Sinonasal squamous cell carcinoma

Case contributed by Ryan Thibodeau
Diagnosis certain

Presentation

One month of bilateral (right > left) redness and itching of the eyes. Now presenting with right eye mass.

Patient Data

Age: 85 years
Gender: Male

Centered within the right anterior ethmoid air cells there is a heterogeneously enhancing mass measuring 4.4 x 3 x 4.9 cm (AP x TV x SI). This mass erodes the right lamina papyracea and right nasal bone and extends into the medial aspect of the right orbit causing lateral displacement of the medial rectus muscle and the globe. The mass appears to involve the right superior oblique extraocular muscle. There is also right proptosis. The mass extends superiorly to involve both frontal sinuses, the right greater than the left. There are areas of osseous erosion involving the inner table of the right frontal sinus as well as the anterior aspect of the cribriform plate. However, a discrete intracranial enhancing component is not identified. The mass extends inferiorly into the right nasal cavity likely relates to the right middle turbinate.

There is near complete opacification of the right maxillary sinus as the maxillary infundibulum appears obstructed by the mass. There is also complete opacification of the left ethmoid air cells as well as the left maxillary sinus. There is opacification of the left sphenoid sinus with obstruction of the left sphenoethmoid recess. There is also increased left sphenoid sinus wall thickening suggestive of chronic sinusitis.

The left orbit is unremarkable.

Corresponding to the recent CT findings, there is a large mass predominantly involving the right ethmoid sinus, with extension into the right orbit and right frontal sinus, into the nasal cavity, and across the midline to the left ethmoid sinus, and minimally across the midline of the frontal sinus. The mass is predominantly T2-isointense and shows heterogeneous enhancement. There is associated lateral displacement of the right globe, and proptosis. Tumor extends anteriorly from the ethmoid sinus into the medial canthus and subcutaneous tissue along the superomedial aspect of the right orbit.

Although there appears to be focal bony dehiscence along the roof of the right orbit and the posterior table of the frontal sinus on CT, there is no evidence of intradural tumor. There is no abnormal enhancement of the meninges or brain parenchyma.

The sphenoid sinus, and bilateral maxillary sinuses are filled with mucus; there is peripheral enhancement which appears to be membranous (as with retention cysts) and a similar appearance in some of the left ethmoid sinus and most of the frontal sinus cavities; this appears to be secondary obstructive inflammatory disease rather than tumor.

The left orbit is unremarkable.

Case Discussion

This is a case of a squamous cell carcinoma. Gross pathologic examination revealed multiple fragments of tan/pink soft tissue. Histopathologic examination revealed a moderately differentiated invasive keratinizing squamous cell carcinoma in the right sinus and orbit.

The patient received an anterior cranial base resection with anterolateral free flap reconstruction. He received induction chemotherapy and received adjuvant radiotherapy. He did well post-operatively without evidence for tumor recurrence for the past several years.

CO-AUTHORS:
Mason Soeder

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