Post on 12-Feb-2018
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Paranasal Sinus Mucoceles
Ashley Agan, MSIV Faculty Advisor: Patricia A. maeso, MD
University of Texas Medical Branch Department of Otolaryngology
Grand Rounds Presentation November 22, 2010
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Outline
Introduction
Anatomy
Physiology
Pathophysiology
Symptoms
Treatment
Case Presentation
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Introduction
What is a mucocele? Mucoceles are epithelium-lined, mucus-containing sacs
that completely fill a paranasal sinus
Caused by obstruction of the sinus ostium or obstruction of a mucous secreting gland
– Benign
– Expansion can cause destruction of surrounding structures
– Infected mucopyocele
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Epidemiology • Rare in United States
• Can take as many as 10-15 years to produce symptoms
• Most commonly found in frontal and ethmoid sinuses
• Japan – increased incidence of maxillary sinus mucoceles • Radical surgery was common for sinusitis
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Prevalence
• 1978 Natvig and Larsen – 112 patients with mucoceles from 1947 to 1974
77% Frontal Sinus
14% Frontal/anterior ethmoid
5% Anterior ethmoid
1% Posterior ethmoid
3% Maxillary
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Anatomy Maxillary Sinus
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Anatomy Frontal Sinus
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Anatomy Frontal Sinus
– Funnel-shaped
– Vary in size and shape
– Generally have central septum
– Floor slopes inferiorly to the midline
– Primary ostium located on the floor close to the midline
Frontal Recess • Hourglass-like narrowing between frontal sinus and anterior middle meatus • Obstruction results in a loss of ventilation and mucus clearance from frontal sinus
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Anatomy
Sphenoid Sinus
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Physiology
• Sinuses are lined by ciliated respiratory epithelium
• Mucous blanket on surface
• Cilia propel mucus in specific pattern of flow – mucociliary clearance
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Maxillary Sinus
• Mucous flow originates in the antral floor
• Flow is directed centripetally toward primary ostium
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Frontal Sinus
• Mucous flows up medial wall, laterally across roof, and medially along floor
• Some mucous exits through primary ostium
• The rest is recirculated
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Appearance
• Macroscopically » Thick walled grayish cyst
• Histology » Pseudo-stratified columnar epithelial cells
» Few ciliated cells
» Sterile mucus and cholesterol crystals
» Hypertrophic goblet cells
» Fibrous thickening of submucosa
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Pathophysiology
• Obstruction of ostium or outflow tract or of mucus secreting gland
–Inflammation –Trauma/Surgery
–Fractures –Caldwell Luc Procedure
–Mass –Radiotherapy → scarring
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Caldwell Luc Procedure
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Pathophysiology
• Secretion of mucus continues → accumulation
• Pressure increases
– Bone devascularization
– Osteolysis
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Pathophysiology
• Inflammation – cytokines
– IL-1, -6
– TNF alpha
– PGE2
– Bone resorption by osteoclasts
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Clinical Features • Headache
• Facial pressure
• Facial swelling/deformity
• Dental Pain
• Nasal Obstruction
• Ophthalmic manifestations – Proptosis, Periorbital pain,
Impaired ocular mobility, Blurred/loss of vision, Diplopia
• Neurologic manifestations –Confusion –Meningitis –CSF leak
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Ophthalmic Manifestations
• Maxillary, Frontal, Anterior ethmoids –
– Proptosis, Periorbital pain, decreased ocular mobility
– Pressure on globe pushes it outwards
– Expansion on to extraocular muscles restricts movement
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Ophthalmic Manifestations • Sphenoid, posterior ethmoids –
– Blurred vision & decreased ocular mobility
– Expansion of sinus wall may compress optic nerve or compromise its blood supply → optic atrophy
– Direct spread of suppuration → optic neuritis
– Involvement of abducent or oculomotor nerve can cause palsy
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Complications
• Vision loss – Associated with sudden onset of visual loss by spread of
infection or inflammation to optic nerve → poor prognosis (permanent blindness)
– Gradual vision loss caused by ischemia → better prognosis (resolution of ophthalmic symptoms)
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Suspicious Historical Elements
• Facial trauma
• Surgery
• Allergic/inflammatory sinus disease
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Imaging
• CT scan
– Sinus walls bow radially outwards
– Thin or thick sinus walls
– Bony erosions
– Mucocele appears homogeneous and airless
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45 year old male with left maxillary sinus mucocele
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37 year old male with bilateral postoperative maxillary sinus mucoceles
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Imaging • MRI
– Protein and water concentrations vary
– Viscosity varies
– Not best imaging modality
– Good for differentiating mucocele from sinonasal tumors (particularly contrast enhanced)
» Mucoceles have thin peripheral linear enhancement
» Tumors have diffuse enhancement
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Treatment
• Surgical removal or drainage is the only way to prevent intracranial and/or orbital complications
• Surgery » External
» Endoscopic
» Both
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External
• Indicated if orbital or intracranial involvement
• Good for fronto-ethmoidal mucoceles
• Several different variations
» Riedel
» Killian
» Lynch-Howarth
» Lothrop
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Riedel’s Procedure
• Removal of anterior wall and floor of frontal sinus
• Entire mucosal lining removed
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Lynch-Howarth
• Curved incision from inferomedial eyebrow, along upper third of nose
• Medial wall of orbit perforated
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Osteoplastic Flap
• Cut is made through eyebrows
• Scalp is lifted
• Frontal sinus obliterated with fat
• Bone replaced
• Better cosmesis
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Endoscopic Approach
• Endoscopic management with marsupialization
– Complete removal of the cyst lining is not required
– Recurrence rates are near 0%
– Goal is establishment of sinus drainage
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Recurrence
• Risk factors
– Surgery during acute infection
– Presence of multiple mucoceles
– Significant extension outside the sinus wall
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Surveillance
• Periodic nasal endoscopy in the office is recommended to assess patency of ostium
• Recurrences are few if adequate drainage is established
• It can take many years for mucoceles to recur
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Case Presentation • 50 yo female
• Referred for chronic sinus issues
• Chief complaint of significant left facial pain and pressure for the past 9 years
• PMH significant for allergic rhinitis and previous episodes of acute sinusitis
• PSH significant for Le Fort I Osteotomy with maxillary advancement procedure done as a child
» Dental cyst found on CT one year previously
» Patient lost job and was without insurance so was not evaluated by OMFS
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Case Presentation
• Physical Exam
– No polyps or masses
– Extraocular muscles intact
– Nasal mucosa showed no crusting, hypertrophy, or congestion
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Case Presentation • Dental cyst found on CT one year previously
• Repeat CT
– CT scan read “expansile unilocular homogeneous lesion with thin sclerotic margins associated with the left posterior most tooth apex”
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Case Presentation
• Patient was seen by OMFS
• Curettage and lavage of the left maxillary sinus and I&D of abscess was performed
• Pain and pressure resolved but returned two weeks later
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Case Presentation
• CT was reviewed in conjunction with an assessment of the surgery notes
• Lesion was determined to be a mucocele abutting the floor of the maxillary sinus around her teeth
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Case Presentation
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Case Presentation
• FESS and antral puncture with marsupialization of the maxillary mucocele
• 1 month after surgery patient had no more complaints of facial pain or pressure
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Summary • Mucoceles are late complications of sinus ostium
obstruction or mucous gland obstruction
• Expansile lesions that are capable of bony destruction and compromise of surrounding structures
• Endoscopic sinus surgery is the first choice for treatment
• External approaches may be necessary
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Sources 6. Rontal ML. “State of the Art in Craniomaxillofacial Trauma: Frontal Sinus.”
Current Opinion in Otolaryngology & Head and Neck Surgery 2008;16:381-6.
7. Moeller CW, Welch KC. “Prevention and Management of Complications in Sphenoidotomy.” Otolaryngologic Clinics of North America 2010; 43:839-54.
8. Natvig K, Larsen TE. “Mucocele of the paranasal sinuses.” The Journal of Laryngology & Otology 1978; 92:1075-82.
9. East D. “Mucoceles of the Maxillary Antrum.” The Journal of Laryngology & Otology 1985; 99:49-56.
10. Kariya S, Okano M, Hattori H, Sugata Y, et al. “Expression of IL-12 and T helper cell 1 Cytokines in the Fluid of Paranasal Sinus Mucoceles.” American Journal of Otolaryngology – Head and Neck Medicine and Surgery 2007;28:83-6.
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