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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 488-490

Chronic sinusitis or malignancy? Role of an oral and maxillofacial radiologist in comprehending the dilemma: A case report


1 Department of Oral Medicine and Radiology, Dental College, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 School of Dental Sciences, Sharda University, Noida, Uttar Pradesh, India

Date of Submission17-Dec-2021
Date of Decision17-Apr-2022
Date of Acceptance25-Oct-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Anka Sharma
Tutor, Department of Oral Medicine and Radiology, Dental College, Rajendra Institute of Medical Sciences, Ranchi 834 009, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_343_21

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   Abstract 


Maxillary sinus malignancies are rare, constituting just 0.44% of all neoplasms. These malignancies have a male predilection, with a ratio of 2:1. Men in the age range of 39–89 years are mostly affected. The patient presents with a plethora of symptoms that can mimic an odontogenic infection or paranasal sinusitis. This case report discusses and describes the cone-beam computed tomography (CBCT) findings of a patient with malignancy of maxillary sinus misdiagnosed as chronic sinusitis.

Keywords: Chronic sinusitis, malignancy, nasal discharge


How to cite this article:
Sharma A, Sawhney H, Mishra R, Kumar J. Chronic sinusitis or malignancy? Role of an oral and maxillofacial radiologist in comprehending the dilemma: A case report. J Indian Acad Oral Med Radiol 2022;34:488-90

How to cite this URL:
Sharma A, Sawhney H, Mishra R, Kumar J. Chronic sinusitis or malignancy? Role of an oral and maxillofacial radiologist in comprehending the dilemma: A case report. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Feb 2];34:488-90. Available from: http://www.jiaomr.in/text.asp?2022/34/4/488/363035




   Introduction Top


In India, malignant neoplasms of the nose and paranasal sinuses constitute merely 0.44% of all neoplasms. Their prevalence is around 0.57% in males and 0.44% in females. The maxillary sinus is most commonly involved, followed by the ethmoid, frontal, and sphenoid sinus.[1] Etiology is largely unknown. Risk factors include smoking, chronic sinusitis, air pollution, and chemical exposure.[2] The symptoms are nonspecific; thus, the neoplasm is usually misdiagnosed as sinusitis or dental infection.[3]

We, at this moment, present a case of a 39-year-old male being treated for chronic refractory sinusitis for 6 months before presenting to the oral and maxillofacial physician. Here, he was diagnosed with malignancy of the maxillary sinus and was directed for proper management.


   Case Presentation Top


A 39-year-old male, accountant by profession, reported to the Department of Oral Medicine and Radiology with a chief complaint of swelling on the left side of the face for 10 days and swelling in the upper left gums for 5 days.

Approximately 1 year back, he started experiencing recurrent nasal stuffiness and continuous watering from the left eye. The otolaryngologist had prescribed some medications, and the symptoms improved temporarily. Seven months back, he contracted coronavirus disease (COVID), from which he recovered by taking symptomatic measurements. Nasal stuffiness and discharge, however, did not resolve. The otolaryngologist advised Computed Tomography- Paranasal Sinus (CT-PNS) and magnetic resonance imaging (MRI), which suggested chronic sinusitis with probable fungal infection. The patient was posted for surgical intervention (twice), and the excised tissue only revealed an inflammatory component. The symptoms aggravated postoperatively, and nasal discharge was followed by mild swelling on the left side of the face. After 5 days, the patient also started complaining of pain in the upper left teeth on chewing, for which he was then referred for a dental opinion. He denied any deleterious habits (smoking, alcohol intake). On examination, a diffuse, mild swelling was noted in the left malar region. The left nostril appeared depressed with mild superior displacement of the left eye [Figure 1]. The swelling was soft to firm in consistency and slightly tender on palpation. Cervical lymphadenopathy was absent. Intraorally, mild obliteration of the left buccal vestibule was noted in the 23–25 region. Teeth were noncarious. A provisional diagnosis of an odontogenic cyst or tumor affecting the left maxillary sinus was made. Differential diagnoses included surgical ciliated cyst, malignancy, and mucocele. Cone-beam computed tomography (CBCT) of the maxilla revealed an ill-defined soft tissue radiopacity in the left maxillary sinus eroding all the walls of the left maxillary sinus and left orbit (except the floor). The left maxillary and ethmoid sinuses were obliterated. Knife-edge root resorption of 27 and perforation of the buccal and palatal cortical plate in the 24–25 region was noted [Figure 2]. A clinical–radiographic diagnosis of malignancy of the left maxillary sinus was postulated. The patient pursued reassessment of the excised tissue, which revealed low-grade adenocarcinoma of the maxillary sinus. He was scheduled for partial maxillectomy (left side), and an obturator was provided for the defect. One month of postoperative healing was good [Figure 3].
Figure 1: Diffuse swelling over left side of the face. Note the superior displacement of left eye (red arrow) and obliteration of left nasal aperture (yellow arrow)

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Figure 2: CBCT slices showing the extent of the lesion and its effects on adjacent structures. CBCT = cone-beam computed tomography. (a) Coronal view showing a soft tissue radiopacity involving left maxillary sinus causing superior displacement of left infraorbital rim and destruction of turbinates. (b) Axial view showing expansion and erosion of anteromedial and posterolateral wall of left maxillary sinus. (c) Erosion of the buccal cortical plate. (d) Root resorption in 27

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Figure 3: Postoperative extraoral view

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   Discussion Top


Maxillary sinus malignancies are rare, constituting merely 0.44% of all neoplasms. These malignancies have a male predilection (2:1). Men in the age range of 39–89 years are mostly affected.[4]

Since the maxillary sinus is a large air space, the tumor mass continues to grow without producing any symptoms.[3] In a retrospective study of 110 cases of maxillary sinus malignancies, Waldron et al.[4] found that 59% of patients presented with pain, 40% with oral symptoms, and 38% with facial swelling as the chief complaint. Nasal obstruction and epistaxis were reported in 35% and 25% of cases, respectively. Other less-common features were epiphora, diplopia, and paresthesia. However, in most cases, the symptoms are nonspecific and occur when the tumor mass extends to erode the sinus walls.[5] The average time from the beginning of symptoms to diagnosis is about 4 months, and around 90% of cases are diagnosed in advanced T3/T4 stages.[6] In the present case, the patient complained of nasal stuffiness and was treated for it for 6 months with surgical intervention. Differential diagnosis includes cyst of maxillary origin: mucocele; surgical ciliated cyst; Odontogenic Keratocyst (OKC), tumors: fibro-osseous lesions; malignancies; and fungal osteomyelitis. Mucoceles occur in frontal sinus, fibro-osseous lesions usually occur at young age; and if found in adults, they are firm and too hard in consistency. OKC, ciliated surgical cyst, and fungal osteomyelitis are ruled out histopathologically. To evaluate the extent of the tumor, CBCT and contrast-enhanced computed tomography (CECT) are advocated. MRI is implicated in differentiating malignancy from inflammatory disorders like inflammatory pseudotumor.[7]

The maxillary sinus drains into retropharyngeal lymph nodes which are inaccessible to palpation. Hence, nodal metastasis is rarely documented in sinus malignancies.[1] However, a confirmation can be done using a positron emission tomography (PET) scan. In the present case, PET was not performed.

Histopathologically, 80% of the maxillary sinus malignancies are squamous cell carcinomas.[1]

Contrera et al.,[8] in a review, have discussed some newly emerging sinonasal malignancies like teratocarcinosarcoma and renal cell-like adenocarcinoma. The present case was histopathologically proven as low-grade, nonintestinal adenocarcinoma.

Surgery, radiotherapy, and chemotherapy treat these malignancies in various combinations and sequences. The 5-year survival rate is 43%, while the overall survival is 52%.[9]


   Conclusion Top


The present case report describes how malignancies of sinonasal origin can masquerade inflammatory conditions. Given their rare occurrence and a wide plethora of presenting symptoms, these malignancies are usually diagnosed at an advanced stage. Thus, it is impeccable for dentists to rule out malignancy in patients with nonspecific dental pain and chronic sinusitis.

Patient perspective: “I am concerned with the discharge from my nose and continuous watering of the left eye. I never knew this could be cancer.”

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

The authors are grateful to the patient for his cooperation and to the pathology department for reviewing the slide to confirm the diagnosis.

Key message

Malignant neoplasms of the paranasal sinus often present with a plethora of nonspecific symptoms and are thus misdiagnosed as sinusitis or dental infections at early stages. As they have a poor survival rate, it is impeccable to consider them in the differential diagnosis of chronic sinusitis and nonspecific dental pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Dhingra PL. Diseases of the Ear, Nose & Throat. Elsevier India ; 2010.  Back to cited text no. 1
    
2.
Won HS, Chun SH, Kim B, Chung SR, Yoo IR, Jung CK, et al. Treatment outcome of maxillary sinus cancer. Rare Tumors 2009;1:36. doi: 10.4081/rt. 2009.e36.  Back to cited text no. 2
    
3.
Ramachamparambathu AK, Vengal M, Mufeed A, Siyo N, Ahmed A. Carcinoma of maxillary sinus masquerading as odontogenic infection. J Clin Diagn Res 2016;10:11-3.  Back to cited text no. 3
    
4.
Waldron JN, O'Sullivan B, Gullane P. Carcinoma of the maxillary antrum: A retrospective analysis of 110 cases. Radiother Oncol 2000;57:167-73.  Back to cited text no. 4
    
5.
St. Pierre S, Baker S. Squamous cell carcinoma of the maxillary sinus: Analysis of 66 cases. Head and Neck Surg 1983;5:508-13.  Back to cited text no. 5
    
6.
Carrillo JF, Guemes A, Ramirez-Ortega MC, Onate-Ocana LF. Prognostic factors in the maxillary sinus and nasal cavity carcinoma. Eur J Surg Oncol 2005;31:1206-12.  Back to cited text no. 6
    
7.
Naveen J, Sonalika WG, Prabhu S, Gopalkrishnan K. Inflammatory pseudotumor of maxillary sinus: Mimicking as an aggressive malignancy. J Oral Maxillofac Pathol 2011;15:344-5.  Back to cited text no. 7
  [Full text]  
8.
Contrera KJ, Woody NM, Rahman M, Sindwani R, Burkey BB. Clinical management of emerging sinonasal malignancies. Head Neck 2020;42:2202-12.  Back to cited text no. 8
    
9.
Bhattacharyya N. Factors affecting survival in maxillary sinus cancer. J Oral Maxillofac Surg 2003;61:1016-21.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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