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Hemangioma of the maxillary sinus
Hemangioma of the maxillary sinus Douglas S. Most, D.D.S., Brunswick,
Maine
Hemangiomas of the maxillary sinus are rare. Hemangiomas of the maxillary sinus with an associated phlebolith have not been previously reported. Severe bleeding can occur upon surgical removal of hemangiomas. (ORAL SURC. ORAL MED. ORAL PATHOL. 60~485-486, 1985)
H
emangiomas are common lesions of the head, neck, and oral cavity. They most often involve the lips, tongue, and buccal mucosa.’ Hemangiomas of the sinuses, however, are rare. A review of the literature revealed only one case of a hemangioma of the maxillary sinus de novo and no case in which there was an associated phlebolith. The case reported by Afshin and Sharmin* of a hemangioma involving the maxillary sinus originated in the alveolar processand invaded the sinus. Afshin and Sharmin also note that hemangiomas “are rare within the oral cavity,” a statement that does not appear to be accurate. Fordham published a case that appears to be of maxillary sinus origin. This case had a radiographic appearance similar to Afshin and Sharmin’s case (that is, radiodensity). Neither case involved a phlebolith. Shklar and Meyer4 reported a series of 694 vascular tumors involving the oral regions. Of these, 354 were classified as hemangiomas. There is no mention of any occurring in the maxillary sinus. Fu and Per& reported 256 casesof nonepithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx. Eighty-five of these were vascular tumors, and only two (an angiomatosis and a malignant hemangioendothelioma) involved the maxillary sinus. Eastman Kodak Company6 published a report of multiple hemangiomas with associated phleboliths. These apparently involved soft tissues only. The article points out that the clinician should consider phleboliths when entertaining a differential diagnosis of calcification of tuberculosis, calcified lymph nodes, or salivary gland stones. No mention is made of the fact that radiographically a phlebolith can appear quite similar to the crown of a tooth.
Fig. 1.
CASEREPORT
A 39-year-old white woman was referred for evaluation of a radiopaque mass within the maxillary sinus. The patient’s chief complaint was “sinus headaches.” The patient reported having had her four third molars extracted several years earlier, without any difficulty or postoperative sequelae. She was not informed of any iatrogenic misfortune. Examination was essentially noncontributory. A complete dentition (except for the four third molars) was noted to be in good repair. No obvious soft-tissue pathosis was present. A panoramic x-ray film (Fig. 1) revealed a radiopacity in the right maxillary sinus. A working differential diagnosis of supernumerary malposed tooth, displaced maxillary right third molar, and odontogenic neoplasm was established. With the patient under general anesthesiain the hospital setting, a full-thickness mucogingival flap was raised in the maxillary right quadrant in preparation for a CaldwellLuc procedure. A No. 6 round bur was used to make a hole
486
Most
Oral Surg. November, 1985
in the sinus above and between the premolars. Upon removal of the drill, profuse bleeding was noted. It was obvious from the tactile senseof the handpiece that tissue within the sinus had been encountered. Direct pressure was of no avail in controlling the hemorrhage. It was decided that the opening should be enlarged in an attempt to control the bleeding. The antral window was enlarged, but by this time more than 1,000 cc of blood had been lost. A large, firm, rubbery mass was encountered. The mass was removed with hemostats and curettes, and the bleeding immediately ceased. A small “toothlike” mass was also curetted out. A sterile petralatum gauze pack was placed into the sinus and a nasal antrostomy was performed. Postoperatively, the patient developed a sinusitis which was eventually treated successfully with erythromycin. It took several days for the hemoglobin level to return to normal. Pathology
report
Gross examination. The specimen consisted of two similar, membranous, soft pieces of mottled light brown tissue, together measuring 3 X 2.5 X 0.8 cm. Microscopic examination. The. surface was covered in part with a respiratory type of epithelium. The stroma contained some mucous and serous glands, and in deeper portions there was a rather sharply circumscribed but not encapsulated lesion composedof congeries of endotheliumlined spacesseparated by fibrocollagenous connective tissue septa. The stroma was infiltrated by some eosinophils and moderate numbers of round cells. The diagnosis was capillary hemangioma.
CONCLUSION
This case report should make every practitioner aware that (1) hemangiomas can occur in the maxillary sinus de novo, (2) a hemangioma with a phlebolith can easily be mistaken for another lesion, and (3) surgical intervention involving hemangiomas can lead to sudden loss of large quantities of blood. REFERENCES 1. Schafer W, Hine M, Levy B: Textbook of oral pathology, ed.
2, Philadelphia, 1963, W.B. Saunders Company, pp. 126127. 2. Afshin H, Sharmin R: Hemangioma involving the maxillary sinus. ORAL SURG ORAL MED ORAL PATHOL 38: 204-208, 1974. 3. Fordham S: Hemangioma of the maxillary sinus. Ear Nose Throat J 157: 33-335, 1978. 4. Shklar G, Meyer I: Vascular tumors of the mouth and jaws. ORAL SURG ORAL MED ORAL PATHOL 19: 335-358, 1965.
5. Fu Y, Perzin K: Non-epithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx: a clinicopathologic studv. Cancer 33: 1275-1288. 1974. 6. Eastman Kodak Company: Dental radiography and photography, Pamphlet M3-206, Rochester, N.Y., 1980. Reprint requests to:
Dr. Douglas S. Most Parkview Professional Building Brunswick, ME 04011
Maine
Hemangiomas of the maxillary sinus are rare. Hemangiomas of the maxillary sinus with an associated phlebolith have not been previously reported. Severe bleeding can occur upon surgical removal of hemangiomas. (ORAL SURC. ORAL MED. ORAL PATHOL. 60~485-486, 1985)
H
emangiomas are common lesions of the head, neck, and oral cavity. They most often involve the lips, tongue, and buccal mucosa.’ Hemangiomas of the sinuses, however, are rare. A review of the literature revealed only one case of a hemangioma of the maxillary sinus de novo and no case in which there was an associated phlebolith. The case reported by Afshin and Sharmin* of a hemangioma involving the maxillary sinus originated in the alveolar processand invaded the sinus. Afshin and Sharmin also note that hemangiomas “are rare within the oral cavity,” a statement that does not appear to be accurate. Fordham published a case that appears to be of maxillary sinus origin. This case had a radiographic appearance similar to Afshin and Sharmin’s case (that is, radiodensity). Neither case involved a phlebolith. Shklar and Meyer4 reported a series of 694 vascular tumors involving the oral regions. Of these, 354 were classified as hemangiomas. There is no mention of any occurring in the maxillary sinus. Fu and Per& reported 256 casesof nonepithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx. Eighty-five of these were vascular tumors, and only two (an angiomatosis and a malignant hemangioendothelioma) involved the maxillary sinus. Eastman Kodak Company6 published a report of multiple hemangiomas with associated phleboliths. These apparently involved soft tissues only. The article points out that the clinician should consider phleboliths when entertaining a differential diagnosis of calcification of tuberculosis, calcified lymph nodes, or salivary gland stones. No mention is made of the fact that radiographically a phlebolith can appear quite similar to the crown of a tooth.
Fig. 1.
CASEREPORT
A 39-year-old white woman was referred for evaluation of a radiopaque mass within the maxillary sinus. The patient’s chief complaint was “sinus headaches.” The patient reported having had her four third molars extracted several years earlier, without any difficulty or postoperative sequelae. She was not informed of any iatrogenic misfortune. Examination was essentially noncontributory. A complete dentition (except for the four third molars) was noted to be in good repair. No obvious soft-tissue pathosis was present. A panoramic x-ray film (Fig. 1) revealed a radiopacity in the right maxillary sinus. A working differential diagnosis of supernumerary malposed tooth, displaced maxillary right third molar, and odontogenic neoplasm was established. With the patient under general anesthesiain the hospital setting, a full-thickness mucogingival flap was raised in the maxillary right quadrant in preparation for a CaldwellLuc procedure. A No. 6 round bur was used to make a hole
486
Most
Oral Surg. November, 1985
in the sinus above and between the premolars. Upon removal of the drill, profuse bleeding was noted. It was obvious from the tactile senseof the handpiece that tissue within the sinus had been encountered. Direct pressure was of no avail in controlling the hemorrhage. It was decided that the opening should be enlarged in an attempt to control the bleeding. The antral window was enlarged, but by this time more than 1,000 cc of blood had been lost. A large, firm, rubbery mass was encountered. The mass was removed with hemostats and curettes, and the bleeding immediately ceased. A small “toothlike” mass was also curetted out. A sterile petralatum gauze pack was placed into the sinus and a nasal antrostomy was performed. Postoperatively, the patient developed a sinusitis which was eventually treated successfully with erythromycin. It took several days for the hemoglobin level to return to normal. Pathology
report
Gross examination. The specimen consisted of two similar, membranous, soft pieces of mottled light brown tissue, together measuring 3 X 2.5 X 0.8 cm. Microscopic examination. The. surface was covered in part with a respiratory type of epithelium. The stroma contained some mucous and serous glands, and in deeper portions there was a rather sharply circumscribed but not encapsulated lesion composedof congeries of endotheliumlined spacesseparated by fibrocollagenous connective tissue septa. The stroma was infiltrated by some eosinophils and moderate numbers of round cells. The diagnosis was capillary hemangioma.
CONCLUSION
This case report should make every practitioner aware that (1) hemangiomas can occur in the maxillary sinus de novo, (2) a hemangioma with a phlebolith can easily be mistaken for another lesion, and (3) surgical intervention involving hemangiomas can lead to sudden loss of large quantities of blood. REFERENCES 1. Schafer W, Hine M, Levy B: Textbook of oral pathology, ed.
2, Philadelphia, 1963, W.B. Saunders Company, pp. 126127. 2. Afshin H, Sharmin R: Hemangioma involving the maxillary sinus. ORAL SURG ORAL MED ORAL PATHOL 38: 204-208, 1974. 3. Fordham S: Hemangioma of the maxillary sinus. Ear Nose Throat J 157: 33-335, 1978. 4. Shklar G, Meyer I: Vascular tumors of the mouth and jaws. ORAL SURG ORAL MED ORAL PATHOL 19: 335-358, 1965.
5. Fu Y, Perzin K: Non-epithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx: a clinicopathologic studv. Cancer 33: 1275-1288. 1974. 6. Eastman Kodak Company: Dental radiography and photography, Pamphlet M3-206, Rochester, N.Y., 1980. Reprint requests to:
Dr. Douglas S. Most Parkview Professional Building Brunswick, ME 04011