REVIEW ARTICLE
A systematic review of sinonasal oncocytomas and oncocytic carcinomas:
Diagnosis, management, and technical considerations
Zerina Hodzic, BS1 , Nicholas R. Rowan, MD2 , Ryota Kashiwazaki, MD2 , Thomas J. Willson, MD2 ,
Eric W. Wang, MD2 and Stella E. Lee, MD2
Background: Oncocytomas and oncocytic carcinomas are
rare tumors of the sinonasal cavity with the propensity for
local invasion. This report and systematic review details a
case of a nasal oncocytoma involving the lacrimal sac and
provides an update of the current literature.
Methods: A systematic literature review was performed us-
ing PubMed and Ovid databases. The data obtained from
published articles with sinonasal oncocytoma/oncocytic
carcinoma as the primary diagnosis included patient demo-
graphics, presentation, radiographic and histologic findings,
management, and recurrence rates.
Results: Twenty cases were identified. The most common
symptoms were epistaxis (n = 11) and nasal obstruction
(n = 11). Involvement of the nasal cavity was most com-
mon (n = 17), followed by the paranasal sinuses (n = 13)
and nasolacrimal apparatus (n = 4). Recurrence occurred
in 55% of cases. Recurrence was associated with invasion
or infiltration found on histology or the presence of both
invasion/infiltration and mitotic figures/pleomorphism (p <
0.05), with no significant relationship between recurrence
and age at diagnosis (p = 0.42), sex (p = 0.65), and loca-
O ncocytomas and oncocytic carcinomas are epithe-
lial cell tumors defined by the presence of abundant
eosinophilic granular cytoplasm as a consequence of rich
mitochondrial content. They can arise in several organs,
including the kidney, breast, prostate gland, and major
salivary glands, most commonly the parotid gland.1
1 University
of Pittsburgh School of Medicine, Pittsburgh, PA;
2 Department of Otolaryngology–Head and Neck Surgery, University of
Pittsburgh Medical Center, Pittsburgh, PA
Correspondence to: Stella E. Lee, MD, Department of Otolaryngology–
Head and Neck Surgery, University of Pittsburgh Medical Center, UPMC
Mercy, Suite 11500, Building B 1400 Locust Street, Pittsburgh, PA 15219;
e-mail: lees6@upmc.edu
Potential conflict of interest: None.
Received: 12 September 2016; Revised: 1 November 2016; Accepted:
27 November 2016
DOI: 10.1002/alr.21902
View this article online at wileyonlinelibrary.com.
1 International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017
tion of tumor (p = 0.14). The authors present the case of
a 73-year-old woman with a 5-month history of worsening
epistaxis and biopsy-proven oncocytoma. Complete surgi-
cal resection of the tumor using combined endonasal endo-
scopic and anterior orbitotomy approach is described.
Conclusion: Oncocytomas and oncocytic carcinomas are
rare tumors of the sinonasal cavity with a high rate of lo-
cal recurrence and orbital involvement. Surgical resection
is the treatment of choice and complete resection can be
achieved with an endoscopic endonasal approach.  C 2017
ARS-AAOA, LLC.
Key Words:
nasal oncocytoma; nasal oncocytic carcinoma; oncocy-
toma; paranasal sinuses
How to Cite this Article:
Hodzic Z, Rowan NR, Kashiwazaki R, Willson TJ, Wang
EW, Lee SE. A systematic review of sinonasal oncocy-
tomas and oncocytic carcinomas: Diagnosis, management,
and technical considerations. Int Forum Allergy Rhinol.
2017;XX:1–11.
Although most commonly identified in the major sali-
vary glands, oncocytomas and oncocytic carcinomas may
also arise in minor salivary gland tissue in anatomic subsites
of the head and neck, including the paranasal sinuses, na-
solacrimal system, and nasopharynx. Compared with on-
cocytomas of the major salivary glands, those that arise
elsewhere from minor salivary glands tend to be more lo-
cally invasive with greater malignant potential, classified
as oncocytic carcinomas.2 A literature review reveals <40
documented cases of oncocytomas and oncocytic carcino-
mas of sinonasal origin.
Given the rarity of these tumors, there is no standard
management approach, with several different surgical tech-
niques reported in the literature, including both the open
and endoscopic approaches, in addition to variable use of
radiotherapy.
Herein we report the case of an oncocytoma of the
nasal cavity involving the lacrimal sac that was removed
successfully with a combined endoscopic endonasal and
Hodzic et al.

FIGURE 1. (A) Sinonasal oncocytoma as shown by axial (i), coronal (ii), and sagittal (iii) computed tomography, demonstrating a soft-tissue mass superior to
the right inferior turbinate extending along the lateral wall of the nasal cavity to the inferomedial right orbit toward the medial canthal region. (B) Intraoperative
photograph of oncocytoma superior to the inferior turbinate at the right lateral nasal wall. (C) Low-power magnification of hematoxylin-eosin stain of specimen
showing nests of oncocytes, characterized by granular eosinophilic cytoplasm. IT = inferior turbinate; M = mass; NS = nasal septum; UP = uncinate process
of ethmoid bone.

external anterior orbitotomy approach. In addition, a sys-
tematic review was conducted of all cases of oncocytoma
and oncocytic carcinomas of sinonasal origin to provide an
update on diagnosis and management.
Case report
A 73-year-old woman presented with a 5-month history
of gradually worsening unilateral epistaxis. Otherwise, the
patient was asymptomatic. Specifically, she denied rhin-
orrhea, epiphora, and anosmia, and reported a score of
3 on the 22-item Sino-Nasal Outcome Test (SNOT-22).
Six years earlier, she underwent a right dacryocystorhinos-
tomy (DCR), performed for epiphora. The right lacrimal
sac was not biopsied at that time. The patient did not
have a history of cigarette smoking, with no contributing
environmental exposures, specifically woodworking, heavy
metals, or radiation. Endoscopic evaluation revealed a well-
defined vascular mass involving the lateral wall of the right
nasal cavity (Figure 1B). Medially, the mass abutted but did
not appear to involve the middle turbinate. There was no
active bleeding.
A maxillofacial computed tomography (CT) scan was
performed and revealed a 2.0 × 1.4 × 1.7 soft-tissue mass
filling the osseous canal of the nasolacrimal duct and ex-
tending to the medial canthal region (Figure 1A). Magnetic
resonance imaging (MRI) demonstrated enhancement with
invasion into the medial wall of the orbit. Biopsy was con-
sistent with oncocytoma.
Resection of the lesion was performed using a combined
open and endoscopic approach in conjunction with oculo-
plastics. The mass was found to be originating inferior to
the existing DCR site was removed en bloc from the nasal
cavity.

International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017 2
Sinonasal Oncocytomas

FIGURE 2. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram is shown.

Final pathology confirmed the diagnosis of a sinonasal
oncocytoma. Light microscopy revealed an oncocytic glan-
dular neoplasm with retained myoepithelial cells (Figure
1C). The neoplasm had a seromucinous acinar phenotype
with a tubulopapillary growth pattern. There were no mi-
totic figures or necrosis, with a low proliferative index
based on Ki-67 assessment.
The patient was doing well at her 1-week, 1-month, and
6-month postoperative follow-up appointments, without
evidence of recurrence. She is scheduled for routine follow-
up to monitor for recurrence.
Methods
Study design
A systematic literature review protocol was designed us-
ing the Preferred Reporting Items of Systematic Reviews
and Meta-Analysis (PRISMA) model (Figure 2).3 Given the
rarity of published studies on sinonasal oncocytomas and
oncocytic carcinomas, the literature review was limited to
case reports.
Inclusion and exclusion criteria
Inclusion criteria included all case reports of oncoctyomas
and oncocytic carcinomas of sinonasal origin, including
the nasal cavity and paranasal sinuses, examining out-
comes, particularly recurrence. Literature was excluded if
there was insufficient follow-up information or if tumor
location was limited to the nasolacrimal duct or lacrimal
sac with no involvement of the nasal cavity or paranasal
sinuses.
Search strategy
A systematic literature review was performed in Octo-
ber 2015, using the PubMed and Ovid databases, by 2

3 International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017
Hodzic et al.
independent reviewers. MeSH search terms utilized in-
cluded “nasal oncocytoma,” “nasal oncocytic carcinoma,”
and “nasal oxyphilic adenoma,” with search limitations for
human subjects and English language. There was no limita-
tion with respect to publication date. All articles detailing
sinonasal oncocytoma as the primary diagnosis were in-
cluded in the analysis. Articles were reviewed based on title
and abstract information to eliminate duplicate and irrele-
vant articles. The references of the remaining articles were
also reviewed to yield additional case reports.
Data extraction
Full-text article analysis was performed by 2 independent
reviewers for inclusion. Published studies meeting the in-
clusion criteria were analyzed further for data abstraction,
including author information, year of publication, patient
demographics, presentation at diagnosis, radiographic and
histologic findings, management, and outcome, specifically
recurrence.
Statistical analysis
Statistical analysis was performed using GraphPad Prism
statistical software (GraphPad, Inc., La Jolla, CA). The
Fisher’s exact test was utilized for categorical risk factors
(sex, tumor location, and histology) associated with recur-
rence. The Student t test was conducted to study age at
diagnosis and recurrence. Results are reported as mean ±
standard deviation. Statistical significance was judged at
the p = 0.05 level.
Results
Literature review
PubMed and Ovid searches resulted in 82 total articles,
61 of which were excluded for either being duplicates or
irrelevant based on title and abstract information. Six addi-
tional case reports were identified by reviewing references.
Twenty-seven articles were assessed for eligibility. Three
articles were excluded because there was no follow-up in-
formation, specifically with regard to recurrence. Three ar-
ticles were excluded, as their primary tumor site was either
the lacrimal sac or nasolacrimal duct without involvement
of the nasal cavity or paranasal sinuses. Accordingly, 21
articles were identified as sinonasal oncocytoma and onco-
cytic carcinomas. Two articles addressed the same patient
for a total of 20 case reports recognized in the systematic
review of the literature. Details of the included case reports
are presented in Table 1, which includes patients’ demo-
graphics, initial presentation with respect to symptoms and
duration of symptoms before diagnosis, location of tumor,
course of disease, and histology.
Comparison of oncocytomas and oncocytic
carcinomas
There were 9 cases of oncocytomas, including the cur-
rent case, and 12 cases of oncocytic carcinomas (Table 2).
Three of the 12 cases of oncocytic carcinomas were ini-
tially described as oncocytomas and recurred as oncocytic
carcinomas.4–7 Of the total 21 cases, there was a male
predominance (3:2, 60%) with an average age of 61.3 ±
15.8 years at diagnosis (range, 23–84 years). There was
no significant difference between oncocytomas and onco-
cytic carcinomas with respect to age (p = 0.64) and sex
(p = 1.00).
Twenty cases detailed the presenting symptoms (Table 2).
Data analysis included the 6 most common symptoms:
epistaxis; nasal obstruction; epiphora; rhinorrhea; hear-
ing loss; and palpable mass. The most common presenting
symptoms were epistaxis and nasal obstruction (n = 11,
55%). The average symptom duration before diagnosis was
19.3 ± 32.8 months (n = 12). However, oncocytomas (n =
6) were found to present, on average, 10.3 ± 11.5 months
before diagnosis as compared with oncocytic carcinomas
(n = 6) presenting, on average, 28.3 ± 45.1 months before
diagnosis.
Sinonasal subsites involved at presentation and recur-
rence are detailed in Table 2. The most common loca-
tion was the nasal cavity (n = 17, 81%). Involvement
of paranasal sinuses occurred in 13 cases (62%). Of the
paranasal sinuses cases, maxillary sinus (n = 9, 69%)
and ethmoid sinus (n = 8, 62%) involvement were most
common.
When oncocytomas were examined independently, on-
cocyctic carcinomas had significantly greater paranasal in-
volvement (p = 0.002) and trended toward significance
with orbital extension of tumor (p = 0.067) compared
with oncocytomas. However, there was no significant dif-
ference between oncocytomas and oncocytic carcinomas
with respect to involvement of the nasal cavity (p =
0.27), nasopharynx (p = 0.55), and nasolacrimal apparatus
(p = 0.60).
Histology
All 20 cases reported eosinophilic granular cytoplasm as a
consequence of a high mitochondrial count, which is nec-
essary for diagnosis. Histology was further analyzed for
presence of mitotic figures and pleomorphism as well as ev-
idence of infiltration or invasion. Only cases in which histol-
ogy characteristics were explicitly mentioned were included
in analysis. As expected, oncocytic carcinomas showed a
greater proportion of both mitoses/pleomorphism (n = 5,
71%) and invasion/infiltration (n = 6, 86%).
Locoregional and distant metastasis
These diseases have varying courses, ranging from lim-
ited sinonasal involvement with surgical resection to mul-
tiple recurrences and metastases with both surgery and
radiotherapy employed. In addition to involvement of
the sinonasal space, 3 cases had regional lymph node
involvement (14%).6, 8, 9 Furthermore, regional metasta-
sis occurred in 2 cases, specifically with the involve-
ment of skin and subcutaneous tissue, (9%) and distant
International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017 4
Sinonasal Oncocytomas

TABLE 1. Literature review of sinonasal oncocytomas and oncocytic carcinomas

Author Patient Symptoms Location Course Histology

9
Abe et al, 2007 47/male Epistaxis and nasal Nasal cavity (inferior Excision via endoscopic medial Diagnosis: Oncocytic carcinoma.
obstruction for 1 year. turbinate) initially, maxillectomy (Denker Nuclear pleomorphism,
nasolacrimal duct approach). invasion into orbit intravascular invasion; cells
and orbit with plus metastasis to lymph nodes arranged in trabeculae,
recurrence along warranted modified radical sheets, or clusters.
with regional and neck dissection 40 days after
distant metastases. first surgery plus postoperative
radiotherapy (50 Gy) and
tegafur/uracil. Recurrence
again in 1 year in skin of neck
plus systemic multiple bone
metastases, so nedaplatin and
fluorouracil were started and
continued until his death 2.5
years after initial diagnosis.
Altman et al, 67/female Nasal obstruction and Nasal cavity (inferior Medial maxillectomy via Diagnosis: Oncocytoma. No
199821 rhinorrhea with meatus and inferior Caldwell-Luc approach; no invasion/ infiltration; cells
secondary sinusitis turbinate). recurrence after 5 years. arranged in sheets and
refractory to medication nodular aggregates.
for 1 year.
Banerjee et al, 64/male Unilateral hearing loss. Nasopharynx. Excision through lateral palatal Diagnosis: Oncocytoma. No
199522 splitting approach; no invasion/infiltration; cells
recurrence after 2 years. arranged as glandular
structures.
Chui et al, 198523 58/female Epiphora and nasal Nasal cavity initially, Excision via lateral rhinotomy; Diagnosis: Oncocytic carcinoma.
obstruction. paranasal sinuses recurrence 2 years later, No mitotic figures, invasion
(ethmoid) and orbit en-bloc excision via bifrontal into bone.
with recurrence. craniotomy given spread to
sinuses and orbit; no
recurrence 5 years after initial
diagnosis.
Cohen and 61/male Epistaxis and nasal Nasal cavity, paranasal Medial maxillectomy via Diagnosis: Oncocytoma,
Batsakis, obstruction for 1 year; sinuses (maxillary), Caldwell-Luc approach; oncocytic carcinoma with
19864 ; Johns, rhinorrhea for 6 and orbit. recurrence 5 and 7 years after recurrence. At first
19735 months. initial diagnosis. presentation: no mitotic
figures, bone invasion; cells
arranged in solid nests,
anastomosing cords, or
tubes.
Colreavy et al, 68/male Recent-onset hearing loss. Nasopharynx Excision via Le Fort I osteotomy Diagnosis: Oncocytoma. No
20012 (obstruction of plus CO2 laser, no recurrence mitotic figures, no
Eustachian tube). after 18 months. invasion/infiltration, cells
arranged in nests and
glandular structures.
Comin et al, 60/female Epistaxis for 1 month. Nasal cavity (medial Excision of tumor with no Diagnosis: Oncocytoma. No
199724 wall). recurrence after 3 years. mitotic figures, no
invasion/infiltration; cells
arranged in nests,
anastomosing cords, or
acinar-like structures.
Corbridge et al, 78/female Nasal obstruction for 2 Nasal cavity, paranasal Excision via lateral rhinotomy, no Diagnosis: Oncocytic carcinoma.
19968 months. sinuses (ethmoid, radical neck dissection or Mitotic figures,
sphenoid, frontal), radiotherapy as per patient; pleomorphism, infiltrative
lymph nodes. recurrence after 7 months plus with intralymphatic spread.
regional metastasis, terminal
care.
(Continued)

5 International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017
Hodzic et al.

TABLE 1. Continued

Author Patient Symptoms Location Course Histology

DiMaio et al, 32/male Nasal obstruction. Nasal cavity and Local excision plus postoperative Diagnosis: Oncocytic carcinoma.
198010 paranasal sinuses radiotherapy, recurrence after Pleomorphism, rare mitotic
(maxillary and 7 years, treated with surgery figures, no
ethmoid). and radiotherapy; no invasion/infiltration.
recurrence 8 years after initial
diagnosis.
Fons et al, 201313 81/male Epistaxis for 1 week. Nasal cavity (inferior Excision via endoscopic medial Diagnosis: Oncocytoma. No
meatus, inferior maxillectomy; no recurrence mitotic figures; cells arranged
turbinate, middle after 1.5 years. in solid nests, short
turbinate). trabeculae, and follicles.
Handler and Ward, 64/male Cheek and teeth Paranasal sinuses Maxillectomy with orbital floor Diagnosis: Oncocytoma. Rare
197925 paresthesias for (maxillary sinus). removal; no recurrence after mitotic figures, infiltration
2 years. 1 year. into stroma; cells arranged in
nests, cords, and acinar-like
structures.
Hu et al, 20106 73/male Epistaxis. Nasal cavity initially, Initially presented as oncocytoma. Diagnosis: Oncocytoma,
paranasal sinuses Excision via lateral rhinotomy oncocytic carcinoma with
(maxillary, frontal, with recurrences after 5 and recurrence. Nuclear atypia,
sphenoid, ethmoid), 7 years after initial diagnosis, perineural invasion,
orbit, anterior skull with neck dissection not done infiltration into bone, tumor
base, lymph nodes despite metastatic necrosis; cells arranged in
with recurrence. lymphadenopathies (confirmed nests (final histology).
with positron emission
tomography scan) plus
postoperative radiotherapy (66
Gy to neck, 59.4 head in 33
fractions); no recurrence 9
years after initial diagnosis.
Jung et al, 201326 64/male Epistaxis epiphora, nasal Nasal cavity, Excision via endoscopic inferior Diagnosis: Oncocytic carcinoma.
obstruction for nasolacrimal duct, medial maxillectomy plus Pleomorphism, with
12 months. lacrimal sac, dacryocystectomy, patient destructive, infiltrating
paranasal sinuses refused radiotherapy; 9 months pattern; cells arranged in
(maxillary). later, epiphora, purulent nests.
rhinorrhea, swelling and
tenderness of medial canthal
area so excision via
transconjuctival approach plus
postoperative radiotherapy
(60 Gy in 33 fractions over 8
weeks); no recurrence 2 years
after initial diagnosis.
Klausen et al, 66/male Nasal obstruction for Nasal cavity (middle Excision of tumor with no Diagnosis: Oncocytoma. No
199227 2 years. turbinate). recurrence after 2 years. mitotic figures, no
invasion/infiltration.
Mahmoud, 197911 50/male Epistaxis and nasal Nasal cavity (lateral Transnasal excision of tumor; Diagnosis: Oncocytic carcinoma.
obstruction for 1 year. nasal wall, middle recurrence in 3 years (treated Cells arranged in acinar-like
meatus and middle with radiotherapy only), and structures.
turbinate), 13 years after initial diagnosis
paranasal sinus (treated with total
(maxillary) with maxillectomy); no recurrence
recurrence. 14 years after initial diagnosis.
Mikhail et al, 84/female Unilateral facial pain and Nasal cavity, paranasal Radical maxillectomy and orbital Diagnosis: Oncocytic carcinoma.
198828 swelling, epistaxis, sinuses (maxillary), exenteration; no recurrence Mitotic figures and
diplopia on upward orbit, infratemporal after 1 year. pleomorphism, prominent
gaze, numbness of right fossa. nucleoli, bone invasion; cells
infraorbital area. arranged as nests and
glandular structures.
(Continued)

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Sinonasal Oncocytomas

TABLE 1. Continued

Author Patient Symptoms Location Course Histology

Miracco et al, 23/female Palpable mass for 1 year, Nasal cavity (medial Excision of tumor with no Diagnosis: Oncocytoma. No
198629 epistaxis for 10 days. wall). recurrence after 1 year. mitotic
figures/pleomorphism, no
invasion/infiltration; cells
arranged in sheets, chords,
or acinar-like structures.
Nayak et al, 50/female Unilateral nasal Nasal cavity initially, Presented initially as oncocytoma, Diagnosis: Oncocytic carcinoma.
199920 obstruction and paranasal sinuses, which was excised; recurrence Cells arranged as glandular
rhinorrhea for 10 years; (maxillary, frontal, 10 years later treated with structures.
unilateral epistaxis, and ethmoid), extended medial maxillectomy
bilateral hearing loss nasopharynx with via lateral rhinotomy, followed
1 week earlier with recurrence. by postoperative radiotherapy
recurrence. (60 Gy in 28 fractions over
6 weeks); no recurrence seen
11.5 years after initial
diagnosis.
Perlman et al, 80/male Information not provided. Lacrimal sac initially, Initially presented in lacrimal sac Diagnosis: Oncocytoma,
19957 paranasal sinuses as oncocytoma, treated with oncocytic carcinoma with
(ethmoid and surgical excision; recurrence recurrence. Cells arranged as
maxillary), orbit 3 years later with extension to glandular structures,
with recurrence. paranasal sinuses treated via recurrences noted to have
Caldwell-Luc approach plus atypical nuclei and increased
radiotherapy; recurrence 7 and mitotic activity.
12 years after diagnosis treated
with surgery.
Savic et al, 198930 45/? Epistaxis and nasal Nasal cavity and Excision via Denker procedure; Diagnosis: Oncocytic carcinoma.
obstruction. paranasal sinuses recurrence in 1 year (treated Rare mitotic figures,
(ethmoid, with surgery); no recurrence infiltration into stroma; cells
sphenoid). 4 years after initial diagnosis. arranged in acinar-like
structure

metastasis was present in only 1 case (5%).8, 9 Accordingly,
given the difference in tumor location, as well as involve-
ment of lymph nodes and regional and distant metastases,
different treatment approaches were understandably uti-
lized, including the use of radical neck dissection, radio-
therapy, and chemotherapy in the setting of locoregional
and distant metastases. Of the reported sinonasal onocy-
tomas and oncocytic carcinomas, 2 patients died with dis-
ease, 1 from locoregional metastases and the other from
widespread lymph node metastases (10%).8, 9
Treatment
All oncocytomas and oncocytic carcinomas were surgically
resected at initial presentation, 95% of which were solely
treated surgically (n = 20). Only 1 case utilized postop-
erative radiotherapy with initial presentation.10 Ten cases
specified which surgical approach was attempted for tumor
resection, most commonly either with a lateral rhinotomy
or a Caldwell-Luc approach, both of which were utilized
in 3 cases (30% of open surgical approaches). Conversely,
the endoscopic approach was attempted in 3 cases (14%).
There were no reports in the literature of a combined open
and endoscopic approach for initial tumor resection.
Treatment of oncocytomas and oncocytic carcinomas did
not differ at initial presentation, specifically when com-
paring between use of open and endoscopic surgical ap-
proaches (p = 1.0) as well as the use of either the lateral
rhinotomy or Caldwell-Luc approach (p = 0.47).
The treatment approach to recurrent cases of oncocytic
carcinomas differed in that radiotherapy was used with
greater frequency (p = 0.003); specifically, 45% (n = 5)
utilized radiotherapy in conjunction with surgical resec-
tion, with only 3 cases treated with surgical resection alone
(27%) (Table 3). Radiotherapy and chemotherapy were
both attempted as sole treatments for recurrent tumors
(9%). This is in contrast to the initial treatment of sinonasal
oncocytomas and oncocytic carcinomas, in which postoper-
ative radiotherapy was minimally utilized and every tumor
was surgically resected.
Recurrence
Eleven of the 20 case reports of sinonasal oncocytomas and
oncocytic carcinomas exhibited recurrence (n = 11). Of
these, 3 initially presented as oncocytomas that recurred
as oncocytic carcinomas.4–7 Within this group, transfor-
mation occurred, on average, 7.3 years from the initial

7 International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017
Hodzic et al.

TABLE 2. Characteristics of oncocytomas and oncocytic carcinomas

Patient information Total Oncocytoma Oncocytic carcinoma

Age (years) 61.3 ± 15.8 62.9 ± 16.1 60.2 ± 16.1

(range, 23-84) (range, 23-81) (range, 32-84)
Sex (male:female) 3:2 5:4 7:4
Symptoms
Epistaxis 11/20 0.55 4/9 0.44 7/11 0.64
Nasal obstruction 11/20 0.55 2/9 0.22 9/11 0.82
Rhinorrhea 4/20 0.20 1/9 0.11 3/11 0.27
Epiphora 2/20 0.10 0 0 2/11 0.18
Hearing loss 3/20 0.15 2/9 0.22 1/11 0.09
Palpable mass 2/20 0.10 1/9 0.11 1/11 0.09
Duration of symptoms 19.3 ± 32.8 10.3 ± 11.5 28.3 ± 45.1
(months)
Location
Nasal cavity 17/21 0.81 6/9 0.67 11/12 0.92
Paranasal sinus 13/21 0.62 2/9 0.22 11/12 0.92
Maxillary 9/13 0.69 1/2 0.5 8/11 0.73
Ethmoid 8/13 0.62 1/2 0.5 7/11 0.64
Sphenoid 3/13 0.23 0/2 0 3/11 0.27
Frontal 3/13 0.23 0/2 0 3/11 0.27
Nasopharynx 2/21 0.10 2/9 0.22 1/12 0.08
Nasolacrimal apparatus 4/21 0.19 1/9 0.11 3/12 0.25
Orbit 8/21 0.38 1/9 0.11 7/12 0.58
Histology
Mitotic figures/pleomorphism 7/16 0.44 2/9 0.22 5/7 0.71
Invasion/infiltration 9/16 0.56 3/9 0.33 6/7 0.86
Both characteristics 5/14 0.36 1/7 0.14 4/7 0.57
Neither characteristic 4/14 0.29 4/7 0.57 0/7 0
Metastasis
Lymph nodes 3/21 0.14 0 0 3/12 0.25
Regional 2/21 0.09 0 0 2/12 0.17
Distant 1/21 0.05 0 0 1/12 0.08
Treatment
Resection only 20/21 0.95 9/9 1.00 11/12 0.92
Open approach 10//21 0.48 4/9 0.44 4/12 0.33
Lateral rhinotomy 3/10 0.30 0/4 0 2/4 0.50
Caldwell-Luc 3/10 0.30 2/4 0.50 2/4 0.50
Endoscopic 3/21 0.14 2/9 0.22 1/12 0.08
Resection + radiotherapy 1/21 0.05 0/0 0 1/12 0.08
Recurrence 11/20 0.55 3/11 0.27 8/9 0.89

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Sinonasal Oncocytomas

TABLE 3. Treatment of recurrent oncocytic carcinomas TABLE 4. Analysis of factors associated with recurrence

Time to recurrence (months) 42.2 ± 35.8 Variable Recurrence p value

Intervention Sex 0.650

Resection only 3/11 0.27 Men 7/12 0.58
Radiotherapy only 1/11 0.09 Women 3/7 0.43
Resection and radiotherapy 5/11 0.45 Age at diagnosis (years) 0.418
Chemotherapy 1/11 0.09 20-30 0/1 0
No intervention 1/11 0.09 31-40 1/1 1.00
Multiple recurrences 3/9 0.33 41-50 4/4 1.00
51-60 1/2 0.50

diagnosis of oncocytoma to histologically proven oncocytic 61-70 2/7 0.71

carcinoma.4–7 The case described in this study was not in- 71-80 3/4 0.75
cluded in the recurrence analysis, given the limited follow-
81-90 0/2 0
up time compared with published case reports. Of the 11
reported tumors, the average time to recurrence occurred at Location of tumor 0.145
42.2 ± 35.8 months. Most recurrences occurred within 12 Nasal cavity only 4/9 0.44
months (n = 3) or after 37 months (n = 4). Conversely, the
average follow-up times at which the authors established Involvement of paranasal sinuses 6/7 0.86
no recurrence (n = 9) was 24.0 ± 15.6 months. Notably, 3 Histology
cases demonstrated multiple recurrences, which comprised
Mitoses/pleomorphism 6/7 0.86 0.060
33% of recurrent sinonasal oncocytic carcinomas.4–6, 11
Significance was assessed between various risk factors Invasion/infiltration 7/9 0.78 0.041a
and first recurrence, including sex, age at diagnosis, lo- Both characteristics 4/5 0.80 0.048a
cation of tumor, and histologic findings (Table 4). There
Neither characteristic 0/4 0
was no relationship between factors and risk for recur-
rence with respect to sex (p = 0.650) and age at diag- Treatment
nosis (p = 0.418). Risk for recurrence was assessed for Open approach 4/8 0.50 1.00
tumors that initially presented in both the nasal cavity
and sinuses with respect to those that were confined to Endoscopic approach 1/2 0.50
the nasal cavity at presentation. Compared with tumors Lateral rhinotomy 3/3 1.00 0.40
only involving the nasal cavity (n = 9), those extending
Caldwell-Luc 1/3 0.33
into the paranasal sinuses (n = 7) were not at significantly
increased risk for recurrence (p = 0.145). Histology was a
Statistically significant.
the most important factor in determining risk for recur-
rence. Presence of either mitoses or pleomorphism trended
toward significance (p = 0.060). However, the presence of particularly adenocarcinomas, are strongly associated with
either invasion/infiltration alone (p = 0.048) or both mi- occupational contact encountered during woodworking,
toses/pleomorphism and invasion/infiltration (p = 0.048) whereas use of radiation has been associated with salivary
was significantly associated with recurrence. There was no gland tumors in addition to several industry occupational
significant relationship between treatment approach and re- exposures. Abe et al reported a case of sinonasal oncocytic
currence when comparing open and endoscopic approaches carcinoma with regional and distant metastases in which
(p = 1.0), as well as when comparing between the use of lat- the patient had occupational exposure in powder metal-
eral rhinotomy and the Caldwell-Luc approach for tumor lurgy for 12 years, suggesting a possible role for exposure
resection access (p = 0.40). history in the pathogenesis of these tumors.9
There is no sex predilection for oncocytomas, whereas
oncocytic carcinomas show a slight male predominance.
Discussion The literature review revealed the average age of diagno-
Oncocytomas and oncocytic carcinomas can present in sis for both oncocytomas and oncocytic carcinoma is 61.3
several locations throughout the body, such as the kid- years, but with a wide age range for diagnosis, unlike their
ney, thyroid gland, and major and minor salivary glands.1 major salivary gland equivalents that are diagnosed pre-
The cause of sinonasal oncocytomas and oncocytic carci- dominantly late in life. Given this, it is unclear whether
nomas is presently unknown. Conversely, nasal cancers, significant occupational and environmental exposure

9 International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017
Hodzic et al.
durations are a precipitating factor in the development of
these tumors.
The diagnosis of oncocytomas and oncocytic carcino-
mas depends primarily on presenting symptoms and clin-
ical suspicion followed by imaging and tissue biopsy. The
initial presentation, however, is relatively nonspecific. They
most commonly present with symptoms of unilateral epis-
taxis, nasal obstruction, and rhinorrhea, which are symp-
toms suggestive for a space-occupying lesion within the
sinonasal space, but are neither sensitive nor specific. The
most common site of these tumors within the sinonasal
space is the nasal cavity, but involvement of the nasophar-
ynx, nasolacrimal duct, and paranasal sinuses have all been
described.
The duration of symptoms before diagnosis is variable,
ranging from acute epistaxis to several years of nasal ob-
struction. Patients present with symptoms for over a year,
averaging 19.3 months before diagnosis. This length of time
may be attributed to the initial nonspecific nature of patient
symptoms. Notably, sinonasal oncocytomas present, on av-
erage, for 10.3 months before diagnosis, whereas oncocytic
carcinomas have symptoms, on average, for 28.3 months
before diagnosis. This has prognostic significance, as longer
symptom duration allows for greater tumor extension and,
consequently, increased opportunity for local destruction
and possibly malignant transformation. Accordingly, when
these symptoms are unilateral, there should be high clinical
suspicion for a space-occupying lesion with further workup
warranted.
Histology is pivotal for the diagnosis of oncocytomas
and oncocytic carcinomas. An oncocyte, the predominant
cell of oncocytomas and oncocytic carcinomas, is a large
polyhedral cell with a granular eosinophilic cytoplasm as
a consequence of rich mitochondrial content.1 Of note,
oncocytomas and oncocytic carcinomas are not the most
common oncocytic tumors of the head and neck.12 The
differential for oncocytic salivary gland tumors primar-
ily includes Warthin tumors and salivary duct carcinoma,
whereas the differential for oncocytic upper aerodigestive
tract tumors ranges from Schneiderian papillomas (onco-
cytic type) to malignant mucosal melanoma.12 Diagnosis
depends on detection of mitochondrial content with a phos-
photungstic acid hematoxylin (PTAH) stain or with elec-
tron microscopy.13 Ultrastructure with electron microscopy
is the best form of diagnosis.14
Oncocytic carcinomas are distinguished from oncocy-
tomas with the presence of frequent mitoses and cellular
pleomorphism in conjunction with local invasion or in-
filtration histologically; perineural, intravascular, or lym-
phatic invasion; and regional or distant metastases.14 These
definitions were initially described for oncocytomas of the
major salivary glands; however, they have been used to dif-
ferentiate between sinonasal oncocytomas and oncocytic
carcinomas.
Presence of either invasion or infiltration alone (p =
0.041) or both histologic findings (p = 0.048) was sig-
nificantly associated with recurrence. Thus, a diagnosis of
oncocytoma does not infer a completely benign course, as
presence of these histologic findings suggests a locally ag-
gressive tumor with potential for recurrence. Moreover, a
diagnosis of oncocytic carcinoma implies the presence of
these histologic findings as well as significant risk for re-
currence. Nevertheless, there are several variables at play
for disease course and prognosis, such as extent of local
destruction, tumor location, presence of metastasis, and
variability in treatment approaches.
Oncocytic tumors of the sinonasal tract, compared with
those of the major salivary glands, are more likely to be ma-
lignant, with more frequent local invasion and recurrence.
Surgical excision is the principal treatment. There have been
several surgical approaches used for excision of sinonasal
oncocytic lesions. The major limitation of reported cases of
these tumors is the lack of information regarding specific
surgical approaches and resection margins. Given the doc-
umented cases of oncocytomas and oncocytic carcinomas
spanning <50 years, it is impossible to accurately assess
the benefit of outdated surgical approaches, as otolaryngol-
ogy moves toward increased use of endoscopic approaches
for all sinonasal tumors. There were 2 cases in which en-
doscopic endonasal approaches were utilized solely. Con-
versely, open approaches were explicitly described in over
half of the cases, most commonly the lateral rhinotomy and
Caldwell-Luc approaches.
When compared with traditional open approaches, the
endoscopic approach offers ready access to both the nasal
cavity and nasolacrimal apparatus as well as excellent vi-
sualization. The endoscopic approach depends on both op-
timal preoperative imaging and experience of the surgical
team.15
A multidisciplinary, team-based approach can help facil-
itate appropriate resection when disease involves the orbit
and skull base. Collaboration with oculoplastics and neu-
rosurgery colleagues when appropriate can help facilitate
complete resection and optimal outcome.16, 17
Rather inconsistently, radiotherapy and even chemother-
apy have been used to treat oncocytic carcinomas
postoperatively (Table 4). There is debate whether ra-
diotherapy is useful in preventing recurrence, with the
suggestion that these tumors are radioresitant.11 However,
when there is local invasion and destruction, regional
and distant metastasis, lymph node involvement, or his-
tologic evidence of carcinoma, postoperative radiotherapy
can be a useful approach to prevent recurrence and
spread, as these complications require a more aggressive
treatment approach.18 Currently, there is insufficient
information regarding the utility of systemic chemotherapy
in the treatment of sinonasal cancers.19 Ultimately, a
diagnosis of oncocytic carcinoma of sinonasal origin
warrants careful monitoring and follow-up, as it is lo-
cally destructive and capable of metastasis and multiple
recurrences.
Sinonasal oncocytomas and oncocytic carcinomas carry
a wide range of disease courses as depicted in the liter-
ature, ranging from definitive surgical removal without
International Forum of Allergy & Rhinology, Vol. 0, No. 00, xxxx 2017 10
Sinonasal Oncocytomas

recurrence to reports of multiple recurrences and metastatic
disease. Patients with sinonasal oncocytic carcinoma have
a 55% rate of recurrence among all reported cases. The
true rate of recurrence is unclear given the variable pe-
riods of follow-up described in the literature. Recurrence
was found to occur, on average, 42.2 ± 35.8 months af-
ter initial diagnosis, whereas the average reported time
for no recurrence of these tumors was 24.0 ± 15.6
months, meaning there is a window of time in pub-
lished cases where recurrence was still possible.4, 5 Given
that recurrence commonly occurs within a year as well
as several years after initial diagnosis, follow-up during
the initial period is important in this patient population
(Table 1).
Of note, 3 cases have described the development of on-
cocytic carcinoma from an initial diagnosis of oncocytoma.
Tumor recurrence occurred approximately 7.3 years from
initial diagnosis.4–7 This highlights the importance of regu-
lar follow-up in this patient population. Nevertheless, onco-
cytomas have a favorable prognosis with complete surgical
excision and appropriate follow-up.
Conversely, oncocytic carcinomas tended to be locally
aggressive, with several cases of orbital invasion (38%).
Metastasis is rare, with only 1 report of distant metas-
tases and 3 cases of regional metastasis and lymph
node involvment.6, 8, 9 There are only 2 reported cases of
sinonasal oncocytic carcinomas in which patients died with
the disease.8, 9 Accordingly, follow-up is critical for several
years after diagnosis to prevent local destruction of impor-
tant structures.
Analysis of this systematic review was limited by the in-
frequency of this disease and was subsequently comprised
of case reports presented over a >50-year period. Accord-
ingly, there was variability in standard of diagnosis and
treatment.
In addition, given the small sample size of sinonasal on-
cocytomas and oncocytic carcinomas, the authors’ data are
susceptible to type I error with respect to histologic find-
ings and type II error with respect to sex, age, and tumor
location.
Conclusion
Oncocytomas and oncocytic carcinomas are rare, locally
invasive tumors of the sinonasal space with a proclivity for
recurrence. Histologic findings are particularly important
for predicting disease course and devising the treatment
approach.
Given their location and nature, complete surgical exci-
sion via the endoscopic approach is possible in appropriate
cases. Involvement of the nasolacrimal apparatus occurs in
up to 20% of cases, with orbital extension appearing in
nearly 40% of cases. In these circumstances, a combined
orbitotomy and endonasal endoscopic approach can lead
to a favorable outcome.
Acknowledgements
The authors thank Raja R. Seethala, MD, Department of
Pathology, University of Pittsburgh Medical Center, for
providing the pathology photographs.

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