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Metastatic thyroid carcinoma of the mandible: Case report
1314
METASTATIC
THYROID
CARCINOMA
J Oral Maxillofac Surg 47:1314-1316. 1989
Metastatic Thyroid Carcinoma of the Mandible: Case Report MICHAEL A. KAHN, DDS,* AND PAUL T. McCORD, DDSt Metastatic thyroid carcinoma to the jaws is a rare event. Several large case series have estimated the incidence at l%, lW3which may be slightly low due to limitations of postmortem protocols and inadequate autopsy examinations. Overall, this carcinoma affects females more frequently, especially after the fourth decade of life (36%).4 Statistical analyses of case series and reports reveal that breast, lung, and kidney are most often the primary origin of metastasis to the oral environs (50% to 60%)5; the thyroid gland as the primary site (5% to 6%) compares with the gastrointestinal tract, prostate, and liver.* In recent years there has been a paucity of reports concerning cases of thyroid carcinoma metastasizing to the jaws. The following case report of follicular thyroid carcinoma is presented to review the clinicopathologic characteristics of the lesion so the practitioner will include it in an appropriate differential diagnosis. Report
of a Case
In December 1985, an oral surgeon saw a nonambulatory 82-year-old white woman with a painful, livercolored, mandibular vestibular swelling adjacent to a mobile tooth No. 22. The clinical impression was a dental abscess, and a periapical radiograph showed pararadicular alveolar destruction without a definite inferior border. Due to the patient’s nonambulatory status, it was difficult to obtain more diagnostic periapical films, and a panoramic radiograph was not possible. A review of the patient’s medical history revealed a long, incomplete history of thyroid disease. In 1954, she
* Assistant Professor, Department of Biologic and Diagnostic Sciences, University of Tennessee, College of Dentistry, Memphis, Tennessee. t In private practice, Cleveland, Tennessee. Address correspondence and reprint requests to Dr Kahn: Department of Biologic and Diagnostic Sciences, University of Tennessee, College of Dentistry, 875 Union Ave, Memphis, TN 38163. 0 1989 geons
American
Association
0278-2391/89/4712-0022$3.00/O
of Oral
and
Maxillofacial
Sur-
had undergone a thyroidectomy due to the presence of an unspecified tumor. In April 1958, a mediastinal tumor of unknown nature was excised, and 5% years later hyperthyroidism was diagnosed. Twenty-two years later, in February 1980, the patient developed a metastatic focus of thyroid carcinoma in the tibia. At that time an attempted needle biopsy of the tibia resulted in profuse bleeding. After microscopic review of the resected tissue, the presence of metastatic thyroid carcinoma was confirmed. Subsequently, between 1980 and 1985, metastases to the lungs and pelvis occurred. Medical complications included cardiovascular disease, atria1 fibrillation, and congestive heart failure. Throughout this period, the patient remained mentally alert. The patient was admitted to the hospital on December 18, 1985, for aspiration of the mandibular swelling in anticipation of an incision and drainage procedure. Aspiration resulted in 30 mL of a foamy, bloody fluid; the resultant bleeding was controlled with gentle pressure. Because of the patient’s medical history and symptoms, the tentative diagnosis was metastatic thyroid carcinoma. The following day, a computerized tomographic (CT) scan showed a large lesion of the anterior mandible (Fig 1). During the next 9 days, commencing January 8, 1986, the patient received a cumulative direct-beam dose of 20 Gy. Unfortunately, the mass did not reduce, but rather appeared to expand further superiorly into the oral cavity, and the patient reported an increase in pain. On January 22, therapeutic radioactive iodine (13’1) was administered. The mass continued to increase in size, becoming more painful, and the patient’s oral intake decreased accordingly. A new CT scan revealed only a small, intact inferior medial plate of the mandible, near the genial tubercles. The patient was scheduled on March 5 for a resection of the mass, which now extended from the mandibular left midbody to the right symphysis and parasymphysis. Due to the patient’s poor health, it was decided to remove the lesion before expected loss of continuity of the inferior mandibular border. The dark brown, hemorrhagicappearing mass was excised, and the bony crypt was debrided with mastoid bone burs. Partial closure was achieved, and the wound was packed with iodoform gauze. Total blood loss was 800 mL. The patient experienced postoperative congestive heart failure and was discharged after 14 days. At 5-day intervals, the surgical packing was changed by the oral surgeon in the patient’s home. This routine continued until granulation tissue developed, at which time the patient and her family irrigated the area until the defect healed. One and one-half years
KAHN
1315
AND McCORD
pattern and containing a single, indistinct, central nucleolus. The granular cytoplasm was faintly acidophilic, with indistinct borders. Mitotic figures were infrequent, and cellular pleomorphism was lacking. In addition, a focus of tumor cells had a more papillary configuration. Numerous, small endothelial-lined channels were interspersed among the cells. Occasional areas of focal sclerosis were also seen. An overlay of chronic cellular inflammatory infiltrate, composed primarily of lymphocytes and plasma cells, was located in the superficial lamina propria. Based on these histological findings, a diagnosis of follicular thyroid carcinoma was rendered.
Discussion This case report illustrates many clinicopathologic aspects of metastatic thyroid carcinoma to the craniofacial
FIGURE 1. Initial CT scan of the patient shows a large lesion of the anterior mandible with extensive involvement of soft and hard tissues.
later, the patient died from cardiovascular failure. There had been no recurrence of the carcinoma, and the patient’s oral intake in the interim had been excellent. MICROSCOPIC
PATHOLOGY
Review of a routine hematoxylin-eosin-stained microscopic slide of the excised lesion showed a wedge of mucosa focally surfaced by hyperplastic, stratified squamous epithelium exhibiting mild exocytosis. The lamina propria consisted of dense fibrous connective tissue largely replaced by a uniform population of cells distributed in solid nests and cords (Fig 2). The nests and cords contained numerous, small, abortive follicles, usually lacking a luminal content and lined by a single layer of cuboidal cells. The cells were composed of basophilic oval nuclei with a stippled, evenly distributed, chromatin
FIGURE 2. Photomicrograph of the metastatic thyroid carcinoma in the mandible containing numerous follicles, some of which contain eosinophilic material in their lumen. Note the lack of mitotic figures and significant cellular pleomorphism. (Hematoxylin-eosin stain. Original magnification, X 160.)
complex,
specifically
the jaws. Elderly
women are most often affected, commonly after having a long-standing nontoxic goiter or other conditions causing an enlarged and nodular thyroid.637 Due to the patient’s incomplete medical history, one can only speculate on her original thyroid condition. Thyroid carcinoma metastasizes most commonly to the lungs and bone,4,6 as illustrated in this patient. The hematogenous
route is most often
in-
volved, either by way of the systemic circulation or occasionally through the paravertebral plexus (Batson’s) of veins.2*8 Lymphatic spread, although less common, is also seen. If multiple metastatic foci result, as in this case, the hematogenous route is much more likely. Tovi et al9 have reported a similar case exhibiting multiple bony metastases. The mandible rather than the maxilla is the usual metastatic site, owing to its much higher incidence of retained embryonic red bone marrow.’ Symptoms usually include pain, swelling, and loosening of teeth, as experienced by this patient. In addition, failure of an extraction site to heal, bleeding, trismus, and ulceration are possible symptoms.2’5’10 Clinicians should be aware of a mandibular metastasis mimicking an inflammatory condition such as periodontitis, periapical lesions, osteomyelitis, or pericoronitis. When a patient has had thyroid carcinoma, a clinician’s index of suspicion should be raised sufficiently to suspect a metastatic focus. Occasionally, radiographic survey will aid in the differential diagnosis. Metastatic thyroid carcinomas are generally osteolytic, possessing an irregular, indistinct scalloped margin. An altered trabeculation pattern also may be seen. Unfortunately, the patient’s nonambulatory status precluded traditional radiographic surveys of diagnostic quality. However, an additional important mode of diagnostic imaging, the CT scan, which can be used on the
1316
recumbent patient, was available. The CT scan illustrated the aggressive, expansile nature of the lesion manifested in cortical bone erosion and extensive soft tissue involvement. The follicular variant of thyroid carcinoma is the most frequently involved histologic type in metastatic cases.’ However, Markitziu et al’ recently reported a case of papillary thyroid carcinoma metastatic to the parotid gland and mandibular ramus. It is rare for a particular case to be composed entirely of one histological type.6 For example, this case had one focus reminiscent of the papillary variant. A range of differentiation may be seen-at one extreme, solid abortive follicles, whereas at the other, neoplastic tissues virtually identical in appearance to normal-functioning thyroid gland. The histologic appearance in this case most closely resembled a less-differentiated form because its follicles were immature and frequently lacking colloid. Investigators have maintained that poor differentiation correlates with a more aggressive clinical course.’ Quite typically, even in an aggressiveacting disease, as seen here, infrequent mitosis and a lack of significant cellular pleomorphism exist. The most significant histologic aspect of this case was the high degree of vascularity. Other investigators have commented on this characteristic,6~8,9~ii~1z and several metastatic lesions have been clinically misdiagnosed as arteriovenous malformations.6*891’ If the clinician suspects a vascular tumor after auscultation or angiography, an embolization procedure should be considered before surgery. The differential diagnosis of irregular mandibular radiolucencies may include other entities besides arteriovenous malformations and dental inflammatory conditions. With the appropriate medical and dental history, a primary oral soft tissue malignancy with osseous invasion should be considered, as well as a possible second primary malignant mandibular lesion. A benign cyst or tumor of the mandible, such as ameloblastoma, should also be ruled out.8 However, if a history of a thyroid lesion can be determined, the increased likelihood of a thyroid metastasis must be considered. The growth rate of a thyroid carcinoma may be very slow, and the metastatic presence in the bone or lung may be undetected or remain dormant for long periods. The patient described here exemplified this by experiencing a time span of 32 years between her initial thyroidectomy for an unknown lesion and the jaw metastasis.
METASTATIC
THYROID
CARCINOMA
Therapy for the metastatic site generally consists of surgical resection and either radioactive iodine (1311) or external-beam radiation. Long-term prognosis is poor, with an average of 40% of patients alive 4 years after the diagnosis of metastasis.6 Although follicular thyroid carcinoma is generally most responsive to radioactive iodine, results can be inconsistent, as illustrated in this case. This case report of metastatic follicular thyroid carcinoma to the mandible illustrates the frequent, highly vascular nature of the lesion and the long time span possible between initial thyroid disease and the appearance of a metastatic focus. It emphasizes that with the appropriate medical history a radiolucent lesion of the mandible mimicking an inflammatory dental condition or vascular entity may be an undiagnosed metastatic focus of thyroid carcinoma. Although this is a rare occurrence, the clinician’s index of suspicion must remain high to the possibility that one is dealing with a metastatic thyroid carcinoma until it is proven otherwise. References 1. Batsakis JG: Tumors of the Head and Neck: Clinical and Pathological Considerations (ed 2). Baltimore, MD, William & Wilkins. 1979. D 240 2. Meyer I, Shklar G: Malignam tumors metastatic to mouth and jaws. Oral Surg 20:350, 1965 3. Bhaskar SN: Synopsis of Oral Pathology (ed 7). St Louis, Mosby, 1986, p 356 4. Nagamine Y, Suzuki J, Katakura R, et al: Skull metastasis of thyroid carcinoma: Study of 12 cases. J Neurosurg 63:526, 1985 5. Clausen F, Poulsen H: Metastatic carcinoma to the jaws. Acta Path01 Microbial Immunol Stand 57:361, 1963 6. Meissner WA, Warren S: Tumors of the thyroid gland, in Firminger HI (ed): Atlas of Tumor Pathology, Second Series, Fascicle 4. Washington, DC, Armed Forces Institute of Pathology, 1968, p 84 7. Markitziu A, Fisher D, Marmary Y: Thyroid papillary carcinoma presenting as jaw and parotid gland metastases. Int J Oral Maxillofac Surg 15648, 1986 8. Parichatikanond P, Parichatikanond P, Damrongvadha P, et al: Jaw metastasis from follicular carcinoma of thyroid gland simulating ameloblastoma. J Med Assoc Thai 67:362, 1984 9. Tovi F, Leiberman A, Hirsch M: Uncommon clinical manifestations in a case of thyroid carcinoma. Head Neck Surg 61974, 1984 10. Castigliano SG, Rominger CJ: Metastatic malignancy of the jaws. Am J Surg 87:4%, 1954 11. Ripp GA, Wendth AJ, Vitale P: Metastatic thyroid carcinoma of the mandible mimicking an arteriovenous malformation. J Oral Surg 35:743, 1977 12. Renner GJ, Davis WE, Templer JW: Metastasis of thyroid carcinoma to the paranasal sinuses. Otolaryngol Head Neck Surg 92:233, 1984
METASTATIC
THYROID
CARCINOMA
J Oral Maxillofac Surg 47:1314-1316. 1989
Metastatic Thyroid Carcinoma of the Mandible: Case Report MICHAEL A. KAHN, DDS,* AND PAUL T. McCORD, DDSt Metastatic thyroid carcinoma to the jaws is a rare event. Several large case series have estimated the incidence at l%, lW3which may be slightly low due to limitations of postmortem protocols and inadequate autopsy examinations. Overall, this carcinoma affects females more frequently, especially after the fourth decade of life (36%).4 Statistical analyses of case series and reports reveal that breast, lung, and kidney are most often the primary origin of metastasis to the oral environs (50% to 60%)5; the thyroid gland as the primary site (5% to 6%) compares with the gastrointestinal tract, prostate, and liver.* In recent years there has been a paucity of reports concerning cases of thyroid carcinoma metastasizing to the jaws. The following case report of follicular thyroid carcinoma is presented to review the clinicopathologic characteristics of the lesion so the practitioner will include it in an appropriate differential diagnosis. Report
of a Case
In December 1985, an oral surgeon saw a nonambulatory 82-year-old white woman with a painful, livercolored, mandibular vestibular swelling adjacent to a mobile tooth No. 22. The clinical impression was a dental abscess, and a periapical radiograph showed pararadicular alveolar destruction without a definite inferior border. Due to the patient’s nonambulatory status, it was difficult to obtain more diagnostic periapical films, and a panoramic radiograph was not possible. A review of the patient’s medical history revealed a long, incomplete history of thyroid disease. In 1954, she
* Assistant Professor, Department of Biologic and Diagnostic Sciences, University of Tennessee, College of Dentistry, Memphis, Tennessee. t In private practice, Cleveland, Tennessee. Address correspondence and reprint requests to Dr Kahn: Department of Biologic and Diagnostic Sciences, University of Tennessee, College of Dentistry, 875 Union Ave, Memphis, TN 38163. 0 1989 geons
American
Association
0278-2391/89/4712-0022$3.00/O
of Oral
and
Maxillofacial
Sur-
had undergone a thyroidectomy due to the presence of an unspecified tumor. In April 1958, a mediastinal tumor of unknown nature was excised, and 5% years later hyperthyroidism was diagnosed. Twenty-two years later, in February 1980, the patient developed a metastatic focus of thyroid carcinoma in the tibia. At that time an attempted needle biopsy of the tibia resulted in profuse bleeding. After microscopic review of the resected tissue, the presence of metastatic thyroid carcinoma was confirmed. Subsequently, between 1980 and 1985, metastases to the lungs and pelvis occurred. Medical complications included cardiovascular disease, atria1 fibrillation, and congestive heart failure. Throughout this period, the patient remained mentally alert. The patient was admitted to the hospital on December 18, 1985, for aspiration of the mandibular swelling in anticipation of an incision and drainage procedure. Aspiration resulted in 30 mL of a foamy, bloody fluid; the resultant bleeding was controlled with gentle pressure. Because of the patient’s medical history and symptoms, the tentative diagnosis was metastatic thyroid carcinoma. The following day, a computerized tomographic (CT) scan showed a large lesion of the anterior mandible (Fig 1). During the next 9 days, commencing January 8, 1986, the patient received a cumulative direct-beam dose of 20 Gy. Unfortunately, the mass did not reduce, but rather appeared to expand further superiorly into the oral cavity, and the patient reported an increase in pain. On January 22, therapeutic radioactive iodine (13’1) was administered. The mass continued to increase in size, becoming more painful, and the patient’s oral intake decreased accordingly. A new CT scan revealed only a small, intact inferior medial plate of the mandible, near the genial tubercles. The patient was scheduled on March 5 for a resection of the mass, which now extended from the mandibular left midbody to the right symphysis and parasymphysis. Due to the patient’s poor health, it was decided to remove the lesion before expected loss of continuity of the inferior mandibular border. The dark brown, hemorrhagicappearing mass was excised, and the bony crypt was debrided with mastoid bone burs. Partial closure was achieved, and the wound was packed with iodoform gauze. Total blood loss was 800 mL. The patient experienced postoperative congestive heart failure and was discharged after 14 days. At 5-day intervals, the surgical packing was changed by the oral surgeon in the patient’s home. This routine continued until granulation tissue developed, at which time the patient and her family irrigated the area until the defect healed. One and one-half years
KAHN
1315
AND McCORD
pattern and containing a single, indistinct, central nucleolus. The granular cytoplasm was faintly acidophilic, with indistinct borders. Mitotic figures were infrequent, and cellular pleomorphism was lacking. In addition, a focus of tumor cells had a more papillary configuration. Numerous, small endothelial-lined channels were interspersed among the cells. Occasional areas of focal sclerosis were also seen. An overlay of chronic cellular inflammatory infiltrate, composed primarily of lymphocytes and plasma cells, was located in the superficial lamina propria. Based on these histological findings, a diagnosis of follicular thyroid carcinoma was rendered.
Discussion This case report illustrates many clinicopathologic aspects of metastatic thyroid carcinoma to the craniofacial
FIGURE 1. Initial CT scan of the patient shows a large lesion of the anterior mandible with extensive involvement of soft and hard tissues.
later, the patient died from cardiovascular failure. There had been no recurrence of the carcinoma, and the patient’s oral intake in the interim had been excellent. MICROSCOPIC
PATHOLOGY
Review of a routine hematoxylin-eosin-stained microscopic slide of the excised lesion showed a wedge of mucosa focally surfaced by hyperplastic, stratified squamous epithelium exhibiting mild exocytosis. The lamina propria consisted of dense fibrous connective tissue largely replaced by a uniform population of cells distributed in solid nests and cords (Fig 2). The nests and cords contained numerous, small, abortive follicles, usually lacking a luminal content and lined by a single layer of cuboidal cells. The cells were composed of basophilic oval nuclei with a stippled, evenly distributed, chromatin
FIGURE 2. Photomicrograph of the metastatic thyroid carcinoma in the mandible containing numerous follicles, some of which contain eosinophilic material in their lumen. Note the lack of mitotic figures and significant cellular pleomorphism. (Hematoxylin-eosin stain. Original magnification, X 160.)
complex,
specifically
the jaws. Elderly
women are most often affected, commonly after having a long-standing nontoxic goiter or other conditions causing an enlarged and nodular thyroid.637 Due to the patient’s incomplete medical history, one can only speculate on her original thyroid condition. Thyroid carcinoma metastasizes most commonly to the lungs and bone,4,6 as illustrated in this patient. The hematogenous
route is most often
in-
volved, either by way of the systemic circulation or occasionally through the paravertebral plexus (Batson’s) of veins.2*8 Lymphatic spread, although less common, is also seen. If multiple metastatic foci result, as in this case, the hematogenous route is much more likely. Tovi et al9 have reported a similar case exhibiting multiple bony metastases. The mandible rather than the maxilla is the usual metastatic site, owing to its much higher incidence of retained embryonic red bone marrow.’ Symptoms usually include pain, swelling, and loosening of teeth, as experienced by this patient. In addition, failure of an extraction site to heal, bleeding, trismus, and ulceration are possible symptoms.2’5’10 Clinicians should be aware of a mandibular metastasis mimicking an inflammatory condition such as periodontitis, periapical lesions, osteomyelitis, or pericoronitis. When a patient has had thyroid carcinoma, a clinician’s index of suspicion should be raised sufficiently to suspect a metastatic focus. Occasionally, radiographic survey will aid in the differential diagnosis. Metastatic thyroid carcinomas are generally osteolytic, possessing an irregular, indistinct scalloped margin. An altered trabeculation pattern also may be seen. Unfortunately, the patient’s nonambulatory status precluded traditional radiographic surveys of diagnostic quality. However, an additional important mode of diagnostic imaging, the CT scan, which can be used on the
1316
recumbent patient, was available. The CT scan illustrated the aggressive, expansile nature of the lesion manifested in cortical bone erosion and extensive soft tissue involvement. The follicular variant of thyroid carcinoma is the most frequently involved histologic type in metastatic cases.’ However, Markitziu et al’ recently reported a case of papillary thyroid carcinoma metastatic to the parotid gland and mandibular ramus. It is rare for a particular case to be composed entirely of one histological type.6 For example, this case had one focus reminiscent of the papillary variant. A range of differentiation may be seen-at one extreme, solid abortive follicles, whereas at the other, neoplastic tissues virtually identical in appearance to normal-functioning thyroid gland. The histologic appearance in this case most closely resembled a less-differentiated form because its follicles were immature and frequently lacking colloid. Investigators have maintained that poor differentiation correlates with a more aggressive clinical course.’ Quite typically, even in an aggressiveacting disease, as seen here, infrequent mitosis and a lack of significant cellular pleomorphism exist. The most significant histologic aspect of this case was the high degree of vascularity. Other investigators have commented on this characteristic,6~8,9~ii~1z and several metastatic lesions have been clinically misdiagnosed as arteriovenous malformations.6*891’ If the clinician suspects a vascular tumor after auscultation or angiography, an embolization procedure should be considered before surgery. The differential diagnosis of irregular mandibular radiolucencies may include other entities besides arteriovenous malformations and dental inflammatory conditions. With the appropriate medical and dental history, a primary oral soft tissue malignancy with osseous invasion should be considered, as well as a possible second primary malignant mandibular lesion. A benign cyst or tumor of the mandible, such as ameloblastoma, should also be ruled out.8 However, if a history of a thyroid lesion can be determined, the increased likelihood of a thyroid metastasis must be considered. The growth rate of a thyroid carcinoma may be very slow, and the metastatic presence in the bone or lung may be undetected or remain dormant for long periods. The patient described here exemplified this by experiencing a time span of 32 years between her initial thyroidectomy for an unknown lesion and the jaw metastasis.
METASTATIC
THYROID
CARCINOMA
Therapy for the metastatic site generally consists of surgical resection and either radioactive iodine (1311) or external-beam radiation. Long-term prognosis is poor, with an average of 40% of patients alive 4 years after the diagnosis of metastasis.6 Although follicular thyroid carcinoma is generally most responsive to radioactive iodine, results can be inconsistent, as illustrated in this case. This case report of metastatic follicular thyroid carcinoma to the mandible illustrates the frequent, highly vascular nature of the lesion and the long time span possible between initial thyroid disease and the appearance of a metastatic focus. It emphasizes that with the appropriate medical history a radiolucent lesion of the mandible mimicking an inflammatory dental condition or vascular entity may be an undiagnosed metastatic focus of thyroid carcinoma. Although this is a rare occurrence, the clinician’s index of suspicion must remain high to the possibility that one is dealing with a metastatic thyroid carcinoma until it is proven otherwise. References 1. Batsakis JG: Tumors of the Head and Neck: Clinical and Pathological Considerations (ed 2). Baltimore, MD, William & Wilkins. 1979. D 240 2. Meyer I, Shklar G: Malignam tumors metastatic to mouth and jaws. Oral Surg 20:350, 1965 3. Bhaskar SN: Synopsis of Oral Pathology (ed 7). St Louis, Mosby, 1986, p 356 4. Nagamine Y, Suzuki J, Katakura R, et al: Skull metastasis of thyroid carcinoma: Study of 12 cases. J Neurosurg 63:526, 1985 5. Clausen F, Poulsen H: Metastatic carcinoma to the jaws. Acta Path01 Microbial Immunol Stand 57:361, 1963 6. Meissner WA, Warren S: Tumors of the thyroid gland, in Firminger HI (ed): Atlas of Tumor Pathology, Second Series, Fascicle 4. Washington, DC, Armed Forces Institute of Pathology, 1968, p 84 7. Markitziu A, Fisher D, Marmary Y: Thyroid papillary carcinoma presenting as jaw and parotid gland metastases. Int J Oral Maxillofac Surg 15648, 1986 8. Parichatikanond P, Parichatikanond P, Damrongvadha P, et al: Jaw metastasis from follicular carcinoma of thyroid gland simulating ameloblastoma. J Med Assoc Thai 67:362, 1984 9. Tovi F, Leiberman A, Hirsch M: Uncommon clinical manifestations in a case of thyroid carcinoma. Head Neck Surg 61974, 1984 10. Castigliano SG, Rominger CJ: Metastatic malignancy of the jaws. Am J Surg 87:4%, 1954 11. Ripp GA, Wendth AJ, Vitale P: Metastatic thyroid carcinoma of the mandible mimicking an arteriovenous malformation. J Oral Surg 35:743, 1977 12. Renner GJ, Davis WE, Templer JW: Metastasis of thyroid carcinoma to the paranasal sinuses. Otolaryngol Head Neck Surg 92:233, 1984