Paranasal Sinus Mucoceles - UTMB Health - Welcome to · PDF filePage 3 Introduction What is a...

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

Outline

Introduction

Anatomy

Physiology

Pathophysiology

Symptoms

Treatment

Case Presentation

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

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

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

Anatomy Maxillary Sinus

Anatomy Frontal Sinus

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

Anatomy

Sphenoid Sinus

Physiology

• Sinuses are lined by ciliated respiratory epithelium

• Mucous blanket on surface

• Cilia propel mucus in specific pattern of flow – mucociliary clearance

Maxillary Sinus

• Mucous flow originates in the antral floor

• Flow is directed centripetally toward primary ostium

Frontal Sinus

• Mucous flows up medial wall, laterally across roof, and medially along floor

• Some mucous exits through primary ostium

• The rest is recirculated

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

Pathophysiology

• Obstruction of ostium or outflow tract or of mucus secreting gland

–Inflammation –Trauma/Surgery

–Fractures –Caldwell Luc Procedure

–Mass –Radiotherapy → scarring

Caldwell Luc Procedure

Pathophysiology

• Secretion of mucus continues → accumulation

• Pressure increases

– Bone devascularization

– Osteolysis

Pathophysiology

• Inflammation – cytokines

– IL-1, -6

– TNF alpha

– PGE2

– Bone resorption by osteoclasts

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

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

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

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)

Suspicious Historical Elements

• Facial trauma

• Surgery

• Allergic/inflammatory sinus disease

Imaging

• CT scan

– Sinus walls bow radially outwards

– Thin or thick sinus walls

– Bony erosions

– Mucocele appears homogeneous and airless

45 year old male with left maxillary sinus mucocele

37 year old male with bilateral postoperative maxillary sinus mucoceles

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

Treatment

• Surgical removal or drainage is the only way to prevent intracranial and/or orbital complications

• Surgery » External

» Endoscopic

» Both

External

• Indicated if orbital or intracranial involvement

• Good for fronto-ethmoidal mucoceles

• Several different variations

» Riedel

» Killian

» Lynch-Howarth

» Lothrop

Riedel’s Procedure

• Removal of anterior wall and floor of frontal sinus

• Entire mucosal lining removed

Lynch-Howarth

• Curved incision from inferomedial eyebrow, along upper third of nose

• Medial wall of orbit perforated

Osteoplastic Flap

• Cut is made through eyebrows

• Scalp is lifted

• Frontal sinus obliterated with fat

• Bone replaced

• Better cosmesis

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

Recurrence

• Risk factors

– Surgery during acute infection

– Presence of multiple mucoceles

– Significant extension outside the sinus wall

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

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

Case Presentation

• Physical Exam

– No polyps or masses

– Extraocular muscles intact

– Nasal mucosa showed no crusting, hypertrophy, or congestion

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”

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

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

Case Presentation

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

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

Sources 1. Flint, PW, Cummings CW. "Chronic Frontal Sinus Disease." Cummings

Otolaryngology: Head & Neck Surgery. Philadelpha, PA: Mosby Elsevier, 2010. Print.

2. Cagigal BP, Lezcano JB, Blanco RF, Cantera JMG, Cuellar LAS, Hernandez AV. “Frontal Sinus Mucocele with Intracranial and Intraorbital Extension.” Medicina Oral , Patología Oral y Cirugía Bucal 2006; 11:E527-30.

3. Malard O, Gayet-Delacroix M, Jegoux F, Faure A, Bordure P, de Montreuil CB. “Spontaneous Sphenoid sinus Mucocele Revealed by Meningitis and Brain Abscess in a 12-year-old Child.” American Journal of Neuroradiology 2004; 25:873-875.

4. Yap SK, Yap EY. “Frontal Sinus Mucoceles Causing Proptosis – Two Case Reports.” Annals Academy of Medicine Singapore 1998; 27:744-7.

5. Tseng CC, Ho CY, Kao SC. “Ophthalmic Manifestations of Paranasal Sinus Mucoceles.” Journal of Chinese Medical Association 2005; 68:260-4.

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.

11. Har-El G. “Endoscopic Management of 108 Sinus Mucoceles.” Laryngoscope 2001; 111:2131-4.

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