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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 112-115

Squamous cell carcinoma of the maxillary antrum mimicking invasive fungal sinusitis: The diagnostic dilemma of an extensive paranasal sinus mass


1 Department of Radiology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria
2 Department of Morbid Anatomy and Forensic Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria

Date of Web Publication27-Oct-2015

Correspondence Address:
Olufunso Simisola Aduayi
P.O. Box - 2039, O.A.U, Ile-Ife, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.168366

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  Abstract 

Tumors of the paranasal sinuses are rare. Most patients present with an advanced stage of the disease because initial symptoms are often ignored or thought to be due to other less serious conditions that may affect the head and neck region. A case of advanced squamous cell carcinoma of the maxillary antrum mimicking invasive fungal sinusitis is discussed. The patient had radiological investigation with computed tomography (CT) scan displayed in axial, coronal, and three-dimensional (3D) sagittal reconstruction views. A wedge biopsy of the mass was sent for histopathology and fungal studies for definitive diagnosis.

Keywords: Computed tomography, histopathology, paranasal sinus tumor, wedge biopsy


How to cite this article:
Aduayi OS, Famurewa OC, Adetiloye VA, Omonisi AE. Squamous cell carcinoma of the maxillary antrum mimicking invasive fungal sinusitis: The diagnostic dilemma of an extensive paranasal sinus mass. J Health Res Rev 2015;2:112-5

How to cite this URL:
Aduayi OS, Famurewa OC, Adetiloye VA, Omonisi AE. Squamous cell carcinoma of the maxillary antrum mimicking invasive fungal sinusitis: The diagnostic dilemma of an extensive paranasal sinus mass. J Health Res Rev [serial online] 2015 [cited 2019 Dec 9];2:112-5. Available from: http://www.jhrr.org/text.asp?2015/2/3/112/168366


  Introduction Top


Cancers of the paranasal sinuses constitute 3% of head and neck malignancies.[1] Men are more often affected compared to women [1],[2],[3] and commonly present in the fifth and sixth decade of age. Squamous cell carcinoma constitutes over 80% of all malignancies that arise in the nasal cavity and paranasal sinuses. Approximately, 70% occurs in the maxillary sinus, 12% in the nasal cavity, and the remainder in the nasal vestibule and remaining sinuses.[4] The close proximity of nasal and paranasal sinuses to the brain and orbit increases the risk of the tumor invasion into the surrounding tissues over time, causing severe morbidity.


  Case Report Top


A 42-year-old man presented with a history of bilateral nasal blockage of 1 year, with progressive swelling of the roof of the mouth of 10 months, recurrent left side epistaxis of 8 months, and a left-sided nasal ulcer of 6 months duration. There was associated loosening and spontaneous expulsion of the teeth on the left side of the upper jaw and a change in voice that became nasal.

At presentation patient was chronically ill looking mildly pale. Examination of the nose revealed broadening of the external nasal pyramid with multiple nontender firm swellings covered with crusts on the right side. A left-sided exophytic lesion and an ulcer with ragged edges discharging pus, a pale fleshy mass in the left nasal vestibule, erosion of the inferior left nasal turbinate, and some secretions were seen in the postnasal space. The gingivolabial sulcus was eroded on the left and a fistulous connection was seen on the anterior gingival surfaces. The hard palate was hyperemic and a left oroantral fistula was also seen. There were multiple nontender submandibular lymph nodes. An initial impression of granulomatous invasive fungal sinusitis was made.

Cranial computed tomography (CT) showed a soft tissue mass extending from the lower end of the left maxillary bone to the hard palate and the nasal septum. There was complete opacification of the left maxillary sinus with osteolysis involving the medial, lateral, and anterior walls [Figure 1]. Asymmetry of the soft tissue over the left maxillary antrum with extension into the right maxillary bone was seen but no connection to the buccal cavity was demonstrated. The nasopharynx was occluded; there was destruction of the dental alveolus with loss of dentition predominantly at the left side of the upper jaw. The mass enhanced heterogeneously after contrast administration [Figure 2]. No intracranial involvement was seen. A three-dimensional (3D) reconstruction of the cranial CT also demonstrated the extensive bony erosion and loss of dentition on the left side of the upper jaw [Figure 3].
Figure 1: A coronal view (bone window) of the cranial computed tomography scan showing a soft tissue density with extensive bony infiltration and osteolysis on the left side of the face. Note the opacification of the maxillary and ethmoidal sinuses (worse on the left)

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Figure 2: An axial view of a postcontrast cranial computed tomography scan showing the heterogeneously enhancing extensive soft tissue mass occupying the left maxillary sinus with invasion of the adjacent structures

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Figure 3: A three-dimensional (3D) image reconstruction of the cranial computed tomography scan demonstrating extensive bony erosion and loss of dentition on the left side of the upper jaw

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Patient had a wedge biopsy of the mass for histopathology and fungal studies. The histology report [Figure 4] [Figure 5] [Figure 6] confirmed an anaplastic form of invasive squamous cell carcinoma of the maxillary antrum. He was placed on antibiotics, analgesics, nasal douching three times daily and was referred to another tertiary hospital for radiotherapy.
Figure 4: Photomicrograph shows whorls of anaplastic squamous cells invading the underlying soft tissue. Hematoxylin and eosin (H and E) stain (low-power magnification)

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Figure 5: Photomicrograph shows whorls of anaplastic squamous cells invading the underlying soft tissue forming keratin pearl with foci of necrosis. H and E stain (low-power magnification)

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Figure 6: Photomicrograph shows anaplastic squamous cells invading the underlying soft tissue showing the characteristic polygonal cells with distinct cell borders and more abundant, eosinophilic cytoplasm. H and E stain (high-power magnification)

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  Discussion Top


Maxillary sinus carcinoma has a predilection for males with a male-to-female ratio of 2.3:1. The age range is 38-89 years with a mean age of 64 years.[3] Early symptoms of maxillary sinus carcinoma are often nonspecific, and may be confused with allergies or sinus infection and are often neglected for a long time. As tumors grow, they may cause nasal blockage, bleeding, and purulent discharge. Larger tumors can cause severe headaches or blurry vision,[5] there may be associated changes in the dentition and hard palate. These were demonstrated in the case presented.

The role of imaging is to identify the location of the mass, determine extent of invasion of adjacent structures, and detect possible metastasis. All these are crucial for tumor staging and management.

Cranial CT scan helps to define the extent of the tumor, assess the degree of bony destruction, and rule out intracranial extension. Signs of malignancy on CT include osteolysis of sinus walls, heterogeneous opacity of the sinus, or nasal cavity with heterogeneous enhancement. CT scan has a higher accuracy at determining both bony remodeling and erosion of the skull base and sinuses and demonstration of orbital invasion due to its ability to evaluate both the bony orbital wall and adjacent fat. All these were achieved by doing a cranial CT scan for this patient.

Magnetic resonance imaging (MRI) is vital in establishing the presence or absence of factors that determine resectability such as orbital invasion, perineural spread, skull base invasion, intracranial extension, and invasion of the masticator and parapharyngeal spaces by tumor.[6] MRI has the advantage of multiplanar imaging with optimal tissue contrast and differentiates neoplasm from adjacent inflammation and retained secretions in the multiple sinus cavities.

Plain radiography being a two-dimensional (2D) imaging modality with a lot of anatomical overlap will not provide adequate details of the extent of invasion, especially into the brain tissue and orbits. Hence, it is least preferred for imaging of paranasal sinus tumors.

The definitive diagnosis of a paranasal sinus tumor is by histology and biopsy samples for this purpose can be obtained with the aid of nasal endoscopy, in addition to viewing the tumor.

Carcinoma of the maxillary sinus is relatively uncommon and a histopathology analysis of 63 cases recorded between 1994 and 1999 at Tata Memorial Hospital, India, revealed 52 of 62 patients with this condition; the tumor was well differentiated in 4 patients, moderately differentiated in 25 patients, and poorly differentiated in 23 patients.[7] The majority of tumors occurring in the maxillary antrum are of epithelial origin and squamous cell carcinoma corresponds to more than 80% of all cases of malignant neoplasms, adenoid cystic carcinoma being the second more frequent of them. The rate incidence of distant metastasis is usually low in cases of well-differentiated squamous carcinoma of the maxillary antrum, and this condition is more frequent in the poorly differentiated subtype.[8]

Maxillary sinus cancer is very difficult to treat and traditionally has been associated with a poor prognosis. One reason for these poor outcomes is the close anatomic proximity of the nasal cavity and paranasal sinuses to vital structures such as the skull base, brain, orbit, and carotid artery.[9] This complex location makes complete surgical resection a challenging and sometimes impossible task.[9] Tumors of the maxillary sinus are treated with maxillectomy,[10] the extent of which is dictated by the extent of tumor invasion. Sinonasal malignancies are treated by anterior craniofacial resection (ACFR) if they involve the skull base. Chemotherapy and radiotherapy can also be used in selected cases. The index patient presented at a very late stage and could only be offered radiotherapy. The differential diagnosis of this condition includes chronic sinus infection such as invasive fungal sinusitis and Wegener granulomatosis that is an autoimmune disease.


  Conclusion Top


In conclusion, the diagnosis of paranasal sinus malignancies requires a high index of suspicion, and should be considered in cases of persistent, progressively worsening sinonasal symptoms. Radiological imaging and histopathology confirmation are crucial at the early stage in order to institute appropriate treatment and increase the chances of survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

 
  References Top

1.
Llorente JL, López F, Suárez C, Hermsen MA. Sinonasal carcinoma: Clinical, pathological, genetic and therapeutic advances. Nat Rev Clin Oncol 2014;11:460-72.  Back to cited text no. 1
    
2.
Chidzonga MM, Mahomva L. Squamous cell carcinoma of the oral cavity, maxillary antrum and lip in a Zimbabwean population: A descriptive epidemiological study. Oral Oncol 2006;42:184-9.  Back to cited text no. 2
    
3.
Waldron JN, O'Sullivan B, Gullane P, Witterick IJ, Liu FF, Payne D, et al. Carcinoma of the maxillary antrum: A retrospective analysis of 110 cases. Radiother Oncol 2000;57:167-73.  Back to cited text no. 3
    
4.
Tiwari R, Hardillo JA, Mehta D, Slotman B, Tobi H, Croonenburg E, et al. Squamous cell carcinoma of maxillary sinus. Head Neck 2000;22:164-9.  Back to cited text no. 4
    
5.
Paulino AC, Marks JE, Bricker P, Melian E, Reddy SP, Emami B. Results of treatment of patients with maxillary sinus carcinoma. Cancer 1998;83:457-65.  Back to cited text no. 5
    
6.
Raghavan P, Phillips CD. Magnetic resonance imaging of sinonasal malignancies. Top Magn Reson Imaging2007;18:259-67.  Back to cited text no. 6
    
7.
Qureshi SS, Chaukar DA, Talole SD, D'Cruz AK. Squamous cell carcinoma of the maxillary sinus: A Tata Memorial Hospital experience. Indian J Cancer 2006;43:26-9.  Back to cited text no. 7
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8.
de Souza RP, Cordeiro FB, Gonzalez FM, Yamashiro I, Paes AJ Jr, Tornin OS, et al. Maxillary sinus carcinoma: An analysis of ten cases. Radiol Bras 2006;39:397-400.  Back to cited text no. 8
    
9.
Vasudevan V, Kailasam S, Radhika MB, Venkatappa M, Devaiah D, Shrihari TG, et al. Well-differentiated squamous cell carcinoma of maxillary sinus. J Indian Aca Oral Med Radiol 2012;24:250-4.  Back to cited text no. 9
    
10.
Kreeft AM, Smeele LE, Rasch CR, Hauptmann M, Rietveld DH, Leemans CR, et al. Preoperative imaging and surgical margins in maxillectomy patients. Head Neck 2012;34:1652-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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