Metastatic carcinoma of the ethmoid sinus ERIK Θ. NELSON, MD, MICHAEL E. GOLDMAN, MD, and MASOUD HEMMATI, MD, Chicago, Illinois

Primary carcinoma of the paranasal sinuses ac­ counts for approximately 0.3% of cancers occurring in human beings. Estimates of its incidence range from 1:100,000 to 1:170,000 in the population. '· 2 Metastatic carcinoma of the paranasal sinuses is far less common than primary carcinoma. Ninety-seven cases of metas­ tasis to the paranasal sinuses, including only 16 cases of metastasis to the ethmoid sinus, have been reported in the literature (Table 1 ) . " The mechanism of metastasis to the paranasal sinuses is unclear; however, Batson7 postulated hematogenous spread through the prevertebral venous plexus. The Valsalva maneuver may cause retrograde flow through this valveless low-pressure system, which communicates with the venous system of the thorax, abdomen, and pelvis, and carries tumor emboli to the pterygoid plexus and paranasal sinuses. In this article, a review of metastatic tumors to the paranasal sinuses is presented and a case of breast can­ cer metastatic to the ethmoid sinus is discussed. CASI «PORT A 42-year-old woman was diagnosed in December 1985 as having intraductal carcinoma of the right breast. A seg­ mental mastectomy and axillary dissection was performed. The surgical margins were positive; however, five axillary nodes were all free of metastasis. The tumor was negative for estrogen and progesterone receptors. Five days later, a total mastectomy was performed. Residual carcinoma was not seen in this specimen. No adjuvant therapy was given to the patient. In March 1987, bilateral throbbing frontal headaches de­ veloped and progressively increased in severity. The patient was treated for migraine headaches, with no relief. Two

From the Department of Otolaryngology-Head and Neck Surgery (Drs. Nelson and Goldman) and Radiology (Dr. Hemmati), Michael Reese Hospital and Medical Center. Submitted for publication May 1, 1989; revision received Sept. 6, 1989; accepted Oct. 10, 1989. Reprint requests: Michael E. Goldman, MD, Department of Otolaryngology-Head and Neck Surgery, Michael Reese Hospital and Medical Center, Lake Shore Drive at 31st St., Chicago, IL 60616. 23/4/17282

months later, a yellowish postnasal drip developed. A com­ puted tomography (CT) scan demonstrated mucosal thick­ ening of therightethmoid sinus. The patient was treated with antibiotics and nasal decongestants, with no relief of her symptoms. Four months after the onset of her headaches, right eye symptoms developed rapidly. These symptoms in­ cluded pain, diplopia with eccentric gaze, periorbital numb­ ness, and epiphora. The patient was subsequently referred to us for otolaryngologic consultation. The patient's medical history is signif­ icant for stage IIB Hodgkin's disease of the supraclavicular area, diagnosed at age 22 years. She was treated with radiation therapy and had remained free of Hodgkin's disease for 20 years. On examination, the patient was noted to be in moderate distress from herrighteye pain. The eye was 4-mm proptotic, with no inflammation or chemosis. Complete ophthalmoplegia was present and forced duction revealed mild restriction. The visual acuity was 20/50 and unchanged from previous examinations. The pupillary and fundoscopic examination was normal. Anesthesia was present in the supraorbital and infraorbital nerve distributions. On intranasal examination, moderate edema of therightmiddle meatus was present, with no inflammation or drainage. The nasal airway was patent. Cervical adenopathy was absent. Local recurrence of breast cancer was not present. The remainder of the physical ex­ amination was normal. Laboratory tests revealed a WBC count of 12.5 with 86 neutrophils. The liver enzymes were mildly elevated. The chest x-ray film, which was normal 1 month earlier, dem­ onstrated multiple nodules in both lung fields. A CT scan of the paranasal sinuses and orbits, with and without infusion of contrast, showed soft tissue densities occupying the eth­ moid sinuses and fluid in the sphenoid sinuses (Fig. I, A). A small amount of fluid was present in the right maxillary sinus, also. There was no evidence of bony erosion or contrast enhancement. The right globe was slightly proptotic, with an intraconal soft tissue mass in the posterosuperior aspect of the orbit (Fig. 1, B). The optic nerve and recti muscles were intact. Magnetic resonance imaging (MRI) was obtained to rule out an intracranial lesion; however, one was not seen. A soft tissue mass lesion was again demonstrated in the ethmoid sinuses and right orbit (Fig. 2). Soft tissue densities of the maxillary and sphenoid sinuses showed higher intensity in the T2-weighted images when compared to the intensity of the soft tissue present in the ethmoid sinuses, suggesting that the soft tissue densities present in the sphenoid and maxillary sinuses were fluid and the densities in the ethmoid sinuses were inflammatory or neoplastic lesions. A CT scan of the

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Case Reports

Fig. 1. CT scan of orbits and sinuses with contrast. A, Soft tissue density in ethmoid sinuses, fluid in sphenoid sinuses, mild proptosls of the right globe. B, Intraconal soft tissue mass In the right orbit.

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Fig. 2. MRI of the orbits and sinuses, T2-weighted Image. Soft tissue mass in ethmoid sinuses and right orbit, fluid In the sphe­ noid sinuses.

T a b l e 1. Metastasis to the paranasal sinuses Author(s)

Maxillary

Ethmoid

Bernstein et al.3 Barrs et al.4 Kent and Majumdar5 Bizon and Newman6

40

15

TOTALS

15 55

Sphenoid

Frontal

Total

12

73 8

15

J_

J_ 16

chest and abdomen revealed multiple nodules consistent with metastatic disease in the lungs and liver. In July 1987, a right external ethmoidectomy was per­ formed. The mucosa of the ethmoid sinus was edcmatous, with minimal inflammation. The lamina papyracea and bony septa were intact. Right sphenoid and maxillary sinusotomies were performed. A small amount of mucoid fluid was present in both sinuses, with minimal mucosal thickening. The orbit was then explored. No mass lesion was present in the superior orbital fissure. The periorbita was incised and the retrobulbar fat was dissected. No intraconal mass was identified. Post-

14

12

97

operatively, the patient reported marked relief of her head­ aches and eye pain. Her vision and ocular examination re­ mained unchanged. Histopathology of the ethmoid sinus tissue revealed extensive infiltration of the submucosal lym­ phatic and vascular channels, with adcnocarcinoma consistent with metastatic breast cancer (Fig. 3). The patient received adriamycin, vincristine, and cytoxan postoperatively, with transient improvement in her ophthalmoplegia. A second course of chemotherapy was done 4 months later. The patient died 6 months after the diagnosis of metastatic disease, with no recurrence of her eye pain.

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OtolaryngologyHead and Neck Surgery

Case Reports

Flg. 3. Ethmoid sinus mucosa with Infiltration of the submucosal lymphatic and vascular channels with metastatlc breast carcinoma. (Hematoxylin-eosln stain; original magnification x 80.)

DISCUSSION Involvement of the paranasal sinuses with metastatic carcinoma is uncommon. In 1966, Bernstein et al.3 reviewed the literature and found 40 cases of maxillary sinus metastasis, 15 cases of ethmoid sinus metastasis, 12 cases of frontal sinus metastasis, and 6 cases of sphenoid sinus metastasis, for a total of 73 cases. Barrs et al.4 have reported eight additional cases of metastatic tumors to the sphenoid sinus. Since then, 15 more cases of metastasis to the maxillary sinus have been reviewed by Kent and Majumdar.5 One additional case of mel­ anoma with metastasis to the ethmoid sinus has been reported by Bizon and Newman.6 These reports are summarized in Table 1. Hypernephroma is the most common tumor to metastasize to the paranasal sinuses, followed by breast, lung, and seminoma in order of frequency.3'6 Of the 15 cases of ethmoid sinus metastasis reported by Bernstein et al. , 3 13 were hypernephromas. One case each of lung and pancreas carcinoma metastatic to the ethmoid sinus were included in their report. The case we have de­ scribed is the first reported case of breast carcinoma with metastasis to the ethmoid sinus. The symptoms of metastatic tumors to the paranasal sinuses include epistaxis, nasal mass or swelling, nasal

obstruction, and pain in decreasing order of frequency. These symptoms are similar to those of infection. When the treatment of sinus infection does not result in res­ olution of symptoms, the possibility of malignancy must be considered. Malignancy should be given greater consideration if risk factors are present for pri­ mary carcinoma, such as environmental exposure to nickel or wood dust, or if the patient has a history of cancer. When cancer is diagnosed in a paranasal sinus, a thorough search for a distant primary tumor must be made to rule out metastatic disease. Although sinus metastasis may occur in patients with known metastatic disease, a sinus metastasis may be the first sign of an undiagnosed primary tumor,4 or—as described in the case report—prompt the diagnosis of diffuse metastasis from a known primary tumor. In addition to nasal symptoms, ocular symptoms may also occur in both primary and metastatic malignancy of the paranasal sinuses by extension of tumor into the orbit.4 These symptoms include facial pain, numbness, diplopia, epiphora, blepharoptosis, decreased visual acuity, and proptosis. Metastatic disease to the orbit is not rare and will manifest similar symptoms.'' In fact, Bloch and Gartner10 have found histopathologic evi­ dence of metastasis to the eye and orbit in 12% of 230 patients with metastatic carcinoma. Although gross tu-

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Volume 103 Number 1 July 1990

Case Reports

nior could not be identified within the orbit of the patient * the present case report, microscopic disease was un­ doubtedly responsible for her ocular symptoms and ra­ diographiefindings.It is likely that metastasis occurred first to the sinus and then spread to the orbit because the sinus symptoms proceeded the ocular symptoms and the bulk of disease was present in the ethmoid sinus. The clinical significance of soft tissue densities within the ethmoid sinus on radiographie studies is dif­ ficult to determine. Som et al." reviewed the radiographic findings of 400 CT scans with ethmoid sinus disease. Their data indicated that soft tissue findings were nonspecific and that osseous findings were most helpful in making diagnoses. They concluded that ma­ lignant lesions could not be diagnosed by CT unless hone destruction was present. MRI is useful in deter­ mining the extent of a neoplastic lesion. In the case Presented in this report, MRI accurately differentiated areas of tumor involvement from areas with reactive changes and fluid accumulation. External ethmoidectomy and decompression of the orbit provided tissue for diagnosis and relieved the pa­ tient of her primary symptom of severe ocular and facial pain. Surgery is recommended in metastatic carcinoma of the paranasal sinuses for diagnosis and palliation of symptoms. The surgery should not be radical in extent.

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Further treatment with chemotherapy or radiation ther­ apy is suggested when indicated. REFERENCES

1. Macbeth R. Malignant disease of the paranasal sinuses. J Laryngol Otol 1965;79:591-612. 2. Einer A, Koch H. Combined radiological and surgical therapy of cancer of the ethmoid. Acta Otolaryngol 1974;78:270-6. 3. Bernstein JM, Montgomery WW, Balogh K. Metastatic tumors to the maxilla, nose, and paranasal sinuses. Laryngoscope 1966;76:621-50. 4. Barre DM, McDonald TJ, Whisnant JP. Metastatic tumors to the sphenoid sinus. Laryngoscope 1979;89:1239-43. 5. Kent SE, Majumdar B. Metastatic tumors in the maxillary sinus: a report of two cases and a review of the literature. J Laryngol Otol 1985;99:459-62. 6. Bizon JG, Newman RK. Metastatic melanoma to the ethmoid sinus. Arch Otolaryngol 1986;112:664-7. 7. Batson OV. The function of the vertebral veins and their role in the spread of metastasis. Ann Surg 1988;112:138-49. 8. Lampe HB, St. Pierre S, Baker SR. Carcinoma of the ethmoid sinus. Ann J Otolaryngol 1986;7:290-12. 9. Henderson JW. Orbital tumors. Philadelphia: WB Saunders, 1973:474-94. 10. Bloch RS, Gartner S. The incidence of ocular metastatic car­ cinoma. Arch Ophthalmol I97U;85:673-5. 11. Som PM, Lawson W, Biller HF, Lanzieri CF. Ethmoid sinus disease: CT evaluation in 400 cases. Radiology 1986; 159: 591-7.

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Metastatic carcinoma of the ethmoid sinus.

Metastatic carcinoma of the ethmoid sinus ERIK Θ. NELSON, MD, MICHAEL E. GOLDMAN, MD, and MASOUD HEMMATI, MD, Chicago, Illinois Primary carcinoma of...
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