Meningiomas in the Nose & Paranasal Sinuse,s J.
M.
BAKSHI, S.
W.
AHMED, M . CHAKRABORTY
Two cases of extracranial meningiomas arising in nose and paranasal sinuses are reported. Both these cases reported within one year and presented as a growth in the paranasal sinuses and nasal cavity.
lacing bundles of elongated fibroblasts with narrow nuclei are the histological features.
The Meningioma is considered to be the commonest intracranial tumour. Cushing in his series of 1146 intracranial tumours found 12 percent to be meningiomas. Jennet (1970) observed at autopsy that every third intracranial tumour was a meningioma. Extracranial meningiomas are however quite rare. Vakil (1974) mentions that only 10 cases of primary meningiomas of paranasal sinus were reported till 1972. She reported another case of a 10 year old female with a tumour arising irt the left ethmoid and sphenoid sinuses.
Case Reports
These are generally thought of as benign.
Case No. 1--K., 18 years old, wife of a soldier was referred to the E N T department on 24 Nov. 1973 with the history of bulging of the left eye ball and progressive left nasal obstruction of 2 months duration. It was not preceded by or accompanied with local pain, headache, fever or nasal discharge. She had no visual disturbance.
Sheehan 1931, Devine (1947), Hill (1962), Madonia (1962), Narasimha Rao (1964) have reported cases. The primary extracranial meningioma possibly arises from the arachnoid cell rests of the cranial nerve sheaths, or without any connection with a nerve or foraman (Hoye, H o a r and Murray, 1960). According to Belal (1955) these arachnoid cell rests may be pinched off and are left behind during embryonal development. Kjeldsberg and Minckles (1972) believe that the junction relating to meningo-endoneural transitions around the olfactory fillaments are the sites of origin of nasal meningiomas. These tumours are firm pink with lobulated or finely nodular surface on which vessels ramify. Some are gritty with flecks of calcification while a few are rock hard. Whorls of spindle cells around central hyaline material which eventually calcifies forming psammoma bodies or interJ. M. Bakshi. Specialist in Otolaryngology, Military Hospital, Secunderabad. S. W. Ahrned. Specialist in Otolaryngology, Military Hospital, Agra., M. Chakraborty. Additional Adviser in Pathelogy Command Pathology Laboratory Delhi Cantt.
slight limitation of abduction, upwards and downwards movement. The left nasal fossa was filled with a hard swelling which pushed the lateral wall and septum to the right side. There was complete obstruction of the nose. The tumour was covered by normal mucosa, which was smooth and did not bleed to touch. T h e mass was also seen in the left choana. T h e ears and throat showed no abnormality. The routine blood and urine examination reports were within normal limits. The X-ray of the paranasal sinuses showed a radioopaque shadow obliterating the left nasal fossa, pushing the septum to right, there was complete opacity of the left antrum and extension of the opacity to the ethmodial area and the medial half of the left orbit. The left frontal sinus was also hazy. O n 27 Nov. 1973 the left antrum was opened by a Caldwell Luc approach. It was filled with a pale pinkish solid mass which was gritty. A piece was removed for biopsy. There was no appreciable bleeding. The histological diagnosis was 'benign meningioma.'
Fig. 1. Histopathology of tumour in case No. 1 Meningothelial cells are arranged in sheets with fasciculi of spindle cellsin between.
She gave a past history o f a fall from a height of about 5 feet about 4 months back. At that time she had bruised the left side of her face and bled slightly from the left nose. She had completely recovered from the effects of fall before the onset of the proptosis. She had amenorrhoea of 2 months duration. This was her first pregnancy. General and systemic examination showed no abnormality. Local examination revealed that the left eye ball was markedly proptosed (28 mm as compared to 17 m m of the right eye) forward, downward and laterally. The eye examination (including fundus tension and adenexa) were normal. Vision in the left eye was 6f9. There was
Indian Journal of Otolaryngology, Volume 31, No. 3, September, 1979
On 20 Dec. 1973 the removal of the growth was undertaken under G.A. The incision was as for lateral rhinotomy. The bone was gouged to expose the antrum, nasal fossa, ethmoidal region and the left frontal sinus which had been invaded partially only. The tumour was removed piecemeal from the antrum, nasal fossa and the ethmoidal region. T h e medial wall of the left orbit had been pushed outwards by the tumour tissue. The cavity was packed with vaseline ribbon gauze and the wound sutured. The pack was removed after 48 hours and the post-operative recovery was uneventful. The tfistopathological examination of the tumour tissue showed meningothelial cells arranged in sheets with fasciculi of spindle cells in between a benign meningioma (Fig. 1.). 83
NASAL M E N I N G I O M A S - - B A K S H I et al Apparently the tumour was extracranial as there were no neurological signs and there was no radiological evidence of erosion of the base of the skull. A left carotid angiogram was done. It did not reveal any evidence of an intracranial tumour. O n Feb. 1974, a small smooth globular swelling was noticed in the roof of the operated cavity. It was thought to be a recurrence. O n 7 Feb. 1974, under G.A. the area was exposed again by the previous approach. T h e globular mass was dissected off the bony roof and traced back towards to the posterior aspect of the orbit. T h e removal appeared complete, however the dissection could not be carried further posteriorly as the tumour was adjacent to the optic nerve. The recovery was again uneventful. The histopathological report of the removed tissue showed it to be granulation tissue with psammoma bodies in a small area. H e r proptosis however did not improve. T h e patient delivered a normal male child in July 1974. She was again reviewed in Jan. 1975, clinically and radiologieally. There was 11o evidence of recurrence. She was keen on improvement of her proptosis. It was decided to correct the proptosis by removal of the bony medial wall of the orbit, however at surgery again the posterior extension could not be removed as it would have jeopardised her vision. l~ieces of soft tissue removed from superior and posterior portion of orbit however did not reveal any meningioma. T h e patient was reviewed again in Jan. 1976 and showed no evidence of recurrence of tumour. She did not report for review after this date. Case No. 2--S.S., a 25 year old male, was referred to the E N T service in June, 1974, with diminished vision in the left eye for the last 3 months, left sided nasal discharge and left nasal obstruction of one months duration. The visual acuity had been gradually decreasing and at the time of reporting his vision from the left eye had markedly
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diminished. The nasal complaints had started following an attack of common cold. H e had no other complaints. There was no history of previous injury or any other illness. The examination revealed that the left nasal fossa was full of mucopurulent discharge and a pale pink mass was seen in upper part extending into the posterior choana. The left eyeball was prominent. The eye and adenexa were normal
the tumour removed piecemeal, tI was extending behind the orbit and could be cleared only with difficulty. The floor of the orbit was partly eroded and the ethmoidal cells were destroyed. The bleeding was moderate at the time of operation. H e had an uneventful post-operative recovery. His vision started improving following the operation and fifteen days after the operation, he had 6[9 vision in the left eye. On 31st July, 1974, a small granulating mass was visualised high up in the left nasal cavity. I t was removed under G.A. on 8th August, 1974. Histologically it was found to be only granulation tissue and no tumour tissue was found. T h e patient was kept under observation and again reviewed on 20th October, 1974, when no evidence of tumour was observed.
On 26th October, 1974, the patient developed jaundice while in hospital. H e was treated for the same and after recovery was sent on sick leave. Fig. 2. Histopathology of tnmour in case H e was reviewed on 30th April, No. 2. Fasciculi of spindle shaped cells with 1975, when no recurrence was whorling and irregular distribution of men- detected. ingo-thelial cells and vascular proliferation. in appearance, the media were clear and the fundi were normal 9 The movements o f the eye balls were full and free. T h e vision in the left eye was reduced to only finger counting at one metre. 9 Routine examination of blood and urine were within normal limits. The X-rays revealed on opaque left maxillary antrum and haziness of ethmoidal cells on the left side. O n 13th J u n e 1974 the left maxillary antrum was exposed by the Caldwell-luc approach. H a e morrhagic serous fluid from a cyst was removed. Underneath, a firm gritty reddish mass was filling the antrum. A part of ;t was removed and subjecteJ to histopathology, which was reported as a meningioma (Fig. 2). X-ray of the base of skull and left carotid angiography were normal. O n 4th July, 1974, the left maxillary antrum was opened by a lateral rhinotomy approach and
Discussion Two cases of benign meningiomas have been reported. Both these cases reported within one year and presented as growths in the paranasal sinuses and nasal cavity. Both the cases were young adults, one being a male and other a female. Case No. 1 had a history of injury and had shown rapid increase in the symptoms during pregnancy. The presenting symptom in this case was proptosis. In case No. 2 the presenting symptom was blindness. Thus in both cases, the tumour had shown pressure effects on the eye and had affected the orbital wall. The tumour was chiefly occupying the maxillary antrum, had irdiltrated into the ethmoids, and presented into the nasal fossa. The complete removal in both the cases was difficult due to extension of the tumour behind the orbit. Neurological signs were present only in the second case. Apparently, both the cases were primarily extracraniaI meningiomas.
Indian Journal of Otolaryngology, Volume 31, No. 3, September, 1979
NASAL M E N I N G I O M A S - - B A K S H I et al There was complete absence of any features suggestive of an intracranial space occupying lesion. A tumour which had invaded the maxillary antrum, the ethmoids and the orbit should certainly have had some features of an intracranial lesion if it was an extension of the primary intracranial tumour, specially as in both the cases the symptoms were rapidly progressive. References
1. Belal, A. (1955): Meningiomas infiltrating the nasal cavities, nasal sinuses and orbit. Journal of Laryngology and Otology, 69: 59-69. 2, Hill, C. L. (1962): Meningioma of the maxillary sinuses, Archives of Otolaryngology, 76: 547-549.
Radiography had not shown any evidence of erosion of bones in the base of the skull. Angiography also did not reveal any intracranial tumour. Over the period of followup there has been no evidence of activity of any intracranial lesion. It cannot be said with certainty that the tumour has been completely extirpated in both the cases as it was extending behind the orbit. 3. Hoye, S. J., Hoar, C. S. and Murray, J.E. (1960) : Extracranial mengiomas presenting as a tumour of neck. American Journal of Surgery, 100: 486-489. 4. Jennet, W. B. (1970) : An introduction to neurosurgery. William Heinman Medical Books Limited, London, 2nd edition.
Indian Journal of Otolaryngology, Volume 31, No. 3, September, 1979
Histologically the lesions were benign meningiomas. Malignant transformation of such a growth m a y occur after repeated removal. The histiogenesis of the tumour is difficult to assess. Origin from the sheath of cranial nerves can be a possibility, specially in the second case. 5. Kjeldsberg, C. R., Mincldes, J. (1972): Meningiomas presenting as nasal polyp. Cancer, 29: 153-156. 6. Sheehan, I"t. B. (1931): Psammoma in maxillary antrum. Journal of Laryngology and Otology, 46: 117.
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