ORIGINAL ARTICLE
Chronic lymphocytic leukemia of the oropharyngeal cavity and paranasal sinuses: a case series and literature review Myles F. Melton, BA and Aaron N. Pearlman, MD
Background: Chronic lymphocytic leukemia (CLL) is an indolent B-lineage neoplasm responsible for 30% of all leukemias. The median age of onset is 67 years with a male predominance of 2:1. Localized infiltration in the oropharynx and paranasal sinuses is exceptionally rare. The aims of this study were (1) to add an additional case series of CLL with involvement of the oropharynx and paranasal sinuses to the literature and (2) to determine incidence and demographic data.
of men had oropharynx invasion vs 50% of females (p = 0.15), which suggests a nonsignificant trend. Conclusion: The results of our study indicate that CLL infiltrates the oropharynx or paranasal sinuses in less than 1% of CLL cases. Although there seems to be no age bias between invasion in the oropharynx and the paranasal sinuses, there is a trend whereby women appear more likely C 2015 to experience invasion of the paranasal sinuses. ARS-AAOA, LLC.
Methods: Retrospective chart review from 1990 to 2014.
Key Words: Results: Five cases were found in our case series, representing 0.74% of the total number of cases analyzed (5/680). Sixteen additional cases were identified through literature review, resulting in a total of 21 cases of CLL (13 men, 8 women) with involvement of the oropharynx (n = 15) and paranasal sinuses (n = 6). The average age of patients with CLL in the oropharynx was 62 years whereas in the paranasal sinuses it was 52 years (p = 0.16). The average age of female cases was 62 years and the average age of male cases was 58 years (p = 0.63). Almost 85% (84.6%)
C
hronic lymphocytic leukemia (CLL) is a B-lineage neoplasm with a median age of onset of 67 years and a male predominance of 2:1. CLL is relatively common in the United States, affecting around 15,000 people per year; yet, localized infiltration in the oropharynx and paranasal sinuses is exceptionally rare. Accordingly, the literature only contains 16 cases1–8 to date, with 9 of these cases coming from a single case series.1 In CLL, small lymphocytes that appear to be mature are found in the blood, bone marrow, and lymphoid tissues. Department of Otorhinolaryngology–Head and Neck Surgery, Weill Cornell Medical College, NewYork-Presybterian Hospital, New York, NY Correspondence to: Aaron N. Pearlman, MD, Department of Otorhinolaryngology–Head and Neck Surgery, Weill Cornell Medical College, NewYork-Presybterian Hospital, 1305 York Avenue, 5th Floor, New York, NY 10021; e-mail: [email protected] Potential conflict of interest: None provided. Received: 28 February 2015; Revised: 20 April 2015; Accepted: 26 May 2015 DOI: 10.1002/alr.21584 View this article online at wileyonlinelibrary.com.
1055
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
leukemic infiltration; neoplasms secondary primary; neoplasm invasiveness; neoplasms by site; neoplastic processes How to Cite this Article: Melton MF, Pearlman AN. Chronic lymphocytic leukemia of the oropharyngeal cavity and paranasal sinuses: a case series and literature review. Int Forum Allergy Rhinol. 2015;5:1055–1058.
Because of its indolent nature, CLL is responsible for 30% of all leukemias at any point in time, making it the most prevalent leukemia among adults from Western societies. Given the rarity of CLL infiltration of the oropharynx or paranasal sinuses, we aimed to enrich the literature with a case series of CLL patients at a tertiary care medical center who experienced such CLL infiltration. By compiling our case series with those previously published, demographic data for these patients can be made available.
Materials and methods This study was certified by our institutional review board (protocol #1406015229). A retrospective chart review was conducted on all consecutive records from the institution’s pathology database between 1990 and 2014 that had the diagnosis of CLL. A total of 680 cases were identified and these were then analyzed for involvement of the oropharynx and paranasal sinuses. Because many different anatomical terms could be used in the pathology records to label a
Melton and Pearlman
TABLE 1. Case series at author institution
Subject# Age (years) Gender
Location
Unifocal or multifocal
Pain
Sinusitis/ mucositis
1
44
M
Waldeyer
Unifocal
No
Yes
No
No
Yes
27
Yes
2
81
F
Waldeyer
Unifocal
Yes
Yes
Yes
Yes
Yes
1.5
No
3
47
M
Palatine tonsil
Multifocal
Yes
No
Yes
Yes
No
0
Yes
4
57
M
Maxillary sinus
Unifocal
No
Yes
No
No
Yes
10
Yes
5
58
F
Minor salivary gland
Unifocal
No
Yes
No
No
No
0
No
specimen from within the oropharynx or paranasal sinuses (eg, base of tongue, tonsil, etc.), the cases were reviewed individually, and, ultimately, 5 cases were identified for inclusion. The electronic medical record was then used to collect demographic data for the included cases. Further, in order to expand the usefulness of the study, the basic demographic data points available in the 16 previously published patient cases were compiled and combined with our case series. Statistical analysis was performed using Student t test in Microsoft Excel (Microsoft Corp., Redmond, WA). All p values are 2-sided with statistical significance evaluated at the 0.05 alpha level.
Dysphagia Dysphonia Smoking Pack-years Alcohol use
TABLE 2. Cases from literature Subject# (Citation)
Age (years)
Gender
1
57
M
Waldeyer ring
1
7 (Triantafillidou et al. )
81
M
Minor salivary glands
8 (Triantafillidou et al.1 )
54
M
Minor salivary glands
9 (Triantafillidou et al.1 )
70
M
Minor salivary glands
10 (Triantafillidou et al.1 )
65
M
Minor salivary glands
11 (Triantafillidou et al.1 )
6 (Triantafillidou et al. )
50
M
Minor salivary glands
1
70
F
Mucosa of maxilla
1
62
F
Mucosa of maxilla
1
40
F
Mucosa of maxilla
12 (Triantafillidou et al. ) 13 (Triantafillidou et al. ) 14 (Triantafillidou et al. )
Results Five cases were found in our case series, representing 0.74% of the total number of cases analyzed (5/680). These 5 cases were added to the 16 found in the literature to yield 21 total cases. Table 1 contains the demographic data for the 5 cases at our hospital. Table 2 contains available demographic data for the cases previously reported in the literature to date. All cases at our institution were diagnosed by biopsy of the sites indicated in Table 1. Subjects #1 and #2 were newly diagnosed with CLL at the time of biopsy of the oropharynx or paranasal sinuses. Subjects #3, #4, and #5 had a CLL diagnosis for multiple years prior to oropharynx or paranasal sinus invasion. In all cases, the invasion was only discovered when the clinical signs and symptoms became evident (Table 1) and then a biopsy was performed. Fifteen cases contained lesions located in the oropharynx whereas 6 cases contained lesions located in the paranasal sinuses. The average age of patients with CLL in the oropharynx was 62 years whereas the average age of patients with CLL in the paranasal sinuses was 52 years (p = 0.16 when compared to oropharynx average age). When the single age outlier (ie, the 25-year-old patient) was removed from the paranasal sinuses list, the average for that group became 58 years (p = 0.5 when compared to oropharynx average age). The average age of female cases in the data set was 62 years and the average age of male cases in the data set was 58 years (p = 0.63). Almost 85% (84.6%) of men
Location
2
15 (Chaudhry et al. )
82
F
Hard palate
3
65
M
Hard palate
4
17 (Vibhute et al. )
62
M
Hard palate
18 (Johnston et al.5 )
60
M
Paranasal sinuses
19 (Wong et al.6 )
25
F
Paranasal sinuses
45
M
Gingiva
74
F
Superior vestibule
16 (Henefer et al. )
20 (Presant et al.7 ) 8
21 (Alessandrini et al. )
had oropharynx invasion vs 50% of females (p = 0.15, nonsignificant trend indicated). Molecular and genetic characteristics of the CLL cells were not reliably available for all cases (eg, BCL-1, Zap70, and p53), and, as a result, any overall analysis had to be abandoned. Further, the literature cases infrequently reported additional characteristics (dysphagia, dysphonia, etc.) for reported cases, so an overall analysis of these findings also had to be abandoned. Of note, all cases in our series were unifocal except subject #3. Figures 1 and 2 demonstrate the histology of CLL with pharyngeal invasion (subject #5).
Discussion CLL is believed to arise from a specific subset of post-germinal B cells with mutated immunoglobulin (Ig)
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
1056
CLL of oropharyngeal cavity/paranasal sinuses
FIGURE 1. Dense lymphoid infiltrate beneath benign squamous epithelium. Uninvolved mucosal glands are seen.
heavy-chain variable-region genes.9 Cytological markers include the B cell markers CD20 and CD23 along with CD5, a marker normally found on mature T cells. CLL appears on peripheral blood smears as large numbers of small round lymphocytes that can be easily damaged, leading to “smudge cells.”10 The results of our study indicate that CLL infiltrates the oropharynx or paranasal sinuses in less than 1% of CLL cases. Of all published cases, the average age of oropharynx or paranasal sinus infiltration is 59 ± 15 years (mean ± standard deviation [SD]), with a range of 25 to 82 years of age. The ratio of men to women is 13:8 or 1.6:1. When this ratio is corrected for the fact that CLL occurs in men twice as frequently as women, the gender difference regarding invasion reverts in significance. This is due to the fact that a ratio of invasion of 2:1 (men:women) would equate to equal invasion rates on a per case basis. As a result, our value (1.6:1 men:women) could be interpreted as an indication that women with CLL experience invasion of the oropharynx and paranasal sinuses more frequently than men with CLL. Although it may have seemed that there was a trend toward a significant difference in the age of patients with CLL invasion in the oropharynx vs invasion in the paranasal sinuses (p = 0.16), this trend can be attributed to the 25year-old patient in the paranasal sinuses category. When this case was removed from that list, the p value became 0.50. As a result, there seems to be no age bias between invasion in the oropharynx and invasion in the paranasal sinuses. There is a trend in the data where invasion of the oropharynx favors men, but this trend did not reach significance (p = 0.15). More cases will need to be reported in the litera-
1057
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
FIGURE 2. Monotonous population of small lymphoid cells with round nuclei, clumped chromatin, and scant cytoplasm. A small proliferation center (pseudofollicle) composed of a mixture of small lymphocytes, prolymphocytes, and paraimmunoblasts is seen.
ture before it can be determined whether or not this trend is indicative of a true underlying difference. Diagnosing extranodal CLL is of vital importance for the proper treatment of patients because this entity can be easily misdiagnosed as chronic rhinosinusitis or chronic infection of the nasopharynx or oropharynx. These other diagnoses would result in ineffective treatments (eg, antibiotics). Ultimately, it is also possible that the finding of CLL invasion in the oropharynx or paranasal sinuses would represent a progression of CLL and warrant initiation of treatment. Making the diagnosis requires a high index of clinical suspicion.
Conclusion CLL invades the oropharynx and paranasal sinuses in fewer than 1% of cases. Although some trends regarding gender, age, and location of invasion can be identified, no statistical significance was discovered. The diagnosis of CLL invasion requires a high index of clinical suspicion given its rare nature. Finally, more cases need to be reported in the literature so that the available data set can be properly powered to reveal any significant trends which may exist among patients with CLL invading the oropharynx and paranasal sinuses.
Acknowledgment We thank Paul Christos for his statistical expertise. We also thank Wayne Tam and Theresa Scognamiglio for providing histological analysis and guiding the search for CLL cases at our institution.
Melton and Pearlman
References 1.
2.
3.
Triantafillidou K, Dimitrakopoulos J, Lordanidis F, Gkagkalis A. Extranodal non-Hodgkin lymphomas of the oral cavity and maxillofacial region: a clinical study of 58 cases and review of the literature. J Oral Maxillofac Surg. 2012;70:2776–2785. Chaudhry AP, Sabes WR, Gorlin RJ. Unusual oral manifestations of chronic lymphatic leukemia: report of a case. Oral Surg Oral Med Oral Pathol. 1962;15:446–449. Henefer E, Nelson J, Beaupree. Palatal enlargement in chronic lymphocytic leukemia: report of case. J Oral Surg. 1970;28:371–375.
4.
5.
6.
7.
Vibhute P, Carneiro E, Genden E, Som P. Palatal enlargement in chronic lymphocytic leukemia. AJNR Am J Neuroradiol. 2006;27:1649–1650. Johnston R, Altman KW, Gartenhaus RB. Chronic lymphocytic leukemia manifesting in the paranasal sinuses. Otolaryngol Head Neck Surg. 2002;127:582– 584. Wong R, Gliklich R, Rubin P, Goodman M. Bilateral nasolacrimal duct obstruction managed with endoscopic techniques. Arch Otolaryngol Head Neck Surg. 1998;124:703–706. Presant CA, Safdar SH, Cherrick H. Gingival leukemic infiltration in chronic lymphocytic leukemia. Oral Surg Oral Med Oral Pathol. 1973;36:672–674.
8.
Alessandrini M, Micarelli A, Mugnaini F, De Padova A, Pavone I, Bruno E. Unusual case of oral chronic lymphocytic leukemia presenting as recurrent epistaxis and asymptomatic intraoral swelling. Rev Stomatol Chir Maxillofac. 2012;113:455–457. 9. Zhang S, Kipps T. The pathogenesis of chronic lymphocytic leukemia. Ann Rev Pathol. 2014;9:103–118. 10. Aster J, Freedman A. Non-Hodgkin lymphomas and chronic lymphocytic leukemias. In: Bunn H, Aster J, eds. Pathophysiology of Blood Disorders. New York: McGraw-Hill; 2011:260–278.
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
1058
Chronic lymphocytic leukemia of the oropharyngeal cavity and paranasal sinuses: a case series and literature review Myles F. Melton, BA and Aaron N. Pearlman, MD
Background: Chronic lymphocytic leukemia (CLL) is an indolent B-lineage neoplasm responsible for 30% of all leukemias. The median age of onset is 67 years with a male predominance of 2:1. Localized infiltration in the oropharynx and paranasal sinuses is exceptionally rare. The aims of this study were (1) to add an additional case series of CLL with involvement of the oropharynx and paranasal sinuses to the literature and (2) to determine incidence and demographic data.
of men had oropharynx invasion vs 50% of females (p = 0.15), which suggests a nonsignificant trend. Conclusion: The results of our study indicate that CLL infiltrates the oropharynx or paranasal sinuses in less than 1% of CLL cases. Although there seems to be no age bias between invasion in the oropharynx and the paranasal sinuses, there is a trend whereby women appear more likely C 2015 to experience invasion of the paranasal sinuses. ARS-AAOA, LLC.
Methods: Retrospective chart review from 1990 to 2014.
Key Words: Results: Five cases were found in our case series, representing 0.74% of the total number of cases analyzed (5/680). Sixteen additional cases were identified through literature review, resulting in a total of 21 cases of CLL (13 men, 8 women) with involvement of the oropharynx (n = 15) and paranasal sinuses (n = 6). The average age of patients with CLL in the oropharynx was 62 years whereas in the paranasal sinuses it was 52 years (p = 0.16). The average age of female cases was 62 years and the average age of male cases was 58 years (p = 0.63). Almost 85% (84.6%)
C
hronic lymphocytic leukemia (CLL) is a B-lineage neoplasm with a median age of onset of 67 years and a male predominance of 2:1. CLL is relatively common in the United States, affecting around 15,000 people per year; yet, localized infiltration in the oropharynx and paranasal sinuses is exceptionally rare. Accordingly, the literature only contains 16 cases1–8 to date, with 9 of these cases coming from a single case series.1 In CLL, small lymphocytes that appear to be mature are found in the blood, bone marrow, and lymphoid tissues. Department of Otorhinolaryngology–Head and Neck Surgery, Weill Cornell Medical College, NewYork-Presybterian Hospital, New York, NY Correspondence to: Aaron N. Pearlman, MD, Department of Otorhinolaryngology–Head and Neck Surgery, Weill Cornell Medical College, NewYork-Presybterian Hospital, 1305 York Avenue, 5th Floor, New York, NY 10021; e-mail: [email protected] Potential conflict of interest: None provided. Received: 28 February 2015; Revised: 20 April 2015; Accepted: 26 May 2015 DOI: 10.1002/alr.21584 View this article online at wileyonlinelibrary.com.
1055
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
leukemic infiltration; neoplasms secondary primary; neoplasm invasiveness; neoplasms by site; neoplastic processes How to Cite this Article: Melton MF, Pearlman AN. Chronic lymphocytic leukemia of the oropharyngeal cavity and paranasal sinuses: a case series and literature review. Int Forum Allergy Rhinol. 2015;5:1055–1058.
Because of its indolent nature, CLL is responsible for 30% of all leukemias at any point in time, making it the most prevalent leukemia among adults from Western societies. Given the rarity of CLL infiltration of the oropharynx or paranasal sinuses, we aimed to enrich the literature with a case series of CLL patients at a tertiary care medical center who experienced such CLL infiltration. By compiling our case series with those previously published, demographic data for these patients can be made available.
Materials and methods This study was certified by our institutional review board (protocol #1406015229). A retrospective chart review was conducted on all consecutive records from the institution’s pathology database between 1990 and 2014 that had the diagnosis of CLL. A total of 680 cases were identified and these were then analyzed for involvement of the oropharynx and paranasal sinuses. Because many different anatomical terms could be used in the pathology records to label a
Melton and Pearlman
TABLE 1. Case series at author institution
Subject# Age (years) Gender
Location
Unifocal or multifocal
Pain
Sinusitis/ mucositis
1
44
M
Waldeyer
Unifocal
No
Yes
No
No
Yes
27
Yes
2
81
F
Waldeyer
Unifocal
Yes
Yes
Yes
Yes
Yes
1.5
No
3
47
M
Palatine tonsil
Multifocal
Yes
No
Yes
Yes
No
0
Yes
4
57
M
Maxillary sinus
Unifocal
No
Yes
No
No
Yes
10
Yes
5
58
F
Minor salivary gland
Unifocal
No
Yes
No
No
No
0
No
specimen from within the oropharynx or paranasal sinuses (eg, base of tongue, tonsil, etc.), the cases were reviewed individually, and, ultimately, 5 cases were identified for inclusion. The electronic medical record was then used to collect demographic data for the included cases. Further, in order to expand the usefulness of the study, the basic demographic data points available in the 16 previously published patient cases were compiled and combined with our case series. Statistical analysis was performed using Student t test in Microsoft Excel (Microsoft Corp., Redmond, WA). All p values are 2-sided with statistical significance evaluated at the 0.05 alpha level.
Dysphagia Dysphonia Smoking Pack-years Alcohol use
TABLE 2. Cases from literature Subject# (Citation)
Age (years)
Gender
1
57
M
Waldeyer ring
1
7 (Triantafillidou et al. )
81
M
Minor salivary glands
8 (Triantafillidou et al.1 )
54
M
Minor salivary glands
9 (Triantafillidou et al.1 )
70
M
Minor salivary glands
10 (Triantafillidou et al.1 )
65
M
Minor salivary glands
11 (Triantafillidou et al.1 )
6 (Triantafillidou et al. )
50
M
Minor salivary glands
1
70
F
Mucosa of maxilla
1
62
F
Mucosa of maxilla
1
40
F
Mucosa of maxilla
12 (Triantafillidou et al. ) 13 (Triantafillidou et al. ) 14 (Triantafillidou et al. )
Results Five cases were found in our case series, representing 0.74% of the total number of cases analyzed (5/680). These 5 cases were added to the 16 found in the literature to yield 21 total cases. Table 1 contains the demographic data for the 5 cases at our hospital. Table 2 contains available demographic data for the cases previously reported in the literature to date. All cases at our institution were diagnosed by biopsy of the sites indicated in Table 1. Subjects #1 and #2 were newly diagnosed with CLL at the time of biopsy of the oropharynx or paranasal sinuses. Subjects #3, #4, and #5 had a CLL diagnosis for multiple years prior to oropharynx or paranasal sinus invasion. In all cases, the invasion was only discovered when the clinical signs and symptoms became evident (Table 1) and then a biopsy was performed. Fifteen cases contained lesions located in the oropharynx whereas 6 cases contained lesions located in the paranasal sinuses. The average age of patients with CLL in the oropharynx was 62 years whereas the average age of patients with CLL in the paranasal sinuses was 52 years (p = 0.16 when compared to oropharynx average age). When the single age outlier (ie, the 25-year-old patient) was removed from the paranasal sinuses list, the average for that group became 58 years (p = 0.5 when compared to oropharynx average age). The average age of female cases in the data set was 62 years and the average age of male cases in the data set was 58 years (p = 0.63). Almost 85% (84.6%) of men
Location
2
15 (Chaudhry et al. )
82
F
Hard palate
3
65
M
Hard palate
4
17 (Vibhute et al. )
62
M
Hard palate
18 (Johnston et al.5 )
60
M
Paranasal sinuses
19 (Wong et al.6 )
25
F
Paranasal sinuses
45
M
Gingiva
74
F
Superior vestibule
16 (Henefer et al. )
20 (Presant et al.7 ) 8
21 (Alessandrini et al. )
had oropharynx invasion vs 50% of females (p = 0.15, nonsignificant trend indicated). Molecular and genetic characteristics of the CLL cells were not reliably available for all cases (eg, BCL-1, Zap70, and p53), and, as a result, any overall analysis had to be abandoned. Further, the literature cases infrequently reported additional characteristics (dysphagia, dysphonia, etc.) for reported cases, so an overall analysis of these findings also had to be abandoned. Of note, all cases in our series were unifocal except subject #3. Figures 1 and 2 demonstrate the histology of CLL with pharyngeal invasion (subject #5).
Discussion CLL is believed to arise from a specific subset of post-germinal B cells with mutated immunoglobulin (Ig)
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
1056
CLL of oropharyngeal cavity/paranasal sinuses
FIGURE 1. Dense lymphoid infiltrate beneath benign squamous epithelium. Uninvolved mucosal glands are seen.
heavy-chain variable-region genes.9 Cytological markers include the B cell markers CD20 and CD23 along with CD5, a marker normally found on mature T cells. CLL appears on peripheral blood smears as large numbers of small round lymphocytes that can be easily damaged, leading to “smudge cells.”10 The results of our study indicate that CLL infiltrates the oropharynx or paranasal sinuses in less than 1% of CLL cases. Of all published cases, the average age of oropharynx or paranasal sinus infiltration is 59 ± 15 years (mean ± standard deviation [SD]), with a range of 25 to 82 years of age. The ratio of men to women is 13:8 or 1.6:1. When this ratio is corrected for the fact that CLL occurs in men twice as frequently as women, the gender difference regarding invasion reverts in significance. This is due to the fact that a ratio of invasion of 2:1 (men:women) would equate to equal invasion rates on a per case basis. As a result, our value (1.6:1 men:women) could be interpreted as an indication that women with CLL experience invasion of the oropharynx and paranasal sinuses more frequently than men with CLL. Although it may have seemed that there was a trend toward a significant difference in the age of patients with CLL invasion in the oropharynx vs invasion in the paranasal sinuses (p = 0.16), this trend can be attributed to the 25year-old patient in the paranasal sinuses category. When this case was removed from that list, the p value became 0.50. As a result, there seems to be no age bias between invasion in the oropharynx and invasion in the paranasal sinuses. There is a trend in the data where invasion of the oropharynx favors men, but this trend did not reach significance (p = 0.15). More cases will need to be reported in the litera-
1057
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
FIGURE 2. Monotonous population of small lymphoid cells with round nuclei, clumped chromatin, and scant cytoplasm. A small proliferation center (pseudofollicle) composed of a mixture of small lymphocytes, prolymphocytes, and paraimmunoblasts is seen.
ture before it can be determined whether or not this trend is indicative of a true underlying difference. Diagnosing extranodal CLL is of vital importance for the proper treatment of patients because this entity can be easily misdiagnosed as chronic rhinosinusitis or chronic infection of the nasopharynx or oropharynx. These other diagnoses would result in ineffective treatments (eg, antibiotics). Ultimately, it is also possible that the finding of CLL invasion in the oropharynx or paranasal sinuses would represent a progression of CLL and warrant initiation of treatment. Making the diagnosis requires a high index of clinical suspicion.
Conclusion CLL invades the oropharynx and paranasal sinuses in fewer than 1% of cases. Although some trends regarding gender, age, and location of invasion can be identified, no statistical significance was discovered. The diagnosis of CLL invasion requires a high index of clinical suspicion given its rare nature. Finally, more cases need to be reported in the literature so that the available data set can be properly powered to reveal any significant trends which may exist among patients with CLL invading the oropharynx and paranasal sinuses.
Acknowledgment We thank Paul Christos for his statistical expertise. We also thank Wayne Tam and Theresa Scognamiglio for providing histological analysis and guiding the search for CLL cases at our institution.
Melton and Pearlman
References 1.
2.
3.
Triantafillidou K, Dimitrakopoulos J, Lordanidis F, Gkagkalis A. Extranodal non-Hodgkin lymphomas of the oral cavity and maxillofacial region: a clinical study of 58 cases and review of the literature. J Oral Maxillofac Surg. 2012;70:2776–2785. Chaudhry AP, Sabes WR, Gorlin RJ. Unusual oral manifestations of chronic lymphatic leukemia: report of a case. Oral Surg Oral Med Oral Pathol. 1962;15:446–449. Henefer E, Nelson J, Beaupree. Palatal enlargement in chronic lymphocytic leukemia: report of case. J Oral Surg. 1970;28:371–375.
4.
5.
6.
7.
Vibhute P, Carneiro E, Genden E, Som P. Palatal enlargement in chronic lymphocytic leukemia. AJNR Am J Neuroradiol. 2006;27:1649–1650. Johnston R, Altman KW, Gartenhaus RB. Chronic lymphocytic leukemia manifesting in the paranasal sinuses. Otolaryngol Head Neck Surg. 2002;127:582– 584. Wong R, Gliklich R, Rubin P, Goodman M. Bilateral nasolacrimal duct obstruction managed with endoscopic techniques. Arch Otolaryngol Head Neck Surg. 1998;124:703–706. Presant CA, Safdar SH, Cherrick H. Gingival leukemic infiltration in chronic lymphocytic leukemia. Oral Surg Oral Med Oral Pathol. 1973;36:672–674.
8.
Alessandrini M, Micarelli A, Mugnaini F, De Padova A, Pavone I, Bruno E. Unusual case of oral chronic lymphocytic leukemia presenting as recurrent epistaxis and asymptomatic intraoral swelling. Rev Stomatol Chir Maxillofac. 2012;113:455–457. 9. Zhang S, Kipps T. The pathogenesis of chronic lymphocytic leukemia. Ann Rev Pathol. 2014;9:103–118. 10. Aster J, Freedman A. Non-Hodgkin lymphomas and chronic lymphocytic leukemias. In: Bunn H, Aster J, eds. Pathophysiology of Blood Disorders. New York: McGraw-Hill; 2011:260–278.
International Forum of Allergy & Rhinology, Vol. 5, No. 11, November 2015
1058
