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A Case of Persistent Frontal Swelling

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An 85-year-old woman with a history of arthritis, hypercholesterolemia, hypertension, and glaucoma presented to the clinic for evaluation of chronic sinusitis. Symptoms included a several-year history of frontal pain, pressure, clear nasal discharge, and progressive nontender facial swelling above her glabella. She denied nasal disturbance, prior sinus surgery, asthma, or acetylsalicylic acid (aspirin) sensitivity. Symptoms were refractory to treatment with several rounds of oral antibiotics and oral steroids. Physical examination findings revealed symmetric facial movement with prominent glabellar swelling and soft tissue thickening. Nasal endoscopy findings revealed a soft tissue mass anterior to the axilla of the middle turbinates bilaterally, with normal-appearing mucosa overlying. Computed tomography and magnetic resonance imaging (MRI) scans were obtained for further evaluation (Figure, A). Recommendations were made to proceed to the operating room for biopsy of the nasal mass. Pathology results revealed uniform, epithelioid cells arranged in a whorled, lobulated growth pattern without atypia, necrosis, increased cellularity, or diffuse growth pattern (Figure, B and C).

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C. Sinonasal meningioma

Pathology results showed characteristic whorled meningothelial arrangement of cells with round to oval spindle-shaped nuclei, low mitotic activity, and presence of intranuclear cytoplasmic inclusions and psammoma bodies. Pertinent immunohistochemistry stains included positive epithelial membrane antigen, and negative cytokeratins, smooth muscle actin and synaptophysin; S100 may be weakly positive. Pathology results were confirmatory for sinonasal meningioma.

Meningiomas are the most common primary central nervous system tumors and account for approximately one-third of all primary brain and spinal tumors.1 Risk factors for meningiomas include ionizing radiation exposure, genetic predisposition, obesity, and hormonal factors (as suggested by a higher incidence in postpubertal women compared with men). Meningiomas are classified by the World Health Organization (WHO) with the general basis of WHO grade 1, 2, or 3 as being benign, atypical, or malignant tumors, respectively.2

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Article Information

Corresponding Author: Amrita Ray, DO, MPH, Department of Otolaryngology–Head and Neck Surgery, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 (amritasray@gmail.com).

Published Online: July 30, 2020. doi:10.1001/jamaoto.2020.1610

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We would also like to thank Scott Stringer, MD, University of Mississippi Medical Center, for his editing assistance with the manuscript. He was not compensated for this contribution.

References
1.
Park  JK . Epidemiology, pathology, clinical features, and diagnosis of meningioma. UpToDate. Accessed July 1, 2020. https://www.uptodate.com/contents/epidemiology-pathology-clinical-features-and-diagnosis-of-meningioma
2.
Buerki  RA , Horbinski  CM , Kruser  T , Horowitz  PM , James  CD , Lukas  RV .  An overview of meningiomas.   Future Oncol. 2018;14(21):2161-2177. doi:10.2217/fon-2018-0006 PubMedGoogle ScholarCrossref
3.
Thompson  LD , Gyure  KA .  Extracranial sinonasal tract meningiomas: a clinicopathologic study of 30 cases with a review of the literature.   Am J Surg Pathol. 2000;24(5):640-650. doi:10.1097/00000478-200005000-00002 PubMedGoogle ScholarCrossref
4.
Mattox  A , Hughes  B , Oleson  J , Reardon  D , McLendon  R , Adamson  C .  Treatment recommendations for primary extradural meningiomas.   Cancer. 2011;117(1):24-38. doi:10.1002/cncr.25384PubMedGoogle ScholarCrossref
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