The dilemma of midline destructive lesions: a case series and diagnostic review☆☆☆
Received 1 April 2008 published online 31 March 2009.
Abstract
Background
Midline destructive lesions (MDLs) of the nose are a diagnostic dilemma due to an extensive differential diagnosis and vague presenting signs and symptoms. Etiologies may be neoplastic, autoimmune, traumatic, infectious, or unknown.
Study Design
Case series and review of the literature were done.
Methods
Medical records of 8 patients presenting with an MDL were reviewed.
Results
Each patient received nasal endoscopy, computed tomography scan of the sinuses, laboratory workup, culture (aerobes, anaerobes, fungus, and acid-fast bacilli), and biopsy with flow cytometry. Laboratory tests included complete blood count, basic metabolic panel, erythrocyte sedimentation rate, angiotensin-converting enzyme, antineutrophil antibodies, rheumatoid factor, anti-Ro and anti-La antibodies, Epstein-Barr virus antibodies, coccidiomycosis serology, HIV antibodies, fluorescent treponemal antibody absorption, classic antineutrophil cytoplasmic antibodies, perinuclear antineutrophil cytoplasmic antibody, proteinase 3, and myeloperoxidase. Choice of diagnostic study was individualized for each patient. Two patients were diagnosed with natural killer/T-cell lymphoma, 2 were diagnosed with Wegener's granulomatosis, and 4 remained idiopathic, despite the extensive workup. A diagnostic algorithm to aid in the approach to MDLs is presented.
Conclusions
The diagnosis of MDLs remains difficult but is aided by a systematic approach and familiarity with multiple diagnostic techniques. It is imperative to take multiple tissue specimens from various sites, send them fresh, and communicate suspicion of lymphoma. Despite diagnostic advances and improved understanding of the diseases underlying MDLs, an etiology is often not identified.
aDepartment of Otolaryngology—Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
bDepartment of Otorhinolaryngology, Weill Cornell Medical Center, New York, NY, USA
cDepartment of Otolaryngology—Head and Neck Surgery, Northwestern University, Chicago, IL, USA
Corresponding author. Department of Otolaryngology—Head and Neck Surgery, Northwestern University, 303 East Chicago Avenue, Searle 12-561, Chicago, IL 60611, USA. Tel.: +1 312 695 8182; fax: +1 312 392 6781.
☆ This manuscript was presented as a poster at the Combined Otolaryngologic Sections Meeting, American Rhinologic Society, Orlando, FL, April 2008.
ABSTRACT