Low-grade myofibrosarcoma of the maxillary sinus:Two case reports

BACKGROUND Low-grade myofibroblastic sarcoma(LGMS)is an extremely rare tumor characterized by the malignant proliferation of myofibroblasts.LGMS most commonly develops in adults,predominantly in males,in the head and neck region,oral cavity,especially on the tongue,mandible,and larynx.This article presents 2 cases of LGMS localized to the maxillary sinus and provides an overview of the available literature.CASE SUMMARY Two patients with LGMS located in the maxillary sinus underwent surgery at the Department of Head and Neck Surgery.Case 1:A 46-year-old patient was admitted to the clinic with suspected LGMS recurrence in the right maxillary sinus(rT4aN0M0),with symptoms of pain in the suborbital area,watering of the right eye,thick discharge from the right nostril,and augmented facial asymmetry.After open biopsy-confirmed LGMS,the patient underwent expanded maxillectomy of the right side with immediate palate reconstruction using a microvascular skin flap harvested surgically from the middle arm.The patient qualified for adjuvant radiotherapy for the postoperative bed,with an additional margin.Currently,the patient is under 1.5 years of observation with no evidence of disease.Case 2:A 45-year-old man was admitted to our clinic with facial asymmetry,strabismus,exophthalmos,and visual impairment in the right eye.Six months earlier,the patient had undergone partial jaw resection at another hospital for fibromatosis.A contrast-enhanced computed tomography scan revealed a tumor mass in the postoperative log after an earlier procedure.An open biopsy confirmed lowgrade fibrosarcoma(rT4aN0M0).The patient qualified for an extended total right maxillectomy with orbital excision and right hemimandibulectomy with immediate microvascular reconstruction using an anterolateral thigh flap.The patient subsequently underwent adjuvant radiotherapy to the postoperative area.After 9 months,recurrence occurred in the right mandibular arch below the irradiated area.The lesion infiltrated the base of the skull,which warranted the withdrawal of radiotherapy and salvage surgery.The patient qualified for palliative chemotherapy with a regimen of doxorubicin+dacarbazine+cyclophosphamide and palliative radiotherapy for bone metastases.The patient died 26 months after surgical treatment.The cases have been assessed and compared with cases in the literature.CONCLUSION No specific diagnostic criteria or treatment strategies have been developed for LGMS.The treatment used for LGMS is the same as that used for sinonasal cancer radical tumor excision;adjuvant radiotherapy or chemoradiotherapy should also be considered.They have low malignant potential but are highly invasive,tend to recur,and metastasize to distant sites.Patients should undergo regular follow-up examinations to detect recurrence or metastasis at an early stage.Patients should be treated and observed at the highest referral centers.

Maxillary Sinus Schwannoma—A Rare Tumor with Rarer Site of Occurrence

Schwannoma or neurilemmoma is a neurogenic tumor. Around 25% - 45% cases of schwannomas occur in the head and neck, of which less than 4% occurs in the nasal cavity and the paranasal sinuses. Isolated schwannomas of the maxillary sinus appear to be extremely rare. We present one such rare case of Right Maxillary Sinus schwannoma in a 48-year-old lady with swelling in the right cheek for 3 years. Infrastructure maxillectomy of the right side was done using Weber-Fergusson approach with Dieffenbach’s modification. The patient made a good postoperative recovery. We report this case keeping in mind the rarity in occurrence of isolated maxillary schwannomas.

Minimally invasive endoscopic maxillary sinus lifting and immediate implant placement: A case report

BACKGROUND This case report discusses a modified approach for maxillary sinus augmentation,in which platelet-rich fibrin,endoscope,simultaneous implant placement,and sinus floor elevation(PESS)were applied for a maxillary sinus floor lift in a 40-year-old patient.CASE SUMMARY A 40-year-old woman suffered missing upper right first molar.Implant stability quotient and cone-beam computed tomography(CBCT)were used to evaluate the diagnosis.CBCT showed insufficient posterior maxillary bone with a mean residual alveolar bone height of only 3.5 mm.The patient underwent a minimally invasive sinus floor elevation endoscopically.The sinus membrane was elevated in two stages,and a 12-mm implant was placed immediately.At 3 mo postoperatively,the final impressions were accomplished,and a full-ceramic crown was fit-placed.A 6-mo follow-up demonstrated satisfactory aesthetic and functional results.CONCLUSION This is the first report to use an endoscope for maxillary sinus floor lifting in cases with severe and insufficient bone height.This case report demonstrates the advantages of the PESS technique,which include minimal invasiveness with high precision,being applicable in cases with a residual alveolar bone height<4 mm with a promising result,and a shortened treatment period from 12 to 3 mo.

Sequential Fluorescent Labeling Observation of Maxillary Sinus Augmentation by a Tissue-engineered Bone Complex in Canine Model

Aim To evaluate the effects of maxillary sinus floor elevation by a tissue-engineered bone complex of β-tricalcium phosphate （β-TCP） and autologous osteoblasts in dogs. Methodology Autologous osteoblasts from adult Beagle dogs were cultured in vitro. They were further combined with β-TCP to construct the tissue-engineered bone complex. 12 cases of maxillary sinus floor elevation surgery were made bilaterally in 6 animals and randomly repaired with the following 3 groups of materials： Group A （osteoblasts/D-TCP）; Group B （β-TCP）; Group C （autogenous bone） （n=4 per group）. A polychrome sequential fluorescent labeling was performed post-operatively and the animals were sacrificed 24 weeks after operation for histological observation.Results Our results showed that autologous osteoblasts were successfully expanded and the osteoblastic phenol- types were confirmed by ALP and Alizarin red staining. The cells could attach and proliferate well on the surface of the ~3-TCP scaffold. The fluorescent and histological observation showed that the tissue-engineered bone complex had an earlier mineralization and more bone formation inside the scaffold than β-TCP along or even autologous bone. It had also maximally maintained the elevated sinus height than both control groups. Conclusion Porous 13-TCP has served as a good scaffold for autologous osteoblasts seeding. The tissue-engineered bone complex with β-TCP and autologous osteoblasts might be a better alternative to autologous bone for the clinical edentulous maxillary sinus augmentation.

Embryonal rhabdomyosarcoma in the maxillary sinus with orbital involvement in a pediatric patient:Case report

This report presents a case of embryonal rhabdomyosarcoma(e RMS) located in the left maxillary sinus and invading the orbital cavity in a ten-year-old male patient who was treated at a referral hospital.The images provided from the computed tomography showed a heterogeneous mass with soft-tissue density,occupying part of the left half of the face inside the maxillary sinus,and infiltrating and destroying the bone structure of the maxillary sinus,left orbit,ethmoidal cells,nasal cavity,and sphenoid sinus.An analysis of the histological sections revealed an undifferentiated malignant neoplasm infiltrating the skeletal muscle tissue.The immunohistochemical analysis was positive for the antigens:MyoD 1,myogenin,desmin,and Ki67(100% positivity in neoplastic cells),allowing the identification of the tumour as an eR MS.The treatment protocol included initial chemotherapy followed by radiotherapy and finally surgery.The total time of the treatment was nine months,and in 18-mo of follow-up period did not show no local recurrences and a lack of visual impairment.

An Unusual Maxillary Sinus Foreign Body and Its Endoscopic Assisted Removal

Foreign bodies in maxillary sinuses are uncommon. But the incidence is on a rise. Herewith we present a case of foreign bodies (glass pieces) in left maxillary sinus and bilateral nasolacrimal ducts, which is managed endoscopically.

Accidental Entry of Foreign Body in Maxillary Sinus—A Case Report

Extraction of the first molar or premolar is the commonest cause of oro-antral fistula. Management involves identification of the same, removal of any foreign body from the maxillary sinus, if present, followed by appropriate flap for closer. A case is presented when a gutta percha (GP) point was accidentally dislodged into the right maxillary sinus during preliminary diagnosis of the oro-antral fistula. The surgical management of the case is described and is the appropriate treatment plan.

Water-filled balloon in the postoperative resection cavity improves dose distribution to target volumes in radiotherapy of maxillary sinus carcinoma

Postoperative radiotherapy is a major treatment for patients with maxillary sinus carcinoma. However, the irregular resection cavity poses a technical difficulty for this treatment, causing uneven dose distribution to target volumes. In this study, we evaluated the dose distribution to target volumes and normal tissues in postoperative intensity-modulated radiotherapy (IMRT) after placing a water-filled balloon into the resection cavity. Three postoperative patients with advanced maxillary sinus carcinoma were selected in this trial. Water-filled balloons and supporting dental stents were fabricated according to the size of the maxillary resection cavity. Simulation CT scans were performed with or without water-filled balloons, IMRT treatment plans were established, and dose distribution to target volumes and organs at risk were evaluated. Compared to those in the treatment plan without balloons, the dose (D98) delivered to 98% of the gross tumor volume (GTV) increased by 2.1 Gy (P = 0.009), homogeneity index (HI) improved by 2.3% (P = 0.001), and target volume conformity index (TCI) of 68 Gy increased by 18.5% (P = 0.011) in the plan with balloons. Dosimetry endpoints of normal tissues around target regions in both plans were not significantly different (P > 0.05) except for the optic chiasm. In the plan without balloons, 68 Gy high-dose regions did not entirely cover target volumes in the ethmoid sinus, posteromedial wall of the maxillary sinus, or surgical margin of the hard palate. In contrast, 68 Gy high-dose regions entirely covered the GTV in the plan with balloons. These results suggest that placing a water-filled balloon in the resection cavity for postoperative IMRT of maxillary sinus c arcinoma can reduce low-dose regions and markedly and simultaneously increase dose homogeneity and conformity of target volumes.

Mesenchymal stem cells in maxillary sinus augmentation: A systematic review with meta-analysis

AIM: To investigate the effectiveness of mesenchymal stem cells(MSCs) in maxillary sinus augmentation(MSA), with various scaffold materials.METHODS: MEDLINE, EMBASE and SCOPUS were searched using keywords such as sinus graft, MSA, maxillary sinus lift, sinus floor elevation, MSC and cellbased, in different combinations. The searches included full text articles written in English, published over a 10-year period(2004-2014). Inclusion criteria were clinical/radiographic and histologic/ histomorphometric studies in humans and animals, on the use of MSCs in MSA. Meta-analysis was performed only for experimental studies(randomized controlled trials and controlled trials) involving MSA, with an outcome measurement of histologic evaluation with histomorphometric analysis reported. Mean and standard deviation values of newly formed bone from each study were used, and weighted mean values were assessed to account for the difference in the number of subjects among the different studies. To compare the results between the test and the control groups, the differences of regenerated bone in mean and 95% confidence intervals were calculated.RESULTS: Thirty-nine studies(18 animal studies and 21 human studies) published over a 10-year period(between 2004 and 2014) were considered to be eligible for inclusion in the present literature review. These studies demonstrated considerable variation with respect to study type, study design, follow-up, and results. Metaanalysis was performed on 9 studies(7 animal studies and 2 human studies). The weighted mean difference estimate from a random-effect model was 9.5%(95%CI: 3.6%-15.4%), suggesting a positive effect of stem cells on bone regeneration. Heterogeneity was measured by the I2 index. The formal test confirmed the presence of substantial heterogeneity(I2 = 83%, P < 0.0001). In attempt to explain the substantial heterogeneity observed, we considered a meta-regression model with publication year, support type(animal vs humans) andfollow-up length(8 or 12 wk) as covariates. After adding publication year, support type and follow-up length to the meta-regression model, heterogeneity was no longer significant(I2 = 33%, P = 0.25).CONCLUSION: Several studies have demonstrated the potential for cell-based approaches in MSA; further clinical trials are needed to confirm these results.

A Large Calcifying Cystic Odontogenic Tumor Occupying the Maxillary Sinus: A Case Report and Review of Literature

Calcifying cystic odontogenic tumor (CCOT) is an uncommon benign cystic neoplasm of the jaw that develops from the odontogenic epithelium. It is clinically characterized as a painless—slow-growing tumor that affects the maxilla as well as the mandible, and generally occurs in young adults in the third or fourth decade of life. Herein, we present the case of a 16-year-old Japanese boy who showed a CCOT in the maxillary sinus. Panoramic radiography showed a unilocular lesion in the left maxillary sinus. Computed tomography showed an approximately 5-cm well-defined unilocular expansile lesion with multiple radiopaque calcific specks, arising from the left maxillary alveolar ridge. The lesion was surgically removed, under general anesthesia, and the patient was followed up for 3 years after the surgery, and there have not been any signs of recurrence.

The Importance of Three-Dimensional Imaging from CBCT in Elucidating a Well-Defined Radiolucency Image within the Maxillary Sinus: A Case Report

This study describes a case of antral septum with alveolar process extension that is identified using cone-beam computed tomography (CBCT). Periapical radiolucency was observed in the maxillary sinus, and clinical and radiographic examinations ruled out the possibility of odontogenic lesions. CBCT was performed to elucidate the radiolucency identified using periapical radiography. A 3-D image indicated that the maxillary sinus extended into the alveolar process toward the palatal cortical bone in the region of the maxillary right first molar, as well as an antral septum extending from the inferior and lateral wall of the right maxillary sinus. CBCT is an important tool for use in dental practice because CBCT images reveal the entire volume of the maxillary sinus and allow for identification of patient anatomy and anatomical variations, which is essential for planning appropriate surgical interventions.

Minimally invasive maxillary sinus augmentation with simultaneous implantation on an elderly patient:A case report

BACKGROUND In this case study,a minimally invasive transalveolar approach using platelet-rich fibrin and bone substitute with simultaneous implantation was carried out in an elderly patient.We analyzed the cone-beam computed tomography(CBCT)findings to evaluate bone regeneration.CASE SUMMARY A 65-year-old female with no contraindications for dental implants and loss of maxillary bilateral molars is described.Examination by CBCT showed the available vertical bone height in the bilateral posterior maxilla was 0.5-6.8 mm in the left and 2.8-6.5 mm in the right.The patient underwent a transalveolar approach using platelet-rich fibrin and bone substitute with simulataneous placement of an implant 10 mm in length.Six months post-surgery,the implant showed excellent osseointegration with the bone graft.Thereafter,full-ceramic crowns were fitted.Follow-up at 2 years demonstrated satisfactory prognosis.CONCLUSION Platelet-rich fibrin and bone substitute can be used to augment the maxillary sinus with a vertical bone height less than 4 mm.

Extension of Calcifying Epithelial Odontogenic Tumor to the Maxillary Sinus: A Case Report

The calcifying epithelial odontogenic tumor (CEOT) is a rare and benign odontogenic epithelial neoplasm. This tumor accounts for less than 1% of all odontogenic tumors. It normally affects patients between 30 and 50 years old, and it is typically located in the posterior region of the mandible. Involvement of the maxillary sinus has previously been published only in six cases. This report presents a single case of CEOT that invades the maxillary sinus in a 69-year-old male. We performed a left partial maxillectomy and immediate reconstruction of the defect with a temporalis muscle flap. A comprehensive immunohistochemical study was reported. No recurrences have been found after 8 years of follow-up.

Case of primary extracranial meningioma of the maxillary sinus presenting as buccal swelling associated with headache:A case report

BACKGROUND Meningiomas are benign tumors that originate from the meningothelial arachnoid cells,but they rarely develop extracranially.There is no specific surgical guideline for resecting them in the maxillary sinus,and little is known about their biological behavior and operative management.CASE SUMMARY We present a 54-year-old female patient referred to our department with a primary extracranial meningioma that presented as buccal swelling associated with headache.On clinical examination the mass was non-tender,fixed,sessile and non-pulsatile situating in the right maxillary sinus.Computed tomography scan showed a well-defined mass of 7 cm×6 cm×6 cm compressing the surrounding structures.Magnetic resonance imaging revealed a well circumscribed heterogenous lesion with necrotic center and relatively hypointense on T2-weighted imaging.Imaging studies revealed no evidence of intracranial extension and metastatic nests.Biopsy showed grade I primary extracranial with low mitotic activity.Total maxillectomy with excision of tumor and adjacent paranasal structures following reconstruction of the orbit and maxilla with tissue patch was done by the maxillofacial surgeon.The biopsy reported fibrous meningioma based on the hematoxylin and eosin section.On immunohistochemistry the tumor cells were positive for vimentin,focally positive for epithelial membrane antigen and CD99 and negative for signal transducer and activator of transcription 6.The mass was removed surgically with reconstruction,and the pathological studies confirmed the diagnosis to be an extracranial meningioma.The present study briefly reviews the current knowledge concerning the diagnosis and treatment of extracranial meningiomas in the head and neck area and offers suggestions for managing extracranial meningiomas in the paranasal sinuses.CONCLUSION To conclude,extracranial meningiomas in the paranasal sinuses may be successfully managed by surgical treatment without evident post-surgery complications.

Diffuse large B cell lymphoma originating from the maxillary sinus with skin metastases:A case report and review of literature

BACKGROUND Diffuse large B-cell lymphoma(DLBCL)is the most common type of malignant lymphoma(ML),accounting for 30%-40%of cases of non-Hodgkin’s lymphoma(NHL)in adults.Primary paranasal sinus lymphoma is a rare presentation of extranodal NHL that accounts for only 0.17%of all lymphomas.ML from the maxillary sinus(MS)is a particularly rare presentation,and is thus often difficult to diagnose.We have reported the first known case of DLBCL originating from the MS with rapidly occurrent multiple skin metastasis.CASE SUMMARY An 81-year-old Japanese man visited our hospital due to continuous pain for 12 d in the left maxillary nerve area.His medical history included splenectomy due to a traffic injury,an old right cerebral infarction from when he was 74-years-old,hypertension,and type 2 diabetes mellitus.A plain head computed tomography(CT)scan revealed a 3 cm×3.1 cm×3 cm sized left MS.On day 25,left diplopia and ptosis occurred,and a follow-up CT on day 31 revealed the growth of the left MS mass.Based on an MS biopsy on day 50,we established a definitive diagnosis of DLBCL,non-germinal center B-cell-like originating from the left MS.The patient was admitted on day 62 due to rapid deterioration of his condition,and a plain CT scan revealed the further growth of the left MS mass,as well as multiple systemic metastasis,including of the skin.A skin biopsy on day 70 was found to be the same as that of the left MS mass.We notified the patient and his family of the disease,and they opted for palliative care,considering on his condition and age.The patient died on day 80.CONCLUSION This case suggests the need for careful,detailed examination,and for careful follow-up,when encountering patients presenting with a mass.

A Loculated Pyocele of Maxillary Sinus—A Rare Case Report

Pyocele of maxillary sinus occurs unusually, when its mucocele content gets secondarily infected. Most of the pyocele occupies the frontal and anterior ethmoid sinus involving the frontal-ethmoidal complex expanding into the orbit leading to ocular disorders. Maxillary sinus presentation is rare, and our patient had a well defined loculated pyocele in her right maxillary sinus that we suspected with radiological images and was confirmed by needle aspiration under endoscopic guidance to the pyocele sac. Here we would like to describe more in detail about the nature of the mucopyocele in paranasal sinuses, its presentation and various surgical modalities of treating the pyocele.

The Relationship between Dental Indentation and Maxillary Sinusitis

Purpose: To determine the relationship between the dental root indentation and maxillary sinusitis. Methods: We assessed the records of the patients who underwent paranasal sinus computed tomography imaging for suspected sinusitis. Results: We identified a total of 52 patients with a pre-diagnosis of maxillary sinusitis. Dental indentation was detected in 58 of 104 (55.7%) sinuses. Forty six of 58 sinuses (79.3%) with dental indentation had mucosal thickening higher than 2 mm. The difference between the groups was statistically significant (p = 0.007). Conclusion: Dental indentation should be kept in mind as a reason for chronic maxillary sinus inflammation, if an underlying cause cannot be identified.

A Case of Angioleiomyoma of the Maxillary Sinus

Angioleiomyoma (ALM) is a benign tumor that occurs most frequently in the subcutaneous tissue of the upper and lower extremities. ALM arising in the sinonasal tract is rare, with fewer than 1% of cases presenting in this region. Only two cases localized to the sinuses have been reported to date in the literature. We report a case of a 30-year-old man complaining of a headache noted to have a concomitant lesion in the maxillary sinus. Histopathological examination following surgical resection confirmed a diagnosis of ALM. This report is the first known report of ALM limited to the maxillary sinus, and the first report to present the imaging data in the ALM in the sinus.

Treatment of traumatic globe dislocated completely into the maxillary sinus

Dear Sir, I am Dr. Bei Xu, from Department of Ophthalmology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China. I want to present a rare case of the treatment of traumatic globe dislocated completely into the maxillary sinus. A 46-year-old female was admitted to emergency unit due to traffic accident, presenting disturbance of consciousness for nine hours.

Morphometric analysis of the relationships between the maxillary first molar and maxillary sinus floor

Objectives: To assess the relationships between the maxillary first molar and the maxillary sinus floor in a group of patients referred to a dental clinic. Methods: Ninety-seven patients were recruited for this study. The distances between the examined roots (mesio-buccal, disto-buccal and palatal) as well as furcations, and the sinus floor, were evaluated using cone beam computed tomography, and grouped as follows: class 0: distance = 0 mm;class 1: 0 mm < distance < 2 mm;class 2: 2 mm ≤ distance < 4 mm;class 3: 4 mm ≤ distance < 6 mm;class 4: 6 mm ≤ distance. The Spearman’s Rank Correlation coefficient was used to test the univariate associations between furca-tion-sinus floor distance and each root class. Results: The prevalence of class 0 was the highest for the palatal root (44.33%), followed in descending order by mesio-buccal (40.21%), and disto-buccal (38.14%) roots. The highest correlation coefficient was recorded when assessing the relationship between furcation-sinus floor distance and palatal root classes (rho = 0.66, p < 0.001, n = 97). Conclusions: Altogether, the results suggest that the palatal root of the maxillary first molar not only had the closest relationship with the sinus floor, but also proved to be the best predictor for the furcation-sinus floor distance. The clinician should be aware of the anatomical and morphological details of this root, especially when taking surgical decisions.