Benign sinonasal disease mimicking malignant neoplasm of the nose

OtolaryngologyHead and Neck Surgery Volume 121 Number 2

patient underwent an extended right radical neck dissection with resection of the common, internal, and external carotid arteries and preservation of the vagus and hypoglossal nerves. Results: Intraoperative EEG recordings were unchanged before and after clamping, suggesting that performing the bypass graft under carotid occlusion would not result in neurologic injury. A common-to-internal carotid saphenous vein bypass graft was placed to minimize the risk of late emboli from the stump of the internal carotid. After surgery, the patient developed immediate right lower facial weakness, hoarseness from a paretic right true vocal cord, and ipsilateral deviation of the tongue. Trigeminal, abducens, vestibularcochlear, and glossopharyngeal nerve functions were preserved. The contralateral cranial nerve, motor function, and sensation remained intact. MRI revealed a massive brain stem infarct with adequate perfusion through the graft. Pontomedullary ischemia was unexpected as the facial, vagus, and hypoglossal nuclei are perfused by branches of the basilar artery, whose flow was never interrupted. Conclusion: Despite progressive neural recovery, the patient developed intracranial metastases and died 5 months later. These deficits were consistent with either multiple isolated right brain stem infarcts that selectively affected the nuclei or tracts of VII, X, and XII or an ipsilateral central VII nerve paralysis with peripheral X and XII involvement. 143

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were absent. Ectopic bone marrow was identified in the middle ear cavity. This marrow protruded from the bone posterior to the EAC. The cochlea had 2.5 turns and a well-developed organ of Corti. The spiral ganglion was normal. However, there were 2 wide communications in the vestibule. One communication was located between the utricle and saccule, and the other was observed between the utricle and the lateral semicircular canal (LSCC) ampulla. The LSCC was hypoplastic, with a diameter of 2 mm. The vestibular aqueduct and endolymphatic sac (ES) were enlarged. The epithelial surface of ES was also abnormal in that no rugae were present. In the left ear, we were unable to evaluate the lateral part of the middle ear because it was damaged severely during removal. However, it was noted that the tympanic and mastoid portions of the FN were displaced laterally, and the STM was absent. The inner ear was similar to that in the right ear. Conclusions: Isotretinoin is still prescribed to many young women after a single pregnancy test is performed. Although the patients are warned that isotretinoin is teratogenic, continued administration during an undetected pregnancy is a distinct, unavoidable possibility. Thus, otologists should be prepared to encounter ear anomalies and associated clinical symptoms in patients with this syndrome. 144

Benign Sinonasal Disease Mimicking Malignant Neoplasm of the Nose

KEN ISHIJIMA MD; ISAMU SANDO MD DMEDSC; Pittsburgh PA

DEBORSHI ROY MD; AHMED M S SOL/MAN MD; AIJAZ ALVI MD FACS; Philadelphia PA

Objectives: Vitamin A and its derivatives are very efficacious against persistent cystic acne but are also known teratogens, which may cause systemic congenital anomalies. There are relatively few reports of anomalies of the ear after prenatal ingestion of isotretinoin, a vitamin A derivative. Jahn et al clino ically described patients with auricular malformation due to isotretinoin. Schuknecht was the first to describe the histopathological changes in a single case of middle and inner ear malformations in isotretinoin syndrome. We describe our histopathologic observations in a second case of this syndrome. Methods: A white boy was born to a mother who had been treated with isotretinoin (Accutane) for acne during early pregnancy. There was no familial history of heredity disease. Clinically, he had aural anomalies. The patient died of cardiac arrest at the age of 4 years. The temporal bone specimens were fixed and sectioned horizontally at 20 ktm. Every tenth section was stained with hematoxylin and eosin and mounted for light microscopic study. Results: In the right ear, multiple anomalies were observed in the external, middle, and inner ear. The external auditory canal (EAC) was narrow. The ossictes had anomalous shapes. The facial nerve (FN) was hypoplastic and was displaced laterally. The chorda tympani nerve and stapedius muscle (STM)

Objectives: Bony destruction of the skull base and facial bones is a hallmark of malignant lesions of the nose and paranasal sinuses. However, the differential diagnosis must always include benign sinonasal diseases as well as systemic illnesses that may affect the nose. In this series, 3 patients presented with signs and symptoms of invasive nasal disease. Extensive workup, including imaging studies, laboratory testing, and intraoperative biopsies, revealed benign disease processes. Methods: Chart review and follow-up of 3 patients who presented to our otolaryngology clinic with various sinonasal complaints, including congestion, obstruction, facial pain and pressure, and rhinorrhea. All 3 patients underwent nasal endoscopy in the office, CT and/or MRI, laboratory tests, and intraoperative examination with biopsy. Results: Initial evaluation and radiologic evaluation of all 3 patients indicated the presence of unilateral sinonasal disease with bony destruction and skull base erosion. A presumptive diagnosis of malignant neoplastic disease was made in all 3 cases. However, surgical pathology revealed a benign diagnosis in all 3 cases. One patient had extensive sinonasal polyposis, another had cocaine-induced granulomatous disease, and the other had Wegener's granulomatosis.

Multiple Temporal Bone Anomalies in Isotretinoin Syndrome

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OtolaryngologyHead and NeckSurgery

August 1999

Scientific Posters

Conclusion: Although the index of suspicion for malignancy is high for most patients with locally invasive and/or destructive sinonasal disease, benign disease processes of the nose as well as systemic illnesses must be a part of the differential diagnosis. When clinically indicated, appropriate imaging and laboratory testing should be employed to avoid false diagnosis and improper therapy. 145

Confocal Reflectance Microscopy: A Noninvasive Imaging System for the Detection of Oral Precancer W MATTHEW WHITE BS; NIKOS S SOUKOS DDS PHD; MILIND RAJADHYAKSHA PHD; R ROX ANDERSON MD; RICHARD L FABIAN MD; Boston MA

Objectives: This study tests the hypothesis that confocal reflectance microscopy (CRM) can be a simple, safe, and highly acceptable diagnostic test, which may enable the clinician to detect oral precancer earlier and more accurately than currently possible with routine screening. Using this device, we characterized the microscopic anatomy of oral lesions in vivo. Methods: 111CRM, back-scattered light from unstained living tissue is detected. The images are in gray scale of horizontal (en face) planes and show morphologic detail that is similar to that seen with routine histology. CRM produces subcellular-level resolution images of epithelial and subepithelial layers to a depth of 0.5 ram. The images are in real time such that dynamic events (eg, blood flow) can be visualized and digitally recorded. Confocal reflectance images of normal and pathologic oral epithelium were obtained from 10 patients (7 with leukoplakia and 3 with lichen planus). A biopsy was obtained at the same site of imaging for histopathologic correlation. Results: Confocal images revealed epithelial changes suggestive of premalignancy; specifically, epithelial thickening and increased nuclear pleomorphism and density were visualized in the confocal images. Infiltration of the lamina propria by inflammatory cells and liquefaction of the basal layer were evident in patients with oral lichen planus. Conclusion: This imaging modality appears promising for the delineation of microscopic features that signal the progression of oral premalignancy to cancer. 146

A Novel Approach for Repair of Craniofacial Defects GARTH T OLSON ME); BRENDAN C STACKJR MD; Safnt Louis MO

Objective: We present a method for craniofacial reconstruction using recently released bioahsorbable and osteoconductive materials. Background." Different methods of craniofacial reconstruc-

tion have been described that suffer from reliance upon alloplastic materials. Although biocompatible, these materials are still foreign bodies and may become infected or extrude over time. The development of implantable bioceramics and absorbable fixation devices has allowed for the possibility for craniofacial reconstruction using materials that will be ultimately replaced by bony ingrowth. Methods: The use of absorbable plates or hydroxyapatite cement in craniofacial reconstruction has been reported, but use of these 2 methods in combination has not. We present a case involving a patient who underwent cranial reconstruction with a metal reconstruction plate 38 years prior to presentation with frontal cellulitis and a drainage tract to the skin. The plate was removed, and the forehead defect was eventually reconstructed with Synthes absorbable mesh and Synthes CRS calcium phosphate bone cement. Results." Comparison of before and after photographs demonstrates excellent cosmesis and skull contour. There was no evidence of recurrence of infection or extrusion. This choice of materials for reconstruction is advantageous due the resorbable properties of the mesh and the osteoconductive properties of the calcium hydroxide matrix. We were able to repair a large skull defect (40 cm 2) with this method. Conclusion: Large defects of the skull may be safely repaired with a combination of materials that resorb over time and allow for osteoblast ingrowth and matrix remodeling of the implanted material. The reconstruction method we describe reduces reliance on permanent implants, which may tend to extrude or become infected. 147

Management of Cranial Defects after Frontal Osteoplastic Flap BRIAN RUBINSTEINMD; E BRADLEYSTRONG MD; Elk Grove CA; Sacramento CA

Objectives: Osteoplastic flap/frontal sinus obliteration remains the gold standard for definitive treatment of chronic frontal sinusitis. A cosmetic deformity (embossment) at the osteotomy site occurs in approximately 10% of patients. Bone resorption at the osteotomy site results in a visible linear depression of the skin. We report a clinical case and present a new technique for correction of embossment associated with the frontal osteoplastic flap. Methods: A patient underwent a frontal osteoblastic flap procedure. One year after surgery he was noted to have significant embossment at the osteetomy site. Surgical correction of the deformity involved a bicoronal flap, followed by removal of the fibrous tissue and neocortex from the previous osteotomy site. A cutting burr was used to harvest bone pate from a more cephalic portion of the frontal bone. The bony