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8 Benign Neoplasms and Tumor-Like Lesions Roberto Maroldi, Marco Berlucchi, Davide Farina, Davide Tomenzoli, Andrea Borghesi, and Luca Pianta

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8 Benign Neoplasms and Tumor-Like Lesions Roberto Maroldi, Marco Berlucchi, Davide Farina, Davide Tomenzoli, Andrea Borghesi, and Luca Pianta Benign Neoplasms and Tumor-Like Lesions 107 8 Benign Neoplasms and Tumor-Like Lesions Roberto Maroldi, Marco Berlucchi, Davide Farina, Davide Tomenzoli, Andrea Borghesi, and Luca Pianta CONTENTS 8.6.6 Follow-Up 131 8.7 Juvenile Angiofi broma 131 8.1 Osteoma 107 8.7.1 Defi nition, Epidemiology, Pattern of Growth 131 8.1.1 Defi nition, Epidemiology, Pattern of Growth 107 8.7.2 Clinical and Endoscopic Findings 132 8.1.2 Clinical and Endoscopic Findings 108 8.7.3 Treatment Guidelines 132 8.1.3 Treatment Guidelines 108 8.7.4 Key Information to Be Provided by Imaging 133 8.1.4 Key Information to Be Provided by Imaging 109 8.7.5 Imaging Findings 133 8.1.5 Imaging Findings 109 8.7.6 Follow-Up 141 8.1.6 Follow-Up 110 8.8 Pyogenic Granuloma 8.2 Fibrous Dysplasia and Ossifying Fibroma 110 (Lobular Capillary Hemangioma) 145 8.2.1 Defi nition, Epidemiology, Pattern of Growth 110 8.8.1 Defi nition, Epidemiology, Pattern of Growth 145 8.2.2 Clinical and Endoscopic Findings 111 8.8.2 Treatment Guidelines 145 8.2.3 Treatment Guidelines 112 8.8.3 Key Information to Be Provided by Imaging 146 8.2.4 Key Information to Be Provided by Imaging 112 8.8.4 Imaging Findings 146 8.2.5 Imaging Findings 112 8.9 Unusual Benign Lesions 147 8.2.6 Follow-Up 114 8.9.1 Pleomorphic Adenoma (Mixed Tumor) 147 8.3 Aneurysmal Bone Cyst 114 8.9.2 Schwannoma 149 8.3.1 Defi nition, Epidemiology, Pattern of Growth 114 8.9.3 Leiomyoma 150 8.3.2 Clinical and Endoscopic Findings 115 8.9.4 Paraganglioma 151 8.3.3 Treatment Guidelines 115 References 152 8.3.4 Key Information to Be Provided by Imaging 115 8.3.5 Imaging Findings 115 8.3.6 Follow-Up 116 8.4 Sinonasal Mucocele 117 8.4.1 Defi nition, Epidemiology, Pattern of Growth 117 8.1 8.4.2 Clinical and Endoscopic Findings 117 Osteoma 8.4.3 Treatment Guidelines 117 8.4.4 Key Information to Be Provided by Imaging 118 8.4.5 Imaging Findings 118 8.1.1 8.4.6 Follow-Up 121 Defi nition, Epidemiology, Pattern of Growth 8.5 Abnormal Sinus Pneumatization 121 8.5.1 Defi nition and Epidemiology 121 Osteoma is a benign, slow-growing osteoblastic tu- 8.5.2 Pathogenesis 121 mor, more commonly located in the outer table of the 8.5.3 Clinical and Endoscopic Findings 121 8.5.4 Treatment Guidelines 122 calvarium, the mandible, the paranasal sinuses, and 8.5.5 Key Information to Be Provided by Imaging 122 occasionally in tubular bones (Samy and Mostafa 8.5.6 Imaging Findings 122 1971; Kransdorf et al. 1991; Sayan et al. 2002). 8.6 Inverted Papilloma and Other It is the most frequent benign tumor of the nose Schneiderian Papillomas 122 and sinonasal, since being found in 1% of patients 8.6.1 Defi nition, Epidemiology, Pattern of Growth 122 8.6.2 Clinical and Endoscopic Findings 124 who undergo plain sinus radiographs and in 3% of 8.6.3 Treatment Guidelines 125 CT examinations obtained for sinonasal symptoms 8.6.4 Key Information to Be Provided by Imaging 126 (Earwaker 1993). Osteoma usually presents between 8.6.5 Imaging Findings 126 the third and sixth decade of life, with a male pre- dominance of 1.5–2.6:1 (Metha and Grewal 1963; R. Maroldi, Professor, MD; D. Farina, MD; A. Borghesi, MD Atallah and Jay 1981). About 80% of osteomas oc- Department of Radiology University of Brescia, Piazzale cur in the frontal sinus, while ethmoid and maxillary Spedali Civili 1, Brescia, 25123, Italy Earwaker M. Berlucchi, MD; D. Tomenzoli, MD; L. Pianta, MD sinus are affected in about 20% of cases ( Department of Otorhinolaryngology University of Brescia, 1993). Isolated cases of sphenoid osteoma have been Piazzale Spedali Civili 1, Brescia, 25123, Italy observed (Fu and Perzin 1974). 108 R. Maroldi et al. Histologically, osteomas are divided into three Signs and symptoms of orbital or lacrymal pathway categories: (1) the ivory or “eburnated” osteoma is involvement (i.e., proptosis or exophthalmos, chemo- composed of hard, dense bone, lacking a haversian sis, diplopia, orbital pain, epiphora, decreased visual system and containing only a minimal amount of acuity, and even transient blindness) may be observed fi brous tissue; (2) the osteoma spongiosum (mature in large size lesions. Intracranial extension may be as- osteoma) contains more trabecular tissue and often sociated with complications such as CSF leak, menin- marrow component. It is surrounded by mature can- gitis, brain abscess, pneumocephalus, seizures, hemi- cellous bone with small haversian systems; (3) the paresis, and bitemporal quadrantanopsia (Bartlett mixed osteoma contains both aspects of ivory and 1971; Hartwidge and Va r m a 1984; Huneidi and mature subtypes (Fu and Perzin 1974). Afshar 1989; Rappaport and Attia 1994). The etiology of the lesion is still unknown and In most cases, endoscopic evaluation of patients with speculative. Three main hypotheses have been osteoma is completely negative, the tumor being located proposed: (1) the embryologic theory, which pos- inside a paranasal sinus. Displacement of nasal struc- tulates that osteoma arises at the junction be- tures, such as the middle turbinate or the medial maxil- tween the embryonic cartilaginous ethmoid and lary wall in case of an ethmoid or maxillary osteoma, the membranous frontal bones, does not explain respectively, may be observed. Direct visualization of the large number of osteomas located far from the the tumor is infrequent, occurring in large osteomas fronto-ethmoid junction; (2) the traumatic theory occupying the nasal fossa: the lesion appears as a fi rm identifies a previous trauma as the possible patho- mass covered by normal or atrophic mucosa. genetic event; (3) the infective theory is related to the concomitant observation of osteoma and rhi- nosinusitis in about 30% of patients. Other theo- 8.1.3 ries consider osteomas osteodysplastic lesions, Treatment Guidelines osteogenic hamartomas, embryonic bone rests, or as the result of sinus polyp ossification (Namdar Treatment of asymptomatic osteomas is controver- et al. 1998). sial: some authors suggest tumor removal regard- Osteomas can occur in conjunction with Gardner’s less of size, whereas others recommend a “wait and syndrome, which is characterized by the association see” policy with serial CT scan controls (Savic and of osteomas with intestinal polyposis and multiple Djeric 1990; Brodish et al. 1999). soft tissue tumors, such as dermoid cysts and fi bro- Namdar et al. (1998) suggested the following mas (Atallah and Jay 1981). guidelines for treatment: in case of associated nasal Osteomas of the paranasal sinuses are often as- obstruction or rhinosinusitis, medical therapy with ymptomatic and may be serendipitously detected on antibiotics, decongestants, and steroids may be appro- routine radiologic examinations. Furthermore, tu- priate. Whenever medical therapy fails because of tu- mor growth is slow and occasionally characterized by mor location, the lesion is adjacent to frontal sinus os- a tendency to displace and compress the surround- tium or more than 50% of the frontal sinus is occupied, ing structures (about 10% of cases). Intracranial and or a noticeable increase in size has been documented intraorbital extent of sinus osteomas may occur as a by serial CT scans, surgery is recommended. Finally, late event (Rappaport and Attia 1994; Namdar et chronic headache may be an indication for surgery al. 1998; Huang et al. 2001). when other causes are excluded. Removal of the lesion may alternatively require a microendoscopic procedure or an external approach, 8.1.2 in relation to tumor location, volume, and extension. Clinical and Endoscopic Findings Schick et al. (2001) precisely defi ned the limits and the indications for a microendoscopic removal: while Frontal headache or facial pain, depending on tumor most ethmoid osteomas can be resected endonasally, location, are the most frequently reported symptoms. frontal osteomas are considered to be accessible Pain is presumably due to pressure caused by tumor whenever located medial to a virtual sagittal plane expansion, to an acute or chronic sinusitis secondary upward prolonging the lamina papyracea and origi- to sinus ostium blockage, or to a secondary mucocele nating from the inferior aspect of the posterior fron- (Lieberman and Tovi 1984; Manaka et al. 1998). tal sinus wall. Microendoscopic removal of frontal Nasal obstruction and mucopurulent rhinorrhea are sinus osteomas can be achieved through Draf’s type rarely present. II or III frontal sinusotomy. Benign Neoplasms and Tumor-Like Lesions 109 Tumor extension beyond the paranasal sinuses, on CT scans – of a radiodense mass occupying the or large osteomas which can not be entirely exposed frontal sinus (more commonly) or, less frequently, the through the nose must be removed via an external ethmoid or maxillary sinus (Gillman et al. 1997). approach (Smith and Calcaterra 1989; Namdar According to the amount of mineralized bone within et al. 1998; Brodish et al. 1999; Schick et al. 2001). the lesion, osteomas may exhibit very high density, Osteoplastic frontal sinusotomy (with or without fat resembling cortical bone, or a gradually decreasing obliteration), with a coronal or uni-/bilateral brow X-ray opacity/density to a “ground-glass” pattern incision, allows direct access to the frontal sinus and (Fig. 8.1). All different patterns can be found at once removal of osteomas with anterior and/or posterior in the same lesion (Som and Brandwein 1996). No wall involvement. Craniofacial resection has been enhancement is to be expected; nonetheless, contrast described for the removal of giant fronto-ethmoid administration is normally unnecessary to obtain a osteomas with intracranial complications (Blitzer diagnosis.
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