Nigerian Journal of Surgical Sciences

ORIGINAL ARTICLE
Year
: 2014  |  Volume : 24  |  Issue : 1  |  Page : 12--17

Maxillary antral lesions: An analysis of 108 cases seen in a Tertiary Hospital in Benin City, Nigeria


Osawe Felix Omoregie1, Amina Lami Okhakhu2,  
1 Department of Oral Pathology/Oral Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
2 Department of Ear, Nose and Throat, University of Benin Teaching Hospital, Benin City, Nigeria

Correspondence Address:
Osawe Felix Omoregie
Department of Oral Pathology/Oral Medicine, University of Benin Teaching Hospital, Benin City
Nigeria

Abstract

Aim: This article aims to determine the clinicodemographic pattern and histopathological types of the maxillary antral lesions in a Nigerian population. Materials and Methods: Eleven years retrospective review of case records of patients with histologically diagnosed maxillary antral lesions seen at the Otorhinolaryngological and Oral Pathology/Medicine Departments, University of Benin Teaching Hospital, Benin City, Nigeria was performed. Result: A total of 108 patients with maxillary lesions were seen during the period under review, comprising of 57 (52.8%) males and 51 (47.2%) females, giving a ratio of 1.1:1. The patients«SQ» mean age was 41 years (±1.9 standard deviation) and the peak age group was the third decade of life (n = 22, 20.4%). The most frequent clinical features were painless maxillary swelling (n = 91, 84.3%), nasal discharge (n = 41, 38.0%), nasal obstruction (n = 34, 31.5%) and toothache (n = 30, 28.0%). Most patients (n = 31, 28.7%) presented for treatment within a year of onset of the lesion (n = 69, 63.9%) and the left maxillary antrum was the most commonly affected site (n = 64, 59.3%). The antral lesions were mostly malignant lesions (n = 56, 51.9%), with squamous cell carcinoma accounting for 37 (34.3%) of the cases; followed by benign lesions (n = 23, 21.3%), inflammatory/infective lesions (n = 13, 12.0%), cystic lesions (n = 9, 8.3%), and reactive lesions (n = 8, 7.4%). Conclusion: A high prevalence of neoplastic maxillary antral lesions, consisting mostly of malignant lesion was observed in this study. Routine histopathological examination of recurrent or persistent maxillary antral lesions is recommended for early detection of malignant lesions or malignant transformations among reactive or benign antral lesions.



How to cite this article:
Omoregie OF, Okhakhu AL. Maxillary antral lesions: An analysis of 108 cases seen in a Tertiary Hospital in Benin City, Nigeria.Niger J Surg Sci 2014;24:12-17


How to cite this URL:
Omoregie OF, Okhakhu AL. Maxillary antral lesions: An analysis of 108 cases seen in a Tertiary Hospital in Benin City, Nigeria. Niger J Surg Sci [serial online] 2014 [cited 2021 Jul 28 ];24:12-17
Available from: https://www.njssjournal.org/text.asp?2014/24/1/12/134534


Full Text

 INTRODUCTION



Maxillary antral lesions include nonneoplastic lesions (inflammatory, cystic and reactive types) and neoplastic lesions (malignant and benign types). Tumors of the sinonasal tract are characterized by early local extension, which usually makes it difficult to confirm the sinus of origin. Wang et al. [1] recently reported on the clinicopathological characteristics of neoplastic sinonasal lesions, which shows almost equal ratio of the benign to malignant lesions, with maxillary antrum as the predominant site for paranasal sinus neoplasia. The maxillary antrum is a common site for malignant lesions when compared with other sinonasal sites. [2]

Previous studies have reported various maxillary antral lesions of odontogenic, rhinogenic or sinus origin. The most common antral lesions of odontogenic origin are antral sinusitis and radicular cyst. [3],[4],[5],[6],[7],[8],[9] Others are odontogenic tumors [10],[11],[12],[13],[14],[15],[16] and odontogenic cysts [17],[18],[19],[20] involving the maxillary antrum. Antral lesions of sinonasal origin include sinusitis, [21],[22] cyst and pseudocyst, [23],[24] squamous cell carcinoma [25],[26] and adenocarcinoma of minor salivary glands. [2],[27] Furthermore, maxillary nonodontogenic jaw tumors may extend into the antrum, such as adenocarcinoma of palatal minor salivary glands, [28] ossifying fibroma, [29] osteoma, [30] and fibrous dysplasia. [31]

Lesions of the maxillary antrum often present with symptoms such as nasal obstruction, nasal discharge, epistaxis, cheek swelling, toothache, loosening of posterior teeth in the upper jaw, and orbital symptoms. [32] Various imaging techniques, especially computer tomography have been found useful in the diagnosis of maxillary antral lesions. [21],[22],[33] However, histopathological examination of maxillary antral lesion remains the most important diagnostic tool. There is dearth of literature on studies which compares the clinicopathological characteristics of neoplastic, cystic, inflammatory and reactive antral lesions in our environment.

Previous study on management of maxillary sinus lift outlines the role of ear, nose and throat (ENT) Surgeon in collaboration with a dentist (dental implantologist). [34] This study aims to determine the clinicodemographic pattern and histopathological types of maxillary antral lesions in a Nigerian population; through collaboration between a dentist (an oral and maxillofacial pathologist involved in histopathological diagnosis of maxillary antral lesions) and ENT surgeon (involved in clinical diagnosis and treatment of maxillary antral lesions).

 MATERIALS AND METHODS



Ethical approval was obtained from the Hospital Ethical Committee to perform 11 years (between September 2000 and August 2011) retrospective review of the case records of all patients who were managed for maxillary antral lesion at the Otorhinolaryngological (ORL) and Oral Pathology/Medicine (OPM) Departments of the University of Benin Teaching Hospital, Benin City, Nigeria. This tertiary hospital receives referral mainly from the South-South Zone of the country.

The information retrieved from the case records included the age, and gender of the patients, the affected side and the mode of presentation (maxillary swelling, nasal obstruction, nasal discharge, epistaxis, palatal/skin ulceration, and toothache), and histopathological types of the antral lesions. Bivariate analysis and statistical testing of the data using SPSS version 16 was performed, to estimate the strength of correlation of the variables analyzed using Pearson's Chi-square correlation. The confidence level was set at 95% and P < 0.05 was regarded as significant.

 RESULTS



A total of 108 patients with maxillary antral lesions were seen during the period under review. There were 45 (41.7%) and 63 (58.3%) cases from ORL and OPM clinics, respectively. The patients were 57 (52.8%) males and 51 (47.2%) females, giving a ratio of 1.1:1. The age of the patients ranged from 2 to 77 years, with a mean age of 41 years (±1.9 standard deviation) and the peak age groups were the third and fourth decades of life (n = 42, 38.9%) [Table 1]. The most common presenting clinical feature was maxillary swelling (n = 91, 84.3%), followed by nasal discharge (n = 41, 38.0%), nasal obstruction (n = 34, 31.5%), toothache (n = 30, 27.8%), epistaxis (n = 19, 17.6%), and ulceration (n = 15, 13.8%) [Table 2]. Majority of the patients presented within 1 year after onset of symptoms (n = 69, 63.9%) and 11 (10.2%) of the patients presented within 7 weeks after onset of symptoms; while 24 (22.2%) cases and 15 (13.9%) cases presented between 2-5 years and above 5 years after onset of symptoms, respectively [Table 3]. The antral lesions mostly affected the left side (n = 64, 59.3%), while 44 (40.7%) cases occurred on the right side.

The most frequent histopathologically diagnosed antral lesions were neoplastic (n = 79, 73.2%), with malignant types (n = 56, 51.9%) accounting for most of the lesions. Most of the malignant tumors were diagnosed within a year of onset of symptoms (n = 48, 44.4%). The predominant malignant variety was squamous cell carcinoma (n = 37, 34.3%) [Table 4], which presented within a year after onset of symptoms (n = 32, 29.6%), mostly on the left side (n = 23, 21.3%), with maxillary swelling (n = 21, 19.4%), nasal obstruction (n = 21, 19.4%), and nasal discharge (n = 21, 19.4%). The lesion has predilection for patients in the fifth and sixth decades of life (n = 16, 14.8%) and for males (n = 21, 19.4%). The benign lesions (n = 23, 21.3%) consisting mainly of ossifying fibroma (n = 8, 7.4%) [Table 5], which presented within 5 years after onset of symptoms (n = 5, 4.6%), with maxillary swelling (n = 8, 7.4%), found mostly on the left side (n = 5, 4.6%), with predilection for the third decade of life (n = 4, 3.7%) and females (n = 5, 4.6%). The ratio of malignant to benign maxillary antral lesion was 2.4:1.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}

The nonneoplastic antral lesions were mostly inflammatory/infective lesions (n = 13, 12.0%), antral cystic lesions (n = 9, 8.3%) and reactive lesions (n = 7, 6.5%) [Table 6]. The inflammatory/infective lesions consists mainly of antral polyp (n = 8, 7.4%). The inflammatory/infective lesions presented mostly on the left side (n = 9, 8.3%) within 7-12 months after onset of symptoms (n = 6, 5.5%), with nasal discharge (n = 11, 10.2%), nasal obstruction (n = 8, 7.4%), maxillary swelling (n = 4, 3.7%) and toothache (n = 2, 1.9%). There was predilection of the lesion for females (n = 7, 6.5%) and the third decade of life (n = 4, 3.7%). The antral cystic lesions (n = 9, 8.3%) consists mainly of odontogenic cysts (n = 8, 7.4%). The antral cysts presented mostly within 2-5 years (n = 8, 7.4%) after onset of symptoms. The odontogenic cyst occurred mostly on the left side (n = 5, 4.6%), in females (n = 5, 4.6%) and the third decade of life (n = 4, 3.7%), with maxillary swelling (n = 8, 7.4%), toothache (n = 3, 2.8%), epistaxis (n = 1, 0.9%) and ulceration (n = 1, 0.9%). The reactive lesions (n = 7, 6.5%) consisting mainly of fibrous dysplasia (n = 5, 4.6%), which presented above 5 years after onset of symptoms as maxillary swelling (n = 5, 4.6%), with slight predilection for the left side (n = 3, 2.8%) and females (n = 3, 2.8%).

Statistical correlation showed significant association of nasal discharge with histopathological diagnosis of chronic inflammatory lesions (n = 11, 10.2%) and squamous cell carcinoma (n = 21, 19.4%) (P = 0.004). There was significant association of < 6 weeks duration of onset of symptoms with histopathological diagnosis of Burkitt lymphoma (n = 3, 2.8%), a significant association of 7-12 months duration of onset of symptoms with histopathological diagnosis of chronic inflammatory lesions and a significant association of 2-5 years duration of onset of symptoms and females with histopathological diagnosis of dentigerous cyst (n = 4, 3.7%) (P = 0.001).{Table 6}

 DISCUSSION



Most sinonasal neoplasia are reportedly found within median ages of 54 and 57 years, with male predilection and the predominant sites are the nasal cavity and the maxillary antrum, [1] especially for the malignant lesions. [2],[26],[35] Similarly, male predilection and a high prevalence of malignant lesions (51.9%) were observed among the maxillary antral lesions in this study. However, the lesions occurred predominantly in younger age group compared with previous reports. [2] The late presentation of most patients for treatment in this study suggests that most antral lesions with persistent or recurrent symptoms are often taken for granted by the patients simply as sinusitis (being ignorant that there are different histological types of antral lesions), leading to delayed diagnosis and treatment of these lesions.

The majority of the patients in this study presented clinically with maxillary swelling within a few weeks to one year after onset of symptoms, which mostly affected the left antrum. However, previous study by Wang et al. [1] have shown that certain clinical characteristics can be related to specific pathological types of sinonasal tumors. Similarly, this study showed a significant association of nasal discharge with histopathological diagnosis of chronic inflammatory lesions and squamous cell carcinoma of the maxillary antrum. Furthermore, antral lesions presenting in less than 6 weeks, 7-12 months and 2-5 years (in females) after onset of symptoms, were significantly associated with histopathological diagnosis of Burkitt lymphoma, chronic inflammatory lesions and dentigerous cyst, respectively. This study therefore suggests that rapidly growing maxillary antral lesion in children may be a useful clinical indicator to suspect Burkitt lymphoma, while chronic nasal discharge, especially if associated with painful maxillary swelling and toothache, may serve as clinical indicator to suspect antral chronic inflammatory lesions and squamous cell carcinoma. Furthermore, long standing antral lesion in females, especially if associated with painless maxillary swelling and a missing tooth on the affected side, may serve as clinical indicator to suspect a dentigerous cyst. However, these suggested clinical indicators for the antral lesions above necessitate histopathological evaluation to confirm the diagnoses of these lesions.

Neoplastic antral lesions were the predominant lesions in this study, with malignant types accounting for most of the lesions, giving a higher ratio of malignant to benign lesions. In contrast, Wang et al. [1] have reported a higher ratio of benign to malignant sinonasal lesion except in the lymphohematopoietic tissue with a higher ratio of malignant to benign lesion. Majority of the malignant antral lesions in this study was squamous cell carcinoma, with predilection for males in older age group. Similarly, squamous cell carcinoma has been reported as the commonest malignant maxillary antral lesion in Nigerians. [36] However, the study showed a predilection of the lesion for males in younger age group, while female predilection was observed in older age group. [36] The second most frequent antral malignancy in this study was salivary gland adenocarcinoma, with polymorphous low grade adenocarcinoma found mostly in females accounting for most of the lesion. In contrast, adenoid cystic carcinoma has been reported as the most common salivary gland malignancy in the paranasal sinuses, [28],[37] while polymorphous low grade adenocarcinoma is reported to develop commonly from minor salivary gland in the palate and rarely in the maxillary antrum. [38],[39] The non-Hodgkin lymphoma was the third most common malignant antral lesion, with predilection of the non-Hodgkin lymphoma for males, while the Burkitt type occurred predominantly in the first decade of life in this study. This agrees with previous reports that non-Hodgkin lymphoma is common in paranasal sinuses [1],[40] and Burkitt lymphoma of the maxillary sinus has also been reported in an human immunodeficiency virus-positive male. [41]

Apart from malignant antral lesions, the other common antral lesions reviewed in this study were the benign lesions, consisting mostly of ossifying fibroma, with predilection for young adult females. Similarly, Al-Shaham and Samher have reported a case of ossifying fibroma of the maxilla involving the antrum in an adult female. [29] The most common inflammatory lesion in this study was antral polyp, which was found mostly in females and the third decade of life. In contrast, Frosini et al., [42] analyzed a large number of antrochoanal polyps that developed from the mucosa of the maxillary sinus, with predilection for males and a mean age of 40 years. The most common antral cyst in this study was dentigerous cyst, with predilection for females and the third decade of life. Similarly, Buyukkurt et al. [20] have reported three cases of dentigerous cysts surrounding impacted teeth displaced into ectopic positions in the maxillary sinus. Furthermore, this study showed that fibrous dysplasia was the commonest reactive antral lesion, with slight female predilection. This is agrees with previous report of a case of craniofacial fibrous dysplasia in 25 years female involving the right maxillary sinus. [31] This study therefore serves as a baseline finding for the benign, reactive and inflammatory maxillary antral lesions a Nigerian population.

 CONCLUSION



A high prevalence of neoplastic maxillary antral lesions, consisting mostly of malignant lesion was observed in this study. Most of the patients were young adults who presented late for treatment. This study suggested clinical indicators for some antral lesions. Routine histopathological examination of recurrent or persistent maxillary antral lesions is recommended for early detection of malignant lesions or malignant transformations among reactive or benign antral lesions.

References

1Wang X, Shi G, Liu Y, Ji H, He M, Li J, et al. Analysis of the clinical and pathological characteristics of sinonasal neoplasms. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2011;25:1071-5.
2Daryani D, Gopakumar R, Nagaraja A. High-grade mucoepidermoid carcinoma of maxillary sinus. J Oral Maxillofac Pathol 2012;16:137-40.
3Sandler HJ. Clinical update - The teeth and the maxillary sinus: The mutual impact of clinical procedures, disease conditions and their treatment implications. Part 2. Odontogenic sinus disease and elective clinical procedures involving the maxillary antrum: Diagnosis and management. Aust Endod J 1999;25:32-6.
4Mehra P, Murad H. Maxillary sinus disease of odontogenic origin. Otolaryngol Clin North Am 2004;37:347-64.
5Brook I. Microbiology of acute and chronic maxillary sinusitis associated with an odontogenic origin. Laryngoscope 2005;115:823-5.
6Brook I. Sinusitis of odontogenic origin. Otolaryngol Head Neck Surg 2006;135:349-55.
7Mehra P, Jeong D. Maxillary sinusitis of odontogenic origin. Curr Allergy Asthma Rep 2009;9:238-43.
8Chemli H, Mnejja M, Dhouib M, Karray F, Ghorbel A, Abdelmoula M. Maxillary sinusitis of odontogenic origin: Surgical treatment. Rev Stomatol Chir Maxillofac 2012;113:87-90.
9Baĭdik OD, Sysoliatin PG, Logvinov SV, Elizar′eva NL. Morphofunctional changes of maxillary sinus mucosa in odontogenic fungal sinusitis. Stomatologiia (Mosk) 2011;90:14-6.
10Press SG. Odontogenic tumors of the maxillary sinus. Curr Opin Otolaryngol Head Neck Surg 2008;16:47-54.
11Arjona Amo M, Belmonte Caro R, Valdivieso del Pueblo C, Batista Cruzado A, Torres Lagares D, Gutiérrez Pérez JL. Odontogenic myxoma of nasosinusal localization in a pediatric patient. Cir Pediatr 2011;24:118-21.
12Cicconetti A, Bartoli A, Tallarico M, Maggiani F, Santaniello S. Central odontogenic fibroma interesting the maxillary sinus. A case report and literature survey. Minerva Stomatol 2006;55:229-39.
13Bridle C, Visram K, Piper K, Ali N. Maxillary calcifying epithelial odontogenic (Pindborg) tumor presenting with abnormal eye signs: Case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e12-5.
14Abughazaleh K, Andrus KM, Katsnelson A, White DK. Peripheral ameloblastic fibroma of the maxilla: Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e46-8.
15Gadewar DR, Srikant N. Adenomatoid odontogenic tumour: Tumour or a cyst, a histopathological support for the controversy. Int J Pediatr Otorhinolaryngol 2010;74:333-7.
16Nicolai G, Lorè B, Mariani G, Bollero P, De Marinis L, Calabrese L. Central giant cell granuloma of the jaws. J Craniofac Surg 2010;21:383-6.
17Gupta A, Rai B, Nair MA, Bhut MK. Keratocystic odontogenic tumor with impacted maxillary third molar involving the right maxillary antrum: An unusual case report. Indian J Dent Res 2011;22:157-60.
18Friedrich RE, Zustin J. Ameloblastoma of the maxillary sinus 11 years after extirpation of extensive dentigerous cysts and dystopic wisdom tooth. In Vivo 2010;24:567-70.
19Braun T, Ihrler S, Kisser U, Leunig A. Cystic lesion with a displaced tooth in the maxillary sinus. HNO 2011;59:700-4.
20Buyukkurt MC, Omezli MM, Miloglu O. Dentigerous cyst associated with an ectopic tooth in the maxillary sinus: A report of 3 cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:67-71.
21Yoon JH, Na DG, Byun HS, Koh YH, Chung SK, Dong HJ. Calcification in chronic maxillary sinusitis: Comparison of CT findings with histopathologic results. AJNR Am J Neuroradiol 1999;20:571-4.
22Ozcan KM, Ozcan I, Selcuk A, Akdogan O, Gurgen SG, Deren T, et al. Comparison of Histopathological and CT Findings in Experimental Rabbit Sinusitis. Indian J Otolaryngol Head Neck Surg 2011;63:56-9.
23Herrero Laso JL, Acuña García M, Vallejo Valdezate LA, Varela Durán J, Durán Díez C, Guerra Linares JE. Mucocele of maxillary sinus. An Otorrinolaringol Ibero Am 1997;24:293-301.
24Meer S, Altini M. Cysts and pseudocysts of the maxillary antrum revisited. SADJ 2006;61:10-3.
25Hicsonmez A, Andrieu MN, Karaca M, Kurtman C. Treatment outcome of nasal and paranasal sinus carcinoma. J Otolaryngol 2005;34:379-83.
26Khademi B, Moradi A, Hoseini S, Mohammadianpanah M. Malignant neoplasms of the sinonasal tract: Report of 71 patients and literature review and analysis. Oral Maxillofac Surg 2009;13:191-9.
27Triantafillidou K, Dimitrakopoulos J, Iordanidis F, Koufogiannis D. Mucoepidermoid carcinoma of minor salivary glands: A clinical study of 16 cases and review of the literature. Oral Dis 2006;12:364-70.
28Wiseman SM, Popat SR, Rigual NR, Hicks WL Jr, Orner JB, Wein RO, et al. Adenoid cystic carcinoma of the paranasal sinuses or nasal cavity: A 40-year review of 35 cases. Ear Nose Throat J 2002;81:510-4, 516.
29Al-Shaham AA, Samher AA. Cemento-ossifying fibroma of the maxilla. J Plast Surg Hand Surg 2010;44:318-21.
30Buyuklu F, Akdogan MV, Ozer C, Cakmak O. Growth characteristics and clinical manifestations of the paranasal sinus osteomas. Otolaryngol Head Neck Surg 2011;145:319-23.
31Navarro-Munoz S, Rueda-Medina I, Recio-Bermejo M, Del Saz-Saucedo P, Espejo-Martinez B, Garcia-Ruiz R, et al. Recurrent painful ophthalmoplegia secondary to polyostotic fibrous dysplasia of the maxillary sinuses with involvement of the superior orbital fissure. Rev Neurol 2011;52:90-4.
32Habesoglu TE, Habesoglu M, Surmeli M, Uresin T, Egeli E. Unilateral sinonasal symptoms. J Craniofac Surg 2010;21:2019-22.
33Whyte A, Chapeikin G. Opaque maxillary antrum: A pictorial review. Australas Radiol 2005;49:203-13.
34Pignataro L, Mantovani M, Torretta S, Felisati G, Sambataro G. ENT assessment in the integrated management of candidate for (maxillary) sinus lift. Acta Otorhinolaryngol Ital 2008;28:110-9.
35Wright S T, Pou A. Neoplasms of the Nose and Paranasal Sinuses. Grand Rounds Presentation, UTMB, Department of Otolaryngology. Edited by Quinn F B, Jr and Ryan M W, May 19, 2004.
36Arotiba GT. Malignant neoplasms of the maxillary antrum in Nigerians. West Afr J Med 1998;17:173-8.
37Tran L, Sidrys J, Horton D, Sadeghi A, Parker RG. Malignant salivary gland tumors of the paranasal sinuses and nasal cavity. The UCLA experience. Am J Clin Oncol 1989;12:387-92.
38Etýt D, Altinel D, Bayol Ü, Tan A, Türelýk Ö, Çukurova I. Polymorphous low-grade adenocarcinoma located in the maxillary sinus. Turk Patoloji Derg 2012;28:274-7.
39Lee DH, Yoon TM, Lee JK, Lim SC. Polymorphous low-grade adenocarcinoma of the maxillary sinus. J Craniofac Surg 2013;24:e213-4.
40Weber AL, Rahemtullah A, Ferry JA. Hodgkin and non-Hodgkin lymphoma of the head and neck: Clinical, pathologic, and imaging evaluation. Neuroimaging Clin N Am 2003;13:371-92.
41Schoem SR, Morton AL. Paranasal sinus Burkitt′s lymphoma in a human immunodeficiency virus (HIV) positive male. Ear Nose Throat J 1990;69:844-6.
42Frosini P, Picarella G, De Campora E. Antrochoanal polyp: Analysis of 200 cases. Acta Otorhinolaryngol Ital 2009;29:21-6.