Schwann cell tumor or schwannomas is the benign nerve sheath tumors, which arise mostly from head and neck region and rarely from the nasal and paranasal sinuses. Of these, very few arise solely from the maxillary sinus. This is a case report of a 25-year-old female patient presenting with painful swelling below the right eye turned out to be a rare case of schwannoma arising solely from the maxillary sinus. Details of clinical history, examination, histopathological finding, radiological finding, treatment, and follow-up have been presented

Dixit, Pawan K

Maurya, Malti

Mishra, Brijesh

Upadhyay, Divya Narain

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 130
Case Report
A rare case of schwannoma of maxillary sinus
Pawan K Dixit1, Brijesh Mishra1, Malti Maurya2, Divya Narain Upadhyay1
From 1Post Graduate Department of Plastic Surgery, 2Department of Pathology King George’s Medical University, Lucknow, Uttar Pradesh, India
Correspondence to: Pawan K Dixit, Post Graduate Department of Plastic Surgery, King George’s Medical University, Shah Mina 
Road, Lucknow - 226 003, Uttar Pradesh, India. Phone: +91-7838770179. E-mail: sine.pkd@gmail.com
Received - 12 February 2018 Initial Review - 08 March 2018 Published Online - 24 April 2018
Schwannomas are the tumors of the Schwann cell, which forms the nerve sheath of the peripheral nerve fibers. It is a well-encapsulated mass, clearly circumscribed, and well 
connected to neural tissue of origin. As reported in the literature, 
25–45% cases of schwannoma occur in the head and neck region, 
of which only 2–4% affects the nasal cavity and the paranasal 
sinuses [1,2]. Only 2% of the cases of schwannomas have been 
reported to be malignant, and recurrence occurs in case the tumor 
is incompletely resected [3]. Schwannomas arising solely from 
maxillary sinus are extremely rare. As per the available reports, 
it seems only seven such cases have been reported [4]. We are 
reporting another case of a schwannoma arising solely from the 
maxillary sinus, which will be the eighth case to be reported so 
far.
CASE REPORT
A 25-year-old female presented to the plastic surgery outpatient 
department with complaints of a swelling below the right eye for 
8 months, which was gradually increasing in size and pushing her 
lower eyelid upward. The swelling was slightly painful but was 
not associated with any history of spontaneous rupture, bleeding, 
trauma, nasal blockage, epistaxis, or fever. There was no history 
of any neurological deficit. The patient had a history of Caldwell-
Luc operation done 4 years ago for a radicular cyst on the right 
cheek.
On clinical examination, a 3 cm × 3 cm, firm, well defined, 
mildly tender swelling, extending about 1 cm from medial 
canthus and 2 cm from lateral canthus was present over the right 
infraorbital region (Fig. 1a and b). The swelling was not fixed to 
the skin. Overlying surface of the skin was normal. There was no 
sensory deficit over the right side of the face. Visual acuity was 
normal, but field of vision was decreased inferiorly. We kept the 
differential diagnosis of odontogenic tumors like ameloblastoma, 
fibro-osseous lesions such as fibrous dysplasia, a soft tissue 
neoplasia, and any swelling which arises from that region like a 
radicular cyst. Neurofibroma was also considered as a differential 
during the histopathologic examination.
Magnetic resonance imaging of the face was done which 
showed an ill-defined mixed solid cystic lesion (measuring 2 cm 
× 5 cm × 2.8 cm) displaying signal intensity alteration with solid 
component showing heterogeneous post-contrast enhancement 
with non-enhancing necrotic area, filling the right maxillary 
sinus (Fig. 2). There was evidence of the mild expansion of 
the right maxillary sinus. The lesion was causing an erosion 
of the anterior wall of maxillary sinus with extension into the 
subcutaneous tissue up to the lower eyelid. Incisional biopsy was 
done. On histopathological examination, it was suggestive of 
schwannoma.
After diagnosis, en bloc removal of the tumor with the removal 
of an anterior wall of the maxilla with mucosal lining was performed 
by modified Weber Ferguson approach (Fig. 3a and b). Incision 
was given and deepened up to the bone. Subperiosteal dissection 
was done. The flap was elevated to expose the anterior wall of 
the right maxillary sinus. Intraoperative space-occupying lesion 
was found in the right maxilla. There was an erosion of anterior 
wall of the maxilla, with infiltration by the tumor. The tumor was 
excised along with an anterior wall of the maxilla and mucosal 
lining of the maxillary sinus. Sinus was packed with a saline 
bandage. The wound was then closed in layers. The reflected 
cheek flap was sutured to the normal anatomic site. Excised 
specimen was sent for histopathological examination in the 
department of pathology. Post-operative period was uneventful. 
The saline bandage was removed on post-operative day 2.
ABSTRACT
Schwann cell tumor or schwannomas is the benign nerve sheath tumors, which arise mostly from head and neck region and rarely 
from the nasal and paranasal sinuses. Of these, very few arise solely from the maxillary sinus. This is a case report of a 25-year-
old female patient presenting with painful swelling below the right eye turned out to be a rare case of schwannoma arising solely 
from the maxillary sinus. Details of clinical history, examination, histopathological finding, radiological finding, treatment, and 
follow-up have been presented.
Key words: Antoni A and B, Maxillary sinus, Schwannoma, Verocay bodies
Dixit et al. Schwannoma of maxillary sinus origin
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 131
Final histopathological findings revealed compact 
hypercellular Antoni A areas and myxoid hypocellular Antoni B 
areas. Hypercellular areas had spindle-shaped cells with wavy 
nuclei with the tapered end and ill-defined cytoplasm. Verocay 
bodies were also seen in the hypercellular areas. Hypocellular 
areas were showing hyalinized blood vessels (Fig. 4).
DISCUSSION
Benign schwannoma, also known as neurilemomas or 
neurinomas, is the tumors arising from nerve sheath. Common 
sites for schwannoma are the head and neck region, especially 
the lateral cervical region and mouth. Furthermore, intraorally, 
the tongue is a frequent site of the tumor to grow. Nasal cavity 
and paranasal sinuses are not common sites for the occurrence 
of this tumor [5]. Intranasal nerves, ophthalmic, and maxillary 
division of the trigeminal nerve and branches of an autonomic 
nervous system are the probable site for developing schwannoma 
in the nose and paranasal sinuses. The nerve giving rise to 
schwannoma may not be always identifiable. There seems to be 
no sex predilection and the tumor can occur at any age. Although 
among the previously reported seven cases of schwannomas 
arising solely from the maxillary sinus, five were reported in 
females and our patient is also a female. Schwannomas usually 
remain asymptomatic until they attain enormous size. Symptoms 
related to the site of involvement and also whether malignant 
transformation has occurred or not [6].
Our case was a 25-year-old female, presenting with a painful 
swelling below the right eye for 8 months which gradually increased 
in size. Lesions of maxillary sinus give rise to pain, whereas tumor 
of the nose and ethmoid sinus usually presents with epistaxis. Nasal 
blockage, rhinorrhea, hyposmia, exophthalmos, neuronal deficit, 
and facial swelling may be the other symptoms [7,8].
The gold standard for diagnosis of any lesion still remains 
to be the histopathological examination, which in this patient 
revealed compact hypercellular Antoni A areas and myxoid 
hypocellular Antoni B areas. Previous literature has mentioned 
about the typical biphasic pattern seen in schwannoma, 
consisting of Antoni type A and B areas [9]. Verocay bodies 
were also seen in the hypercellular areas. Verocay bodies were 
first described by Verocay in 1910 and are considered to be the 
diagnostic of schwannoma [10]. Verocay body is comprised a 
stacked arrangement of two rows of elongated palisading nuclei, 
alternating with cellular zones which are made up of cytoplasmic 
processes of Schwann cells (Table 1).
Differentiation between schwannomas and other similar 
looking lesions, for example, leiomyosarcomas and fibrosarcomas 
can be done by immunohistochemical demonstration of laminin 
in the tumor. The immunohistochemical staining using marker 
S-100 protein was positive. This is a neural crest marker antigen 
and it confirms the diagnosis of schwannoma [11].
There is a rare chance of the tumor turning into malignant 
one. Complete surgical removal of the tumor mass remains the 
treatment of choice and the choice of surgical procedure depends 
on the site and size of the tumor. In this patient, en bloc removal 
of the tumor was done by modified Weber Ferguson approach. 
The post-operative period was uneventful, and the patient was 
discharged with antibiotics and analgesics. No complications 
were reported at 1, 3, and 6-month follow-up.
Figure 2: Magnetic resonance imaging showing solid lesion filling 
right maxillary sinus
Figure 1: Swelling below right eye. (a) Front view, (b) lateral view
Figure 4: Schwannoma: (a) Showing both cellular areas with Verocay 
bodies (arrow) and myxoid hypocellular areas (H and E, ×100). 
(b) Diffuse positivity shown for S-100, ×100
a
Figure 3: (a) Weber Ferguson approach, (b) excised specimen
b
ba
ba
Dixit et al. Schwannoma of maxillary sinus origin
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 132
A successful en bloc removal of the tumor minimizes the 
chances of recurrence of the tumor. Since in our patient, the 
tumor was benign; therefore, there was no role of radiotherapy or 
chemotherapy [12]. Prognosis for benign tumor remains good, as 
in our patient, and she responded well to the treatment provided.
CONCLUSION
Schwannoma of the maxillary sinus is a rare clinical entity. 
Complete excision of the tumor is the treatment of choice for 
a benign schwannoma with good prognosis and with minimal 
chance of recurrence.
REFERENCES
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Table 1: Review of previously reported cases9
Case Age/sex Symptoms Lesion Follow-up Authors
1 60/F Unavailable Schwannoma (plexiform neurofibromatosis) None Stout (1935)
2 42/F Pain Malignant schwannoma 7 months Millard and Bushar (1952)
3 24/F Pain Schwannoma 16 months Debin et al. (1961)
4 38/F Enlarging mass, exophthalmos Schwannoma 12 months Cross (1967)
5 45/M Unavailable Schwannoma (plexiform neurofibromatosis) 7 years Robitale et al. (1975)
6 17/M Proptosis Schwannoma 6 months Sanjay Khanna et al. (2003)
7 60/F Swelling, fever Schwannoma 3 months Oshin Hegde (2016)
8 25/F Pain, swelling Schwannoma 6 months Present authors
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Dixit PK, Mishra B, Maurya M, Upadhyay DN. 
A rare case of schwannoma of maxillary sinus. Indian J Case Reports. 
2018;4(2):130-132.


A rare case of schwannoma of maxillary sinus

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A rare case of schwannoma of maxillary sinus

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