Paranasal Sinus Mucoceles

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Paranasal Sinus Mucoceles

• Ashley Agan, MSIV
• 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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Riedels 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 ID 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

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