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CASE REPORT

Well-differentiated Squamous Cell Carcinoma ofMaxillary SinusVijeev Vasudevan, S Kailasam, MB Radhika, Manjunath Venkatappa, Devaraju Devaiah, TG Shrihari, M Sudhakara

ABSTRACT

Paranasal sinus malignancies are exceedingly rare. Chronicrespiratory tract infections, nasal congestive symptoms andrhinosinusitis are much more prevalent in recent days andmanifest many symptoms that overlap with those of sinusmalignancy. Symptoms may be nonspecific and indolent formonths or even years, leading to delay in diagnosis andconsequent advanced diseased stage at presentation. Themajority of maxillary sinus tumors in the literature have presentedwith advanced stage, resulting in generally poor survivaloutcomes. Hence, it is imperative that maxillofacial stomatologistshould be aware of sinus pathologies, to diagnose early and itshould alert them to include in differential diagnosis.

Keywords: Squamous cell carcinoma, Maxillary sinus, X-raytomography, Diagnosis.

How to cite this article: Vasudevan V, Kailasam S,Radhika MB, Venkatappa M, Devaiah D, Shrihari TG,Sudhakara M. Well-differentiated Squamous Cell Carcinomaof Maxillary Sinus. J Indian Aca Oral Med Radiol 2012;24(3):250-254.

Source of support: Nil

Conflict of interest: None declared

INTRODUCTION

Maxillary sinus cancer is relatively rare neoplasm with anincidence representing a small percentage (0.2%) of humanmalignant tumors and only 1.5% of all head and neckmalignant neoplasms.1 Because of the relative rarity ofcarcinoma of the maxillary sinus, institutional experienceis usually limited. The incidence seems to vary in differentparts of the world, with Asian countries reporting highnumbers of cases.2 Maxillary sinus cancer is very difficultto treat and traditionally have been associated with a poorprognosis. One reason for these poor outcomes is the closeanatomic proximity of the nasal cavity and paranasal sinusesto vital structures, such as the skull base, brain, orbit andcarotid artery. This complex location makes completesurgical resection a challenging and sometimes impossibletask. In addition, these tumors tend to be asymptomatic atearly stages, appearing more frequently at late stages onceextensive local invasion has occurred.

CASE REPORT

A healthy 50-year-old man was referred to our oral medicinedepartment with the chief complaint of pain and swellingof the left maxillary quadrant with nasal discharge. The

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patient had just completed a 5 days course of antibioticsand analgesics for a presumed infection of odontogenicorigin with minimal improvement in his symptoms. Hismedical history revealed a 3 pack/day, cigarette/beediessmoking habit since childhood. He also had a habit of usingnasal snuff. Patient is on treatment for cough and chest painsince 5 years. Patient gave a history of tooth removal formobility 5 days back in same quadrant and ulcer in relationto same post-treatment.

Clinical examination showed a moderately firm softtissue swelling in the area of the left maxillary region; itsmaximum dimension measured 2 cm (Fig. 1A). The lesionwas mildly painful to palpation. Lymph node blocks on theneck did not have any positive sign.

On further questioning, the patient reported slightparesthesia involving the distribution of the left posteriorsuperior alveolar nerves. Ulceroproliferative growthmeasuring around 4 × 4 cm in maximum diameter was notedin relation to 25, 26, 28 region, some purulent drainage wasobtained from the unhealed extraction socket in relation to26, 27 (Fig. 1B). Generalized attrition, cervical abrasionand mobility were noted.

A preliminary panoramic radiograph revealed missing26, 27 and 16 and few decayed teeth and generalizedmoderate to severe periodontal bone loss. A poorly definedopacification was noted in the area of the left maxillarysinus. The floor, roof and posterior and medial walls of theleft maxillary sinus appeared to be destroyed (Fig. 2).

Water’s view showed that the opacification of the leftmaxillary sinus has expanded to involve the entire leftmaxillary sinus. Intraoral extension of this mass was alsoevident. The inferior, posterior, lateral and medial walls ofthe left maxillary sinus and the left orbital floor appear tobe destroyed completely (Fig. 3).

The patient was referred to the radiology department ofa local hospital, where plain computed tomography (CT)was performed. The scan revealed significant destructionof the anterior, posterior, medial and lateral walls of themaxillary sinus as well as of the left orbital floor. Featureswere of carcinoma of left maxillary antrum with invasionin to the left orbit, ethmoid air cells, hard palate, nasal cavityand infratemporal fossa (Figs 4A and B).

In view of paresthesia and growth in the area ofcomplaint, a biopsy of the involved areas was deemed

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Fig. 1A: Extraoral photograph taken clinically. Substantialexpansion is apparent over the area of the left maxillary sinus

Fig. 1B: A sizable intraoral mass is evident in the area of the leftmaxillary buccal sulcus. Extending palatally involving alveolar ridge

Fig. 2: Panoramic radiograph reveals a poorly defined opacificationlocated in the area of the left maxillary sinus. The inferior, posteriorand medial walls of the left maxillary sinus and the left orbital floorall appear to be destroyed

necessary to rule out the possibility of an underlyingmalignant process. Surgical exploration of the area revealedan irregular 1 × 1 cm bony defect filled with granulation-like tissue on the posterior-lateral wall of the left maxillary

sinus. This soft tissue was submitted for histopathologicalexamination.

Microscopic examination of the biopsy specimenrevealed pseudostratified epithelial cells with signs ofdysplasia. Invading the deeper connective tissue in the formof well-differentiated squamous cell carcinoma, showingnumerous keratin pearls (Figs 5A and B).

A diagnosis of well-differentiated squamous cellcarcinoma was reached. The patient was referred to the headand neck surgery department for further treatment andexplained about the surgery, chemotherapy andbrachytherapy. Patient declined of treatment due to poorsocioeconomic background. Patient was advised on forpalliative therapy. Later, the patient succumbed within an8 months time.

DISCUSSION

Maxillary sinus carcinoma presents a diagnostic andtherapeutic challenge to the oral diagnostician, surgeon andas well as the radiation oncologist. The early symptoms aregenerally vague and consistent with benign disorders. Whenthe tumors are small sized, they are misdiagnosed as chronicsinusitis, nasal polyp, lacrimal duct obstruction or evencranial arteritis.3

In general, clinical examination of patients presentingwith pain and swelling of the jaws will reveal lesions ofdental etiology, most commonly related to pulpal orperiodontal pathology. However, when such situation exists,it is mandate that dental practitioner must consider thepossibility of a nonodontogenic etiology. It is often betterto determine first, by clinical and radiographic examination,whether the enlargement originates primarily in bone or inthe extraosseous soft tissue. An infection of odontogenicorigin is the most common cause of a soft tissue swelling ofthe maxillary buccal vestibule. Second, the possibility of amalignant neoplasm of the maxillary antrum, althoughuncommon, should be considered.

In the present patient’s case, extensive dental decay andperiodontal disease (mobility of 26, 27), it would haveinitially felt that this swelling was most likely the result ofan acute dental abscess secondary to pulpal involvement.The previous dentist has extracted the teeth. The associatedsoft tissue swelling was the result of tumor expansionthrough a defect in the posterolateral wall of the leftmaxillary sinus. In 40 to 60% of cases, there are facialasymmetry, oral cavity swelling and tumor extension to thenasal cavity. These lesions extend medially toward the nasalcavity; superiorly they may invade the orbit and ethmoidsinus; anterolaterally, they may reach soft tissues and cheek,and inferiorly, the maxillary sinus floor, dental alveolus and

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Fig. 4A: Axial view CT with soft tissues window. Heterogeneous,expansive lesion, with infiltrative aspect, centered on the leftmaxillary sinus

Fig. 4B: Coronal view CT with osseous window. Expansivelesion of left maxillary sinus with medial and anterolateral wallserosion

Fig. 5A: Low power photomicrograph (10×) showing antralwall lining. The epithelial cells are pseudo stratified with signs ofdysplasia

Fig. 5B: Low power photomicrograph (10×) showing dysplasticepithelium invading the deeper connective tissue in the form ofwell differentiated squamous cell carcinoma showing numerouskeratin pearls

Fig. 3: Water’s view shows the opacification of the left maxillarysinus has expanded to involve the entire left maxillary sinus. Intraoralextension of this mass is also evident. The inferior, posterior, lateraland medial walls of the left maxillary

palate. Posteriorly, they may reach the pterygopalatine fossaand pterygoid muscles. Through the pterygoid fossa, theymay superiorly extend toward the orbital fissure and thecavernous sinus.4

Symptoms that are commonly noted with involvementof the sinonasal complex include maxillary swelling,epistaxsis, nasal obstruction or discharge, diplopia andproptosis. When these classic signs are not present, thepossibility of a malignant tumor may be overlooked.5,6

In the given case, patient had maxillary swelling, nasaldischarge and paresthesia of the involved nerve. Signs thatshould alert the clinician to the possibility of a malignanttumor include paresthesia, radiographic evidence ofirregular bone resorption and localized irregular wideningof the periodontal ligament. Among these, paresthesia is anominous sign. Although paresthesia can be related to nerve

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damage secondary to previous surgical procedures,metabolic disorders or infection, it is mandatory that thepossibility of a malignant neoplasm be ruled out in allpatients presenting with paresthesia.7,8

In the present case, the clinical examination of lymphnodes was not palpable for any positive sign towardmalignancy. This low incidence may be associated with thepoor lymphatic draining of the maxillary sinus or with theclinical inaccessibility for the affected lymph nodesdiagnosis. Lymph node blocks on the neck as an initialpresentation are not frequent, appearing in 3 to 20% of cases.The topographic distribution of lymph node metastasis inthe neck usually is dependent on the tumor site, contiguityand high number of capillaries.9-11 However, invasion ofthe parts with rich lymphatic network, such as the oral cavityand nasopharynx, increases the risk of lymph nodemetastases.

In majority of patients, this cancer is diagnosed inadvanced stages, making it difficult to determine the originof the neoplasm. Although the majority of maxillary sinuscarcinomas are locally advanced at diagnosis because itssymptoms are nonspecific and these tumors tend to remainlocalized to maxilla for a long time and, during evolution,they invade adjacent structures.4,12 The most effectivebarrier against tumors propagation is the integrity of theperiosteum that is particularly more resistant in two criticalareas: The skull base and orbit.13

Destruction of maxillary sinus walls, especially theinferior antral wall, can be identified by panoramicradiography. In advanced cases, this imaging modality maynot show evidence of early bone destruction. CT andmagnetic resonance imaging (MRI) is the examination ofchoice in such situation. The primary reason for advisingCT and MRI studies in cases of maxillary sinus carcinomais for better characterizing the invasion of structures beyondthe site of origin. On CT studies, all of the cases present assoft tissue masses in the maxillary sinus cavity, with 70 to90% of cases evidencing bony destruction. CT providesmore details of bone involvement than MRI. At MRI, thesetumors present middle signal intensity on T1-weightedimages and high intensity signal on T2-weighted images,and this method is of help in the evaluation of the posteriorcranial fossa, orbit and perineural/perivascular dissemi-nation, allowing the differentiation between retainedsecretions and neoplastic tissue.3,14

CT helped us in arriving at preliminary diagnosis, buthistopathological examination of biopsied tissue gave adefinitive diagnosis. However, detailed analysis ofhistological findings is beyond the scope of this article.

When formulating a differential diagnosis for maxillarysinus carcinoma, it is mandate to include primary sinonasal

neoplasms (e.g. sinonasal undifferentiated carcinoma,nasopharyngeal carcinoma, lymphoma, esthesioneuro-blastoma, primary sinonasal melanoma and adenocarcinomaof minor salivary gland origin) and metastatic disease.15

Treating maxillary sinus cancer is challenging because ofthe crowded anatomy, proximity of critical structures, suchas the eye and the brain, which preclude wide surgicalexcision and high-dose radiotherapy. The clinical course isindolent at most and low incidence of malignant diseasehere, which makes a low index of suspicion, the majorityof cancers of antrum are seen in a late or moderatelyadvanced stage at the time of diagnosis. Combined-modalitytherapy consisting of surgery and radiotherapy with orwithout intra-arterial chemotherapy is generally used forthe treatment. Local control is a particularly difficultproblem, with the majority of failures occurring at theprimary site. Radiotherapy is accepted as a palliative methodin inoperable cases.16,17

Ohngren’s line is the theoretical plane joining medialcanthus of the eye with the angle of the mandible. This linedivides the maxilla into the infrastructure and superstructure(Fig. 6). It was originally described by Dr Ohngren in 1930to delineate the limits of resectability of a tumor in themaxillary sinus. Tumors superoposterior to Ohngren’s linewere more likely to involve the orbit, ethmoid andpterygopalatine fossa. Malignancy behind Ohngren’s lineis regarded to carry a much poorer prognosis because of therapid spread to the orbit and middle cranial fossae.18

Maxillary sinus is at cross roads of dentistry andotorhinolaryngology occupying a strategic position, as it isconnected directly to nasal cavity and indirectly to oralcavity and maxillary alveolus. Oral diagnosticians shouldbe aware of the clinical signs and symptoms that might leadone to suspect a malignant tumor might be relativelynonspecific, potentially leading to a delay in diagnosis.Therefore, it is important for the oral diagnostician tomaintain a high index of suspicion to allow for early

Fig. 6: Diagrammatic representation of Ohngren’s line

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recognition and referral of these patients. One should haveeagle’s eye in all cases involving swellings of the head andneck. In the presence of signs, such as pain and swellingwith associated paresthesia, or if conventional therapy failsto resolve the swelling rapidly, prompt referral for biopsyis needed to arrive at definitive diagnosis. It is mandate toadvise advanced imaging techniques, such as CT and MRI,when conventional radiography fails to help in diagnosis atthe early stage of disease.

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ABOUT THE AUTHORS

Vijeev Vasudevan

Professor and Head, Department of Oral Medicine and RadiologyKrishnadevaraya College of Dental Sciences and Hospital, BengaluruKarnataka, India

S Kailasam

Professor and Head, Department of Oral Medicine and RadiologyRagas Dental College and Hospital, Chennai, Tamil Nadu, India

MB Radhika

Professor and Head, Department of Oral Pathology, KrishnadevarayaCollege of Dental Sciences and Hospital, Bengaluru, Karnataka, India

Manjunath Venkatappa (Corresponding Author)

Senior Lecturer, Department of Oral Medicine and RadiologyKrishnadevaraya College of Dental Sciences and Hospital, BengaluruKarnataka, India, e-mail: manjuv79@gmail.com

Devaraju Devaiah

Senior Lecturer, Department of Oral Medicine and RadiologyKrishnadevaraya College of Dental Sciences and Hospital, BengaluruKarnataka, India

TG Shrihari

Senior Lecturer, Department of Oral Medicine and RadiologyKrishnadevaraya College of Dental Sciences and Hospital, BengaluruKarnataka, India

M Sudhakara

Senior Lecturer, Department of Oral Pathology, KrishnadevarayaCollege of Dental Sciences and Hospital, Bengaluru, Karnataka, India