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External Auditory Canal Osteoma With Cholesteatoma and Sinus Thrombosis.

nonmalignant lesions. A 37-year-old woman was referred to the department of dentistry of our hospital for evaluation of a painful swelling in the posterior region of the maxilla present for approximately 1 year. A recent history of maxillary right molar extraction was described. The patient denied tobacco consumption, and her medical history was noncontributory. Physical examination showed right-sided facial asymmetry and the presence of a firm mass, measuring approximately 6 4 cm, extending from the hard palate to the vestibular side of the right molar region of the maxilla. A central ulceration of the overlying mucosa was noted in the palate (Fig. 1A). A computed tomography (CT) scan revealed an advanced soft tissue lesion involving the right maxillary antrum, hard palate, and nasal cavity with extensive bony destruction and extension into surrounding structures (Fig. 1B and C). No evidence of lymphadenopathy was found. Polymorphous low-grade adenocarcinoma (PLGA) was diagnosed histologically (Fig. 1D, E, and F). The patient was admitted for surgical intervention, and the lesion was completely removed under general anesthesia. Although the ideal treatment is debated, the patient was also referred to the adjuvant radiation therapy. The literature shows that PLGA is a rare distinctive malignant neoplasm comprising approximately 1% of intraoral salivary gland tumors. Polymorphous low-grade adenocarcinomas are most commonly identified on the palate, have an indolent evolution, and have a low risk for distant metastasis and death. In the current case, despite its large size and extensive bony destruction, no evidence of metastatic disease was found. However, they can recur over decades, and the patients require very long follow-up after treatment. The imaging findings of PLGA are nonspecific, but CT and magnetic resonance (MR) imaging may be helpful in determining the extent of the tumor to provide appropriate management, as performed in the current case. Polymorphous low-grade adenocarcinoma represents a diagnostic challenge for pathologists, because the polymorphic architecture is not a pathognomonic finding of the tumor. Other salivary gland neoplasms including pleomorphic adenoma, monomorphic adenoma, and adenoid cystic carcinoma may show a combination of growth patterns. Therefore, the high morphological and histological heterogeneity of PLGA makes it more difficult to establish a diagnosis, especially if incisional biopsies provide insufficient tissue sampling for analysis. Recently, immunohistochemical analysis has been proposed to distinguish PLGA from other malignant minor salivary gland tumors, especially the adenoid cystic carcinoma, but controversy on this subject persists in the literature. According to de Araújo, for diagnostic purposes, it is essential to characterize the morphology of the cell and the diversity of the histological tumor patterns, and to recall that the PLGA cellular population exhibits a constant cytological appearance, despite a variety of growth patterns. Therefore, immunohistochemistry is valuable in unclear PLGA cases. We concluded that, although rare, PLGA should be included in the differential diagnosis of the firm soft tissue swellings of the oral cavity, especially in the palate. In addition, an accurate histologic analysis is essential to avoid misdiagnosis and to establish an adequate therapeutic conduct.