Neurnradiologv
Neuroradiology 17, 165-171 (1979)
© by Springer-Verlag 1979
Meningioma of the Paranasai Sinuses K. F. Lee t, Jung Ho Suh 2, Y. E. Lee 1 and R. G. Berry 1 1Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA 2 Yonsei University Medical College, Seoul, Korea
Summary. Meningiomas originating in the paranasal
sinuses are rare. These tumors are thought to arise from embryonal arachnoid nests which were pinched off and left behind during embryonic development. We have described various radiographic findings of two patients with meningioma arising in the paranasal sinuses (frontal sinus origin in a 65-year-old female, and sphenoid sinus origin in a 26-year-old female). The paranasal origin ,of meningioma was accurately determined on the basis of CT and arteriography. A review of the 11 cases previously reported and our cases indicates that there are no specific clinical or radiographic findings of meningiomas of the paranasal sinuses.
sphenoid sinus. It is the purpose of this paper to report the cases and review the literature.
Case Reports
Case 1 A female, aged 65, was brought into the emergency room of Thomas Jefferson University Hospital on 24 March 1973 after she suddenly fell down unconscious while shopping. In the emergency room, the patient had two generalized seizures. The patient has been complaining of headaches, dizziness and diplopia for several years.
Key words: Meningioma - Paranasal sinuses - Plain
skull - Tomogram - Angiogram - CT
Physical Examination. There was large painless bony hard mass over the right forehead, which had been enlarging over a year, and slight proptosis of the right eye.
Meningiomas of the Paranasai Siinuses
Radiological Examination. The plain skull roentgenograms disclosed irregular destruction of the right frontal bone with clouding of the right frontal sinus and erosion of the roof of the right orbit (Fig. 1). The tomogram revealed marked expansion of the right frontal sinus in all directions with considerable thinning of the sinus wall which was displaced posteriorly (Fig. 2). There was marginal sclerosis in the superior and lateral part of the irregularly expanded right frontal sinus which was seen on the plain skull roentgenograms and tomograms, indicating a slow growing neoplasm. The carotid arteriogram revealed a slight shift of the anterior cerebral artery in the frontal view (Fig. 3a). The arterial phase of the right carotid angiogram was unremarkable. The anterior falx artery was not demonstrated. In the lateral view of the venous phase, there was posterior and upward
Extracranial extension of an intracranial meningioma to the adjacent bone and muscle has been occasionally observed [12, 15, 17, 19]. Unlike fibrous dysplasia, the intracranial meningiomas rarely encroach upon the paranasal sinuses [4, 7, 16]. In Wolman's series of 375 meningiomas [18], only two involved the nasal cavity and paranasal sinuses through direct extension of the intracranial meningiomas. Primary meningioma originating in the paranasal sinuses is extremely rare [1-3, 8-10, 13, 14]. We were able to find only 11 such cases in the English literature (Table 1). There appears to be no radiological literature dealing with meningioma c f the paranasal sinuses. Recently, we have seen two cases of meningioma arising, one in the frontal sinus the other in the
0028-3940/79/0017/0165/$01.40
166
K, F. Lee et al.: Meningioma of the Paranasal Sinuses
Table 1. Primary meningioma of the paranasal sinuses Author
Age Sex
Clinical findings
Radiological findings
Origin
Pathology
Shahen (1931)
12 M
Progressive maxillary bulging
-
Maxillary antrum (left)
Meningioma
New & Devine (1949)
52 F
Slowly progressive, painless, frontal bulging
Suggestive osteoma
Frontal sinuses
Friable meningioma attached to inner wall
-
-
Frontal sinuses
Meingioma with invasion of antrum and ethmoid sinus
New & Devine (1949) New & Devine (1949)
M
Slowly bulging frontal mass (15 years)
-
Frontal sinus (left)
Meningioma and large osteoma
Ash & Raum (1949)
-
-
Angiogram: Increased vascularity of sphenoid ridge
Maxillary antrum
Meningioma
Right eye proptosis
Opacification of fight PNS with fluid level in right frontal sinus Lipiodol injection-polypoid lesions? mucocele
?
Meningioma involved in the nasal cavity PNS and orbit (right)
Belal (1955)
Hill (1962)
53 M
Right maxillary swelling with exophthalmos
Soft tissue mass in fight antrum with destruction of medial wall
Maxillary antrum
Meningioma
Lindstrom (1969)
40 F
Small polypoid lesion in right nasal cavity
Negative skull and internal carotid angiogram Positive tomogram and external carotid angiogram
Ethmoid
Meningothelial meningioma in ft. ethmoid sinus with invasion of antrum (right)
Majoros (1970)
45 F
Frontal bulging with exophthalmos (left)
Large mass occupying frontal sinus with invasion of left anterior ethmold sinus
Frontal sinus
Meningioma
Rao et al. (1972)
20 M
Frontal swelling with progressive proptosis (left)
Extensive destruction of left frontal bone
Frontal sinus
Very vascular grayish encapsulated meningioma
Rao et al. (1972)
45 F
Frontal swelling with right proptosis
Frontal sinus Rarefaction in frontal sinus region with sclerosis
Lee et al. (1979)
65 F
Painless right frontal bulging, headaches, diplopia, recent seizures
Irregular destruction of frontal bone with clouding of right frontal sinus. Carotid angiogram showed an avascular frontal mass. Positive brain scan. No tumor recurrence on postoperative CT scan
Frontal sinus
Reddish friable meningioma invasding adjacent bone and dura
Lee et al. (1979)
26 F
Frontotemporal headaches, diplopia, stuffy nose, left eye pain
Clouding of sphenoid sinus, Prominent inferior cavernous sinus artery with slight tumor blush. Positive CT scan
Sphenoid sinus
Vascular meningioma
Meningioma
K. F. Lee et al.: Meningioma of the Pamnasal Sinuses
Fig. 1. Case 1. Meningioma in frontal sinus. PA view. Expansion of right frontal sinus with marginal sclerosis and small area of radiolucency with a sclerotic margin (arrows) along superior border of expanded sinus
167
Fig. 2. Case 1. Lateral tomogram of the fight frontal sinus reveals eroded and displaced sinus walls. (arrows) due to large lesion originating in frontal sinus
Fig. 3a and b. Case 1. a Right carotid artefiogram. Slight displacement of anterior cerebral artery to left (arrows). b Venous phase with deviation of cortical veins due to extradural mass (arrows). No tumor blush seen
168
K.F. Lee et al.: Meningioma of the Paranasal Sinuses
Fig. 4. Case 1. Microphotograph (HE x 100) of transitional type of meningioma with psammoma bodies involvingbone and marrow spaces
deviation of the superficial cortical vein in the anterior frontal region without t u m o r blush (Fig. 3 b). A brain scan showed an increased uptake in the region of the right frontalsinus.
Operative Findings. At operation, a reddish-gray friable t u m o r mass 4 x 5 cm in size was r e m o v e d from the right side of the frontal sinus. The posterior wall of the frontal sinus was partially eroded with apparent neoplastic invasion of the adj acent dura which was removed. Pathological Findings. Transitional meningioma with p s a m m o m a bodies was noted microscopically (Fig. 4). The recent followup examination with CT revealed no evidence of a recurrent t u m o r 4 years after operation. A bone defect in the outer table of the frontal b o n e was noted on the right side (Fig. 5). Case 2 A 26-year-old female was admitted on 14 S e p t e m b e r 1977 because of frontotemporal headaches with stuffy nose for 8 months, and intermittent double vision for 3 months. Fig. 5. Case 1. No evidence of recurrent tumor on CT scan 4 years after operation. Outer table of right frontal bone was removed surgically
Physical Examination. The patient had mild proptosis of the left eye with ophthalmoplegia. Otherwise unremarkable.
K. F. Lee et al.: Meningiomaof the Paranasal Sinuses
169
Fig. 6 A-D. Case 2. Meningiomain sphenoid sinus. A C'I"scan reveals increased density obliterating sphenoid sinus which appears to be expanded (arrows).B Cq"scan, slightlyhigher level than A showsthe sella turcica to be normal, indicatingno intracranial extensionof tumor. Follow-up CT scansin transaxial (C) and coronal (D) planes obtained one year after trans-sphenoidal surgeryshows a nodular hyperostosis (asterisk)in the right side of the sphenoid sinus associated with thickeningof its wall (arrows).AC = anterior clinoidprocess
Radiological Examinations. The skull roentgenograms revealed total opacification of the sphenoid sinus and the CT scan an increased density obliterating the sphenoid sinus with no demonstrable bony abnormality (Fig. 6). The carotid arteriogram disclosed hypertrophy of the inferior cavernous sinus artery with a faint tumor blush in the sphenoid sinus (Fig. 7). Operative Findings. At operation, a reddish grey encapsulated vascular tumor was found in the sphenoid sinus and the tumor was totally removed. Pathological Findings. Microscopically a transitional type meningioma was demonstrated (Fig. 8).
Discussion
Shahen [14] in 1931 reported a case in which the tumor originated in the left maxillary antrum. A similar case was reported by Ash et al. in 1964 [1]. Meningioma originating in the ethmoid region has been reported by New and Devine in 1947 [10] and Lindstrom and Lindstrom [8] in 1969. Several cases of meningioma originating in the frontal sinus have been reported [9, 10, 13]. The pathogenesis of ectopic meningioma in the paranasal sinuses has been illustrated by New and Devine [10]. They feel that these tumors arise from embryonal arachnoid nests which were pinched off and left behind during embryonic development.
170
Fig. 7. Case 2. Left carotid arteriogram shows considerable hypertrophy of inferior cavernous artery (large arrow) with faint tumor blush (small arrows)
K. F. Lee et al.: Meningioma of the Paranasal Sinuses
These arachnoid cells may develop meningiomas outside the skull and vertebra along the lines of the fusion of the embryonic bones. The other possibility is blastomatous transformation of heterotopic cellular elements. According to Kernohan and Sayre [5] ectopic meningiomas arise from fragments of arachnoid which have Protruded through the dura mater to lie extradurally in various situations. Extracranial meningiomas in the paranasal sinuses can be divided into two groups: (1) extension of the intracranial meningioma to the paranasal sinuses and (2) ectopic meningioma in the paranasal sinuses. In order to determine the origin of the meningioma, careful inspection of the tumor at operation and the microscopic examination of the paranasal sinuses with adjacent tissue are required. In contrast to the other intracranial meningiomas, there was no tumor blush noted in our case with meningioma of the frontal sinus. Most of the cases reported with meningiomas of the paranasal sinuses had a clinical history of a bulg-
Fig. 8. Case 2. Microphotograph (HE × 100) of transitional type of meningioma with whorl pattern
K. F. Lee et al.: Meningioma of the Paranasal Sinuses ing m a s s o n t h e f r o n t a l [9, 10, 13] o r a n t r a l [1, 3, 8, 14] a r e a a s s o c i a t e d w i t h p r o g r e s s i v e e x o p h t h a l m o s [2, 3, 9, 13]. T h e p l a i n skull films a n d t o m o g r a m s r e v e a l e d t h e n o n - s p e c i f i c findings of c l o u d i n g of t h e p a r a n a s a l sinuses with d e s t r u c t i o n of t h e s u r r o u n d i n g b o n e . A s t h e t u m o r grows, it m a y b l o c k t h e o s t i u m of t h e f r o n t a l sinus with a r e s u l t a n t m u c o c e l e . T h e a n g i o g r a p h i c findings in o u r cases w e r e of a n a v a s c u lar t u m o r in t h e f r o n t a l sinus, a n d a faint t u m o r b l u s h in t h e s p h e n o i d sinus. T h e d i f f e r e n t i a l d i a g n o s i s of m e n i n g i o m a of p a r a n a s a l sinuses f r o m o t h e r c o n d i t i o n s such as m u c o c e l e , sinusitis with o s t e o m y e l i t i s , a n d f i b r o u s dysplasia, is e x t r e m e l y difficult, if n o t i m p o s s i b l e [6, 7].
Reterences la. Ash, J. E., Peck, M. R., Wilkins, J. D.: Tumors of the upper respiratory tract. Atlas of tumor pathology, Sect IV, fasc. 12-96. Washington: Armed Forces Institute of Pathology 1964 lb. Ash, J. E., Raum, M.: Tumors of tl~.enose and sinuses. Atlas of otolaryngic pathology, p. 204. Published under the sponsorship of Am. Acad. Ophthalmol. Otolaryngol. and Am. Registry Pathol. Lithographed by Roskin Photo Offset Corp. New York: Armed Forces Institute of Pathology 1949 2. Belal, A.: Meningioma infiltrating the nasal cavity, nasal sinuses and the orbit. J. Laryngol. 69, 59-69 (1955) 3. Hill, C. L.: Meningioma of the maxillary sinus. Arch Otolaryngol. 76, 547-549 (1962) 4. Kendall, B.: Invasion of the facial bones by basal meningiomas. Br. J. Radiol. 46, 237-244 (1973) 5. Kernohan, J.W., Sayre, G.P.: Meningiomas in tumors of CNS. Atlas of tumor pathology, Sect. X, fasc. 35. Washington: Armed Forces Institute of Pathology 1964 6. Lee, K. F., Hodes, P. J., Greenberg, L., Sinotti, A.: Three rare causes of unilateral exophthalmos. Radiology 90, 1009-1015 (1968)
171 7. Lee, K. F., Whiteley, W. H. III, Schatz, N. J., Edeiken, J., Lin, S., Tsai, F.: Juxtasellar hyperostosis of non-meningiomatous origin. J. Neurosurg. 44, 571-579 (1976) 8. Lindstrtim, C. G., LindstriSm, D.W.: On extracranial meningioma. Acta Otolaryngol. (Stockh.) 68, 451-456 (1969) 9. Majoros, M.: Meningioma of the PNS. Laryngoscope 80, 640-645 (1970) 10. New, G.B., Devine, K.D.: Neurogenic tumors of nose and throat. Arch. Otolaryngol. 46, 163-179 (1947) 11. Pendergrass, E. P., Hope, J. W.: An extracranial meningioma with no apparent intracranial source. Am. J. Roentgenol. 70, 967-970 (1953) 12. Rao, S. B., Dinakar, I., Rao, K. S.: Giant intracranial epidural meingioma. J. Neurosurg. 35, 743-751 (1971) 13. Rao, S. B., Dinakar, I., Reddy, C.R.R.M.: Meningioma of the frontal sinuses. J. Neurosurg. 36, 363-365 (1972) 14. Shahen, H. B.: Psammoma in the maxillary antrum. J. Laryngol. 46, 117 (1931) 15. Smith, A.T.: Ectopic meningioma. Med. J. Aust. 1, 1100-1104 (1973) 16. Stern, W.E.: Meningiomas in the cranio-orbital junction. J. Neurosurg. 38, 428-437 (1973) 17. Suzuki, H., Gilbert, E. F., Zimmermann, B.: Primary extracranial meningioma. Arch. Pathol. 84, 202-206 (1967) 18. Wolman, L., Puth, F.C.: The extracranial spread of meningioma. ENT Digest pp. 46-57, July (1969) 19. Zachariae, L.: A case of extracranial primary meningioma. Acta Path. Microbiol. Scand. 31, 57--60 (1952) Received: 11 May 1978
Dr. K, F. Lee Thomas Jefferson University Hospital 11th and Walnut Streets Philadelphia, PA 19107, USA
Neuroradiology 17, 165-171 (1979)
© by Springer-Verlag 1979
Meningioma of the Paranasai Sinuses K. F. Lee t, Jung Ho Suh 2, Y. E. Lee 1 and R. G. Berry 1 1Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA 2 Yonsei University Medical College, Seoul, Korea
Summary. Meningiomas originating in the paranasal
sinuses are rare. These tumors are thought to arise from embryonal arachnoid nests which were pinched off and left behind during embryonic development. We have described various radiographic findings of two patients with meningioma arising in the paranasal sinuses (frontal sinus origin in a 65-year-old female, and sphenoid sinus origin in a 26-year-old female). The paranasal origin ,of meningioma was accurately determined on the basis of CT and arteriography. A review of the 11 cases previously reported and our cases indicates that there are no specific clinical or radiographic findings of meningiomas of the paranasal sinuses.
sphenoid sinus. It is the purpose of this paper to report the cases and review the literature.
Case Reports
Case 1 A female, aged 65, was brought into the emergency room of Thomas Jefferson University Hospital on 24 March 1973 after she suddenly fell down unconscious while shopping. In the emergency room, the patient had two generalized seizures. The patient has been complaining of headaches, dizziness and diplopia for several years.
Key words: Meningioma - Paranasal sinuses - Plain
skull - Tomogram - Angiogram - CT
Physical Examination. There was large painless bony hard mass over the right forehead, which had been enlarging over a year, and slight proptosis of the right eye.
Meningiomas of the Paranasai Siinuses
Radiological Examination. The plain skull roentgenograms disclosed irregular destruction of the right frontal bone with clouding of the right frontal sinus and erosion of the roof of the right orbit (Fig. 1). The tomogram revealed marked expansion of the right frontal sinus in all directions with considerable thinning of the sinus wall which was displaced posteriorly (Fig. 2). There was marginal sclerosis in the superior and lateral part of the irregularly expanded right frontal sinus which was seen on the plain skull roentgenograms and tomograms, indicating a slow growing neoplasm. The carotid arteriogram revealed a slight shift of the anterior cerebral artery in the frontal view (Fig. 3a). The arterial phase of the right carotid angiogram was unremarkable. The anterior falx artery was not demonstrated. In the lateral view of the venous phase, there was posterior and upward
Extracranial extension of an intracranial meningioma to the adjacent bone and muscle has been occasionally observed [12, 15, 17, 19]. Unlike fibrous dysplasia, the intracranial meningiomas rarely encroach upon the paranasal sinuses [4, 7, 16]. In Wolman's series of 375 meningiomas [18], only two involved the nasal cavity and paranasal sinuses through direct extension of the intracranial meningiomas. Primary meningioma originating in the paranasal sinuses is extremely rare [1-3, 8-10, 13, 14]. We were able to find only 11 such cases in the English literature (Table 1). There appears to be no radiological literature dealing with meningioma c f the paranasal sinuses. Recently, we have seen two cases of meningioma arising, one in the frontal sinus the other in the
0028-3940/79/0017/0165/$01.40
166
K, F. Lee et al.: Meningioma of the Paranasal Sinuses
Table 1. Primary meningioma of the paranasal sinuses Author
Age Sex
Clinical findings
Radiological findings
Origin
Pathology
Shahen (1931)
12 M
Progressive maxillary bulging
-
Maxillary antrum (left)
Meningioma
New & Devine (1949)
52 F
Slowly progressive, painless, frontal bulging
Suggestive osteoma
Frontal sinuses
Friable meningioma attached to inner wall
-
-
Frontal sinuses
Meingioma with invasion of antrum and ethmoid sinus
New & Devine (1949) New & Devine (1949)
M
Slowly bulging frontal mass (15 years)
-
Frontal sinus (left)
Meningioma and large osteoma
Ash & Raum (1949)
-
-
Angiogram: Increased vascularity of sphenoid ridge
Maxillary antrum
Meningioma
Right eye proptosis
Opacification of fight PNS with fluid level in right frontal sinus Lipiodol injection-polypoid lesions? mucocele
?
Meningioma involved in the nasal cavity PNS and orbit (right)
Belal (1955)
Hill (1962)
53 M
Right maxillary swelling with exophthalmos
Soft tissue mass in fight antrum with destruction of medial wall
Maxillary antrum
Meningioma
Lindstrom (1969)
40 F
Small polypoid lesion in right nasal cavity
Negative skull and internal carotid angiogram Positive tomogram and external carotid angiogram
Ethmoid
Meningothelial meningioma in ft. ethmoid sinus with invasion of antrum (right)
Majoros (1970)
45 F
Frontal bulging with exophthalmos (left)
Large mass occupying frontal sinus with invasion of left anterior ethmold sinus
Frontal sinus
Meningioma
Rao et al. (1972)
20 M
Frontal swelling with progressive proptosis (left)
Extensive destruction of left frontal bone
Frontal sinus
Very vascular grayish encapsulated meningioma
Rao et al. (1972)
45 F
Frontal swelling with right proptosis
Frontal sinus Rarefaction in frontal sinus region with sclerosis
Lee et al. (1979)
65 F
Painless right frontal bulging, headaches, diplopia, recent seizures
Irregular destruction of frontal bone with clouding of right frontal sinus. Carotid angiogram showed an avascular frontal mass. Positive brain scan. No tumor recurrence on postoperative CT scan
Frontal sinus
Reddish friable meningioma invasding adjacent bone and dura
Lee et al. (1979)
26 F
Frontotemporal headaches, diplopia, stuffy nose, left eye pain
Clouding of sphenoid sinus, Prominent inferior cavernous sinus artery with slight tumor blush. Positive CT scan
Sphenoid sinus
Vascular meningioma
Meningioma
K. F. Lee et al.: Meningioma of the Pamnasal Sinuses
Fig. 1. Case 1. Meningioma in frontal sinus. PA view. Expansion of right frontal sinus with marginal sclerosis and small area of radiolucency with a sclerotic margin (arrows) along superior border of expanded sinus
167
Fig. 2. Case 1. Lateral tomogram of the fight frontal sinus reveals eroded and displaced sinus walls. (arrows) due to large lesion originating in frontal sinus
Fig. 3a and b. Case 1. a Right carotid artefiogram. Slight displacement of anterior cerebral artery to left (arrows). b Venous phase with deviation of cortical veins due to extradural mass (arrows). No tumor blush seen
168
K.F. Lee et al.: Meningioma of the Paranasal Sinuses
Fig. 4. Case 1. Microphotograph (HE x 100) of transitional type of meningioma with psammoma bodies involvingbone and marrow spaces
deviation of the superficial cortical vein in the anterior frontal region without t u m o r blush (Fig. 3 b). A brain scan showed an increased uptake in the region of the right frontalsinus.
Operative Findings. At operation, a reddish-gray friable t u m o r mass 4 x 5 cm in size was r e m o v e d from the right side of the frontal sinus. The posterior wall of the frontal sinus was partially eroded with apparent neoplastic invasion of the adj acent dura which was removed. Pathological Findings. Transitional meningioma with p s a m m o m a bodies was noted microscopically (Fig. 4). The recent followup examination with CT revealed no evidence of a recurrent t u m o r 4 years after operation. A bone defect in the outer table of the frontal b o n e was noted on the right side (Fig. 5). Case 2 A 26-year-old female was admitted on 14 S e p t e m b e r 1977 because of frontotemporal headaches with stuffy nose for 8 months, and intermittent double vision for 3 months. Fig. 5. Case 1. No evidence of recurrent tumor on CT scan 4 years after operation. Outer table of right frontal bone was removed surgically
Physical Examination. The patient had mild proptosis of the left eye with ophthalmoplegia. Otherwise unremarkable.
K. F. Lee et al.: Meningiomaof the Paranasal Sinuses
169
Fig. 6 A-D. Case 2. Meningiomain sphenoid sinus. A C'I"scan reveals increased density obliterating sphenoid sinus which appears to be expanded (arrows).B Cq"scan, slightlyhigher level than A showsthe sella turcica to be normal, indicatingno intracranial extensionof tumor. Follow-up CT scansin transaxial (C) and coronal (D) planes obtained one year after trans-sphenoidal surgeryshows a nodular hyperostosis (asterisk)in the right side of the sphenoid sinus associated with thickeningof its wall (arrows).AC = anterior clinoidprocess
Radiological Examinations. The skull roentgenograms revealed total opacification of the sphenoid sinus and the CT scan an increased density obliterating the sphenoid sinus with no demonstrable bony abnormality (Fig. 6). The carotid arteriogram disclosed hypertrophy of the inferior cavernous sinus artery with a faint tumor blush in the sphenoid sinus (Fig. 7). Operative Findings. At operation, a reddish grey encapsulated vascular tumor was found in the sphenoid sinus and the tumor was totally removed. Pathological Findings. Microscopically a transitional type meningioma was demonstrated (Fig. 8).
Discussion
Shahen [14] in 1931 reported a case in which the tumor originated in the left maxillary antrum. A similar case was reported by Ash et al. in 1964 [1]. Meningioma originating in the ethmoid region has been reported by New and Devine in 1947 [10] and Lindstrom and Lindstrom [8] in 1969. Several cases of meningioma originating in the frontal sinus have been reported [9, 10, 13]. The pathogenesis of ectopic meningioma in the paranasal sinuses has been illustrated by New and Devine [10]. They feel that these tumors arise from embryonal arachnoid nests which were pinched off and left behind during embryonic development.
170
Fig. 7. Case 2. Left carotid arteriogram shows considerable hypertrophy of inferior cavernous artery (large arrow) with faint tumor blush (small arrows)
K. F. Lee et al.: Meningioma of the Paranasal Sinuses
These arachnoid cells may develop meningiomas outside the skull and vertebra along the lines of the fusion of the embryonic bones. The other possibility is blastomatous transformation of heterotopic cellular elements. According to Kernohan and Sayre [5] ectopic meningiomas arise from fragments of arachnoid which have Protruded through the dura mater to lie extradurally in various situations. Extracranial meningiomas in the paranasal sinuses can be divided into two groups: (1) extension of the intracranial meningioma to the paranasal sinuses and (2) ectopic meningioma in the paranasal sinuses. In order to determine the origin of the meningioma, careful inspection of the tumor at operation and the microscopic examination of the paranasal sinuses with adjacent tissue are required. In contrast to the other intracranial meningiomas, there was no tumor blush noted in our case with meningioma of the frontal sinus. Most of the cases reported with meningiomas of the paranasal sinuses had a clinical history of a bulg-
Fig. 8. Case 2. Microphotograph (HE × 100) of transitional type of meningioma with whorl pattern
K. F. Lee et al.: Meningioma of the Paranasal Sinuses ing m a s s o n t h e f r o n t a l [9, 10, 13] o r a n t r a l [1, 3, 8, 14] a r e a a s s o c i a t e d w i t h p r o g r e s s i v e e x o p h t h a l m o s [2, 3, 9, 13]. T h e p l a i n skull films a n d t o m o g r a m s r e v e a l e d t h e n o n - s p e c i f i c findings of c l o u d i n g of t h e p a r a n a s a l sinuses with d e s t r u c t i o n of t h e s u r r o u n d i n g b o n e . A s t h e t u m o r grows, it m a y b l o c k t h e o s t i u m of t h e f r o n t a l sinus with a r e s u l t a n t m u c o c e l e . T h e a n g i o g r a p h i c findings in o u r cases w e r e of a n a v a s c u lar t u m o r in t h e f r o n t a l sinus, a n d a faint t u m o r b l u s h in t h e s p h e n o i d sinus. T h e d i f f e r e n t i a l d i a g n o s i s of m e n i n g i o m a of p a r a n a s a l sinuses f r o m o t h e r c o n d i t i o n s such as m u c o c e l e , sinusitis with o s t e o m y e l i t i s , a n d f i b r o u s dysplasia, is e x t r e m e l y difficult, if n o t i m p o s s i b l e [6, 7].
Reterences la. Ash, J. E., Peck, M. R., Wilkins, J. D.: Tumors of the upper respiratory tract. Atlas of tumor pathology, Sect IV, fasc. 12-96. Washington: Armed Forces Institute of Pathology 1964 lb. Ash, J. E., Raum, M.: Tumors of tl~.enose and sinuses. Atlas of otolaryngic pathology, p. 204. Published under the sponsorship of Am. Acad. Ophthalmol. Otolaryngol. and Am. Registry Pathol. Lithographed by Roskin Photo Offset Corp. New York: Armed Forces Institute of Pathology 1949 2. Belal, A.: Meningioma infiltrating the nasal cavity, nasal sinuses and the orbit. J. Laryngol. 69, 59-69 (1955) 3. Hill, C. L.: Meningioma of the maxillary sinus. Arch Otolaryngol. 76, 547-549 (1962) 4. Kendall, B.: Invasion of the facial bones by basal meningiomas. Br. J. Radiol. 46, 237-244 (1973) 5. Kernohan, J.W., Sayre, G.P.: Meningiomas in tumors of CNS. Atlas of tumor pathology, Sect. X, fasc. 35. Washington: Armed Forces Institute of Pathology 1964 6. Lee, K. F., Hodes, P. J., Greenberg, L., Sinotti, A.: Three rare causes of unilateral exophthalmos. Radiology 90, 1009-1015 (1968)
171 7. Lee, K. F., Whiteley, W. H. III, Schatz, N. J., Edeiken, J., Lin, S., Tsai, F.: Juxtasellar hyperostosis of non-meningiomatous origin. J. Neurosurg. 44, 571-579 (1976) 8. Lindstrtim, C. G., LindstriSm, D.W.: On extracranial meningioma. Acta Otolaryngol. (Stockh.) 68, 451-456 (1969) 9. Majoros, M.: Meningioma of the PNS. Laryngoscope 80, 640-645 (1970) 10. New, G.B., Devine, K.D.: Neurogenic tumors of nose and throat. Arch. Otolaryngol. 46, 163-179 (1947) 11. Pendergrass, E. P., Hope, J. W.: An extracranial meningioma with no apparent intracranial source. Am. J. Roentgenol. 70, 967-970 (1953) 12. Rao, S. B., Dinakar, I., Rao, K. S.: Giant intracranial epidural meingioma. J. Neurosurg. 35, 743-751 (1971) 13. Rao, S. B., Dinakar, I., Reddy, C.R.R.M.: Meningioma of the frontal sinuses. J. Neurosurg. 36, 363-365 (1972) 14. Shahen, H. B.: Psammoma in the maxillary antrum. J. Laryngol. 46, 117 (1931) 15. Smith, A.T.: Ectopic meningioma. Med. J. Aust. 1, 1100-1104 (1973) 16. Stern, W.E.: Meningiomas in the cranio-orbital junction. J. Neurosurg. 38, 428-437 (1973) 17. Suzuki, H., Gilbert, E. F., Zimmermann, B.: Primary extracranial meningioma. Arch. Pathol. 84, 202-206 (1967) 18. Wolman, L., Puth, F.C.: The extracranial spread of meningioma. ENT Digest pp. 46-57, July (1969) 19. Zachariae, L.: A case of extracranial primary meningioma. Acta Path. Microbiol. Scand. 31, 57--60 (1952) Received: 11 May 1978
Dr. K, F. Lee Thomas Jefferson University Hospital 11th and Walnut Streets Philadelphia, PA 19107, USA
