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Clinical Problem Solving: Pathology
February 2004

Pathology Quiz Case 2—Diagnosis

Author Affiliations
 

FREDERIC B.ASKINMDWILLIAM H.WESTRAMD

Arch Otolaryngol Head Neck Surg. 2004;130(2):241-242. doi:10.1001/archotol.130.2.241

Adenocarcinoma, which accounts for 10% to 20% of all primary malignancies of the nasal cavity and adjacent sinuses, most commonly arises from minor salivary or seromucinous glands.1,2 Intestinal-type adenocarcinoma (ITAC) is a rare subtype that accounts for approximately 4% of all sinonasal adenocarcinomas.3 It appears to be unrelated to salivary gland neoplasia2 and may arise from mucus-secreting ("cylinder") cells of the respiratory mucosa. Sinonasal ITAC has been recognized as a specific disease entity for a century, but a significant association was made between ITAC and industrial wood exposure only 40 years ago, with a 500- to 1000-fold increase in risk for long-time woodworkers compared with the general population.4 Our patient had a significant history of wood-dust exposure through his past profession as well his recent hobby and had been personally building a home shortly before presenting to the emergency department. Patients with such exposure account for about 20% of cases,1 and occupational cases show a strong tendency to arise in the ethmoidal sinuses.1,5 For all ITAC cases combined, the reported sites are the ethmoidal sinuses (40%), nasal cavity (28%), maxillary antrum (23%), and indeterminate (9%).1 Hadfield5 proposed that inhaled dust particles induce squamous metaplasia, with subsequent impairment of mucociliary clearance, thereby increasing the mucosal exposure to the presumed, but unknown, carcinogen within the wood.1 This theory remains unproved. Schmid et al6 proposed that ITACs develop from displaced endoderm similar to that in the intestine, providing a feasible embryologic explanation for the histologic similarity to intestinal tissue, although this hypothesis is controversial.

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