Extensive paranasal sinus mucoceles: a 15-year review of 82 cases

A 28 years surgical experience of 398 sinusal mucoceles: how technologies, techniques and experiences have changed their treatment throughout the years

PURPOSE

Sinonasal mucoceles (SM) are benign, expansive neoformations which require surgical marsupialization to prevent severe complications. The present study reports the larger case history ever published: a 28-years expertise in the surgical management of SM.

METHODS

A retrospective study was conducted on patients surgically treated for SM at the Departments of Otorhinolaryngology of Varese and Pavia, between 1994 and 2022.

RESULTS

398 patients were reported. An endoscopic endonasal marsupialization of SM was performed in 92,5% of cases. 7% of patients underwent a combined approach while 0,5% required an exclusive open surgery. The average follow-up after surgery was 10-60 months. SM overall recurrence was observed in 11,4% of cases.

CONCLUSION

Endonasal endoscopic SM marsupialization is a feasible technique which allows the preservation of the anatomy and physiology avoiding the surgical invasiveness of the external approaches. The well-established surgical expertise in the endonasal endoscopy together with technological improvements widened the indication range of the exclusive endoscopic technique over the traditional open surgery.

The Clinical Course of Paranasal Sinus Mucocoeles-A Retrospective Case Series

Paranasal sinus mucocoeles can be secondary to chronic rhinosinusitis and can result in intra-orbital and intra-cranial complications requiring surgical management. The natural history of conservatively managed mucocoeles is not well established. We aimed to quantify the proportion of radiologically identified paranasal sinus mucocoeles resulting in complications over 10 years. We retrospectively reviewed anonymised data on radiologically diagnosed mucocoeles between 2011 and 2021 at two UK hospitals. We collected data on age at presentation, extent of sinus involvement, management and complications. We identified 60 patients with mucocoeles, of which 35 (58%) were incidental findings from radiological investigations. The mean age was 58 years. Fifteen patients (25%) were managed surgically and one presented with recurrence following surgery. Overall, six patients (10%) had an intra-orbital extension of their mucocoele and three (5%) had an intra-cranial extension. There was no difference in the rates of intra-cranial extension between conservative and surgical cases but surgical cases included a higher rate of intra-orbital extensions (27% vs. 4%, p = 0.01). The proportion of patients requiring surgical intervention in this study is low. Incidental and asymptomatic mucocoeles have a relatively benign disease course and selected uncomplicated cases can be considered for conservative management with serial scanning at 12 months.

Ophthalmic Presentation and Outcome for Sinonasal Mucoceles

PURPOSE

The purpose of this study was to evaluate ophthalmic features and outcomes for patients who present with sinonasal mucoceles expanding into the orbit.

PATIENTS AND METHODS

Retrospective chart review for patients seen in a specialist orbital clinic over 25 years, with a review of demographics, clinical characteristics, imaging features, and outcomes after treatment.

RESULTS

Sixty patients (38 males; 63%) presented at a mean age of 51 years (range 3-89). Symptom duration was extremely variable (1 week-15 years) with a mean of 14 months and median of 4 months-the commonest being periorbital swelling (33/62 orbits) or ache (20 orbits), proptosis (30 orbits), and diplopia (19/50 patients without visual impairment; 38%). Of mucoceles affecting orbital function, 60/62 (97%) were of frontal and/or ethmoid sinus origin, and probable predispositions included past trauma (12/62 orbits) or prior ipsilateral sinus surgery (14 orbits). Forty-two of the 59 (71%) patients who underwent sinus surgery had complete resolution of symptoms within 6 months. Of 10 orbits presenting with moderate to severe visual loss (Snellen 20/60 or worse), the acuity improved in 7/10 (70%) of these after sinus surgery. Although 12/62 (19%) of eyes presented with epiphora, this persisted after sinus surgery in 9 orbits, and areas of occult malignant change were found in 3/9 (33%).

CONCLUSION

Sinus mucoceles expanding into the orbit can cause significant globe displacement, dysmotility, or visual impairment. Symptoms usually resolve within several months after functional sinus surgery, but where symptoms persist (particularly periorbital swelling or epiphora) this might indicate underlying secondary causes, such as occult malignancy.

A Giant Maxillary Mucocele Presenting Left Cheek Swelling

A paranasal sinus mucocele is an epithelial-lined, mucus-containing sac that completely fills the sinus and forms an expandable cystic structure. It most commonly affects the frontal and ethmoidal sinuses, and rarely the maxillary and sphenoid sinuses. Orbital displacement or external disfigurement resulting from the expansion of the frontal or ethmoid sinuses is common; however, facial asymmetry caused by maxillary bone remodeling is rare. We describe a case of large maxillary sinus mucocele that destroyed the maxillary sinus bony wall, resulting in notable left cheek swelling and disfigurement, and review the relevant literature.

Unusual metachronous presentation of bilateral frontoethmoid sinus mucoceles

A case report of a patient with bilateral frontoethmoid mucoceles with no obvious predisposing factors and each side presenting three years apart, with no ongoing nasal or paranasal signs of disease in the interim.Bilateral paranasal sinus mucoceles have rarely been described in the literature; this case is unique, as it is the first description of a metachronous presentation. Additionally, the absence of any predisposing factors such as trauma, surgery or chronic sinusitis in either presentation is unusual.

Orbital and Eyelid Inflammation With "Muciphages" and Extravasated Mucin From an Ethmoido-orbital Mucocele

A 22-year-old woman presented with an acute compressive optic neuropathy due to a ruptured ethmoido-orbital mucocele. She underwent urgent orbital decompression and drainage of the mucocele via an endoscopic approach. Postoperatively, her course was complicated by an orbital compartment syndrome supervened, exhibiting severe eyelid edema caused by infiltration with mucin and mucin-containing macrophages ("muciphages"). Biopsy of the eyelid showed infiltration with "muciphages," macrophages laden with extravasated mucinous material. This is the first report that documents the clinical and histopathologic course of orbital inflammation following mucocele extravasation into the orbit and eyelids.

Optic Neuropathy due to an Ethmoid Mucocele: A Case Report and Literature Review

Mucoceles of the paranasal sinus commonly involve the frontal sinuses, the ethmoid sinuses, and rarely the maxillary or sphenoid sinuses. They often present with sinus pain or pressure, but rarely can present with more severe symptoms such as changes in mental status or vision due to expansion and invasion through the skull base or orbit. A 62-year-old male presented with optic neuropathy, a relative afferent pupillary defect with proptosis and lateral gaze palsy of the left eye. The patient was found to have a large mucocele extending from the left posterior ethmoid sinus into the left orbital apex. Urgent endoscopic sinus surgery was performed jointly between Oculoplastics and Otolaryngology. Post-operatively, the patient had improvement in diplopia, extraocular motion, and proptosis with stable vision. This case demonstrates the importance of early identification and intervention in a rare presentation of a sinus mucocele to prevent serious complications such as vision loss.

Utility of intraoperative flexible endoscopy in frontal sinus surgery

Background:

Surgical management of the frontal sinus can be challenging. Extensive frontal sinus pneumatization may form a far lateral or supraorbital recess that can be difficult to reach by conventional endoscopic surgical techniques, requiring extended approaches such as the Draf III (or endoscopic modified Lothrop) procedure. Rigid endoscopes may not allow visualization of these lateral limits to ensure full evacuation of the disease process.

Methods:

Here we describe the utility of intraoperative flexible endoscopy in two patients with far lateral frontal sinus disease.

Results:

In both cases, flexible endoscopy allowed confirmation of complete evacuation of pathologic material, thereby obviating more extensive surgical dissection.

Conclusion:

In cases where visualization of the far lateral frontal sinus is inadequate with rigid endoscopes, flexible endoscopy can be used to determine the need for more extensive dissection.

Onodi cell mucocele: Case report and review of the literature

Onodi cell mucoceles are rare entities that can cause devastating ocular complications if not treated promptly. Delays in the diagnosis are possible because of the wide range of differential diagnoses of unilateral retrobulbar optic neuropathy. We describe a new case of Onodi cell mucocele in a 39-year-old woman, and we present a comprehensive review of the literature on this entity. To the best of our knowledge, no review of Onodi cell mucoceles has been previously published. Our review found that 69% of patients with an Onodi cell mucocele experienced an improvement in vision after surgical decompression. The vast majority of these patients underwent endoscopic decompression; the timing of surgical decompression did not appear to affect outcomes in terms of vision. Onodi cell mucocele requires a high degree of clinical suspicion for diagnosis and a multidisciplinary approach to management that involves primary care physicians, ophthalmologists, and otolaryngologists. Early surgical treatment via an endoscopic approach is recommended for most patients, regardless of the duration of their ophthalmologic signs and symptoms.

Considerations in the management of giant frontal mucoceles with significant intracranial extension: A systematic review

BACKGROUND

Giant frontal mucoceles, characterized by significant intracranial and/or intraorbital extension, can present with significant neurologic symptoms. Although typical mucoceles are managed endoscopically, giant mucoceles are often treated with an open or combined approach due to various concerns, including frontal lobe displacement, size, and rapid decompression of the intracranial component. The impact of significant intracranial extension on outcomes is not well described.

OBJECTIVE

This review studied key neurologic considerations in the management of giant frontal sinus mucoceles and analyzed outcomes of different management strategies.

METHODS

Systematic literature review by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Thirty-two articles, which represented 85 cases, met inclusion criteria. Neurologic symptoms on presentation ranged from headache (24.7%) and vision loss (12.9%) to extremity weakness (1.2%), frontal lobe syndrome (2.4%), and seizures (4.7%). Twenty-eight patients were treated endoscopically (34.1%), and 54 (65.9%) were treated with an external approach. Twenty-five of the open procedures included a craniotomy. Indications for the open approach included subdural empyema, enucleation, or large anterior table defects. Perioperative antibiotics were not consistently used. No perioperative seizures were reported with any approach. There were six cerebrospinal fluid leaks, all in the patients who underwent open procedures. The overall recurrence rate was 3.5%, with no recurrences reported in patients treated with an open approach. Follow-up ranged from 1 week to 8 years.

CONCLUSIONS

Giant frontal mucoceles often present with various neurologic symptoms. Both open and endoscopic techniques offer excellent results. Endoscopic management is effective and preferred, except in special circumstances. An interdisciplinary team approach should be used to optimize surgical planning.

Sphenoid mucocele with unusual panhypopituitarism

A 13-year-old boy presented with bilateral progressive proptosis, abduction deficit, optic atrophy and features suggestive of hypopituitarism secondary to a sphenoid sinus mucocele. Drainage of the mucocele along with hormone replacement therapy resulted in improvement in visual acuity and abduction.

Bardet-Biedl syndrome and a large concha bullosa pyocele

Bardet-Biedl syndrome is a rare disease involving rode cone dystrophy, polydactyly, obesity, learning disabilities, hypogonadism and renal anomalies, symptoms caused by immotile cilia dysfunction. We report the first case of this syndrome in a teenager with an endonasal mass secondary to pyocele of a concha bullosa. The patient was treated successfully with endoscopic sinus surgery. Nasal obstruction secondary to a middle turbinate pyocele in Bardet-Biedl syndrome has not been described before. The pediatrician and the rhinologist should take this entity into consideration when investigating patients with Bardet-Biedl syndrome and sinonasal symptoms.

The natural history and clinical characteristics of paranasal sinus mucoceles: a clinical review

BACKGROUND

A retrospective data analysis at a university tertiary referral center was conducted to characterize the natural history, clinical characteristics, management principles, and outcomes of paranasal sinus mucoceles.

METHODS

A chart review was performed on 102 patients with a total of 133 paranasal sinus mucoceles who were treated between 1987 and 2011 at the Hospital of the University of Pennsylvania.

RESULTS

The study population included patients with a mean age of 53.1 years (range, 22-82 years). Patients were diagnosed with a mucocele on average 5.3 years following prior functional endoscopic sinus surgery (FESS), 17.7 years following prior paranasal sinus trauma, and 18.1 years following prior open sinus surgery. The most common presenting symptoms were headache (42.1%) and maxillofacial pressure (28.6%). The most common sites were the frontal, frontoethmoidal, and ethmoid sinuses. Fifty-seven mucoceles (44.9%) had intraorbital extension, intracranial extension, or both. Out of 133 mucoceles, 114 underwent ESS without complication.

CONCLUSION

The length of time between prior surgery or trauma and mucocele presentation highlights the importance of long-term follow-up in both patient care and in the understanding and reporting of surgical outcomes. In this study, most patients exhibited nonspecific symptomatology despite extensive mucoceles and a significant incidence of orbital and skull-base erosion. The endoscopic approach can be safely used for the management of such lesions.

Paranasal sinus mucocele

Paranasal sinus mucoceles are epithelium-lined cystic masses usually resulting from obstruction of sinus ostia. They most frequently occur in the frontal and ethmoid sinuses. While ophthalmologic symptoms are most common, patients also report rhinological or neurological complaints. The close proximity of paranasal sinus mucoceles to the orbit and skull base predisposes the patient to significant morbidity. Computed tomography displays a non-enhancing homogenous mass with expansion of bony walls. Magnetic resonance imaging reveals variable intensity of T1-weighted images and a hyperintense mass on T2-weighted images. Histopathologically mucoceles have features of respiratory mucosa with areas of reactive bone formation, hemorrhage, fibrosis, and granulation tissue. Surgical excision is the standard treatment with trends towards endoscopic techniques.

Endoscopic surgery for fronto-ethmoidal mucoceles: a 15-year experience

OBJECTIVE

To add to the existing knowledge of endoscopic surgery for fronto-ethmoidal mucoceles and to determine factors that influence the outcomes of endoscopic surgery.

STUDY DESIGN

Case series with chart review.

SETTING

University adult tertiary care institution.

SUBJECTS AND METHODS

A database of patients treated surgically for mucoceles of the paranasal sinus has been kept by the senior author since 1995. It was used to identify those who have had endoscopic surgery for fronto-ethmoidal mucoceles from 1995 to 2010. All adult patients with 6 months or more of follow-up were included. The database was reviewed and assessed for variables that may affect outcome after surgery.

RESULTS

Forty patients underwent 44 endoscopic procedures for treatment of fronto-ethmoidal mucoceles and the complications of surgery. The mean age was 46.3 years, and mean follow-up time was 74.9 months. Two patients had a history of head trauma. A total of 28 Draf IIa procedures, 13 Draf IIb, and 3 Draf III procedures were performed. Three patients had combined open approaches. Two patients had bilateral surgery, and 2 patients required revision surgery: 1 for restenosis after a Draf IIa procedure (1/28) and 1 for disease recurrence. Stenosis was found in a further 3 patients who had Draf IIb surgery (3/13).

CONCLUSION

The current series represents one of the largest for the endoscopic management of fronto-ethmoidal mucoceles. Endoscopic approaches are suitable for most mucoceles. The most common complication, restenosis of the frontal recess, was more likely following Draf IIb procedures (23%) than Draf IIa (3.6%) procedures.

Sinus mucocele: natural history and long-term recurrence rate

OBJECTIVE

To define the natural history, clinical signs, treatment and the modalities of medium- and long-term follow-up of patients operated for sinus mucocele.

PATIENTS AND METHOD

Retrospective study of all patients operated for sinus mucocele between January 1993 and December 2009 (n=68). Demographic data, symptoms, medical imaging findings, surgical treatment and results were recorded.

RESULTS

The mean age of patients in this series was 53 years (range: 27-82 years, sex ratio: 3/2). The most common site was fronto-ethmoidal. Fifty-one patients (75%) had a history of sinus surgery, essentially for nasal polyposis. Only 15% of mucoceles occurred spontaneously. Presenting symptoms, in decreasing order of frequency, were facial pain or headache (38%), ocular or orbital complications (28%), while 20% of patients were asymptomatic. Surgery was performed by endonasal endoscopic sinus surgery (n=57, 84%) or via a combined, transfacial and endonasal approach, associated with navigation after January 2003. The mean follow-up was 7 years (range: 4 months-16 years). During this follow-up period, 23.5% of patients developed recurrence or a second mucocele after a mean interval of 4 years.

CONCLUSION

This study demonstrates the high recurrence rate of mucocele, particularly in multi-operated patients with chronic sinusitis. Long-term, regular, clinical and radiological follow-up is necessary to detect asymptomatic lesions prior to the onset of complications.

Paranasal sinus mucoceles with ophthalmologic manifestations: a 17-year review of 96 cases

BACKGROUND

The purpose of this study was to assess the characteristics of paranasal sinus mucoceles with ophthalmologic manifestations with a focus on optic neuropathy.

METHODS

From January 1993 to May 2010, 96 consecutive patients diagnosed with paranasal sinus mucoceles with ophthalmologic manifestations were investigated. Clinical and therapeutic factors and demographics were reviewed from medical records. Statistical associations between clinical and therapeutic factors and visual outcomes after surgery were also analyzed.

RESULTS

A total of 352 patients were diagnosed with paranasal sinus mucoceles and underwent surgical treatment. Ninety-six of them presented with ophthalmologic symptoms, and periorbital swelling and pain were the most common symptoms (36.4%) in those patients. Among the 96 patients with ophthalmologic manifestations, 18 (18.8%) were diagnosed with optic neuropathy based on the deterioration of their visual acuity and unilateral relative afferent papillary defect. Ten of these 18 patients showed improvements in their vision after surgical intervention. The statistical analysis of the association between clinical and therapeutic factors and visual outcomes showed that the presence of infection was the only significant factor (p = 0.023).

CONCLUSION

Paranasal sinus mucoceles present various ophthalmologic manifestations. Among them, optic neuropathy may be one of the most devastating conditions. In treating optic neuropathy caused by mucoceles, the presence of infection was the only factor that had any influence on postoperative visual outcomes. Therefore, we conclude that not only surgical drainage and ventilation of the sinus are necessary, but infection control is also a vital factor in treating mucoceles with optic neuropathy.