The patient came to the clinic 22-May-2014 after performing biopsy through the left nostril 19-May-2014 at Jordan hospital with biopsy result done 21-May-2014 telling that she has poorly differentiated sinonasal adnocarcinoma non-intestinal type. The operation was done by CT-scan data done 14-May-2014 for the sinuses and was operated as for polyp.

On examination; The patient has bilateral anosmia for unknown period of time. She still has bloody discharge from the nose. She is neurologically free aside of anosmia. The patient is right handed.

The patient was sent for new CT-scan of the skull base and MRI of the brain and nasal cavities with contrast with MRA of the brain and carotids. She was advised to perform the investigations after the clearing of the nasal discharges. MRI and CT-scan done 26-May-2014 showing a tumor originating from the olfactory bulbs invading the intradural space destroying the planum sphenoidale and extending down to the ethmoid cavities and left side of the sphenoid sinus and the left maxillary cavity. It was occluding the left nostril.

Bifrontal subfrontal craniotomy with reflection of the bone flap to the left. Surgicele was applied as usual over the superior sagittal sinus as usual to avoid bleeding. The anterior edge of the bone flap was created abutting the anterior fossa plan, violating during that the frontal sinuses. The tumor was fulfilling the left part of the frontal sinus. It was sent to fresh frozen biopsy, which gave the result of malignant adenosarcoma. The tumor was violate fleshy, friable. The dura was opened parallel to the anterior edge of the bone defect. The intradural tumor was totally resected. It was completely destroying the left olfactory bulb but the right one was anatomically intact and was preserved. It was possible to close the dura without applying a dural graft with preservation of the right olfactory bulb. Resection of the tumor in the nasal cavity was undertaken and the tumor was completely destroying the medio-inferior wall of the left orbit. The orbital structures were preserved. So as to gain more visual control, it was necessary to create a small bony miniflap at the nasal bone to see the tumor residing directly under the anterior fossa.  The tumor was completely destroying the nasal septum, for what it was removed with tumor. Drilling of the anterior wall of the sphenoid sinus, which was also tumorous in inspection. All the visible parts of the tumor were resected. The dura was closed and the bone flap reflected back to place and three separate stitches were applied to the and bandaging of the head was done. The patient was sent for MRI, which showed a small residual of the tumor near the exit of the left nostril and mild subdural hematoma over the right convexity. The wound was reopened as anew and seeking for the cause of the right subdural hematoma was identified after removing the surgicele. There was dural tear at the posterior edge of bone defect in the right side, which was reaching the lateral wall of the superior sagittal sinus. The hematoma was evacuated and the sinus tear was repaired and the dura was water-tightly closed. The small bone flap was returned to place and fixed and the bifrontal flap was returned to place after applying a piece of muscle to the bone defect at the left substantia crebrosa with glue in both side to keep in in place. Routine closure of the wound. Before weaning the patient, the piece near the exit of the left nostril, was removed using specula through the nostril.

Smooth postoperative recovery. The patient was sent to the ICU for 24 hour observation.

The patient has an aggressive tumor that destroying the bony elements and growing intradural.

The histologic results were sent to 2 separate doctors with promise to perform full investigations to have the final diagnosis without mistakes.

Intraoperative MRI seems to be mandatory in cranial and such skull base surgery. Here the remnant at the most inferior part of the nasal cavity was seen and removed accordingly and the right sided subdural hematoma was seen and the tear of the right side of the SSS was repaired and the hematoma evacuated. The MRI control took less than 10 min, but saved several days and weeks of the possible complications.

The first result was that the neoplastic cells are: EMA +, NSE focal +, S100 focal +, Chromogranin rare positive cells, Synaptophysin focal+, Pan CK =, MNFCK +, GFAP -, TTF1 -, MELAN A -, HMB 45 -, LCA -, CD99 -, Vimentin -, MPO -. Sino-nasal tumor with intracranial extension: High grade undifferentiated malignant tumor, consistent with malignant neuroendocrine tumor ( Dr. Fayez Hajjiri).

Anaplastic tumor of undetermined histogenesis (Dr. Salah Al-Jitawi).