Gamma Knife(R) radiosurgery for recurrent intracranial olfactory neuroblastoma (esthesioneuroblastoma): a case report

ABSTRACT: BACKGROUND: We report the use of salvage radiosurgery to manage an aggressive olfactory neuroblastoma(esthesioneuroblastoma) with multiple recurrences and intracranial extension. CASE PRESENTATION: A 43-year-old Caucasian woman presented 11 years ago with progressive nasal blockage andheadaches. A necrotic polyp originating in her left middle meatus and extending to theethmoid air cells and cribriform plate (Kadish stage C) was radically resected via acraniofacial approach. Four years later, a local recurrence extending into her left cavernoussinus was identified and deemed inoperable. She received vincristine, ifosfamide,doxorubicin and etoposide chemotherapy (with minimal benefit) and external beamradiotherapy (60Gy in 30 fractions) to her skull base. Two years later, tumour extension inher left neck was treated with radical radiotherapy. She developed visual disturbances in herleft eye, which progressed to blindness in the next two years. Having exhaustedchemoradiotherapy, the left cavernous sinus esthesioneuroblastoma was treated with GammaKnife? radiosurgery 2 years ago (20Gy at 50% isodose, tumour volume 7.5cm3). At oneyear, there was dramatic reduction in the tumour and no new symptoms; however, there werenew tumour foci (in her left frontal lobe and above her right orbital apex). These were againtreated with radiosurgery (20Gy at 50% isodose, total tumour volume 0.67cm3). Repeatimaging at six months showed no further disease progression. CONCLUSION: Whilst rare, olfactory neuroblastoma (esthesioneuroblastoma) can present managementchallenges and Gamma Knife(R) radiosurgery may prove a useful strategy in controllingintracranial spread.     

Effects of Localized Hydrophilic Mannitol and Hydrophobic Nelfinavir Administration Targeted to Olfactory Epithelium on Brain Distribution

Many nasally applied compounds gain access to the brain and the central nervous system (CNS) with varying degree. Direct nose-to-brain access is believed to be achieved through nervous connections which travel from the CNS across the cribriform plate into the olfactory region of the nasal cavity. However, current delivery strategies are not targeted to preferentially deposit drugs to the olfactory at cribriform. Therefore, we have developed a pressurized olfactory delivery (POD) device which consistently and non-invasively deposited a majority of drug to the olfactory region of the nasal cavity in rats. Using both a hydrophobic drug, mannitol (log P = -3.1), and a hydrophobic drug, nelfinavir (log P = 6.0), and POD device, we compared brain and blood levels after nasal deposition primarily on the olfactory region with POD or nose drops which deposited primarily on the respiratory region in rats. POD administration of mannitol in rats provided a 3.6-fold (p < 0.05) increase in cortex-to-blood ratio, compared to respiratory epithelium deposition with nose drop. Administration of nelfinavir provided a 13.6-fold (p < 0.05) advantage in cortex-to-blood ratio with POD administration, compared to nose drops. These results suggest that increasing the fraction of drug deposited on the olfactory region of the nasal cavity will result in increased direct nose-to-brain transport.     

Localization of choline acetyltransferase and vasoactive intestinal polypeptide-like immunoreactivity in the nervus terminalis of the fetal and neonatal rat

Ganglia of the nervus terminalis have been shown to contain luteinizing hormone-releasing hormone (LHRH) immunoreactive cells in several mammalian species. These cells are always accompanied by clusters of cells non-immunoreactive to antiserum to LHRH. Using immunocytochemical procedures, we found choline acetyltransferase (ChAT) and vasoactive intestinal polypeptide (VIP) present in cell bodies and in nerve processes throughout the peripheral, intracranial and central projections of the nervus terminalis. In addition, a dense plexus of substance P (SP) immunoreactive fibers was seen in the nasal mucosa surrounding the nasal glandular acini and blood vessels. A number of SP reactive fibers were traced with the olfactory nerves through the cribriform plate of the ethmoid bone and appeared to enter the brain in the area of the central roots of the nervus terminalis.     

Development and rudimentation of the peripheral olfactory system in the harbor porpoise Phocoena phocoena (Mammalia: Cetacea)

Serial sections of 13 embryos and fetuses of the harbor porpoise from 10 mm crown-rump length up to 167 mm total length were studied. Unlike the adult animals, ontogenetic stages of 18–27 mm crown-rump length still show a typical mammalian olfactory bulb. The olfactory bulb primordium is penetrated by olfactory nerve fibers, the latter passing through the cribriform plate. However, the olfactory bulb anlage is gradually reduced in later stages, its placodal component being largely uncoupled from the telencephalon. As a ganglionlike structure, the remains of the placodal component stay in contact with the nasal septum and mucosa via thin bundles of nerve fibers. The ganglion and plexus can be traced within the meninges until the adult stage of the porpoise. There is strong evidence that they represent the material of the terminalis system, which cannot be distinguished from the olfactory system in earlier stages. A vomeronasal organ could not be detected in the embryonal and fetal material investigated.     

Olfactory nerve--a novel invasion route of Neisseria meningitidis to reach the meninges

Neisseria meningitidis is a human-specific pathogen with capacity to cause septic shock and meningitis. It has been hypothesized that invasion of the central nervous system (CNS) is a complication of a bacteremic condition. In this study, we aimed to characterize the invasion route of N. meningitidis to the CNS. Using an intranasally challenged mouse disease model, we found that twenty percent of the mice developed lethal meningitis even though no bacteria could be detected in blood. Upon bacterial infection, epithelial lesions and redistribution of intracellular junction protein N-cadherin were observed at the nasal epithelial mucosa, especially at the olfactory epithelium, which is functionally and anatomically connected to the CNS. Bacteria were detected in the submucosa of the olfactory epithelium, along olfactory nerves in the cribriform plate, at the olfactory bulb and subsequently at the meninges and subarachnoid space. Furthermore, our data suggest that a threshold level of bacteremia is required for the development of meningococcal sepsis. Taken together, N. meningitidis is able to pass directly from nasopharynx to meninges through the olfactory nerve system. This study enhances our understanding how N. meningitidis invades the meninges. The nasal olfactory nerve system may be a novel target for disease prevention that can improve outcome and survival.     

Carbonic anhydrase is present in olfactory receptor cells

Summary A modification of Hansson's histochemical technique was used to reveal carbonic anhydrase activity in mounted cryostat sections of rat olfactory mucosa, after glutaraldehyde fixation. A positive reaction that could be inhibited by acetazolamide was found in a population of olfactory receptor cells, whereas the supporting cells were negative. Axons of receptor cells were also positive and could be traced through the cribriform plate to the olfactory bulb.     

Carbonic anhydrase is present in olfactory receptor cells

A modification of Hansson 's histochemical technique was used to reveal carbonic anhydrase activity in mounted cryostat sections of rat olfactory mucosa, after glutaraldehyde fixation. A positive reaction that could be inhibited by acetazolamide was found in a population of olfactory receptor cells, whereas the supporting cells were negative. Axons of receptor cells were also positive and could be traced through the cribriform plate to the olfactory bulb.     

Quantitative observations on the nasal epithelia and olfactory innervation in bats. Suggested design mechanisms for the olfactory bulb.

The nasal epithelia of two species of bats were quantified with respect to relative surface areas and olfactory epithelial volumes. In the macrosmatic Aribeus jamaicensis 55.9% of the nasal cavity surface was covered by olfactory epithelium (232.4 mm2), in contrast to only 28.9% in the microsmatic Myotis lucifugus (36.4 mm2). The roles of the various nasal epithelia have been discussed as they may relate to olfaction, respiration and echolocation. In the olfactory bulbs of both species, the estimated concentration of mitral cells approximated at 2,500/mm2 compared to an olfactory nerve concentration of 5/mm2. In Artibeus, calculated total volume of olfactory epithelium was on the order of 16 times greater than in Myotis, and Artibeus' olfactory bulb diameter was twice as great. These findings, together with previously published surface, volume and physiological relationships, suggest a developmental design mechanism for an olfactory bulb in which the number of olfactory receptors increases some 450-fold above an initially established ratio of 2:1 between receptors and mitral cells. Key governing factors could be requisite mechanical rigidity of the cribriform plate of the ethmoid bone and response thresholds of higher brain centers.     

Cytologic diagnosis of olfactory neuroblastoma. Report of a case with multiple diagnostic parameters

We present the first case report of an olfactory neuroblastoma (esthesioneuroblastoma) diagnosed by cytologic examination. The patient was a 40-year-old male who had a 13-year history of "adenocarcinoma" of the nasal cavity until the correct diagnosis of olfactory neuroblastoma was made cytologically from pleural fluid shortly before his death. The cells had the typical features of rosette formation, scanty elongated cytoplasm, clustering of cells and nuclear compression resulting in an "onion-skin" appearance. Surgical specimens, several biopsies and fine needle aspiration of a metastatic deposit in a lymph node all showed, retrospectively, features of esthesioneuroblastoma. Electron microscopy showed membrane-bound dense-core secretory granules. Autopsy findings revealed multiple metastases but no tumor at the original site; that tumor had been treated with high-dose radiation therapy as well as systemic chemotherapy. Olfactory neuroblastoma is a rare tumor, but it is important to recognize because it has a better prognosis than the more commonly encountered malignancies of the nose.     

Effect of anatomy on human nasal air flow and odorant transport patterns: implications for olfaction

Recent studies that have compared CT or MRI images of an individual's nasal anatomy and measures of their olfactory sensitivity have found a correlation between specific anatomical areas and performance on olfactory assessments. Using computational fluid dynamics (CFD) techniques, we have developed a method to quickly (相似文献   

A light microscopy study of the migration of Naegleria fowleri from the nasal submucosa to the central nervous system during the early stage of primary amebic meningoencephalitis in mice

The migratory pathway of Naegleria fowleri from the nasal submucosa to the central nervous system (CNS) during the early stage of primary amebic meningoencephalitis (PAM) was investigated in mice. Twenty-one-day-old CD-1 mice were inoculated by intranasal instillation of 1 x 10(6) amebas. Animals were divided into 3 groups of 5 and, after being anesthetized, were killed at intervals of 24, 32, and 48 hr postinoculation by transcardial perfusion with formaldehyde, acetic acid, and methanol. The heads were decalcified, divided in the midsagittal plane, and the area of the cribriform plate removed and embedded in paraffin. Serial sections were cut at 8 microm and stained with a combination of celestin blue, Harris' hematoxylin, and acid fuchsin for light microscopy. Focal inflammation and amebas were observed in the submucosal nerve plexus, olfactory nerves penetrating the cribriform plate, and the olfactory bulb of the brain as early as 24 hr postinoculation. The time periods selected assured that the disease process would not obliterate soft tissue structures. Earlier studies used moribund mice in which the inflammation and the number of amebas were overwhelming. The present study provides convincing evidence that amebas gain initial access to the CNS through olfactory nerves within the cribriform plate during the early stages of PAM.     

Distribution of epithelia and glands of the nasal septum mucosa in the rat.

A histotopographic study of the nasal septum mucosa in rats was made using semi-serial sections stained with PAS-hematoxylin, reconstructed in form of maps representing the structure in a sagittal plane. The stratified squamous, respiratory and olfactory epithelia and Masera's organ cover 14.8, 43.6, 41.6 and 1.8%, respectively, of the septal surface (117.1 mm2). In the vestibular region, only ducts of PAS-negative glands of the respiratory region are found, and below the septum there is the infraseptal gland with PAS-negative acini. In the respiratory region, PAS-negative acinous glands form two groups: the superior and the inferior one occupying 10.5 and 1.5%, respectively, of the septal area. PAS-positive acinous glands are in the inferior half of the respiratory region and in a small anteroinferior portion of the olfactory region. Besides goblet cells broadly distributed, the respiratory epithelium presents scattered intraepithelial PAS-positive glands which are concentrated in the anterior portion and close to the nasopharyngeal duct. In the olfactory region prevail Bowman's PAS-positive glands which are also present in the mucosa of Masera's organ, but are not seen in the olfactory mucosa of Jacobson's organ. In the latter, PAS-positive glands are found in the respiratory mucosa. Globular leukocytes, cells of connective tissue origin, are constantly infiltrating the superior regions of the respiratory and olfactory epithelia, being more numerous in female rats.     

Activating effect of nasal air flow on epileptic electrographic abnormalities in the human EEG. Evidence for the reflect origin of the phenomenon

Deep nasal breathing [with the mouth closed] activates [to a certain extent selectively], in the human EEG, epileptic abnormalities of diencephalotemporal origin [Servít et al. 1977]. This activating effect could be suppressed by local anaesthesia of the mucosa membrane in the superior nasal meatus. The same abnormalities could be elicited or activated by air insufflation into the upper nasal cavity, without pulmonary hyperventilation. These results speak in favour of the assumption that a neural [reflex] mechanism of the activating effect of nasal hyperventilation is involved, with a reflexogenic area in the superior nasal meatus.     

Organization of the Olfactory and Respiratory Skeleton in the Nose of the Gray Short-Tailed Opossum Monodelphis domestica

The internal nasal skeleton in Monodelphis domestica, the gray short-tailed opossum, primarily supports olfactory and respiratory epithelia, the vomeronasal organ, and the nasal gland. This scaffold is built by the median mesethmoid, and the paired vomer and ethmoid bones. The mesethmoid ossifies within the nasal septum cartilage. The bilateral ethmoid segregates respiratory and olfactory regions, and its geometry offers insight into the functional, developmental, and genomic organization of the nose. It forms through partial coalescence of separate elements known as turbinals, which in Monodelphis comprise the maxilloturbinal, nasoturbinal, five endoturbinals, and two ectoturbinals. Geometry of the ethmoid increases respiratory mucosal surface area by a factor of six and olfactory mucosal surface by nearly an order of magnitude. Respiratory epithelium warms and humidifies inspired air, recovers moisture as air is exhaled, and may help mediate brain temperature. In contrast, the olfactory skeleton functions as a series of small funnels that support growth of new olfactory neurons throughout life. Olfactory mucosa lines the mouth of each funnel, forming blind olfactory recesses known as the ethmoid cells, and neuronal axons are funneled from the epithelium through tiny olfactory foramina in the cribriform plate, into close proximity with target glomeruli in the olfactory bulb of the brain where each axon makes its first synapse. The skeleton may thus mediate topological correspondence between odorant receptor areas in the nose with particular glomeruli in the olfactory bulb, enabling growth throughout life of new olfactory neurons and proper targeting by their axons. The geometric arrangement of odorant receptors suggests that a measure of volatility may be a component in the peripheral olfactory code, and that corresponding glomeruli may function in temporal signal processing. Supporting visualizations for this study are available online at www.DigiMorph.org.     

Intracranial pressure accommodation is impaired by blocking pathways leading to extracranial lymphatics

Tracer studies indicate that cerebrospinal fluid (CSF) transport can occur through the cribriform plate into the nasal submucosa, where it is absorbed by cervical lymphatics. We tested the hypothesis that sealing the cribriform plate extracranially would impair the ability of the CSF pressure-regulating systems to compensate for volume infusions. Sheep were challenged with constant flow or constant pressure infusions of artificial CSF into the CSF compartment before and after the nasal mucosal side of the cribriform plate was sealed. With both infusion protocols, the intracranial pressure (ICP) vs. flow rate relationships were shifted significantly to the left when the cribriform plate was blocked. This indicated that obstruction of the cribriform plate reduced CSF clearance. Sham surgical procedures had no significant effects. Estimates of the proportional flow through cribriform and noncribriform routes suggested that cranial CSF absorption occurred primarily through the cribriform plate at low ICPs. Additional drainage sites (arachnoid villi or other lymphatic pathways) appeared to be recruited only when intracranial pressures were elevated. These data challenge the conventional view that CSF is absorbed principally via arachnoid villi and provide further support for the existence of several anatomically distinct cranial CSF transport pathways.     

Accelerated shedding of prions following damage to the olfactory epithelium

In this study, we investigated the role of damage to the nasal mucosa in the shedding of prions into nasal samples as a pathway for prion transmission. Here, we demonstrate that prions can replicate to high levels in the olfactory sensory epithelium (OSE) in hamsters and that induction of apoptosis in olfactory receptor neurons (ORNs) in the OSE resulted in sloughing off of the OSE from nasal turbinates into the lumen of the nasal airway. In the absence of nasotoxic treatment, olfactory marker protein (OMP), which is specific for ORNs, was not detected in nasal lavage samples. However, after nasotoxic treatment that leads to apoptosis of ORNs, both OMP and prion proteins were present in nasal lavage samples. The cellular debris that was released from the OSE into the lumen of the nasal airway was positive for both OMP and the disease-specific isoform of the prion protein, PrP(Sc). By using the real-time quaking-induced conversion assay to quantify prions, a 100- to 1,000-fold increase in prion seeding activity was observed in nasal lavage samples following nasotoxic treatment. Since neurons replicate prions to higher levels than other cell types and ORNs are the most environmentally exposed neurons, we propose that an increase in ORN apoptosis or damage to the nasal mucosa in a host with a preexisting prion infection of the OSE could lead to a substantial increase in the release of prion infectivity into nasal samples. This mechanism of prion shedding from the olfactory mucosa could contribute to prion transmission.     

Blocking cerebrospinal fluid absorption through the cribriform plate increases resting intracranial pressure

Cerebrospinal fluid (CSF) drains through the cribriform plate (CP) in association with the olfactory nerves. From this location, CSF is absorbed into nasal mucosal lymphatics. Recent data suggest that this pathway plays an important role in global CSF transport in sheep. In this report, we tested the hypothesis that blocking CSF transport through this pathway would elevate resting intracranial pressure (ICP). ICP was measured continuously from the cisterna magna of sheep before and after CP obstruction in the same animal. To block CSF transport through the CP, an external ethmoidectomy was performed. The olfactory and adjacent mucosa were removed, and the bone surface was sealed with tissue glue. To restrict our analysis to the cranial CSF system, CSF transport into the spinal subarachnoid compartment was prevented with a ligature tightened around the thecal sac between C1 and C2. Sham surgical procedures had no significant effects, but in the experimental group CP obstruction elevated ICP significantly. Mean postobstruction steady-state pressures (18.0 +/- 3.8 cmH(2)O) were approximately double the preobstruction values (9.2 +/- 0.9 cmH(2)O). These data support the concept that the olfactory pathway represents a major site for CSF drainage.     

Intranasal volume and olfactory function

The aim of this exploratory study was to identify the volume intranasal segments as they relate to parameters of olfactory function. Fifty healthy male volunteers (age range 22-59 years, mean age 28.5 years) were included. Olfactory function was measured by lateralized phenyl ethyl alcohol odor thresholds and odor discrimination, and by bilateral odor identification. Magnetic resonance imaging of the nasal cavity was performed immediately following olfactometry. To correlate the results of olfactometry with intranasal volume, each nasal cavity was divided into 11 segments. Significant correlations were found between the odor thresholds and volumes of the anterior part of the lower and upper meatus of the right nasal cavity. These results reveal that two nasal segments are important for inter-individual differences of odor thresholds in healthy subjects: (i) the segment in the upper meatus below the cribriform plate and (ii) the anterior segment of the inferior meatus. The latter finding is of special interest for nasal surgery, which allows modification of this volume through resection of the inferior turbinate and/or septoplasty.     

Expression of olfactory receptors in the cribriform mesenchyme during prenatal development

Olfactory receptors (ORs) are expressed in sensory neurons of the nasal epithelium, where they are supposed to be involved in the recognition of suitable odorous compounds and in the guidance of outgrowing axons towards the appropriate glomeruli in the olfactory bulb. During development, some olfactory receptor subtypes have also been found in non-sensory tissues, including the cribriform mesenchyme between the prospective olfactory epithelium and the developing telencephalon, but it is elusive if this is a typical phenomenon for ORs. Monitoring the onset and time course of expression for several receptor subtypes revealed that 'extraepithelial' expression of ORs occurs very early and transiently, in particular between embryonic stages E10.25 and E14.0. In later stages, a progressive loss of receptor expressing cells was observed. Molecular phenotyping demonstrated that the receptor expressing cells in the cribriform mesenchyme co-express key elements, including Galpha(olf), ACIII and OMP, characteristic for olfactory neurons in the nasal epithelium. Studies on transgenic OMP/GFP-mice showed that 'extraepithelial' OMP/GFP-positive cells are located in close vicinity to axon bundles projecting from the nasal epithelium to the presumptive olfactory bulb. Moreover, these cells are primarily located where axons fasciculate and change direction towards the anterior part of the forebrain.