Forum for Clinical and Surgical Oral Pathology

Case BBOPF 10-1

Dr. Brian Shumway (University of Louisville, Kentucky, USA) is requesting your opinion. Please send your comments in the window located below the images. This case will be posted from March 6-13, 2010. A summary of the responses will be posted in BBOP.

Clinical History

This is a 52yr old caucasian female with a history of right maxillary sinus augmentation with Bio-Oss graft material 2-3 yrs previously. She now presents with a cloudy sinus on PANX. The surgeon reported loose Bio-Oss material and a thickened sinus membrane. The patient has no reported systemic conditions. From these sections this is what I see: chronic sinusitis, bacteria, and fungal microorganisms (I will suggest they culture the patient as per our microbiologist's recommendations).

The polarizable and eosinophilic materials are what have me confused. I think that the polarizable material is calcium oxalate (none of the local labs do an oxalate stain- I could send to Mayo if this is necessary to confirm) as it seems similar to what I have seen in the literature and it would go along with the fungus present. The eosinophilic material doesn't look like Bio-Oss from the limited articles I could find that show its histologic appearance. While there were no eosinophils in the biopsy, I did a trichrome as this is reported to highlight Charcot Leydon crystals. The material stains bright red but I am not seeing the bipyramidal forms that are reported. There seem to be many different forms that weren't very evident on H&E. I wondered if this was some other type of graft material and maybe the history was inaccurate.

Does anyone know what 2 types of material I may be dealing with and is there a stain that can be done and is it necessary to confirm?

Thanks to anyone who can provide insight.

Sincerely,

Brian Shumway DDS, MS
Oral and Maxillofacial Pathology
University of Louisville

Images

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[Click for a larger image]	Photomic #1- The H&E biopsy shows (#1) inflamed antral mucosa with chronic inflammation in the submucosa (no eosinophils were noted).
[Click for a larger image]	Photomic #2- Also seen are numerous basophilic bacteria (top and far right), a refracticle/clear/polarizable crystalline material (center), an eosinophilic, non-polarizable material (center and left) and pale-staining material suggestive of fungal organisms (clear area- far left).
[Click for a larger image]	Photomic #3- polarized light image showing crystalline material (hexagonal configuration was focally noted- in center) and non-polarized eosinophilic material
[Click for a larger image]	Photomic #4- polarized light showing floret-type arrangement of crystalline material
[Click for a larger image]	Photomic #5- Additional H&E images of the eosinophilic, non-polarizable material- arranged in cylindrical, polygonal, needle-shapes of varying sizes.
[Click for a larger image] [Click for a larger image]	Photomic #6, 7- Trichrome staining highlights the eosinophilic material as bright red and accentuates the variety of appearances.
[Click for a larger image]	Photomic #8- GMS stain showed septated, branching, filamentous hyphae. Our microbiologist said that this could be aspergillus or a number of other species and that culture was indicated.

Addendum [Click for a larger image] [Click for a larger image] [Click for a larger image] Radiographic Interpretation: Chronic sinusitis, right antrum. Possible perforation of implant into right maxillary sinus Possible fenestration of bone over implant fixture replacing tooth #4

Case prepared by Dr. Alfredo Aguirre (BBOP Manager) and Daniel Emmer (Web Administrator, University at Buffalo School of Dental Medicine).