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Diagnostic Oncology Case Studies

“Maxillary

Sinusitis”

and Cancer:

This 31-year-old Caucasian woman complained of a recurrent upper respiratory infection for 9 months. In addition, for the past 2 months she suffered a sore throat, dry cough, and pain over the left maxillary sinus. A clinical diagnosis of sinusitis was made, and she was treated with antibiotics and nasal decongestants, with some improvement. She was seen again 2 months later, at which time she had a purulent discharge from both nostrils. Plain films of the sinuses revealed pansinusitis with air-fluid levels in both maxillary sinuses” (see above). No bone destruction was recognized in this or other views. A chest x-ray and urinalysis were normal. The patient was placed on antibiotics for 3 more weeks, after which repeat radiographs failed to show clearing of the sinuses. The radiologist requested tomograms for more complete assessment of the degree and extent of sinus involvement. These tomograms, performed 1 year after the symptoms began, showed destruction of the medial wall of the left maxillary antrum with a mass extending into the left maxillary, left ethmoid, and sphenoid sinuses (fig. 1). Subsequent biopsy of the tumor in the left maxillary sinus revealed an infiltrating, poorly differentiated squamous cell carcinoma. The metastatic workup was negative, and the tumor appears to be under control 1 year after radiation treatment.

primary cancer of the nasal cavity and the maxillary sinus is rare and may not be considered in the differential diagnosis initially, either by the general physician or the otolaryngologist. Its occurrence in a young woman is even more unusual. This disease usually affects older individuals, predominantly males. By the time plain films of the nasal and paranasal sinuses show signs of cancer, the disease often is locally advanced. Plain films may fail to demonstrate the presence and/or extent of bone erosion, which is the principal sign of malignancy; tomography (preferably polytomography) is more effective in delineating bone destruction. That sinus cancer is often locally advanced at initial diagnosis was shown in Willie’s [1] series of 220 patients, of whom 131 were first treated “symptomatically” for 2-6 months and 47 of them for 6-26 months before the correct diagnosis was made and proper treatment instituted. In primary carcinomas directly involving the paranasal sinuses, a confusing picture may result clinically as well as radiographically from superimposed sinusitis, since neoplasms of the nose, sinuses, or nasopharynx can block the ostia of adjacent sinuses and cause them secondarily to become opacified [2]. More than one sinus is usually involved in sinus infections, with or without associated tumor. Furthermore, while some symptomatic improvement often occurs with antibiotic treatment in either condition, the affected sinuses may not reaerate completely in an otherwise uncomplicated infection (particularly in chronic sinusitis), making a distinction of sinusitis from carcinoma on the follow-up plain films even more difficult.

“

Discussion

Pansinusitis, with or without findings, is a common condition.

associated On the

The Role of Polytomography

radiologic other hand,

This is one of a bimonthly series of case reports prepared by A. Robert Kagan and Richard J. Steckel (Southern California Permanente Medical Group, 1510 North Edgemont, Los Angeles, California 90027, and UCLAJonsson Comprehensive Cancer Center, 924 Westwood Boulevard, Suite 650, Los Angeles, California 90024, respectively) to present and discuss contemporary problems and procedures in the identification and staging of the more common neoplasms. Case contributed by Aroor Rao and Harvey A. Gilbert, Department of Radiation Therapy. Southern California Permanente Medical Group. Address reprint requests to R. J. Steckel. Am J Roentg#{149}nol 131:321-322, C

1978 American

Roentgen

August 1978 Ray Society

321

0361 -803X/78/0800-0321

$00.00

322

DIAGNOSTIC

ONCOLOGY

CASE

STUDIES

tic information cytologic

nasal

mass,

local

in

patients or with

findings,

failure

pain

of

despite

with equivocal unusual features

clinical

plain film or such as a

response

adequate

or

treatment,

increasing

and/or

a neural

deficit.

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After

a histopathologic

diagnosis

is established, tomograms have patients for purposes of staging [5]. For example, demonstrated

bital

floor

cinoma

and/or will

tissue

to

cally,

with

neural

be

the

Fig. 1.-Anteroposterior nasal cavity and extending Widespread bone destruction

The

differential

polytomogram showing large massfilling left into ethmoid and left maxillary sinuses. is evident (arrowheads).

diagnosis

masses

in or about

sinuses

lies

the

between

in

nasal a

adults

cavity

of

and

mucocele

or

soft

the

an

tissue

paranasal

inflammatory

polyp, a benign tumor (such as fibroma or papilloma), and the rare primary malignant tumor. Metastatic tumors to the sinus cavities do occur but are very unusual. Expansion

and

thickening

of the

sinus

walls

occur

with

Wegener’s

films the

granulomatosis),

may

by superimposed presence

ethmoid has

and

been

(intact)

of soft

tissue

maxillary

bone

in

on

bone

presence

plain

and

particularly

When the

masked

structures

thickening,

sinuses.

demonstrated

be

by

in the

destruction of

a

mass,

biopsy is mandatory to rule out cancer. However, the absence of bone destruction, even after a prolonged clinical course, is of no value in ruling out tumor: slowly growing malignancies may remain confined to the sinuses or nasal cavity for long periods, or they may even deflect (expand) the margins of the sinus or the nasal septum (fig. 1) [4]. In practice, patients with presumed inflammatory sinus disease that has recurred or become resistant to treatment may be advised first to have sinus irrigations with cytologic examination and cultures of the washings. If there

is no resolution

after

multiple

washings

with

nega-

tive cytology and appropriate antibiotics, then biopsy should be recommended. When cancer has been established, tomograms are always indicated for evaluation of tumor extent. Although

tomography,

the

need

for

tomograms

biopsy

can

cannot

contribute

be

preempted

useful

diagnos-

by

for

surgically

volume

and

bone

destruction

antral yolume

enlarged

rotundum need for

the

has

morbidity.

Pen-

preoperatively

by

infnaorbital treatment

When

equivocal

demonstrated

involving

pterygoid region or the cnibnifonm plate, an surgical procedure is usually deemed inadvisable. In summary, patients who have radiographic cal

signs

prompt

of sinusitis response

and

to vigorous

sinus

irrigations

with

dude lution

cytologic has not

study. occurred

ization raphy

and biopsy are is not recommended

in patients

who

(sometimes

great

assistance

staging. tomography sively,

may

but

ticularly

in-

resovisual-

for

(even

helpful

yet

tomogmay

and

be of

tumor

retrospect)

is shown

to

on

poly-

A complementary

been seems

intracerebral

role

established to

or confirmatory

conclu-

indicate

that

information or

for use in treatment

in

cytologic made, or

tumor,

in

which

sinuses.

not

prove

confirmation

experience

regarding

a

that

projections)

fail

nasal

has

din-

show undergo

and/or has been

suspect

may

additional

extension)

it can

multiple

destruction

recent

provide

should

film, clinical, of cancer

diagnostic

films

imaging

to

investigations

purposes,

for

of the

CT

treatment

clinically

bone

and

begin

indicated. Whereas sinus tomogas a routine examination for

using

Plain

demonstrate for

are

not

the

extensive

If progressive or continuing within 1 month, operative

equivocal plain After a diagnosis

raphy

do

laboratory

on screening

clarifying findings.

who

of

or the a larger

prognosis.

been

car-

radiotherapeuti-

of increased

worsens

role in all planning of the or-

an

as indicated

of the foramen may indicate the

carcinoma

in maxillary and/or

expectation involvement,

diagnostic

mucoceles and benign tumors, and diffuse osteoblastic changes are common with chronic infections [3, 4]. Bone destruction, which may occur rarely without an associated mass (as in midline lethal granuloma or

region

it necessary

treated

tumor

enlargement foramen,

ethmoid

make

of sinus an important and treatment involvement

it

(par-

intraocular

tumor

planning.

REFERENCES

1.

Willie

C:

sinuses.Acta

2. Poulus the

Malignant

tumors

in the

Otolaryngol[Suppl](Stockh) DO, Dodd GO: The roentgen

nasal

cavity

and

accessory

nose

and

its

65,

diagnosis

paranasal

accessory

1947

of tumors of Radiol

sinuses.

CIin North Am 8:343-360, 1970 3. ZizmorJ, Noyele AM: Inflammatory disease of the paranasal sinuses. Otolaryngol Clin North Am 6:459-472, 1973 4.

Oubois in

Radiology 5.

PJ,

Schultz

expansile

Scanlan

JC,

lesions

of

1 25 : 1 49-1 RL:

Head

58, and

Cancer: A Radiologic Kagan AR, Philadelphia,

Pernin the

RL, nasal

Dastur and

KJ: paranasal

Tomography sinuses.

1977 Neck,

in Diagnosis edited

Approach, Saunders,

1976,

and by

Staging Steckel

pp 84-1 09

of RJ,