title: The dilemma of midline destructive lesions: a case series and diagnostic review.
abstract: BACKGROUND
  Midline destructive lesions (MDLs) of the nose are a diagnostic dilemma due to an extensive differential diagnosis and vague presenting signs and symptoms. Etiologies may be neoplastic, autoimmune, traumatic, infectious, or unknown.
  
  
  METHODS
  Case series and review of the literature were done.
  
  
  METHODS
  Medical records of 8 patients presenting with an MDL were reviewed.
  
  
  RESULTS
  Each patient received nasal endoscopy, computed tomography scan of the sinuses, laboratory workup, culture (aerobes, anaerobes, fungus, and acid-fast bacilli), and biopsy with flow cytometry. Laboratory tests included complete blood count, basic metabolic panel, erythrocyte sedimentation rate, angiotensin-converting enzyme, antineutrophil antibodies, rheumatoid factor, anti-Ro and anti-La antibodies, Epstein-Barr virus antibodies, coccidiomycosis serology, HIV antibodies, fluorescent treponemal antibody absorption, classic antineutrophil cytoplasmic antibodies, perinuclear antineutrophil cytoplasmic antibody, proteinase 3, and myeloperoxidase. Choice of diagnostic study was individualized for each patient. Two patients were diagnosed with natural killer/T-cell lymphoma, 2 were diagnosed with Wegener's granulomatosis, and 4 remained idiopathic, despite the extensive workup. A diagnostic algorithm to aid in the approach to MDLs is presented.
  
  
  CONCLUSIONS
  The diagnosis of MDLs remains difficult but is aided by a systematic approach and familiarity with multiple diagnostic techniques. It is imperative to take multiple tissue specimens from various sites, send them fresh, and communicate suspicion of lymphoma. Despite diagnostic advances and improved understanding of the diseases underlying MDLs, an etiology is often not identified.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Noah P
authors.initials: NP
authors.lastname: Parker
authors.forename: Aaron N
authors.initials: AN
authors.lastname: Pearlman
authors.forename: David B
authors.initials: DB
authors.lastname: Conley
authors.forename: Robert C
authors.initials: RC
authors.lastname: Kern
authors.forename: Rakesh K
authors.initials: RK
authors.lastname: Chandra
mesh_terms: D000328:Adult; D000465:Algorithms; D003937:Diagnosis, Differential; D005260:Female; D006103:Granuloma, Lethal Midline / Q000175:diagnosis*; D014890:Granulomatosis with Polyangiitis / Q000175:diagnosis; D006801:Humans; D016399:Lymphoma, T-Cell / Q000175:diagnosis; D008297:Male; D008875:Middle Aged