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News -> November, 2001 News
Winston Vaughan, MD
Chris Church, MD
Stanford University, Palo Alto, CA
A 56-year-old female presented to her local ER with a two-week history of upper respiratory illness, facial pressure, and decreased vision in the right eye. MRI suggested right ethmoid sinusitis (Figure 1) and the patient was referred for surgery. An ophthalmology evaluation revealed vision less than 20/800 in the right eye. A fine cut CT of the sinuses was obtained revealing a right posterior ethmoid mucocele with bony erosion over the optic nerve (Figure 2).
A right endoscopic partial ethmoidectomy was performed. The on-call team marsupialized a large posterior ethmoid mucocele. Over the next three days the patientŐs visual acuity improved, but color vision remained altered and partial field defects remained. Repeat CT was obtained suggesting persistent edema around the optic nerve. The patient then underwent right endoscopic optic nerve decompression, completion ethmoidectomy, and sphenoidotomy. During this procedure an area of dehiscence within an Onodi cell was seen and decompressed.
Post-operatively, her vision returned to normal, and she has had no further sequelae for two years (Figure 3)
Discussion
Mucoceles are mucous-filled cystic swellings mostly found in frontal and ethmoid sinuses. Less commonly they are noted within the sphenoid sinus. These lesions can cause bony remodeling and erosion due to slow expansion. Occasionally, there may be rapid expansion because of infection. Mucoceles are thought to be related to chronic sinus ostial obstruction, but can also be related to trauma and previous surgery. One report found 20 of 25 patients with sphenoethmoidal mucocele had previous surgery1.
Protrusion of the optic nerve into the sphenoid sinus or within an Onodi cell may be seen during endoscopic sinus surgery (ESS). Mucoceles of this region may therefore present with varying degrees of visual impairment. Reports of optic neuropathy from acute inflammatory conditions as well as chronic pressure are found in the literature2. Yumoto et al. found 12 of 15 patients having ethmoid or sphenoid mucoceles with visual disturbance, having also a partial bony defect in the optic canal at surgery3.
Mucoceles were treated via open approaches in the past. With the development of endoscopic techniques in the 1980s, Kennedy et al suggested ESS as a viable alternative for management. In 1992 Moriyama et al reported on 25 cases of ethmoid and sphenoid mucoceles with visual disturbance managed endoscopically.1,4 Other reports have since confirmed excellent endoscopic results for resolution of visual symptoms and headache.5
Recovery of vision is improved in cases with better preoperative visual acuity, shorter time to surgical decompression and gradual onset of symptoms1,3,6. The use of endoscopic optic nerve decompression and navigation technology has improved our management of this difficult process.
References
- Moriyama H, Hesaka H, Tachibana T, Honda Y. Mucoceles of ethmoid and sphenoid sinus with visual disturbance. Arch Otolaryngol Head Neck Surg 1992;118:142-146.
- Ogata Y, Okinaka Y, Takahashi M. Optic neuropathy caused by an isolated mucocele in an onodi cell. ORL 1998;60:349-352.
- Yumoto E, Hyodo M, Kawakita S, Aibara R. Effect of sinus surgery on visual disturbance caused by spheno-ethmoid mucoceles. Am J Rhinol 1997;11(5):337-43.
- Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith MM. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 1989;99:885-95.
- Benninger MS, Marks S. The endoscopic management of sphenoid and ethmoid mucoceles with orbital and intranasal extension. Rhinology 1995;33(3):157-161.
- Loehrl TA, Leopold DA. Sphenoethmoidal mucocele presenting with bilateral visual compromise. Ann Otol Rhinol Laryngol 2000;109(6):608-610.
Figure1:
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Figure3:
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