Metastatic hepatoma of maxillary sinus with atypical presentationa ns_6119 555..557 Hepatocellular carcinoma (HCC) is the most frequent form of primary liver tumours, which are the third commonest cause of cancer deaths worldwide. Metastasis is a critical prognostic factor and intrahepatic spread occurs much more often than extrahepatic dissemination. The latter targets mainly the lungs, bones and adrenal glands. 1 Metastasis of HCC to the sinonasal region is exceedingly rare, and only 18 cases have been reported so far. 2 Here we report a case of metastatic hepatoma to the maxillary sinus with unilateral otalgia/hearing loss as unusual presenting symptoms.Our patient, a 57-year-old man, presented with a several week history of left-sided ear fullness, hearing loss and nasal congestion. Upon otoscopy, middle ear effusion was noted, and flexible endoscopy revealed a friable necrotic lesion of the left nasal cavity and nasopharynx. The mass extended from the middle meatus, posteriorly to the lateral nasopharyngeal wall and fossa of Rosenmüller. At that time, no cranial nerve deficits were noticed. A subsequent computed tomography (CT) scan showed complete opacification of the left maxillary sinus by a mass with aggressive radiographic features ( Fig. 1). Biopsy of the lesion was positive for moderately differentiated HCC (Fig. 2). The patient had no history of abdominal/ gastrointestinal symptoms. Abdominal and pelvic CT scan demonstrated an ill-defined hepatic mass ( Fig. 3), along with lytic lesions of the T11 vertebra, and the left iliac wing. The remaining metastatic work-up was negative.Manifestations from the maxillary metastasis progressed rapidly to dysphagia, facial swelling, cranial nerve deficits, as well as orbital invasion, and the patient was referred urgently for local radiotherapy to the sinonasal region, followed by chemotherapy. The facial tumour responded by significant regression to the local therapy, but unfortunately the patient expired 11 months after diagnosis due to liver failure.Tumour metastasis to the paranasal sinuses is a rare phenomenon, and the primary neoplasms in order of frequency are of renal, lung and breast origin. Hepatoma has been identified as the source of the sinonasal tumour only in 19 cases, including the present report. Interestingly, all patients are men. Similar to the case described here, the metastatic focus is localized in the maxillary sinus in the majority of reports (7/19, 36.8%), followed by the nasal cavity (6/19, 31.6%). 2 Between these two adjacent subsites, the precise localization of the initial lesion can be challenging, if the carcinoma is advanced on diagnosis.Specifically for the tumours arising inside the maxillary sinus, three-dimensional expansion may affect several nearby craniofacial structures. As Table 1 shows, among all metastatic HCCs to the antrum, the present case demonstrates the greatest extent of spread on presentation, invading the nasopharynx and infratemporal fossa. The magnitude of the tumour is reflected on the initial manifesta t...
