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the description of extragnathic odontogenic sinonasal myxoma is rarely reported in the literature ( 1 ) .
it represents a benign neoplasm of uncertain histogenesis , which often infiltrates through medullary spaces , and is characterized by certain histologic features , notably , the absence of mitotic figures .
we report on a case of extragnathic odontogenic sinonasal myxoma with mitotic features in a male patient .
a 37 year - old gentleman was referred to the otolaryngology clinic with left nasal discharge for six months .
the patient had suffered with an upper respiratory tract infection , which persisted despite several courses of antibiotics .
the patient went on to develop facial pain and fullness in the left side despite conservative management .
computed tomography of the patient preoperatively fibreoptic nasendoscopy revealed a deviated nasal septum with significant oedema of the left middle turbinate with copious purulent secretions emanating from the left middle meatus .
he was started on topical fluticasone propionate nasules in addition to long - term antibiotics .
intraoperative image of recurrence along the maxillary antrum axial computed tomography scans with coronal reformats were acquired through the paranasal sinuses .
there was complete opacification of the left maxillary sinus with obscuration of the osteomeatal complex .
the postnasal spaces were equal and symmetrical and there was no evidence of focal bony destruction .
microphotograph of the biopsy specimen from the mass showing characteristic spindle cells amid the myxoid stroma , consistent with the diagnosis of myxoma the radiological findings correlated with the clinical observations and the patient underwent functional endoscopic sinus surgery ( fess ) to drain the large septic collection in the left maxillary antrum .
the operative findings included significant septic secretions within the left middle meatus and gelatinous soft tissue within the left maxillary antrum , which was sent for histological analysis .
the infection was managed with appropriate antibiotics according to sensitivities , in addition to steroid nasules .
the histological examination revealed a lesion in which bland spindle cells and occasional stellate cells are embedded within a myxoid stroma .
the cells were uniform , cytologically bland and spindle shaped or stellate with a normal chromatin pattern . there were occasional mitotic features but no cytological atypia .
part of a thin bony septum was included and the lesional tissue abutted the bone surface without any evidence of osteoblast or bone formation , or resorption .
immunostaining of the spindle cells was positive for sma and negative for cam 5.2 , ck5/6 , p63 , s100 , smm , desmin , cd31 , or cd34 .
the specimen was examined by several consultant pathologists and sent for a second opinion in light of the presence of mitotic features within the sample , which is otherwise consistent with sinonasal myxoma .
histologic appearance of the specimen indicative of mitotic features in a loose and myxomatous stroma following discussion by the multi - disciplinary team , a working diagnosis of sinonasal myxoma was agreed upon with recommendation for a left caldwell - luc antrostomy , leading to extensive excision of the mass .
the ethmoid biopsy , left posterior ethmoid air cell , and left sphenoid sinus mucosa specimens all include normal respiratory type epithelium with mildly inflamed and oedematous underlying stroma .
there was evidence of possible recurrence along the posterior and lateral wall of the maxillary sinus at routine follow - up .
examination under anaesthesia was performed with 0 , 45 , and 70 degrees scopes respectively .
this revealed recurrence in the posterior wall of the maxillary antrum , which was debrided to a shell of bone .
passage of the 70 degree scope through the canine fossa puncture demonstrated a further mass of abnormal mucosa which was completely debrided along the floor of the orbit .
there were no postoperative complications , and follow - up was arranged for a month thereafter .
odontogenic myxomas are rare , benign neoplasms apparently arising from the mesenchymal portion of the tooth - forming unit known as the dental papillae / dental sac .
the incidence is equal in males and females and these tumours occur over a wide age range but are generally seen in the second and third decades of life .
extragnathic tumours are uncommon and primarily involve the sinonasal tract ; specifically , the maxillary sinus ( antrum ) is most often involved with secondary extension into the nasal cavity .
when symptoms of nasal congestion , epistaxis , or obvious distortion of the face start to occur , these tumours are more advanced , with evidence of bony erosion .
histologically , these tumours show a scant , loosely cellular proliferation consisting of stellate or spindle - shaped cells with a prominent mucoid intercellular substance .
though these tumours are slow - growing , they often behave in an aggressive ( infiltrating ) manner .
metastasis does not occur , and should place the diagnosis in serious doubt as the lesion probably represents a myxoid sarcoma of some type .
recurrence has been reported in a review of 17 paediatric cases with myxoma reported between 1949 and 1987 , following enucleation but not radical surgery ( 2 ) .
benign myxomas have high recurrence rates ( 25% ) , which may be within two years or much later , but despite this the prognosis is good depending on the anatomical location ( 3,4 ) . their local aggressiveness and ability to erode bone should not be underestimated , and they should be totally removed where possible via en - bloc surgical resection with a 1 cm margin ( 5 ) .
discussion of suspected cases within a multidisciplinary team is recommended given the tumour 's infiltrative nature , the need for an accurate histological diagnosis , radiological interpretation , and adequate surgical exposure and clearance .
extragnathic odontogenic sinonasal myxomas can occur with or without mitotic features , unlike previously thought .
we report on the first case in the literature of such a case with mitotic features on microscopic examination .
recommendations on removal of medullary bone past the radiographic borders vary , but 0.5 to 1 cm of medullary bone appears to be prudent .
we present the first - ever documented evidence of mitotic figures in a case of sinonasal myxoma diagnosed in a 37 year - old gentleman . 
 a 37 year - old gentleman was referred to the otolaryngology clinic with left nasal discharge for six months . 
 preoperative images demonstrated obstruction of the left nasal airway with complete opacification of the left maxillary sinus , obscuration of the osteomeatal complex , as well as expansion and thinning of the medial wall of the maxillary antrum . 
 the patient underwent diagnostic funtional endoscopic sinus surgery ( fess ) , therapeutic left caldwell - luc antrostomy , and revision fess following recurrence . 
 the patient was symptom - free at routine follow - up post - op . 
 there has been much debate as to whether the absence of mitotic features in a specimen is absolutely necessary in order to confirm the diagnosis . 
 we postulate that the presence of mitoses is an unusual diagnostic feature in extensive sinonasal myxoma .