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CURRENTOPINION Evaluation and treatment of isolated maxillary

m A. Saleh

The maxillary sinus may be involved in a wide variety ofpresenting symptoms but some have unique features. Thi

eenviews a

llartigowicaith

axi

INTRODUCTION

The maxillary sinus iscraniofacial skeleton, land adjacent to thepterygopalatine andorbit. As such a wide amaxillary sinus, and bare able to expand to aany symptoms or clpresent late, thereforeand management diffof disease processes isof these conditions wreference to recent pu

EVALUATION OF TSINUSES

A patient with isolated maxillary sipresent with a number of clinicasigns. Tunilatepatientalteredsympt

examination including rigid nasendoscopic exam-

Department of Otolaryngology, Charing Cross and Royal Brompton

: jstephens@doctors.org.uk

www.c

REVIEWfacial symmetry, or more rarely oral cavityoms. A full history and thorough clinical

Curr Opin Otolaryngol Head Neck Surg 2013, 21:5057

DOI:10.1097/MOO.0b013e32835af905

o-otolaryngology.com Volume 21 Number 1 February 2013hral nasal obstruction, and epistaxis, althoughs may also complain of orbital symptoms,

Palacee-mailt Lippincott Williams &eatures are pain, HNS), Department of Otolaryngology, Charing Cross Hospital, FulhamRoad, Hammersmith, London,W6 8RF, UK. Tel: 07812148766;he commonest presenting fCorrespondence to Joanna Stephens, MBChB, DOHNS, FRCS (ORL-nus disease mayl symptoms or

Hospitals, Imperial College, London, UKa potential space within theinedwith respiratorymucosa,oral cavity, nasal cavity,

infratemporal fossae and therray of diseases can affect theecause these disease processessignificant size before causinginical signs, they can often, presenting both diagnosticiculties. The wide assortmentdemonstrated in Table 1. Eachill be detailed with particularblished data.

HE MAXILLARY

ination of the nasal cavity are mandatory, and mayidentify polyps, pus, or a mass in the nose giving aclue as to the origin of the symptoms. Computedtomography (CT) scanning is widely accepted asthe investigation of choice in evaluating the para-nasal sinuses, and in-office cone-beam CT scanningis gaining some popularity among endontists toassess whether isolated maxillary disease is odonto-genic in origin [1]. MRI is also a useful examination,more readily demonstrating intracranial extensionor perineural invasion in the case of a malignancy,or distinguishing fluid from soft tissue. It is particu-larly useful in identifying fungal disease with hyper-intensity on T1-weighted images and hypointensityon T2-weighted images [2

&

].in this area.

Recent findingsThe majority of isolated maxillary sinus disease has bmicrobiology of sinusitis have been published. The resurgical management due to improved instrumentation

SummaryOn the basis of the review, diagnosing isolated maxipresentation. When suspected, it is advisable to invesand proceeding to MRI if needed. Often these will shFinal diagnosis is frequently only obtained on histolognow be managed by endoscopic techniques alone w

Keywordsantrum, diagnosis, disease, isolated, management, msinus disease

Joanna C. Stephens and Hesha

Purpose of review Wilkins. Unauthorized disorders. Many of these share commons article reviews some of the recent publications

previously described. Some recent data on thealso highlights the growing role of endoscopic

nd techniques.

y sinus disease can still be delayed due to lateate early with computed tomography scanningcertain features with clues to the diagnosis.l examination. The majority of these disorders canopen surgery required in a small number of cases.

llary sinusreproduction of this article is prohibited.

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MRI has also been shown to be useful in thediagnosis of silent sinus syndrome [3]. Ultrasoundassessmused inpectedthe pretoo unwadjunc

INFEC

The cosinusesorganisHaemopcoccusbacteriisolatedproportion of MRSA and beta lactamase produc-ing bamaxillashouldantibioof antiintraop

saline significantly decreases the bacterial loadwithin the sinus [6].

Fungal disease can also affect themaxillary sinusin the form of a fungal ball, and the commonestpathogens are Aspergillus sp., namely A. fumigatusand A. flavus, although more unusual pathogenssuch as Acremonium sp. and Hyalohyphomycosis sp.may be involved and have been recently described[7,8]. Themanagement of a fungal ball is meticuloussurgical clearance of the fungal material, with norole for systemic antifungals (Fig. 1). Immuno-compromised patients may be affected by a moreaggressive invasive fungal infection, mucormycosis,caused by the fungi Mucorales sp. [9]. Rhinocerebralmucormycosis is a rapidly spreading and potentiallyfatal infection, but in isolated maxillary sinusdisease can be managed with immediate surgicaldebridement and intravenous antifungals [9].

hisielunntlae aatInl sinuses is reported in 95100%, but isolatedillaagp

ine

SILEN

trotea

absve

KEY POINTS

A multitude of diseases can affect the maxillary sinuses. History and clinical examination with a rigid anglednasendoscope will often provide a clue as to thediagnosis.

CT scanning is essential, and MRI may add furthervaluable information.

Biopsy and histological examination are oftennecessary to reach a firm diagnosis.

The majority of lesions can be managedendoscopically.

Table

Nonneop

Infective

Silent sin

Mucosal

Antrocho

Choleste

Mucocoe

Haemato

Inflamma

Isolated maxillary sinus disease Stephens and Saleh

1068-950cteria in smokers with acute and chronicry sinusitis [5]. A dental source of infectionalways be excluded.Management is with oraltics, and possibly surgery in the case of failuremicrobial therapy. If surgery is required,erative irrigation of the maxillary sinus with

Silensyndunilafloorthehypo

1. Classification of diseases affecting the maxillary sinusent of the maxillary sinuses has beenthe evaluation of ICU patients with a sus-maxillary sinusitis, as a bedside test to detectsence of fluid in the sinus in those patientsell to be transported for a CT scan a useful

t to conventional cross-sectional imaging [4].

TION OF THE MAXILLARY SINUS

mmonest infections involving the maxillaryare bacterial. The commonest microbialms isolated are Staphylococcus aureus,hilus influenza, Moraxella catarrhalis, Strepto-pneumoniae and beta lactamase producinga and a recent study into the different florain smokers and nonsmokers found a higher

RKlebencoPatienoduTherexud[10].nasamaxManearlyscarrof thight Lippincott Williams & Wilkins. Unauthorize

lastic Neoplastic benign

Papilloma

us syndrome Fibro-osseous lesions osteoma, ossifyingfibrous dysplasia, osteoblastoma

cyst Salivary gland tumours pleomorphic ade

anal polyp Mesenchymal tumours fibroma, lipoma,

rol granuloma Vasiform tumours haemangiopericytoma

les

ma

tory pseudotumour

8 2013 Wolters Kluwer Health | Lippincott Williams & Wilkinsd reproduction of this article is prohibited.

ry sinus disease has been reported [10].ement is with appropriate antibiotics in thehases, surgery reserved for the inevitableg and fibrosis which occurs in the later stagesdisease.

T SINUS SYNDROME

sinus syndrome, or imploding antrumme, is a rare disease process caused byral collapse of the maxillary sinus and orbitalssociated with negative antral pressure inence of sinus symptoms [11

&&

] and chronicntilation [12]. It typically presents with

Neoplastic malignant

SCC

fibroma, Adenocarcinoma

noma, oncocytoma Sarcoma

myxoma Lymphoma

, haemangioma Adenoid cystic carcinoma

and numerous more

www.co-otolaryngology.com 51noscleroma is a worldwide disease caused byla rhinoscleromatis, and is more commonlytered in temperate and tropical climates [10].s initially present with sore throat andr infiltration involving the oropharynx.re three distinctive and overlapping phases:ive, proliferative, and fibrotic (cicatricial)volvement within the nasal cavity and para-

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enophtby a da reduDiagnothen wthis cosurgerywith trif founantrosttaneouorbit toorbital

controversy exists in the literature as to thetiming of this aspect of the surgery, some centresadvocating repair at the same time as the initialsurgery [12].

The converse problem of pneumosinus dilatans,in which one or more sinuses are dilated withoutfunctional alteration, affects the frontal sinus mostcommonly, followed by the sphenoid, maxillary,and ethmoidal sinuses. The cause is poorly under-stood, although theories include minor traumaand over aeration of the sinuses [13]. Managementis surgical decompression and maxilloplasty [13].

BENIGN LESIONS OF THE MAXILLARYSINUS

Numerous benign lesions can affect the maxillarysinus, we have outlined here those most frequentlyencountered.

Mucosal cyst

Mucosal cysts are a common incidental findingmaging studies, with an incidence betweenand 35.6% [14]. They are typically sphericalitiiaurbe

oc

anna

FIGURE 1. Intraoperative photograph of a fungus ball seenafter performing a large middle meatal antrostomy.

FIGURE

right sileorbital flmedial s

Nose and paranasal sinuses

52halmos and hypoglobus, and is characterizedownward bowing of the orbital floor andction in size of the maxillary sinus [11

&&

].sis is made by initial clinical suspicion, andith CT or MRI [3] (Fig. 2). Management ofndition is surgical, with endoscopic sinusto re-establish maxillary sinus ventilation,imming of a lateralized middle turbinated, careful uncinectomy and middle meatalomy. Bony remodelling usually occurs spon-sly over the next few months to restore theits original position. If this fails to occur,

floor repair is considered although some

on i12.4opacassocNo scan

Antr

Anorigit Lippincott Williams & Wilkins. Unauthorized

2. A coronal computed tomography scan showingnt sinus syndrome with typical retraction of theoor in to the sinus lumen and lateralization of theinus wall.

FIGURE

a mucosdomed s

www.co-otolaryngology.comreproduction of this article is prohibited.

3. A coronal computed tomography scan showingal cyst in the left maxillary sinus. Note the typicalurface and the origin at the floor of the sinus.

Volume 21 Number 1 February 2013hoanal polyp

trochoanal polyp is a soft tissue massting from the maxillary antrum, emerginges on CT scanning (Fig. 3), and are notted with symptoms of chronic rhinosinusitis.gical intervention is required, and patientssimply reassured.

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from the ostium and extending to the choanaethrough the nasal cavity [15]. These polyps differfrom common nasal polyps, as they are solitary,dumbbell shaped, contain fewer mucous glandsand eosinophils, and by definition protrudethrough the choana [16

&

]. Presentation is withunilateral nasal obstruction, and diagnosis is madewith clinical observation of a large smooth polypfilling the nasal cavity, and possibly extending intothe nasopharynx on inspection of the oral cavity,and by characteristic findings on a CT scan (Fig. 4).Bilateral antrochoanal polyps have been reportedin the literature rarely [16

&

]. The site of origin ismost commonly posterior wall, followed by inferiorand lateral walls [17], and management is withendoscopic sinus surgery to remove the polyp inits entirety ensuring removal at the origin via a widemiddle meatal antrostomy [15].

Cholesterol granuloma

Cholesterol granulomas are benign lesionsconsisting of granulation tissue, cholesterol crystals,and foreign body giant cells [18] and are welldescribed in the temporal bone but rare in the para-nasal sinuses [18]. These lesions have been describedin isolation in the maxillary sinus, and treatmentis surgical excision, ensuring complete excision via a

large middle meatal antrostomy to minimize therisk of recurrence.

Mucocoeles

Maxillary sinus mucocoeles are uncommon, thefrontoethmoidal region being far more commonlyaffected. Signs and symptoms reflect the size ofthe lesion, and in the maxillary sinus can presentwith diplopia due to elevation of the orbital floor[19], or with facial swelling or dental problems [20].Bilateral maxillary mucocoeles have rarely beenreported in association with cystic fibrosis [19].Management is endoscopic sinus surgery, with wide

FIGURE

patient sand naspassing

(a)

b)

RE

lefthidral aal c

Isolated maxillary sinus disease Stephens and Saleh

1068-950ight Lippincott Williams & Wilkins. Unauthor

4. An axial computed tomography scan of ahowing a right antrochoanal polyp. Both maxillaryal components can be seen with a narrower partthrough an accessory ostium.

FIGU

largeboneaftermeatanorm

8 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins(d reproduction of this article is prohibited.www.co-otolaryngology.com 535. (a) A coronal computed tomography scan of at maxillary mucocoele showing extensive expansion,nning, and pressure on the orbit. (b) Six monthsinage of the mucocoele through a large middlentrostomy. Note the return of the sinus cavity to itsontours.

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middle meatal antrostomy, allowing adequatelywide drainage to prevent recurrence (Fig. 5).

Haematoma

A haematoma or organized haematoma of themaxillary sinus is an uncommon cause of unilateralnasal obstruction and epistaxis, patients alsooccasionally present with facial swelling or orbitalsymptoms. Pseudonyms include haemorrhagicpseudotumour, and the problem may present inpatients with existing comorbidity such as a bleed-ing dyscrasia or chronic renal failure [21]. Imagingshows a nonenhancing soft tissue mass on bothCT andMRI scanning, with or without bony erosion[18]. Management is endoscopic surgical excisionvia a wide middle meatal antrostomy, possiblycombined with a partial medial maxillectomy,and recurrence is unlikely (Fig. 6).

Inflammatory pseudotumour

Pseudotumours of the head and neck classicallypresent in the orbit, but have been described inthe maxillary sinus. The histological findings arevaried, ranging from predominantly lymphoidtissue to highly fibrotic tissue [22]. A similar lesionis eosinophilic angiocentric fibrosis, lesions causedby eosinophilic perivascular inflammation and

gradual replacement with fibrosis [18]. Treatmentis surgical excision, although systemic steroidtherapy has been used with some success in patientswith in

Benign

The mof benosseouschymaimportdiscuss

Papill

Sinonacyclindinverteapprox25 timInvertewhichwithincharactinto thment minvolvia benighigh r

daattoinFigistioscin

mucosaston]. Tsce aniques such as a maxillary medial sinusotomyb

handnimyclattiodency towards recurrence andmalignant trans-ation, so complete surgical excision is advis-E

FIGURE

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6. A photograph of a maxillary haematoma afterfrom the sinus.manP

sympmassCT (for hexcisendoto mreproduction of this article is prohibited.

verted papillomas are true papillomas lined

Volume 21 Number 1 February 2013een described, allowing the boundariest is achievable endoscopically to be furthered [27]. Patients should be followed up forum of 3 years [26

&&

].lindrical papillomas typically arise oneral nasal wall but have been described inn in the maxillary sinus [28]. There isflammatory pseuotumours [22].

tumours of the maxillary sinus

axillary sinus can be affected by a numberign tumours, namely papillomas, fibro-lesions, salivary gland tumours, mesen-

l tumours and vasiform tumours. The mostant and commonly encountered of these areed below.

omas

sal papillomas can be classified into inverted,rical, and everted, the commonest beingd papillomas. Inverted papilloma occurs inimately 0.54% of all nasal tumours and it ises less frequent than ordinary nasal polyps.d papillomas are benign epithelial tumours,typically arise from the lateral nasal wall orthe maxillary or ethmoid sinuses, with aeristic inverted appearance of the epitheliume underlying stroma, but an intact base-embrane [23]. They can, however, presentng the maxillary sinus in isolation. Althoughn tumour, its potential local aggressiveness,ecurrence rate, and malignant associationte aggressive treatment [24

&

,25].ients typically present with unilateral nasalms, and the clinical findings of a polypoidthe nasal cavity. Diagnosis is confirmedwith. 7) and possibly MRI scanning, and a biopsyological diagnosis. Management is surgicaln, and in the vast majority this is possibleopically. To ensure successful excision, andimize the risk of recurrence, all diseasedshould be removed, proceeding to a sub-

eal dissection to include removal of all sclero-e, with or without a medial maxillectomyhose cases traditionally thought inaccessibleopically include tumours with attachmentsnterior wall of themaxillary sinus, but newer

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Fibro-Fibro-oincludidysplasblastom

Osttypicalincidensinus oonly 5%pathoginflammtissueimaginmanagand wasymptosideredscopicaproced

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RE 8. An axial computed tomography scan of ant with ossifying fibroma in the left maxillary sinus.FIGURE

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Isolated maxillary sinus disease Stephens and Saleh

1068-950tified squamous epithelium, and althoughless malignant potential, complete surgical

n is the management of choice [29].

osseous lesionssseous lesions are a spectrum of disordersng osteomas, ossifying fibromas, fibrous

Lesiosurg

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FIGU

patie7. An axial computed tomography scan showingted papilloma extending from the middle meatus intollary sinus. Areas of high density are seen within thecomponent.ight Lippincott Williams & Wilkins. Unauthorize

ia, cement-ossifying fibroma, and osteo-a.eomas are benign bony tumours whichly present in the frontal sinuses, often as antal finding onX-ray or CT. Isolatedmaxillarysteomas are exceedingly rare, and account forof the cases [30]. Various theories as to the

enesis of osteomas exist, including chronication, trauma, and sequestered embryonal

[31,32]. Diagnosis is made on appropriateg, and if the patient is asymptomatic thenement is conservative, adopting a watchit policy. If the lesion is particularly large ormatic then surgical excision should be con-, and this can sometimes be achieved endo-lly, although often an external or combinedure is necessary to gain the required access.ifying fibroma is a benign tumour comprised, fibrous tissue, calcification, and cementumRadiologically, the lesion is sharply circum-with an eggshell rim and central radiolu-This differentiates it from fibrous dysplasia,has indistinguishable borders (Figs 8 and 9).

reservecosmetstructu

FIGURE

fibrous dground

8 2013 Wolters Kluwer Health | Lippincott Williams & Wilkinscontinue to expand inexorably with time, sol excision is recommended.rous dysplasia most commonly affectsxilla and the mandible in the head andnd presents as a painless expanding massthe typical ground glass appearance on

g [33]. Lesions tend to increase in sizeatients reach their fourth or fifth decadethe disease process burns out. Surgery isd for cases when tumour growth is causingic deformity or compression on surroundingd reproduction of this article is prohibited.

res. Some authors have showed regression of

9. A coronal computed tomography scan showingysplasia affecting the right maxillary sinus. Note theglass appearance and the indistinct borders.

www.co-otolaryngology.com 55

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lesions on using the bisphosphonate pamidronate[34].

Cemento-ossifying fibromas are thought tooriginacompoand fibmay reof dentwith regular follow-up as recurrence has beenreporte

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SCC of the maxillary sinus alone is rare, comprisingless than 3% of all head and neck carcinomas [40].Patients often present late, and only once the

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g and assist the surgery.

NANT TUMOURS OF THELLARY SINUS

ous cell carcinoma (SCC) is the commonestr involving the paranasal sinuses, however,

425. Br

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ry gland tumours

rphic adenomas in the nasal cavity arearticularly in the maxillary sinus alone.re benign tumours, which can be managedomplete surgical excision either endo-lly or via a combined approach. Care isas both recurrence and malignant trans-

ion have been reported [36]. Oncocytomasours composed of epithelial or myoepi-cells with abundant granular eosinophilicsm, extremely rare in the maxillary sinus.ant transformation has been described, son is recommended [37].

chymal tumours

as, lipomas, and myxomas are all un-n benign tumours in the maxillary sinus.managed with endoscopic surgical excision,h myxomas are locally aggressive withrecurrence rate so a wide local excision isended [38].

rm tumours

ngiopericytomas are rare tumours in thend neck, featuring pericytes (extracapillaryistributed around normal vascular channels.gically they can be difficult to distinguishrcomatous lesions, and they have a variableant potential [39]. Wide local excision istory, as late recurrences have been reported,stemic metastases seen in up to 10%. Followuld be long term [18].mangiomas are vascular lesions which canhe entire sino-nasal cavity but are occasion-und in the maxillary sinus in isolation.an be endoscopically excised, however, pre-

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syte from the periodontal ligament and aresed of different amounts of cementum, bone,rous tissue [35]. Tumour growth over timesult in facial asymmetry and displacemental roots. Surgical excision is recommended,

tumsymphistoaremultreproduction of this article is prohibited.

J, Kim J, Kim K, et al. Radiologic characteristics of sinonasal fungus ball:lysis of 119 cases. Acta Radiol 2011; 52:790795.demonstrates the radiological findings associated with fungal ball.no GM, Piludu F, Martucci M, et al. CT & MRI diagnosis of silent sinusme. Radiol Med 2011. [Epub ahead of print].

z M, Celikbilek G, Andic, et al. Maxillary sinusitis in patients ventilated forre head injury and with nostrils free of any foreign body. Injury 2011;37I, Hausfield J. Microbiology of acute and chronic maxillary sinusitis

okers and nonsmokers. Annals of otology. Rhinol Laryngol 2011;07712.rling K, McHugh R, Aruni W, Church C. The impact of intraoperativeirrigations on bacterial load within the maxillary sinus. Int Forum Allergy2011; 1:351355.

c M, Bienvenu A-L, Picot S, et al. Maxillary sinus fungal infectionremonium. Eur Ann Otorhinolaryngol Head Neck Dis 2011; 128:3.

Volume 21 Number 1 February 2013accurate diagnosis, and lesions can often befully managed endoscopically.

wledgements

cts of interest

thors can confirm that no funding has beenfor this article from any source.

ENCES AND RECOMMENDEDINGparticular interest, published within the annual period of review, haveighted as:cial intereststanding interestreferences related to this topic can also be found in the Currentrature section in this issue (p. 89).quently allowed to grow to a significantfore becoming symptomatic, patients often

late, which can make managementry sinus disease is commrs can affect this anatomicr volume has resulted in oral, orbital, or nasalms. Diagnosis is made with a biopsy forgical diagnosis, and CT and MRI scanningndatory, followed by discussion in theisciplinary meeting. Management is withsurgery or radiotherapy, or a combinationtwo modalities depending on the stage ofour, the patients comorbidities, and localls. Other tumours include adenocarcinoma,ma, and adenoid cystic carcinoma to namew, but a full discussion of these is beyond thef this article.

LUSION

on and numerousal area. As lesions

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8. Rai S, Tiwari R, Sandhu S, Rajkumar Y. Hyalohyphomycosis of maxillaryantrum. J Oral Maxillofac Pathol 2012; 16:149152.

9. Pandey A, Bansal V, Asthana A, et al. Maxillary osteomyelitis by mucormy-cosis: report of four cases. Int J Infect Dis 2011; 15:e66e69.

10. Bhowate R, Degwekar S, Rawlani S, Dangore S. Rhinoscleroma with involve-ment of the maxillary sinus, orbital floor, and temperomandibular joint: a casereport. J Oral Maxillofac Surg 2012; 70:135140.

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This is one of the largest case series on an unusual but increasingly frequentlydiagnosed problem.12. Ferri A, Ferri T, Sesenna E. Bilateral silent sinus syndrome: case report and

surgical solution. J Oral Maxillofac Surg 2012; 70e:103106.13. Choi EC, Seong HS, Seung Min N, et al. Surgical correction of pneumosinus

dilatans of maxillary sinus. J Craniofac Surg 2011; 22:978981.14. Kanagalingam J, Bhatia K, Georgalas C, et al. Maxillary mucosal cyst is not a

manifestation of rhinosinusitis: results of a prospective three-dimensional CTstudy of ophthalmic patients. Laryngoscope 2009; 119:812.

15. Elaldl HM, Elmorsy S. Endoscopic surgery in pediatric recurrent antrochoanalpolyp, rule of wide ostium. Int J Paediatr Otorhinolaryngol 2011; 75:13721375.

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This case series demonstrates the appropriate management of antrochoanalpolyps.17. Pinilla M, Gonzalez JR, Garcia-Berrocal J, Vegara J. Endoscopic approach of

antrochoanal polyps. Acta Otorhinolaryngol Esp 1998; 45:345347.18. Duncavage J, Becker S. The maxillary sinus: medical & surgical management.

New York: Thieme Medical Publishers, Inc; 2010.19. Qureishi A, Lennox P, Bottril I. Bilateral maxillary mucoceles: an unusual

presentation of cystic fibrosis. J Laryngol Otol 2012; 126:319321.20. Sreedharan S, Kamath M, Hegde M, et al. Giant mucocoele of the maxillary

antrum: a case report. Indian J Otolaryngol Head Neck Surg 2011; 63:8788.

21. Lee DH, Joo YE, Lim SC. Organised haematoma of the maxillary sinus inpatients with chronic renal failure. J Laryngol Otol 2012; 126:946948.

22. Vivero R, Doshi P, Eloy JA, et al. Primary sclerosing fibro-inflammatorypseudotumour of the maxillary sinus. Ear Nose Throat J 2011; 90:578581.

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24.&

Pagella F, Giourgos G, Matti E, et al. Endoscopic treatment of maxillaryinverte

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This extensive review gives a balanced and thorough examination of the literatureon all aspects of endoscopic management of nasal tumours.27. Wang C, Han D, Zhang L. Modified endoscopic maxillary medail sinusotomy

for sinonasal inverted papilloma with attachment to the anterior medial wall ofmaxillary sinus. ORL 2012; 74:97101.

28. Kusakari J, Hozawa K, Hanazima T, et al. Clinical report: cylindrical cellpapilloma of the paranasal sinus. Arch Otorhinolaryngol 1987; 244:246248.

29. Michaels L, Young M. Histogenesis of papilloma of the nose and paranasalsinuses. Arch Pathol Lab Med 1995; 119:821826.

30. Edmonds M, Clifton N, Khalil H. A large atypical osteoma of the maxillary sinus:a report of a case and management challenges. Eur Arch Otorhinolaryngol2011; 268:315318.

31. Aldren CP, Soames JV, Birchal JP. Bone remodeling in an osteoma of theparanasal sinuses. J Laryngol Otol 1993; 107:633635.

32. Sudhoff H, Theegarten D, Luckhaupt H. Osteoma of the maxillary sinus.Laryngorhinootologie 2001; 80:275277.

33. Lisle DA, Monsour PA, Maskiell CD. Imaging of craniofacial fibrous dysplasia.Cancer 1974; 33:12891305.

34. Chapurlat RD, Gensburger D, Jimenez-Andrade JM, et al. Pathophysiologyand medical treatment of pain in fibrous dysplasia of bone. Orphanet J RareDis 2012; 7 (Suppl 1):S3.

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36. Lu L, Zhou L, Li X, et al. Pleomorphic adenoma of nose and accessory nasalsinuses: a report of 15 cases. Lin Chuang Er Bi Yan Hou Ke Za Zhi 2004;18:549551.

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nerman R, Indelicato D, Morris G, et al. Radiotherapy with or without surgeryr maxillary sinus squamous cell carcinoma: should the clinical N0 neck beated

Isolated maxillary sinus disease Stephens and Saleh

1068-950ight Lippincott Williams & Wilkins. Unauthor

pilloma. tre

8 2013 Wolters Kluwer Health | Lippincott Williams & Wilkinsd reproduction of this article is prohibited.

? Am J Clin Oncol 2011; 34:483487.

www.co-otolaryngology.com 57d papilloma. Rhinology 2011; 49:375380.demonstrates the efficacy of endoscopic treatment in management of

40. Hifo