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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 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

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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
1. 2. Flint, PW, Cummings CW. "Chronic Frontal Sinus Disease." Cummings Otolaryngology: Head & Neck Surgery. Philadelpha, PA: Mosby Elsevier, 2010. Print. Cagigal BP, Lezcano JB, Blanco RF, Cantera JMG, Cuellar LAS, Hernandez AV. Frontal Sinus Mucocele with Intracranial and Intraorbital Extension. Medicina Oral , Patologa Oral y Ciruga Bucal 2006; 11:E527-30. 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. Yap SK, Yap EY. Frontal Sinus Mucoceles Causing Proptosis Two Case Reports. Annals Academy of Medicine Singapore 1998; 27:744-7. Tseng CC, Ho CY, Kao SC. Ophthalmic Manifestations of Paranasal Sinus Mucoceles. Journal of Chinese Medical Association 2005; 68:260-4.

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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;28:836. 11. Har-El G. Endoscopic Management of 108 Sinus Mucoceles. Laryngoscope 2001; 111:2131-4.

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