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Case 5

JM Bonnin1, J Savage2

1Department of Pathology and Laboratory Medicine and 2Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA


A 73-year-old female presented with a 6-month history of paresthesia involving the right infraorbital, maxillary, and nasolabial regions and a 3-day history of diplopia. MR imaging revealed a mass extending from right Meckel's cave into the pterygopalatine fossa and through the inferior orbital fissure. On examination, the extraocular muscles were intact. Facial sensation was diminished in a distribution of the maxillary nerve. There were no other neurological abnormalities.

The lesion was suspected to be a schwannoma of the maxillary and infraorbital nerves. A trans-nasal endoscopic resection with image-guided neuronavigation was performed. Once in the Meckel’s cave, the maxillary nerve was sectioned and then dissected free through the inferior orbital fissure. A portion of the lesion was submitted of intraoperative diagnosis. Intraoperative histopathologic examination revealed a prominent lymphoplasmacytic infiltrate, dense fibrous tissue, and rare large cells. The distal branches of the infraorbital nerve were also resected. The entire resected nerve bundle was submitted was for histopathologic evaluation. 

There were no postoperative complications and the patient was discharged two-days later. There was a subjective improvement of the diplopia but the paresthesias in the territory of the maxillary nerve persisted. Postoperative MR imaging revealed residual areas of enhancement in the Meckle’s cave.  CT scans of the chest, abdomen, and pelvis disclosed a left adrenal mass, thickening of the appendiceal wall, and several small nodules of uncertain significance

Material submitted: one representative H&E stained section


Questions:       Diagnosis?

                        Best ancillary test(s) for definitive classification