The dilemma of midline destructive lesions: a case series and diagnostic review

Parker, Noah P.; Pearlman, Aaron N.; Conley, David B.; Kern, Robert C.; Chandra, Rakesh K.

doi:10.1016/j.amjoto.2008.11.010

« Previous Next »American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Volume 31, Issue 2 , Pages 104-109, March 2010

The dilemma of midline destructive lesions: a case series and diagnostic review☆☆☆

Noah P. Parker, MD
- Department of Otolaryngology—Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
Aaron N. Pearlman, MD
- Department of Otorhinolaryngology, Weill Cornell Medical Center, New York, NY, USA
David B. Conley, MD
- Department of Otolaryngology—Head and Neck Surgery, Northwestern University, Chicago, IL, USA
Robert C. Kern, MD
- Department of Otolaryngology—Head and Neck Surgery, Northwestern University, Chicago, IL, USA
Rakesh K. Chandra, MD
- Department 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.

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.