Complex odontoma of the nasal cavity: a case report.

Abstract

We describe the case of a 76-year-old man who presented with symptoms of chronic nasal obstruction and recurrent sinusitis of many years' duration. The patient's history and radiographic findings established a diagnosis of a complex odontoma of the nasal cavity. The mass was surgically excised, and the diagnosis was confirmed by histopathology. The occurrence of an odontoma in the nasal cavity is extremely rare.

Introduction

Odontomas represent approximately 22% of all odontogenic tumors. (1) They are not true neoplasms; rather, they are hamartomas that form from the growth of completely differentiated epithelial and mesenchymal cells that give rise to ameloblasts and odontoblasts. (2) They are usually discovered in the maxilla or mandible.

In this article, we describe a case of a complex odontoma of the nasal cavity that was surgically removed. The occurrence of an odontoma in this location is extremely rare. In addition, we discuss the characteristics of compound and complex odontomas in general.

Case report

A 76-year-old man presented to the otorhinolaryngology clinic at New York-Presbyterian Hospital with a chief complaint o fright-sided nasal obstruction of many years' duration. The obstruction had contributed to recurrent and continuously worsening sinusitis and a foul odor.

Clinical examination of the right nasal cavity detected a hard calcified mass in the middle meatus. Computed tomography (CT) of the head demonstrated an irregular, radiopaque mass in the right nasal cavity (figure 1). The borders of the lesion were well defined and surrounded by a radiolucent zone. In addition, the images showed chronic sinusitis. Magnetic resonance imaging (MRI) of the face supported the CT findings (figure 2). The mass was diagnosed as a complex odontoma.

The patient underwent endoscopic surgery for removal of the tumor, and his postoperative course was uneventful. The histopathologic analysis confirmed the diagnosis, as the tumor exhibited a haphazard arrangement of enamel, dentin, cementum, and pulp (figure 3). The patient's symptoms abated, and he exhibited no evidence of recurrence on follow-up.

Discussion

Most odontomas are asymptomatic and are not discovered until the second and third decades of life on routine jaw radiography or as a failed eruption of a permanent tooth? The reason for the general absence of symptoms is that odontomas grow slowly and do not cause any significant bony expansion. However, in our patient, the unusual location in the nasal cavity induced chronic sinusitis.

Odontomas contain enamel, dentin, cementum, and pulp. The World Health Organization has subclassified odontomas as compound and complex on the basis of morphologic characteristics. (4) Compound odontomas are characterized by a central core of pulp that is encased in a shell of dentin and partially covered by enamel. Complex odontomas appear as a disorganized mass; they are less common than compound odontomas.

Compound odontomas often occur in the incisor and canine areas of the maxilla. Complex odontomas are usually located in the first and second molar areas of the mandible or the anterior maxilla? Both types are usually present only in bone tissue, but in rare cases they have erupted into the oral cavity. (3)

Radiographically, both compound and complex odontomas appear as clearly outlined, dense radiopaque lesions surrounded by a thin zone of radiolucency. (5) Compound odontomas resemble normal teeth of various shapes and sizes, but complex odontomas appear as amorphous masses.

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Although the growth potential of odontomas is limited, they should be removed because they contain elements that can predispose to cyst formation, cause bone destruction, and interfere with the eruption of permanent teeth. The treatment of choice is surgical enucleation, as there is little or no risk of recurrence. (2) Removal of the tumor is often easy because it is surrounded by soft follicular connective tissue rather than bone. Any apparent recurrence should raise suspicion of an ameloblastic tumor, which requires more aggressive treatment.

The differential diagnosis of benign odontogenic tumors is based on a comparison of the degrees of tissue morphodifferentiation and histodifferentiation. It includes ameloblastoma, odontogenic myxoma, adenomatoid odontogenic tumor, calcifying epithelial odontogenic tumor (Pindborg tumor), calcifying odontogenic cyst (Gorlin cyst), ameloblastic fibroma, ameloblastic fibro-odontoma, compound odontoma, and complex odontoma. (2) The diagnosis in our case was based on the history and radiographic findings and confirmed by histology.

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References

(1.) Bhaskar SN. Synopsis of Oral Pathology. 6th ed. St. Louis: Mosby; 1981:279-84.

(2.) Cummings CW, Flint PW, Haughey BH, et al, eds. Otolaryngology--Head & Neck Surgery. 4th ed. St. Louis: Mosby; 2005:1528.

(3.) Hisatomi M,Asaumi JI, Konouchi H, et al. A case of complex odontoma associated with an impacted lower deciduous second molar and analysis of the 107 odontomas. Oral Dis 2002;8(2):100-5.

(4.) Kramer IR, Pindborg JJ, Shear M. The WHO Histological Typing of Odontogenic Tumours. A commentary on the Second Edition. Cancer 1992;70(12):2988-94.

(5.) Goaz PW, White SC. Oral Radiology: Principles and Interpretation. St. Louis: Mosby; 1987:533-40.

Michelle Soltan, MD; Ashutosh Kacker, MD

From the Department of Otorhinolaryngology, Weill Medical College of Cornell University/New York-Presbyterian Hospital, New York City.

Corresponding author: Ashutosh Kacker, MD, 1305 York Ave., 5th Floor, New York, NY 10021. Phone: [phone]; fax: [phone]; e-mail: [e-mail]