Sinonasal Diffuse Large B-Cell Lymphoma Masquerading as Refractory Sinusitis
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. However, primary involvement of the sinonasal tract is rare and frequently presents with nonspecific symptoms that closely resemble chronic rhinosinusitis. Because sinonasal DLBCL often lacks classic systemic lymphoma symptoms at presentation, diagnosis may be delayed while patients undergo repeated courses of empiric medical therapy for presumed inflammatory or infectious disease. This delay can allow progressive local invasion into adjacent structures before tissue diagnosis is obtained. Recognition of atypical clinical and radiographic features is essential to facilitate timely biopsy, accurate diagnosis, appropriate staging, and prompt initiation of systemic therapy.
Materials and Methods/Case Presentation/Objective:
A 68-year-old woman with a history of hypertension, hyperlipidemia, Graves' disease status post radioactive iodine therapy, and recently diagnosed breast cancer undergoing radiation therapy presented with persistent right-sided nasal congestion, facial pain, and pressure despite multiple courses of antibiotics, intranasal corticosteroids, and systemic corticosteroids. Her symptoms progressively worsened over several weeks without clinical improvement. Computed tomography of the paranasal sinuses demonstrated complete opacification of the right maxillary sinus with mass-like expansion, erosion into the right nasal cavity, extension into the ethmoid air cells, pterygopalatine fossa, and orbital floor with displacement of the extraocular muscles. Given these aggressive imaging findings, nasal endoscopy was performed and revealed a large obstructive right nasal cavity mass. The patient subsequently underwent image-guided right total ethmoidectomy and maxillary antrostomy with complete excision of the lesion for definitive histopathologic evaluation.
Results/Description/Main Outcome Measure(s):
Histopathologic analysis demonstrated diffuse large B-cell lymphoma involving the sinonasal tract. The patient recovered without postoperative complications and was referred to medical oncology for comprehensive staging, including evaluation for additional sites of disease, and initiation of systemic chemoimmunotherapy.
Conclusion(s).:
This case illustrates how extranodal DLBCL may present with symptoms clinically indistinguishable from chronic sinusitis until progressive local invasion and destructive imaging findings prompt biopsy. Unilateral disease, failure of standard medical therapy, and radiographic evidence of bony erosion, orbital extension, and invasion of adjacent anatomic spaces were key indicators of an underlying malignant process requiring urgent evaluation. Sinonasal DLBCL should remain an important diagnostic consideration in patients with persistent unilateral sinonasal symptoms that fail conventional treatment, particularly when imaging demonstrates aggressive features such as bony destruction or orbital involvement. Early recognition of clinical and radiographic red flags, combined with prompt endoscopic biopsy and histopathologic confirmation, is critical for establishing the diagnosis, preventing further local progression, and expediting oncologic management. Increased awareness of sinonasal lymphoma among primary care physicians, otolaryngologists, radiologists, and oncologists may reduce diagnostic delays and improve patient outcomes through earlier staging and timely initiation of appropriate chemoimmunotherapy.
Trademarked Items:
References:
