory responses in the upper airways that are dependent on the anatomic site. These findings have potential implications in the design of new therapeutic interventions for allergic chronic sinusitis. (Otolaryngol Head Neck Surg 1998;118:804-9.)

Interleukin-6 expression in chronic sinusitis: Colocalization of gene transcripts to eosinophils, macrophages, T lymphocytes, and mast cells

Chronic sinusitis in allergic (ACS) and nonallergic (NCS) patients is characterized by persistent inflammation and subepithelial fibrosis of the sinus mucosa. The inflammatory infiltrate is rich in T lymphocytes, monocyte/macrophages, plasma cells, and eosinophils. Th2-type cytokines are thought to regulate inflammatory cell recruitment, activation, survival, and the release of tissue-damaging mediators. Interleukin-6 is a proinflammatory Th2-type cytokine that stimulates fibroblast proliferation and collagen synthesis. Expression of interleukin-6 has been reported in pulmonary fibrosis and a number of other conditions associated with fibrotic tissue changes. In vitro studies have indicated that interleukin-6 is produced by macrophages, T cells, eosinophils, mast cells, and other cell types. Here we examined interleukin-6 messenger RNA and immunoreactivity in the sinus epithelium and subepithelium of subjects with ACS and NCS by in situ hybridization and immunocytochemistry, performed on sinus biopsy and polyp sections obtained from patients. Nasal turbinate biopsy specimens from normal volunteers were used as controls. Interleukin-6 messenger RNA and immunoreactivity were expressed by a significantly greater proportion of epithelial and subepithelial cells in ACS and NCS subjects than in normal controls. There was no difference in epithelial or subepithelial interleukin-6 expression between ACS and NCS patients. Colocalization studies revealed that macrophages, T cells, eosinophils, and mast cells are sources of interleukin-6 messenger RNA in ACS and NCS. The numbers of interleukin-6 messenger RNA—positive cells coexpressing immunoreactivity for the mast-cell marker were significantly greater in ACS than in NCS subjects. The results of this study suggest a role for interleukin-6 in the inflammatory response of chronic sinusitis. (Otolaryngol Head Neck Surg 1998;118:504-11.)

上顎洞結核例

Paranasal tuberculosis is a rare disease and only 26 cases have been reported in the Japanese literature. We describe a case of secondary maxillary tuberculosis.The patient was a 72 year-old female who complained of right nasal discharge and bloody sputum. A CT-scan showed that the right maxillary sinus was diffusely cloudy and had the legion with enhancement effect. The patient had been hospitalized previously for treatment of pulmonary tuberculosis 50 years ago. However there has been no evidence of recrudescence since then. Open biopsy of the maxillary sinus was performed and rapid histopathological examination did not reveal a malignant tumor, Caldwell-Luc surgery, in addition to ethmoidectomy and sphenoidostomy were performed successively. The mucous membrane of the maxillary sinus had some polypoidly thickened lesion and a grayish lesion. The mucous membrane and content of the maxillary sinus were examined by Ziehl-Neelsen's staining and no acid fast bacilli were identified. The diagnosis was made on the basis of histopathological findings which revealed some epithelomd cells under the mucosal epithelium and Langhans giant cells. Detection of Mycobacterium tuberculosis using PCR methods revealed sputum to be negative and the nasal discharge to be positive. We recognized that she did not harbour M. tuberculosis now, but that chemotherapy was necessary. After the operation, isoniazid, ethambutol and rifampicin were administered. Detection of M. tuberculosis using PCR methods was performed 40 days later and the nasal discharge was negative. No recurrence has been noted since she was released from the hospital. Hence PCR methods was able to detect M. tuberculosis rapidly and precisely, it was useful in determining the therapeutic plan and judging therapeutic effects.

Aspergillus sphenoid sinusitis‐induced orbital apex syndrome in HIV infection

Orbital apex syndrome due to aspergillus sphenoid sinusitis is a rare condition. Human immunodeficiency virus (HIV) infection has recently been reported in aspergillus orbital abscess. To the authors' knowledge this is the first reported association of HIV with the orbital apex syndrome. A 37-year-old HIV-infected man presented with headache, reduced vision and progressive ophthalmoplegia in the right eye. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed sphenoid sinusitis. Sphenoid sinus biopsy was performed. Light microscopy revealed infiltrative branching septate fungal hyphae. Fungal culture isolated Aspergillus fumigatus. Atypical fungal infection such as Aspergillus fumigatus sphenoid sinusitis should be suspected in HIV-infected patients with orbital apex syndrome.

上顎洞癌におけるかくたん細胞診の意義

Positive cytology of the sputum of two patients undergoing screening tests for lung cancer led to a diagnosis of cancer of a maxillary sinus.Case 1 was a 55-year-old male who had been treated for chronic bronchitis for several months. His sputum cytology was class V. Roentgenographic and endoscopic examinations of the lower airway showed no abnormalities, but MRI revealed an abnormal shadow in the left maxillary sinus. Open biopsy of the maxillary sinus was performed under general anesthesia. Hsstological examination showed squamous cell carcinoma.Case 2 was a 57-year-old male who had a cytological test of his sputum as part of a routine physical examination. The result was class IIIb. No malignancy was seen in roentgenographic and endoscopic examinations of the lower airway but CT revealed an abnormal shadow in the right maxillary sinus. Biopsy of the maxillary sinus lesion was performed under general anesthesia, and histological examination showed a papilloma with a tiny focus of squamous cell carcinoma.We examined the sputum cytologically in three other patients with maxillary sinus cancer and three with recurrences of this malignancy. Malignant cells were found in the sputum samples of two of the three patients with untreated advanced maxillary sinus cancer and in the sputum of two of the three with recurrent maxillary sinus cancer.The authors conclude that cytological examination of the sputum is useful in the diagnosis of head and neck cancer.

Paranasal Sinus Infection Due to Atypical Mycobacteria in Two Patients with AIDS

Atypical mycobacteria, which are common opportunistic pathogens in patients with AIDS, have not been previously implicated in the pathogenesis of paranasal sinus infections; we describe two such patients. Clinical and radiographic evidence of bilateral maxillary and ethmoid sinusitis was observed for one patient; his infection proved resistant to therapy with conventional antimicrobials and decongestants. Endoscopic ethmoid sinus biopsy yielded a specimen containing acid-fast bacilli (AFB) that were later identified as Mycobacterium kansasii. Antimycobacterial therapy had not resulted in amelioration of the sinusitis > 2 months later, at which time he died of cerebral toxoplasmosis. The second patient presented with a tender right frontotemporal soft-tissue mass; a computed tomogram disclosed that it extended through the frontal bone to the frontal sinus. Inflamed tissue debrided from the sinus contained AFB; cultures first yielded M. kansasii and later Mycobacterium avium complex. Bacteremia due to both organisms was also demonstrated. Infection progressed despite therapy.