Abstract
Diagnosis of maxillary sinus pathologies is challenging. Herewith we describe the clinicopathological features in isolated maxillary sinus lesions in tertiary care hospital in Goa, India. The retrospective study included patients treated between 2017 and 2022, of all age groups and gender, who underwent either a biopsy or surgery, providing a histopathological diagnosis. Of the 117 pathologies, 88 (75.2%) were non-neoplastic. The overall frequency of pathologies were polyp in 40.2%, fungal lesions (18.8%), malignancy (13.7%), chronic rhinosinusitis (11.9%) and inverted papilloma (10.3%). There were 71 men (60.7%) and 46 women (39.3%). There were 10 patients (8.5%) below 20 years of age, of which 8 patients (80%) had non-neoplastic pathology. Common comorbidities were diabetes and hypertension, while symptoms were nasal blockage (75.2%), nasal discharge (47%) and ocular redness (16.2%). Each pathology was evaluated for demography, side of lesion, comorbidity, and symptoms. Most isolated maxillary sinus pathologies were benign lesions. However, a strong clinical suspicion and histopathological confirmation is needed for all lesions in all age groups due to a risk of malignancy.
Keywords: Inverted papilloma, Nasal polyps, Nasal block, Epistaxis, Endoscopic sinus surgery, Ocular redness
Introduction
Maxillary sinus is the largest of all the four pairs of paranasal sinuses [1, 2]. Its volume in adults ranges from 5 to 20 ml [3], with its adult dimensions being height of 36 mm, width of 27 mm and depth of 39 mm [4]. The large size of the sinus allows the lesions to grow to a significant size before the symptoms manifest [5].
The maxillary sinus is present at birth [4]. Thus, the pathologies can affect any age group [5].
The sinus is also commonly involved in pathology [2, 6] presenting a variety of diseases [5–7]. Broadly the diseases can be categorized into neoplastic and non-neoplastic.
Non neoplastic diseases include non-specific infections, specific infections like fungal sinusitis, mucosal cyst, polyp and mucocoeles. Rarer conditions have been reported including infection by actinomycosis [8], concomitant infection of aspergillosis and actinomycosis [9], cholesteatoma [10, 11], organized haematoma, antrolithiasis, etc. Sinusitis remains the most common diagnosis [2, 12]. The sinus occupies a dependent position and inflammatory secretions from frontal and anterior ethmoid sinuses can drain into the maxillary sinus. This, combined with a mucociliary drainage that works against gravity, and anatomic variations in ethmoidal infundibulum, acute inflammation of the sinus may persist and turn chronic without proper treatment [1].
The neoplastic pathology could be benign or malignant. Benign neoplastic diseases can occur as papillomas, fibroosseous lesions, odontogenic tumours, amongst various others [2, 5]. Eighty percent of the malignancies are squamous cell carcinomas, other examples being adenocarcinomas, adenoid cystic carcinomas or sarcomas [3] including the rare forms like low-grade fibromyxoid sarcoma [13] and Ewing’s sarcoma [14, 15]. Sinus malignancies form less than 1% (0.2–0.8%) of all malignancies and only 3% amongst other upper aerodigestive tract neoplasms [16].
Acute and chronic nonspecific sinusitis are diagnosed clinically, but may require other diagnostic aids if symptoms recur, tend to persist [2] or a complication is suspected. Many of the other sinus lesions however, mimic symptoms similar to rhinosinusitis [5, 16]. A high index of suspicion should be maintained and investigate early [7]. Despite availability of excellent tools to aid the clinical examination like nasal endoscopy and radiological investigations, especially Computed Tomography (CT) scan, diagnosis of maxillary sinus lesions still remain a challenge. The nasal endoscopy is widely available and well tolerated by patients but is limited by its inability to visualize sinus interior as the ostium frequently remains hidden by the uncinate process [1, 3]. Most commonly used imaging to delineate pathology is CT scan but most lesions show similar radiopacity features. Only some lesions can be diagnosed based on characteristic CT findings [5]. Histopathological study helps determine the final diagnosis in most situations [7, 12].
Although commonly involved in pathology and despite being the most accessible sinus, diagnostic dilemmas remain and the sinus is an area of frequent revision endoscopic sinus surgery [4]. Understanding the pathologies prevalent in a given population and their clinical presentation could help initiate a better response to diagnosis and treatment [2].
This study aims to describe the clinical and pathological features in patients with maxillary sinus lesions in a tertiary care centre in the state of Goa, India.
Materials and Methods
The study was conducted retrospectively in the Department of Otorhinolaryngology, Goa Medical College and Hospital in Goa, India. The approval of Institutional Ethics Committee was obtained to collect data of patients with maxillary sinus pathologies treated between year 2017–2022 at the hospital.
Patient of any age and gender who underwent either a biopsy or definitive surgical treatment at our hospital, providing us with a histopathological diagnosis were included in the study.
Following patients were excluded:
Patients with involvement of other sinuses, wherein there was ambiguity regarding sinus of origin.
Recurrence of disease in a patient already enrolled in the study.
Mucormycosis of maxilla during Delta wave of the COVID 19 pandemic. Isolated alveolar process involvement was observed. However, since the pandemic was an exclusive event, these patients were excluded to prevent confounding.
Patients’ medical records were incomplete.
A total of 115 patients satisfied the criteria and were included in the study. Two patients presented with a dual pathology, one patient had a polyp on one side and chronic sinusitis in the other maxilla. The second patient had a mucocoele and inverted papilloma in the same sinus. These were considered as separate pathologies for evaluation, whereas patients with bilateral disease of same pathology were considered as a single unit. Thus, a total of 117 pathologies of maxilla were evaluated. Details regarding age, gender, comorbidities, symptoms with their duration and side of lesion were recorded in Microsoft Excel worksheet. Examination findings including endoscopic evaluation, radiological features, suspected clinical diagnosis and operative findings were noted. The final diagnosis as per histopathological report was documented.
Frequencies, percentages, and averages were used to evaluate the variables under study using Microsoft Excel worksheet and SPSS software.
Results and Analysis
Of the 117 maxillary sinus pathologies (see Table 1), 88 (75.2%) were non-neoplastic (NN) while 29 (24.78%) were neoplastic (NP). Thus, non-neoplastic pathologies were 3 times more common. Amongst the 88 non-neoplastic pathologies, polyps (53.4%) formed the dominant group and included antrochoanal polyps (ACP), polyps limited to the sinus or reaching nasal cavity. There were 17 ACPs, 2 in < 20 year age group, 8 in 20–50 year age group and 7 ACPs in those above 50 years. Polyp was followed by, in decreasing order of frequency, chronic rhinosinusitis (CRS, 15.9%), fungal ball (12.5%) and allergic fungal rhinosinusitis (AFRS, 10.2%). Odontogenic focus of infection was observed in 3 out of 14 patients of CRS and 1 patient had developed maxillary sinus osteomyelitis. Of the 29 neoplasms, 16 (55.2%) were malignant while 13 (44.8%) were benign (12 inverted papilloma, 1 osteoma). The malignancies included 10 cases of squamous cell carcinoma (SCC, 62.5% of all malignancies).
Table 1.
Distribution of Maxillary sinus pathologies
| Pathology nonneoplastic (NN) | Total number | % of 117 | % of NN |
|---|---|---|---|
| Polyp | 47 | 40.2 | 53.4 |
| CRS | 14 | 11.9 | 15.9 |
| Fungal ball | 11 | 9.4 | 12.5 |
| AFRS | 9 | 7.7 | 10.2 |
| Mucocoele | 2 | 1.7 | 2.3 |
| Chronic FS | 2 | 1.7 | 2.3 |
| Pyocoele | 1 | 0.9 | 1.1 |
| Dentigerous Cyst | 1 | 0.9 | 1.1 |
| Osteomyelitis | 1 | 0.9 | 1.1 |
| Total NN | 88 | 75.2 |
| Pathology neoplastic (NP) | % of NP | ||
|---|---|---|---|
| Inverted papilloma | 12 | 10.3 | 41.4 |
| SCC | 10 | 8.5 | 34.5 |
| Osteosarcoma | 1 | 0.9 | 3.4 |
| Adenocarcinoma | 1 | 0.9 | 3.4 |
| Adenoid cystic CA | 1 | 0.9 | 3.4 |
| Malignant melanoma | 1 | 0.9 | 3.4 |
| Adamantinoma | 1 | 0.9 | 3.4 |
| Mets from RCC | 1 | 0.9 | 3.4 |
| Osteoma | 1 | 0.9 | 3.4 |
| Total NP | 29 | 24.78 | |
| Total pathology | 117 |
Bold shows distinctly the final values
The pathologies were distributed among 71 men (60.7%) and 46 women (39.3%) (Table 2).
Table 2.
Gender and side distribution of pathologies
| Pathology nonneoplastic (NN) | Total number | Gender | Side | |||
|---|---|---|---|---|---|---|
| Male | Female | Right | Left | Bilateral | ||
| Polyp | 47 | 23 (48.9%) | 24 (51.1%) | 18 (38.3%) | 27 (57.4%) | 2 (4.3%) |
| CRS | 14 | 8 (57.1%) | 6 (42.9%) | 7 (50%) | 7 (50%) | 0 |
| Fungal ball | 11 | 9 (81.8%) | 2 (18.2%) | 4 | 5 | 2 |
| AFRS | 9 | 7 | 2 | 7 | 2 | 0 |
| Mucocoele | 2 | 2 | 0 | 0 | 2 | 0 |
| Chronic FS | 2 | 1 | 1 | 1 | 1 | 0 |
| Pyocoele | 1 | 1 | 0 | 0 | 1 | 0 |
| Dentigerous cyst | 1 | 1 | 0 | 1 | 0 | 0 |
| Osteomyelitis | 1 | 1 | 0 | 0 | 1 | 0 |
| Total NN | 88 | 53 (60.22%) | 35 (39.8%) | 38 (43.2%) | 46 (52.3%) | 4 (4.5%) |
| Pathology neoplastic (NP) | Total number | Gender | Side | |||
|---|---|---|---|---|---|---|
| Male | Female | Right | Left | Bilateral | ||
| Inverted papilloma | 12 | 10 (83.3%) | 2 (16.7%) | 8 (66.7%) | 4 (33.3%) | |
| SCC | 10 | 4 (40%) | 6 (60%) | 8 (80%) | 2 (20%) | |
| Osteosarcoma | 1 | 1 | 0 | 0 | 1 | |
| Adenocarcinoma | 1 | 0 | 1 | 1 | 0 | |
| Adenoid cystic CA | 1 | 0 | 1 | 0 | 1 | |
| Malignant melanoma | 1 | 1 | 0 | 0 | 1 | |
| Adamantinoma | 1 | 1 | 0 | 0 | 1 | |
| Mets from RCC | 1 | 0 | 1 | 0 | 1 | |
| Osteoma | 1 | 1 | 0 | 1 | 0 | |
| Total NP | 29 | 18 (62.1%) | 11 (37.9%) | 18 (62.1%) | 11 (37.9%) | 0 |
| Total NN + NP | 117 | 71 (60.7%) | 46 (39.3%) | 56 (47.9%) | 57 (48.7%) | 4 (3.4%) |
Bold shows distinctly the final values
The distribution of right-sided (47.9%) and left-sided (48.7%) lesions was similar overall (Table 2). While 57.4% of the polyps had left-sided lesion, 77.8% of fungal balls, 66.7% of inverted papilloma (IP) and 80% of SCC had a right-sided lesion. Of the 4 cases of bilateral disease, 2 were ACPs and 2 were bilateral fungal balls.
The age of the patients ranged from 5 to 79 years (mean 45.79). The 5 year old patient had antrochoanal polyp whereas the 79 year old patient had a mucocoele. The distribution of different pathologies in each age group is given in Table 3. Most neoplasms (83.3%) were malignant in 20–50 year age group. Of the 4 SCCs in this age group, 2 were females, aged 34 years (misdiagnosed as polyp) and 35 years, both without comorbidities. A 32 year old pregnant female in third trimester presented with cheek swelling and nasal block and was diagnosed as adenoid cystic carcinoma. She underwent left total maxillectomy within a month of childbirth.
Table 3.
Age and comorbidity distribution
| Pathology nonneoplastic (NN) | Total number | Age | DM | HT | IHD | Others | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| < 20 yrs | 20–50 yrs | > 50 yrs | 20–50 yrs | > 50 yrs | 20–50 yrs | > 50 yrs | > 50 yrs | > 50 yrs | ||
| Polyp | 47 | 7 (14.9%) | 29 (61.7%) | 11 (23.4%) | 3 | 8 | 2 | 5 | 2 | BA |
| CRS | 14 | 0 | 11 (78.6%) | 3 (21.4%) | 4 | 1 | 5 | 2 | ||
| Fungal ball | 11 | 1 (9.1%) | 3 (27.3%) | 7 (63.6%) | 4 | 5 | 1 | COPD/CVA/PTB, ALD | ||
| AFRS | 9 | 0 | 3 | 6 | 3 | 6 | HBsAg + | |||
| Mucocoele | 2 | 0 | 0 | 2 | 2 | 2 | 1 | |||
| Chronic FS | 2 | 0 | 0 | 2 | 1 | 2 | 1 | NALD | ||
| Pyocoele | 1 | 0 | 0 | 1 | ||||||
| Dentigerous cyst | 1 | 0 | 0 | 1 | 1 | 1 | ||||
| Osteomyelitis | 1 | 0 | 1 | 0 | 1 | |||||
| Total NN | 88 | 8 (9.1%) | 47 (53.4%) | 33 (37.5%) | 5 | 20 | 7 | 23 | 5 | 5 |
| Pathology neoplastic (NP) | < 20 yrs | 20–50 yrs | > 50 yrs | 20–50 yrs | > 50 yrs | 20–50 yrs | > 50 yrs | > 50 yrs | > 50 yrs | |
|---|---|---|---|---|---|---|---|---|---|---|
| Inverted papilloma | 12 | 1 (8.3%) | 1 (8.3%) | 10 (83.3%) | 0 | 4 | 0 | 5 | ||
| SCC | 10 | 0 | 4 (40%) | 6 (60%) | 2 | 3 | 1 | 2 | ||
| Osteosarcoma | 1 | 1 | 0 | 0 | ||||||
| Adenocarcinoma | 1 | 0 | 0 | 1 | ||||||
| Adenoid cystic CA | 1 | 0 | 1 | 0 | ||||||
| Malignant melanoma | 1 | 0 | 0 | 1 | ||||||
| Adamantinoma | 1 | 0 | 0 | 1 | ||||||
| Mets from RCC | 1 | 0 | 0 | 1 | ||||||
| Osteoma | 1 | 0 | 0 | 1 | ||||||
| Total NP | 29 | 2 (6.9%) | 6 (20.7%) | 21 (72.4%) | 2 | 7 | 1 | 7 | 0 | 0 |
| Total NN + NP | 117 | 10 (8.6%) | 53 (45.3%) | 54 (46.2%) | 7 | 27 | 8 | 30 | 5 | 5 |
Bold shows distinctly the final values
No patient below 20 years had a comorbidity.
Amongst non-neoplastic lesions (Table 3), patients in 20–50 year group had a lower frequency of diabetes mellitus (DM, 5/47, 10.6%) and hypertension (HT, 7/47, 14.9%). In those above 50 years, 60.6% had DM and 69.7% had HT.
Within neoplasms, 40% IP had DM while 50% had HT. These comorbidities in IP were observed only in those above 50 years. Half the SCC patients in both age groups had DM, but HT was lower.
Other comorbidities were seen only in those above 50 years. This included 5 lesions with ischaemic heart disease (IHD), 1 polyp with bronchial asthma (BA), 1 fungal ball with chronic obstructive pulmonary disease (COPD), cerebrovascular accident (CVA) and pulmonary tuberculosis (PTB), 1 alcoholic liver disease (ALD) with bilateral fungal balls, Hepatitis B positivity in AFRS and a female chronic invasive fungal sinusitis (CIFS) patient with non-alcoholic liver disease (NALD).
Table 4 summarizes the most common symptoms and their duration before surgical intervention. There were 5 lesions with epistaxis (5/117, 4.3%) and included 2 IP, 1 SCC, 1 polyp, and 1 fungal ball. This patient of fungal ball had nasal bleed as the only complaint, nasal endoscopy was normal and the pathology was detected on CT scan. One month later during surgery of this patient, brownish green debris could be visualised in the middle meatus which was confirmed as fungal origin on KOH testing.
Table 4.
Distribution and duration of symptoms, M = months
| Pathology | Nasal block | Nasal discharge | Nasal | Ocular symptoms | Headache | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Nonneoplastic (NN) | ≤ 3 M | > 3 M | TOTAL | ≤ 3 M | > 3 M | TOTAL | mass | Swelling | Redness | Discharge | |
| Polyp | 23 | 16 | 39 | 15 | 10 | 25 | 3 | 1 | 3 | 0 | 2 |
| CRS | 5 | 7 | 12 | 4 | 1 | 5 | 0 | 0 | 2 | 0 | 3 |
| Fungal ball | 5 | 2 | 7 | 3 | 2 | 5 | 0 | 0 | 3 | 0 | 0 |
| AFRS | 2 | 5 | 7 | 4 | 1 | 5 | 0 | 2 | 2 | 0 | 1 |
| Mucocoele | 0 | 1 | 1 | 2 | 0 | 2 | 1 | 0 | 0 | 0 | 0 |
| Chronic FS | 0 | 2 | 2 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 |
| Pyocoele | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 |
| Dentigerous cyst | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 |
| Osteomyelitis | 1 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
| TOTAL (NN = 88) | 36 | 34 | 70 (79.5%) | 29 | 15 | 44 (50%) | 4 (4.5%) | 3 (3.4%) | 12 (13.6%) | 2 (2.3%) | 6 (6.8%) |
| Pathology neoplastic | Nasal block | Nasal discharge | Nasal | Ocular symptoms | Headache | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| ≤ 3 M | > 3 M | TOTAL | ≤ 3 M | > 3 M | TOTAL | Mass | Swelling | Redness | Discharge | ||
| Inverted papilloma | 1 | 7 | 8 | 4 | 1 | 5 | 1 | 1 | 0 | 0 | 0 |
| SCC | 3 | 4 | 7 | 3 | 0 | 3 | 1 | 1 | 4 | 0 | 0 |
| Osteosarcoma | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 |
| Adenocarcinoma | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| Adenoid cystic CA | 1 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
| Malignant melanoma | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 0 |
| Adamantinoma | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 |
| Mets from RCC | 1 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
| Osteoma | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Total (NP = 29) | 6 | 12 | 18 (62.1%) | 10 | 1 | 11 (37.9%) | 3 (10.3%) | 4 (13.8%) | 7 (24.1%) | 1 (3.4%) | 0 |
| Total NN + NP = 117 | 42 | 46 | 88 (75.2%) | 39 | 16 | 55 (47%) | 7 (6%) | 7 (6%) | 19 (16.2%) | 3 (2.6%) | 6 (5.1%) |
Bold shows distinctly the final values
A 68 year old female with stage III SCC was the only patient with proptosis of eye (1/117, 0.9%). She was also 1 amongst the 2 patients with visual disturbance in the form of diplopia (2/117, 1.7%), the other being malignant melanoma. Decreased facial sensation was seen in a 47-year-old male with SCC (1/117, 0.9%). Loss of smell was the only complaint in a 33 year old male with fungal ball which resolved after surgery (1/117, 0.9%). An asymptomatic patient (1/117, 0.9%) was diagnosed as a fungal ball on a CT scan of head done following head trauma.
Table 5 shows distribution of stage and grade of SCC.
Table 5.
Stage and grade distribution of SCC
| Stage of SCC | Grade 2 | Grade 3 |
|---|---|---|
| I | 1 | 1 |
| II | 3 | |
| III | 2 | |
| IV | 3 | |
| 9 | 1 |
There were instances wherein the diagnosis had to be changed after histopathology report. (Table 6). Both stage I SCC were misdiagnosed as polyps, IP being the other frequently missed diagnosis. Histopathology played a key role in differentiating other malignancies from SCC of maxilla.
Table 6.
Patient characteristics in cases with misdiagnosis
| Age (YR) | Gender | Complaint | Diagnosis | HP |
|---|---|---|---|---|
| 14 | F | Nasal block 1 & 1/2 month | Polyp | IP |
| 34 | F | Nasal block 4 month | Polyp | SCC Gr 3, st I |
| 55 | M | Nasal block & discharge 1 year | Polyp | SCC Gr 2, st I |
| 73 | M | Nasal block 8 months, discharge 3 months | Mucocoele | Mucocoele + IP |
| 60 | F | Nasal block, discharge 3 months | Carcinoma | IP |
YR Years
Discussion
Our study in a tertiary care referral hospital and medical college studied the different pathologies affecting the maxillary sinus in the local population. As expected, a wide range of diseases were seen, as observed in other studies [2, 6, 12].
In a study of 214 maxillary sinus lesions, Perez-Sayans et al. observed following frequency of pathology: unspecified sinusitis (44.4%), polyps (18.2%), fungal sinusitis (9.8%), malignant tumours (9.8%) and inverted papilloma (7.5%). The polyps here included only ACPs. The rest were cysts (3.7%), benign tumours (2.3%), mucocoele (2.3%) and other lesions (1.9%) [12]. In our study, the most frequent overall pathology of maxillary sinus was polyp (40.2%, ACPs being 17/117, 14.5%), followed by fungal involvement (18.8%), malignancy (13.7%), chronic rhinosinusitis (11.9%) and inverted papilloma (10.3%). According to a radiologic review study, the prevalence of maxillary sinusitis ranges from 7.5–50% depending on the definition used for diagnosis [17].
Gender
The male: female gender difference in our study was 1.5:1 which is similar to other studies [12, 18]. In both genders, the non-neoplastic lesions were 3 times more common than neoplasms.
Our patients with polyp (including ACPs), CRS and malignancy group did not show significant gender variation, whereas 81.8% of fungal balls, 77.8% of AFRS and 83.3% of inverted papilloma affected males. Drumond et al. did not find a significant difference between the gender and frequency of pathology [2].
In a study of 87 patients of ACPs, 60% were females and 40% were males [19]. Another study mentions that men are afflicted more with ACPs [12]. We did not find any such difference among our polyp patients.
Some studies mention a female preponderance in fungal ball [20, 21], another 2 including an Indian study [22, 23] show a male dominance while another mentions no gender difference [24]. For AFRS, Alshaikh et al. [22] mentions female predominance while Shetty et al. [23] mention male dominance. A major limitation of these studies is that the pathologies of all paranasal sinuses have been evaluated together. In our study, male dominance was observed in both fungal ball and AFRS groups.
Inverted papilloma is known to have 2–5 times more male predominance [5, 12, 25, 26]. The male prevalence was observed as 68.3% by Perez-Sayans et al. [12] and 66.7% by Liu et al. [27] while our study had 83.3% males.
Squamous cell carcinomas are twice more common in males [28, 29]. But in our study, 1.5 times more females than males presented with SCC.
Age
Patients below 20 years comprised only 8.5% of our study population. They showed a predominantly non-neoplastic pathology (80%) and polyp (87.5%) was the most common lesion. Perez-Sayans et al. [12] have reported that only 7.8% of their ACP patients were less than 18 years. In our study, 14.9% of all polyps (11.8% of ACPs) were seen below 20 years.
Inverted papilloma is very rare in children and most patients have been males (9 males, 3 females) in the few case reports available [26]. The IP in our 14 year old female patient was misdiagnosed as a polyp prior to surgery. Osteosarcoma, the most common primary bone malignancy in children, rarely affects the jaws (2–10% cases) and mandibular involvement is more common than maxilla [30, 31]. The only malignancy in our young patients was an osteosarcoma in a 16 year old boy. Thus, there is a low prevalence of maxillary sinus pathologies in patients below 20 years and most tend to be benign.
The rest of the lesions were almost equally distributed between 20–50 year and above 50 year age group with some notable differences. Most maxillary sinus pathologies in 20–50 year group were non-neoplastic (47/53, 88.7%). Polyps and CRS were more common. Malignancies comprised 5/6 (83.3%) of all neoplasms. In patients aged above 50 years, non-neoplastic lesions decreased to 61.1% (33/54). Fungal ball and AFRS were twice more common. All but 2 IPs (83.3%) were in > 50 year age group and malignancies comprised 47.6% (10/21) of all neoplasms. This age distribution of pathologies correlates well with other studies [12, 20]. Considering low prevalence of IP in 20–50 years, most neoplastic pathologies should be viewed with a suspicion of malignancy in this age group.
Side of Lesion
One study had more ACPs (55%) on left side [19] while 64.7% (11/17) of our ACPs were left-sided. Bilateral pathologies occur less frequently and have usually been described for ACPs and fungal balls [19, 20]. This was seen in our study as well. We did not encounter any case with bilateral IP which has a reported rate of 0–5% [32].
Comorbidity
Segal et al. [33] observed common association of bronchial asthma with chronic sinusitis with nasal polyps in children. We had only 1 patient with bronchial asthma, a 65 year female with polyp, who also had DM and HT.
Most common comorbidity was DM and HT. CRS had a higher proportion of both DM and HT compared to polyps in 20–50 year age group (p < 0.05). In those above 50 years, DM was seen in 72.7% of polyps followed by half of all the fungal pathologies, while HT was observed in all AFRS and CIFS patients, 71.4% of fungal ball and 66.7% of CRS patients. HT was twice more common than DM in CRS patients above 50 years. Kim et al. [20] observed a higher frequency of hypertension followed by DM in fungal balls. They have discussed a mechanism of increased peripheral resistance of blood vessels in hypertensives in sinus mucosa, ultimately decreasing perfusion and drainage of the mucosa which may predispose patient to fungal infections.
Kim et al. [20] also had significantly more hypertensives and female predominance in bilateral fungal balls involving any of the sinuses. Both our male patients with bilateral fungal balls did not have DM or HT, only 1 had ALD. Shetty et al. [21] found DM in 44% of all fungal sinusitis and suggested it to be a predisposing factor. Both these studies are limited by their inclusion of pathologies involving all the sinuses. The DM and HT prevalence substantially varies among Indian states, with Goa having the highest prevalence of DM comparable across both rural and urban areas and higher rates of HT [34]. This may explain the higher proportion of fungal sinusitis among chronic sinusitis in our study population (Shetty et al. 42.6%, our study 61%).
Symptomatology
The most common symptom was nasal blockage (75.2%) and nasal discharge (47%) followed by ocular redness (16.2%). This is as seen in other studies [19, 22, 23, 35], but none of these studies have evaluated maxillary sinus exclusively, unlike our study. Santos et al. [28] had more patients of SCC complaining of face (62.1%) and mouth (56.7%) symptoms than nasal complaints (32.8%), mostly swelling and pain. The predominant symptom of malignancies in our study was nasal block followed by nasal discharge, just like any other nasal pathology [36], enforcing the need to be wary especially in adults.
In neoplastic pathologies, ocular redness (24.1%), ocular swelling (13.8%), nasal mass (10.3%) and nasal bleed (10.3%) were more frequently seen compared to non-neoplastic. Headache (5.1%) was seen exclusively in non-neoplastic lesions whereas visual disturbance and proptosis were confined to malignancies. Lombardo et al. [37] have reported a case of maxillary sinus mucocoele presenting only with visual complaints. Bolinger et al. [38] described an adenoid cystic carcinoma with only complaint of left-sided facial numbness in distribution of maxillary division of trigeminal nerve. Right cheek swelling was the presenting complaint in a 16 year old girl with Ewing’s sarcoma [14]. Thus, ocular complaints and complaints emanating from structures around the maxillary sinus deserve a thorough sinus evaluation even without nasal complaints.
Most patients tended to present within 3 months of symptom onset for all symptoms except nasal block. Nasal block was almost equally distributed among < 3 months and > 3 months duration in non-neoplastic pathologies whereas 7 of 8 patients of IP with nasal block presented beyond 3 months. The reasons for this could range from delay in seeking treatment for nasal block by the patient, misdirected treatment by non-specialist doctors prior to referral or treating some patients of IP as a polyp prior to biopsy or use of maximal medical treatment prior to surgery (e.g. In cases of polyp, CRS, AFRS).
Indolent mucormycosis is an emerging pathology, defined as pathological evidence of mucormycosis involving nose or paranasal sinus lasting for more than a month. It can affect both immunocompromised or immune competent patients. It presents with nonspecific symptoms, evolves over a longer time and sometimes vascular invasion and necrosis is absent. A single sinus involvement is more common [12, 39]. Our female patient with CIFS had presented with nasal discharge for 10 months and nasal block for 6 months, had DM, HT and NALD. Biopsy of the proliferative whitish growth revealed nonseptate hyphae of Mucorales species. An awareness of this diagnosis should be present. Our other patient with chronic invasive FS was a male who had granulomatous disease caused by aspergillus species.
Though paranasal sinus malignancies are rare accounting for just 0.2–0.8% of human malignancies, most occur within the maxillary sinus (60–70%) [28, 36]. Squamous cell carcinomas form 60–75% of all paranasal sinus malignancies [28]. Santos et al. [28] had 41.2% cases of SCC, 77% being moderate grade tumours and most in stage III or IV. They had a predominance of adenocarcinomas. Dubal et al. [29] had 87.4% of SCC in their series presenting at > 50 years, of which 64.3% were in stage IV. In our study, SCC formed 62.5% of all malignancies of maxillary sinus and 60% were in patients above 50 years. Ninety percent (9/10) were moderately differentiated tumours and lesions were almost equally distributed amongst the 4 stages. These variations may be attributed to geographical variations.
Metastasis to maxillary sinus is a rare pathology and arises from mostly kidney, lung, breast, thyroid gland and prostate. Renal cell carcinoma (RCC) is the commonest to involve the sinus [12, 40]. We had a single case of such metastasis from RCC.
Maxillary sinus mucocoeles are rare compared to frontal and frontoethmoid lesions and make up less than 10% of all paranasal sinuses mucocoeles [5, 37]. There were 2 patients with mucocoele and 1 of pyocoele in our study. Maxillary mucosal cysts vary widely in prevalence from 3.6% to 35.6% [2,5,17,41,42], depending on the diagnostic method used and indication for imaging [41]. We did not find a single case among our symptomatic patients. This concurs with the observation that these cysts remain asymptomatic and harmless [41]. Kanagalingam et al. [42] did not find any association between presence of such cysts and evidence of sinus and dental disease. This is forwarded as a reason not to operate on these lesions if detected accidentally [5,41,42].
Conclusion
Most isolated maxillary sinus pathologies are benign and affect mostly those above 20 years of age. The role of diabetes mellitus and hypertension in these pathologies, especially CRS and all fungal pathologies need to be studied further. Although clinicoradiological evaluation has a high success rate in identifying the lesions, histopathological confirmation is mandatory especially to rule out malignancies. It also differentiates SCC from other malignancies helping to institute appropriate treatment. The variations seen in different studies might reflect the local conditions, thus knowledge of the distribution of the pathologies in one’s geographical area is of paramount importance. Most studies tend to club together all paranasal sinuses for different etiologies making extraction of data tedious or sometimes irrelevant. Hence more studies are needed that focus solely on the maxillary sinus pathologies to study the change in trends in pathologies over time and geographical variations.
Acknowledgements
We express our sincere gratitude to Prof. Dr. Kulkarni, Department of Preventive and Social Medicine, Goa Medical College, Bambolim, Goa for his help in statistical analysis.
Author Contributions
SL: Conception and design, Data acquisition, analysis and interpretation of data, drafting the article, revisions of article and final approval of article before submission. KMV: Data acquisition, analysis and interpretation of data, drafting the article, and final approval of article before submission. AN: Analysis and interpretation of data, drafting the article, revisions of article and final approval of article before submission. DVL: Analysis and interpretation of data, drafting the article, revisions of article and final approval of article before submission. MT: Revisions of article and final approval of article before submission. CJADS: Revisions of article and final approval of article before submission.
Funding
None.
Declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
Ethical clearance was obtained from the Institutional Ethics Committee, Goa Medical College, Bambolim, Goa.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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