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CORRESPONDENCE
Year : 2013  |  Volume : 9  |  Issue : 2  |  Page : 276-277

A case of obstructive sleep apnea syndrome caused by malignant melanoma in the nasal cavity and paranasal sinus


Department of Pulmonology, Kameda Medical Center, Chiba, Japan

Date of Web Publication13-Jun-2013

Correspondence Address:
Nobuhiro Asai
Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.113384

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 > Abstract 

A 71 year-old obese woman complained of obstructive sleep apnea syndrome (OSAS) related symptoms. The apnea-hypopnea index (AHI) was 73.5/hour. She presented with nasal bleeding to an ENT doctor. A mass on the nasal septum was seen and biopsy was performed. Histological confirmation showed malignant melanoma. The tumor stage proved to be cT4aN2M1 (stage IV) due to multiple metastatic lesions. After palliative irradiation, the nasal tumor was reduced in size and her symptoms of OSAS were improved. The second AHI revealed 13.5/hour. This case was considered to be OSAS caused by a tumor obstructing the nasal cavity. This might suggest the necessity of routine work-up of the upper airway in cases of patients with sleep disorder. Otherwise, OSAS caused by such obstruction might be missed. We report a very rare case with secondary OSAS caused by malignant melanoma in the nasal cavity and paranasal sinus.

Keywords: Obstructive sleep apnea syndrome, malignant melanoma, polysomnographic study


How to cite this article:
Asai N, Ohkuni Y, Kawamura Y, Kaneko N. A case of obstructive sleep apnea syndrome caused by malignant melanoma in the nasal cavity and paranasal sinus. J Can Res Ther 2013;9:276-7

How to cite this URL:
Asai N, Ohkuni Y, Kawamura Y, Kaneko N. A case of obstructive sleep apnea syndrome caused by malignant melanoma in the nasal cavity and paranasal sinus. J Can Res Ther [serial online] 2013 [cited 2019 Oct 18];9:276-7. Available from: http://www.cancerjournal.net/text.asp?2013/9/2/276/113384


 > Introduction Top


Obstructive sleep apnea syndrome (OSAS) is characterized by multiple episodes of upper airway obstruction during sleep resulting in fatal cardiac events such as heart failure and ventricular arrhythmia. Mostly, obesity contributes to worsening of the apnea-hypopnea index (AHI), resulting in OSAS. [1] In fact, clinicians should recognize that there can be others causes for secondary OSAS such as facial malformations, endocrine and other disorders; myxedema, acromegaly or upper airway tumors. [1] Tumors causing secondary OSAS have been sporadically reported. [2]

Primary sinonasal tract mucosal malignant melanomas are extremely rare, accounting for 0.3 to 2% of all malignant melanomas and approximately 4% of head and neck melanomas. [3] We report a very rare case with secondary OSAS caused by malignant melanoma in the nasal cavity.


 > Case Report Top


A 71 year-old obese woman presented with the chief complaint of loud snoring at night, daytime hypersomnia and sluggishness for the latest 3 months and was referred to us. She has a history of hypertension which has required medication for several years. She presented with an Epworth sleepiness scale (ESS) of 10. Physical examination revealed weight 71.4kg, body mass index (BMI) 33.4g/m 2 and blood pressure (BP) 160/90mmHg. A polysomnographic (PSG) study demonstrated an apnea-hypopnea index (AHI) of 73.5/ hour, baseline O 2 saturation (SpO 2 ) and minimal SpO 2 of 95% and 79% respectively. She was diagnosed with OSAS. One day, she complained of nasal bleeding to an ENT doctor. A mass on the nasal septum was seen [Figure 1] and biopsy was performed. Histological confirmation showed malignant melanoma. The tumor stage proved to be cT4aN2M1 (stage%) due to multiple metastatic lesions detected in the 3 rd lumbar vertebrae and liver by Fluoro-2-deoxyglucose positron emission tomography (FDG-PET). While she rejected chemotherapy, she received palliative radiotherapy for the nasal tumor and bone metastasis. After irradiation, the tumor was reduced in size and her symptoms of OSAS such as snoring or daytime hypersomnia were improved and so was the re-study of PSG as AHI of 13.5/hour and baseline and minimal SpO 2 of 97% and 86% respectively. This case was considered to be OSAS caused by a tumor obstructing the nasal cavity.
Figure 1: Contrast enhanced MRI of the head and neck shows a mass in the right nasal cavity and the right ethmoidal sinus

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 > Discussion Top


OSAS caused by a tumor in the nasal cavity or paranasal sinuses is extremely rare. In fact, tumors causing secondary OSAS have been sporadically reported. [4],[5],[6] OSAS caused by malignant melanoma in the nasal cavity and paranasal sinus has never reported as far as we searched on Pubmed.

The presence of OSAS has been known widely among ordinary people. While more patients suspected to have sleep disorder come to a hospital, clinicians tend to care only for sleep disorder alone. It has been reported that female patients with OSAS present with a lower Epworth Sleepiness Score (ESS) than AHI-matched male patients and the severity of the disease might be underestimated. [7] Thus, this patient is thought to be a typical case of a female patient with OSAS. Since it would be quite difficult to distinguish between primary and secondary OSAS, there may possibly be more patients with secondary OSAS caused by tumors and quite a few of them may have unfortunately been missed. Therefore, routine work-up of obstruction in upper airway should be performed for patients with sleep disorders.

In conclusion, we suggest that physicians routinely need to work-up any findings in upper airway which could cause OSAS in patients presenting with sleep disorder.

 
 > References Top

1.Strohl KP, Redline S. Recognition of obstructive sleep apnea. Am J Respir Crit Care Med 1996;154:279-289.  Back to cited text no. 1
    
2.Hoijer U, Ejnell H, Hedner J. Obstructive sleep apnea in patients with pharyngeal tumors. Acta Otolaryngol 1992;11:138-43.  Back to cited text no. 2
    
3.Clifton N, Harrison L, Bradley PJ, Jones NS. Malignant melanoma of nasal cavity and paranasal sinuses: report of 24 patients and literature review. J Laryngol Otol 2011;24:1-7.  Back to cited text no. 3
    
4.Abdullah BJ, Liam CK, Kaur H, Mathew KM. Parapharyngeal space lipoma causing sleep apnoea. Br J Radiol 1997;70:1063-5.  Back to cited text no. 4
    
5.Alving J, Højer-Pedersen E, Schlichting J, Sindrup EH. Obstructive sleep apnea syndrome caused by oral cyst: a case report. Acta Neurol Scand 1985;71:408-10.  Back to cited text no. 5
    
6.Ito M, Tanaka J, Kubota K, Sato H, Takahashi M, Tanaka H, et al. Obstructive sleep apnea syndrome in a patient with superior vena cava syndrome caused by lung cancer. Nihon Kokyuki Gakkai Zasshi 2000;38:471-5. Japanese.  Back to cited text no. 6
    
7.Yukawa K, Inoue Y, Yagyu H, Hasegawa T, Komada Y, Namba K, et al. Gender differences in the clinical characteristics among Japanese patients with obstructive sleep apnea syndrome. Chest 2009; 135: 337-43.  Back to cited text no. 7
    


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