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News -> December, 2005 News
Spencer C. Payne, MD and Mark A. Zacharek, MD
Henry Ford Hospital, Detroit, MI
This is a 42 year old man with a past medical history significant for seasonal allergic rhinitis who presented with complaints of intermittent left eye and forehead swelling over the preceding two months. He had originally presented to his primary care provider three months previously with left facial pain and pressure and discolored nasal discharge. He was diagnosed with acute sinusitis and prescribed a course of amoxicillin. Though his episode of sinusitis resolved, he returned for evaluation one month later with complaints of left eyelid swelling. Despite improvement with antibiotics, he returned twice more with continued complaints of intermittent recurrence of this swelling which would resolve with antibiotic therapy. Eventually a computed tomography (CT) scan was obtained (Figures 1 and 2) which revealed large frontal and maxillary sinus mucoceles with erosion of the frontal sinus into the orbit. He was then referred to the rhinology service.
On physical examination he was found to have obvious left periorbital ecchymosis and edema. Proptosis and upward gaze limitation was noted and ophthalmologic exam confirmed myopia unchanged from baseline. Endoscopic examination of the nasal cavity revealed leftward septal deviation with boggy edema of the middle turbinate and middle meatus. Individual middle meatal structures could not be discerned.
The patient was taken to the operating room where an endoscopic septoplasty was performed in order to facilitate access to the middle meatus. The uncinate was found to be displaced medially and after it was taken down with powered instrumentation; a maxillary antrostomy and anterior ethmoidectomy were completed. Due to significant edema and bleeding, however, the frontal recess was unable to be accessed endoscopically and the decision was made to perform a mini-trephination.
A small medial incision was made just over the superior aspect of the brow and dissection verified superior orbital bony rim dehiscence as seen on CT. The mucocele was sharply opened, the cavity was copiously irrigated with sterile saline, and a small drain was placed. The patient was treated post-operatively with amoxicillin/clavulanate. On follow-up evaluation the patient remained asymptomatic. Endoscopic examination revealed continued patency of the maxillary antrostomy and a probe was easily placed through a medial tract into the frontal sinus. Additionally, the trephination scar was nearly imperceptible.
Discussion
Mucoceles are most commonly frontal or frontoethmoid in origin with maxillary sinus mucoceles accounting for 10% or less. Often resulting from trauma or ostial obstruction, mucoceles often expand gradually, but their progression can be much more rapid during episodes of infection. Frequently, the surrounding bone demonstrates either thickening as a result of osteitis from chronic inflammation or remodeling with resorption secondary to the chronic expansile forces and osteolytic enzymes.
Since the 1980's, endoscopic management of paranasal mucoceles has become increasingly accepted1,2, , and may be the most common method of treatment currently. The specific methods or extent of surgery utilized to marsupialize the mucocele is still debated, but various series have demonstrated recurrence rates ranging from 0-13%.1-4
In the absence of trauma or prior surgery, the etiology of a mucocele may not be clear. This patient's disease was most likely a multi-factorial process. Significant deviation of the septum resulted in lateralization of the middle turbinate with osteomeatal complex (OMC) obstruction. This was further exacerbated by the patient's allergic rhinitis and his disease culminated with an episode of acute sinusitis which ultimately accelerated the process. Neo-osteogenesis, as demonstrated on CT scan, also played a part in the frontal recess obstruction. Since the infundibulum often serves as the common drainage point for the maxillary, frontal and anterior ethmoid cells it is uncertain whether the mucoceles developed simultaneous or if one played a role in the other's development. In either case, the orbital extension with erosion through the superior orbital rim complicated the situation. Even after treatment with steroids and antibiotics, the edema and bleeding encountered intraoperatively necessitated a combined external approach in order to decompress the mucopyocele and treat the infection.
In the patient that does require additional surgery to manage frontal disease, the use of a mini-trephination may be first recommended in combination with endoscopic frontal sinusotomy as it has provided encouraging results and often obviated more extensive procedures such as osteoplastic flap and obliteration. In this instance, the trephination provided a good result. When addressing complicated or large frontal mucoceles, other authors have also advocated for more aggressive management such as an endoscopic Lothrop procedure (Draf III).4 Had this patient needed additional procedures and visualization of the frontal recess and nasofrontal cannulation continued to be difficult, an endoscopic transseptal frontal sinusotomy may also have been appropriate. With this approach, assisted by image guidance, a small perforation of the septum would be created at the septal attachment to the skull base allowing for better exposure, sinus drainage and post-operative evaluation and management.
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The endoscopic management of paranasal sinus mucoceles in combination with more conservative external procedures, such as the mini-trephination, has become an accepted surgical option. These approaches can be initially attempted in order to avoid the complications that may accompany more extensive operations. Medical therapy and optimal management of the etiologic factors should also be employed to minimize disease recurrence.
Figure 1 - Coronal CT scan showing orbital erosion and neo-osteoneogenesis of the frontal recess
Figure 2 - Coronal CT scan showing expansile changes of the maxillary sinus mucocele
Busaba N, Salman SD. Maxillary sinus mucoceles: Clinical presentation and long-term results of endscopic surgical treatment. Laryngoscope. 1999;109:1446-9.
Benninger MS, Marks S. The endoscopic management of sphenoid and ethmoid mucoceles with orbital and intranasal extension. Rhinology. 1995;33:157-61.
Kennedy DW, Josephson JS, Zinreich SJ et al. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope. 1989;99:885-90.
Har-El, G. Endoscopic management of 108 sinus mucoceles. Laryngoscope. 2001;111:2131-4.
Gallagher RM, Gross CW. The role of mini-trephination in the management of frontal sinusitis. Am J Rhinology. 1999;13:289-293.
McLaughlin RB, Hwang PH, Lanza DC. Endoscopic trans-septal frontal sinusotomy: The rationale and results of an alternative technique. 1999;13:279-287.
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