PSEUDOCYSTS AND CYSTS OF THE MAXILLARY SINUS

Antral pseudocysts are common findings on panoramic radiographs. They appear as

dome-shaped, faintly radiopaque lesions arising from the floor of the maxillary sinus.
In the past these sinus changes were incorrectly termed sinus mucoceles, because
previous investigators thought the lesions resulted from mucus extravasation similar to
that seen in salivary glands of soft tissue. In fact, it appears that no comparable mucus
extravasation occurs in the maxillary sinus.

ANTRAL PSEUDOCYST

Antral pseudocyst is the best term for the dome-shaped lesion of the sinus fl oor. The
process usually consists of an inflammatory exudate (serum, not mucin) that has
accumulated under the maxillary sinus mucosa and caused a sessile elevation (Fig. 8-
65). The exudate is surrounded by connective tissue, and the epithelial lining of the
sinus is superior to the fluid. Reviews of large numbers of radiographs have
determined the prevalence, which varies from 1.5% to 14% of the population.

The cause of the inflammatory infiltrate has not been definitively determined, but in a
radiographic review, most cases showed a possible source from an adjacent
odontogenic infection. Primary irritation of the sinus lining, such as that seen from a
sinus infection or allergies, also can theoretically result in the subperiosteal
inflammatory infiltrate.

An increased prevalence of pseudocysts has been noted during the cold winter
months, leading some investigators to associate these lesions with an increased
frequency of upper respiratory tract infections or irritation from dry, forced-air
heating. Although allergies have been proposed as a cause, no increased prevalence
has been noted during the time of peak pollen exposure.

SINUS MUCOCELES

True sinus mucoceles are accumulations of mucin that are completely encased by
epithelium. They occur in two situations. One type of sinus mucocele occurs after
trauma or surgery to the sinus; this type is best known as a surgical ciliated cyst,
traumatic ciliated cyst, or postoperative maxillary cyst. A portion of the sinus
lining becomes separated from the main body of the sinus and forms an epithelium-
lined cavity into which mucin is secreted (see Fig. 8-65). The cyst most frequently
originates after a Caldwell-Luc operation but may arise from difficult extraction of a
maxillary tooth in which the floor of the maxillary sinus is damaged.
Authors have suggested that sinus or nasal epithelium rarely can be transplanted
accidentally to the mandible during genioplasty or chin augmentation procedures and
lead to formation of ciliated cysts in ectopic locations.

The second type of sinus mucocele arises from an obstruction of the sinus ostium,
thereby blocking normal drainage. This blocked sinus then acts like a separate cystlike
structure lined by epithelium and filled with mucin. Sinus mucoceles enlarge in size as
the intraluminal pressure increases and can distend the walls of the sinus and erode
through bone, often clinically mimicking malignancy of antral origin.

Postoperative maxillary cysts appear to be uncommon in the United States and Europe
but are reported more frequently in Japan. Mucoceles arising from ostial obstruction
are much more numerous and most frequently involve the frontal sinus, with the
ethmoid and sphenoid sinuses being affected less often. Maxillary sinus mucoceles are
relatively rare and account for less than 10% of paranasal sinus mucoceles.

RETENTION CYSTS
Retention cysts of the maxillary sinus arise from the partial blockage of a duct of the
seromucous glands or from an invagination of the respiratory epithelium. The mucin is
surrounded by epithelium, and no extravasation occurs. Most retention cysts are
located around the ostium or within antral polyps. The majority of cysts are small, not
evident clinically, and discovered during histopathologic examination of antral polyps.

CLINICAL AND RADIOGRAPHIC FEATURES

Many symptoms have been attributed to sinus mucoceles; however, because of the
confusion between pseudocysts and true mucoceles, it is unclear which symptoms are
associated with pseudocysts and which are related to true sinus mucoceles. Most
pseudocysts are asymptomatic; although it is rare, affected patients may exhibit facial
fullness or report paresthesia, pain, or soreness on palpation. As true sinus mucoceles
enlarge and expand bone, symptoms may develop and vary according to the location
and the degree of expansion and destruction.

Radiographically, the pseudocyst classically appears as a dome-shaped and slightly

radiopaque lesion overlying the intact floor of the maxillary sinus (Figs. 8-66 and 8-67).
Maxillary cysts and neoplasms can simulate the dome-shaped pattern of an antral
pseudocyst, but close examination of these pathoses typically reveals the floor of the
sinus covering the superior aspect of the lesion. When the maxillary sinus is involved
by a true sinus mucocele, the entire sinus will be cloudy. As the lesion enlarges, the
walls of the sinus may become thinned and eventually eroded. Surgical ciliated cysts
are spherical lesions that are separate from the sinus and lack the dome-shaped
appearance of pseudocysts (Fig. 8-68). As these postoperative cysts enlarge, they too
can lead to perforation of the sinus walls. Retention cysts rarely reach a size that would
produce detectable radiographic changes.

HISTOPATHOLOGIC FEATURES
Antral pseudocysts are covered by sinus epithelium and demonstrate a subepithelial
inflammatory exudate that consists of serum occasionally intermixed with
inflammatory cells (Fig. 8-69). Collections of cholesterol clefts and scattered small
dystrophic calcifications may be seen. True sinus mucoceles and surgical ciliated cysts
are true cystic structures lined by ciliated pseudostratified columnar epithelium,
squamous epithelium with mucous cells, or metaplastic squamous epithelium (Fig. 8-
70). A sinus retention cyst shows focal dilatation of a duct associated with the
seromucous glands of the sinus lining. The lumen of the dilated duct is filled with thick
mucus, often intermixed with chronic inflammatory cells.

TREATMENT AND PROGNOSIS

Typically, pseudocysts of the maxillary sinus are harmless, and no treatment is
necessary. The adjacent teeth should be evaluated thoroughly, and any foci of
infection should be eliminated. A few clinicians prefer to confirm their radiographic
impression and rule out a tumor through drainage of the inflammatory exudate.

Removal by means of a Caldwell-Luc operation should be performed on any

radiographically diagnosed lesion that produces signifi cant expansion or is associated
definitively with symptoms such as headache. Because sinus mucoceles and surgical
ciliated cysts are expansile and destructive lesions, the traditional therapy for these
pathoses is assured surgical removal. Numerous investigators also have shown that
sinus mucoceles arising from ostial obstruction often do not require surgical excision
and respond well to endoscopic middle meatal antrostomy and marsupialization of the
mucocele.