Osseous mass in a maxillary sinus of an adult male from the 16th–17th-century Spain: Differential diagnosis
Introduction
The maxillary sinus is the largest of the four paranasal sinuses and, being anatomically adjacent to the dentate region of the maxilla, is a frequent source of pathological modification. Calcifications or formation of new bone are characteristic of lesions of the maxillary sinus and include osteosarcoma, chondrosarcoma, as well as calcifying and osteoblastic tumors. However, the site of origin is not necessarily the epicenter of the lesion (Farman and Nortjé, 2007). The maxillary sinus constitutes a path of least resistance for the growth of other maxillary lesions, such as cysts and benign neoplasms. Large benign tumors and cysts might be present without resulting in clinically perceptible maxillofacial expansion (Neville et al., 2016).
Osseous masses in the maxillary sinus have rarely been described in the osteoarchaeological literature. Although some bone tumors or tumor-like lesions have been reported in the maxillofacial region in archaeological skeletal remains (Assis et al., 2018), only three cases have been described within the maxillary sinus (Colard et al., 2008; Silva and Wasterlain, 2010; Nicklisch et al., 2018). However, it is believed that a similar range of prevalence of bone tumors affected past and present populations (Marques et al., 2018). The lower frequencies reported for past populations may be due to three main reasons: first, the frequency of bone tumors may have been lower due to the lower average life expectancy up to the 20th century (Nicklisch et al., 2018); second, not all neoplastic diseases leave traces on or in the bone, therefore missed by paleopathologists (Marques et al., 2018); and third, pathological conditions in the osteoarchaeological literature may be more difficult to differentially diagnose (Marques et al., 2018).
The scarcity of similar cases in the paleopathological literature, and the fact that such osseous masses represent a diagnostic challenge owing to the absence of histopathological analysis, makes differential diagnosis based on macroscopic and radiological characteristics relevant. This paper aims to undertake differential diagnosis of an osseous mass found within the left maxillary sinus of an adult male cranium from the cemetery of the San Salvador de Palat de Rey church in León, northwestern Spain (Fig. 1), and to assist with diagnosis in osteoarchaeological studies.
Section snippets
Archeological context
The San Salvador de Palat de Rey church is located in the historic center of the city of León, northwestern Spain (Fig. 1). This church is considered the oldest in the city. It was built by King Ramiro II “El Grande” (931/32-951 AD) in the second quarter of the 10th century, and was integrated into a monastic complex for his daughter Elvira next to the Royal Palace (Flórez, 1756). In 1215, being part of one of the most important way-stations on the pilgrimage route of Saint James of
Biological profile
The cranium PRII5 is that of a 30+-year-old male of European Ancestry (Affiliation = 1; p-value = 0.70; Accuracy = 0.94; Positive Predictive Value = 0.90). Male sex was obtained by both the morphological analysis and the discriminant function analysis. In fact, the latter indicated a 90 % probability of this cranium being that of a male.
Oral pathology
The maxillae were relatively well preserved (Fig. 1, Fig. 2). Twelve teeth were lost ante-mortem, leaving the alveolar sockets in different stages of
Discussion
Establishing a diagnosis in paleopathology, although important, is a complex procedure. The key features used to narrow down the etiological possibilities for the lesion under investigation were its macroscopic characteristics, anatomical distribution, radiographic features, as well as the individual sex, age and ancestry. The modified Istanbul Terminological Framework (Appleby et al., 2015) was adopted to aid reporting of the differential diagnosis.
Conclusions
Although differential diagnosis of the paleopathological lesions described in this study is limited, the macroscopic and radiological features of the reported osseous mass are highly consistent with a diagnosis of ossifying fibroma. During life, the León individual may have presented facial signs associated with the expansion of the tumor occupying the left maxillary sinus, such as swelling, unilateral proptosis with diplopia, persistent nasal obstruction, rhinorrhea and epiphora, as well as
Declaration of Competing Interest
The authors state that they do not have any conflict of interest to declare.
Acknowledgements
The authors thank the Centro de Investigação em Antropologia e Saúde (CIAS), Medical Image Unit - Centro Hospitalar e Universitário de Coimbra, and Erasmus + Program. Laura González-Garrido thanks Fernando Miguel Hernández and Museo de León for the access to the archaeological documentation, and Dr. Luis Caro Dobón and Dra. Humildad Rodríguez Otero for their support. Sofia N. Wasterlain was financed by national funds from the FCT - Fundação para a Ciência e Tecnologia, project grant reference
References (59)
- et al.
Fibro-osseous and other lesions of bone in the jaws
Radiol. Clin. N. Am.
(2018) - et al.
Increasing confidence in paleopathological diagnosis - application of the Istanbul terminological framework
Int. J. Paleopathol.
(2015) - et al.
Is it a cystic or a cyst-like condition? Discussing the etiology of an unusual large mandibular lesion in a Roman skeleton from Quinta da Torrinha/Quinta de Santo António (Almada, Portugal)
Int. J. Paleopathol.
(2018) - et al.
Cementoblastoma: an innocuous neoplasm? A clinicopathologic study of 44 cases and review of the literature with special emphasis on recurrence
Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod.
(2002) - et al.
Juvenile ossifying fibroma of the jaws and paranasal sinuses: a systematic review of the cases reported in the literature
Int. J. Oral Maxillofac. Surg.
(2020) Maxillofacial fibro-osseous lesions
Clin. Radiol.
(2015)- et al.
Absence of evidence or evidence of absence? A discussion on paleoepidemiology of neoplasms with contributions from two Portuguese human skeletal reference collections (19th-20th century)
Int. J. Paleopathol.
(2018) - et al.
Frontal sinus osteoma in a 16th century skeleton from Zagreb, Croatia
Int. J. Paleopathol.
(2013) - et al.
Paleopathological evidence of paranasal lesions: two cases of frontal sinus osteomata from Imperial Rome
Int. J. Paleopathol.
(2018) - et al.
A rare case of osteoblastoma from medieval Tuscany
Lancet Oncol.
(2018)