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Atopy, proptosis, and nasal polyposis
  1. V Rupaa,
  2. M Jacobb,
  3. M S Mathewsc
  1. aChristian Medical College and Hospital, Vellore, India: Department of Ear, Nose, and Throat, bDepartment of General Pathology, cDepartment of Microbiology
  1. Dr V Rupa, Department of ENT, Christian Medical College and Hospital, Vellore-632004, Indiarupavedantam{at}hotmail.com

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A 24 year old women presented with a history of increased prominence of the right eye and right sided headache of two months' duration. She had a two year history of recurrent, right sided nasal obstruction. She had undergone nasal polypectomy on two occasions previously at a local hospital. There was no history of diminution in vision, diplopia, fever, seizures, loss of consciousness, or epistaxis. She was not a diabetic, hypertensive, or asthmatic. There was a strong history of atopy.

On examination, she was found to be alert and afebrile. There was right sided proptosis. Fundoscopy and vision were normal. Nasal examination revealed multiple pale glistening polyps filling the right nasal cavity appearing to arise from the middle and superior meatus bilaterally. Computed tomography (fig 1) of the paranasal sinuses showed a hypodense mass filling the right anterior and posterior ethmoids, maxillary, frontal, and sphenoid sinuses bilaterally. The mass had eroded the floor and roof of the frontal sinus and roof of ethmoid sinus without dural invasion. The lamina papyraceae was thinned out. The mass extended into the superior part of the orbit but there was no optic nerve compression. Irregular hyperdense areas were seen within the mass.

Figure 1

Computed tomography of paranasal sinuses showing hypodense soft tissue masses filling right ethmoid and maxillary sinuses and expanding right ethmoid sinuses with thinning of lamina papyraceae and erosion of the roof; hyperdense areas representing allergic mucin are seen within the mass.

Blood tests results were normal except for eosinophilia (13%). The patient underwent excision of the nasal mass via a lateral rhinotomy approach using a Lynch-Howarth incision. This approach was preferred over an endoscopic approach because of better access to the frontal sinus. Operative findings included the presence of multiple polyps interspersed with clumps of blackish-brown material with a peanut butter-like consistency (allergic mucin) filling the ethmoid and sphenoid sinuses bilaterally. The excised specimen was sent for histopathology and fungal culture. The histopathological appearance was diagnostic (fig 2). Aspergillus flavus was isolated on fungal culture. Postoperatively, she had complete resolution of proptosis, nasal obstruction, and headache.

Figure 2

Haematoxylin and eosin stained section of allergic mucin showing eosinophilic mucin with layers of necrotic cells and fungal hyphae; there is no tissue invasion.

Questions

(1)
What is the diagnosis?
(2)
What is allergic mucin?
(3)
What is the pathophysiology of the disease?

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