Clinico-Pathologic Conference: Case 3

Abstract

A 17-year old male was referred to the otolaryngology clinic with a history of nasal obstruction for 3 years. Physical examination uncovered mild asymmetry and proptosis of the left eye; palpation revealed softness of the posterior left hard palate and anterior maxilla, with no erosion. Nasal endoscopy, using a 4 mm, 30-degree sinus telescope, revealed complete obstruction of both nostrils.Computed tomography (CT) without contrast revealed a nearly 6 cm sharply marginated unilocular expansile radiolucent lesion appearing to arise from the left maxillary alveolar ridge. The lesion eroded the apices of teeth and extended from tooth #13 through unerupted tooth #16. It expanded into the left maxillary sinus and left nasal cavity and elevated the left orbital floor, with a thinned but intact eggshell-like margin. No definite calcifications were evident within the lesion on CT (Fig. 1a, b, c, d). Differential DiagnosisThe radiological features were interpreted to be consistent with a slowly growing lesion rather than an aggressive process. The pathology was thought to arise from either a traumatic, infectious, nonneoplastic or neoplastic process. Within the neoplastic category, benign, locally aggressive or low-grade malignant lesions were considered.The epicenter of the lesion was thought to originate, in order of decreasing likelihood, from the maxillary sinus, the maxilla or the nose or, least likely, to represent a metastasis or to be of intracranial origin. When evaluating an origin from the maxillary sinus or nasal cavity several conditions were included in the differential diagnosis.