Pediatric paranasal sinus mucoceles: etiologic factors, management and outcome

Paranasal mucoceles in children with cystic fibrosis: Management of a not so rare clinical condition

PURPOSE

Paranasal mucocele (PM) is reported as a complication in children with cystic fibrosis (CF) in up to 4% of patients. The objective of this study was to identify PMs in the personal large series of children with CF and to assess their diagnosis and treatment.

MATERIAL AND METHODS

Medical records of children with CF and PM who were admitted and treated by means of endoscopic nasal surgery between 2004 and 2020 were retrospectively reviewed.

RESULTS

Thirty-four patients were included in the study (mean age 7.7 years). CT scan of sinuses showed a total of 53 PMs. Nasal endoscopic findings suggestive for PM were present in almost 80% of patients. PMs were located in the maxillary, ethmoid, and sphenoid sinuses in 29/34 (85.3%, bilateral in 17 cases), 4/34 (11.8%) and 1/34 (2.9%) patients, respectively. Marsupialization of PMs was performed in all patients using an endoscopic transnasal approach. No complications were observed. Resolution of symptoms and normalization of the endoscopic nasal picture was evident in all patients. After a mean follow-up of 85 months, no recurrences were observed.

CONCLUSIONS

To the best of our knowledge, this is the largest series of CF patients with PMs. Even if not frequently reported in the literature, PMs should not be considered an uncommon finding in patients affected by CF. Routine nasal endoscopy is mandatory to favor early diagnosis. Endoscopic transnasal marsupialization represents the gold standard of care for patients with CF and PM(s).

Frontal mucopyocele with bone erosion in a 7-year-old child - exclusively endoscopic endonasal approach - a case report

A mucocele is a benign lesion that predominantly affects the paranasal sinuses, with a slow growth rate and expansive pattern. When infected, it is known as mucopyocele. Presentation of a frontal mucopyocele can be found more frequently in adults. In contrast, it is rarely seen in children since pneumatization of the sinuses usually takes place after age 7. This report aims to present one case of a frontal mucopyocele as an important complication of a pansinusitis in a 7-year-old child and discuss the diagnosis, surgical approach, and differentials. Endoscopic endonasal surgery is a safe approach and must be taken into consideration in these situations.

Rare Diseases of the Orbit

This article provides an overview of rare orbital diseases. Congenital malformations, inflammatory diseases, benign and malignant neoplasias are described. Although it represents a relatively small area of the body the orbit contains multiple different tissues. Therefore, a great variety of diseases can be found within the orbital space. That is the reason, why both the completeness and the level of detail in the description of particular diseases must be somewhat limited. Nevertheless, clinical manifestations, important aspects of diagnosis, treatment strategies, and, when specific data are available, the prognosis are described. The authors tried to highlight the most characteristic aspects of the different diseases to describe their relevant aspects in spite of the brevity of the subsections.

Bilateral Ethmoidal Mucocele Causing Proptosis in a Child

OBJECTIVES

Paranasal sinus mucocele is a benign cystic lesion, lined with respiratory epithelium and filled with mucoid secretions, which is generally seen in the ethmoid or frontal sinuses. Inflammation, trauma, fibrosis, neoplasm, and previous surgery play a role in etiology. Treatment of this condition requires marsupialization and drainage. Endoscopic surgery is the gold standard procedure.

METHODS

A 2-year-old boy was referred to our clinic with a diagnosis of bilateral ethmoid mucocele causing proptosis in the right eye. General clinical examinations and routine blood analysis revealed normal health condition of the patient and comorbidities such as cystic fibrosis (CF) and/or ciliary dysfunction were excluded. The patient was operated with an endoscopic endonasal approach.

RESULTS

As far as we know, our article reports the first case of bilateral ethmoidal sinus mucocele with no underlying comorbidity, such as cystic fibrosis or ciliary dyskinesia.

CONCLUSIONS

Children are rarely affected by mucocele and if present at early age, there is usually an underlying cause. In pediatric patients with signs and symptoms suggestive of a mucocele, it is important to rule out other benign and malignant paranasal sinus pathologies. Marsupialization and drainage via endoscopic endonasal approach is the preferred treatment modality.

The endonasal endoscopic management of pediatric lateral frontal mucocele

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Frontal mucoceles in children are rare.

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A child with lateral frontal mucocele with no known etiology.

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This shows the usefulness of image-guided endoscopic sinus surgery.

Objectives

The aim of this report is to show the usefulness of endoscopic sinus surgery in management of lateral frontal mucocele in pediatric patient.

Case presentation

A 14 years old girl presented with right frontal bone depression and headache. CT and MRI showed lateral mucocele occupying the right frontal sinus. The patient was managed successfully by image-guided endoscopic sinus surgery and she was well after two years follow up.

Discussion & conclusion

Frontal mucoceles in children are rare. We report a rare case of a child with lateral frontal mucocele with no known etiology, treated successfully by image-guided endoscopic sinus surgery with no recurrence after two years follow-up. This case shows the usefulness of image-guided endoscopic sinus surgery in treatment of lateral frontal mucocele in children.

Frontal pyomucocoele as forehead swelling in a five-year-old girl

Mucocoeles are slow-growing, locally aggressive, mucus-containing cysts, lined by epithelium, which, when infected, are called pyomucocoeles. We present the case of a five-year-old girl who presented with a frontal pyomucocoele requiring decompression and adequate antibiotics.

[Pediatric acute dacryocystitis due to frontoethmoidal mucocele]

BACKGROUND

Pediatric acute dacryocystitis typically develops due to persistence of Hasner's membrane. Pediatric paranasal mucoceles are rare entities. In contrast, chronic dacryocystitis in cases of congenital dacryostenosis is one of the most frequent pediatric ophthalmologic issues.

METHODS

The case report of a 10-year-old girl suffering acute dacryocystitis is presented.

RESULTS

The area around the left lacrimal sac showed a painful swelling with edema and hyperemia. Systemic and local antibiotic therapy resulted in only slight improvement. Dacryoendoscopy detected acute dacryocystitis with significant stenosis of the nasolacrimal duct. The nasolacrimal duct was widened dacryoendoscopically and autostable bicanalicular nasolacrimal intubation was performed. Nevertheless, the lacrimal ducts were blocked subtotally and a widening of the ethmoid on the left side was shown by rhinoscopy. Magnetic resonance imaging confirmed a frontoethmoidal mucocele which was treated by marsupialization. During the 24-month follow-up there was no recurrence of acute dacryocystitis. There were no signs of sinusitis.

CONCLUSION

Paranasal mucoceles, e. g., ethmoidal mucoceles, can compress the lacrimal pathways and cause acute lacrimal inflammation in childhood. Paranasal mucoceles should thus be excluded in cases of unclear masses in the lacrimal region.

Mucocele: Clinical Characteristics and Outcomes in 46 Operated Patients

Introduction  Paranasal sinus mucocele is a benign, expansive lesion associated with paranasal sinus obstruction. It affects mostly adults, and is most common in the frontal and ethmoidal sinuses.

Objective  To evaluate outcomes in patients undergoing surgical treatment for paranasal sinus mucocele.

Methods  Retrospective review of medical records of patients treated for paranasal sinus mucocele at the ENT department of a tertiary care hospital between 2005 and 2016.

Results  Forty-six patients underwent surgical treatment of paranasal sinus mucocele. The mean age was 50.1 years, and 56.5% were male. The most prevalent symptom was pain, and the frontal sinus was most commonly affected. The vast majority of patients (89.1%) underwent endoscopic sinus marsupialization; 10.9% required combined open and endoscopic access. Seven recurrences occurred.

Conclusion  Sinus mucocele is an expansive disease that primarily affects the frontal sinus of adult patients. In most cases, endoscopic surgery is an effective treatment modality.

Update on pediatric sinus surgery: indications and outcomes

PURPOSE OF REVIEW

To review the recent literature of pediatric endoscopic sinus surgery (ESS).

RECENT FINDINGS

Sinus balloon catheter dilation is an important addition to the surgical treatment tools for pediatric chronic rhinosinusitis (PCRS). ESS is a safe and effective therapeutic modality for uncomplicated PCRS. For PCRS complicated by comorbidities including cystic fibrosis and primary ciliary dyskinesia, ESS and adjuvant medical therapy confers significant sinus, pulmonary, and quality of life benefits to pediatric patients.

SUMMARY

ESS is a safe and effective treatment modality in the management of pediatric acute and chronic sinus disorders.

Posttravmatik frontoetmoidal mukopiyosel

Paranasal sinus mucoceles are mucus-containing cystic structures with an epithelial lining that completely fills in the paranasal sinuses. Although they are benign in nature, they may result in the destruction of the surrounding bony structures over time. Clinical findings such as exophthalmia, visual impairment, and diplopia occur due to pressure of the fronto-ethmoidal mucocele on the orbita. Currently, the endoscopic intranasal approach is preferred in the treatment of paranasal sinus mucoceles due to its minimal morbidity and low recurrence rates. Here, we present a patient aged 12 years who had a right fronto-ethmoidal mucopyocele secondary to a probable trauma 2 years prior, which resulted in proptosis due to pressure on the orbita.

Sudden hemianopsia secondary to ethmoid sinus mucocele

Paranasal sinus mucoceles are benign cystic lesions, filled with mucus, occurring due to an obstruction of involved sinus ostium. They are indolent, locally expansive, and destructive. Surgical treatment must be performed and, when done at the correct time, may prevent sequelae. We present a case of ethmoid sinus mucocele with orbit involvement and permanent optical nerve injury.

Giant ethmoid mucocele presenting as an orbital mass

Mucocele is a benign and expansile cystic lesion lined with respiratory mucosa of pseudo stratified columnar epithelium. Mucocele most commonly produces bone destruction within the paranasal sinuses. It mostly involves the frontal sinus followed by ethmoid and rarely sphenoid and maxillary sinuses. We report a case of giant ethmoid mucocele who presented with history of progressive unilateral protrusion of eye since 5 years. CT scan revealed a large mucocele of the ethmoid sinus with orbital extension on the same side. He was successfully treated with endoscopic sinus surgery.

Giant mucocele originating from the middle concha in a 5-year-old child: a case report

INTRODUCTION

Mucoceles are mucus-filled, epithelial-lined sacs that slowly develop in the paranasal sinuses when sinus or concha bullosa drainage is obstructed by inflammatory processes, trauma, or prior surgery. They are extremely rare in children. Symptoms usually arise from the nasal obstruction or compression of neighboring structures.

CASE PRESENTATION

This case report describes a 5-year-old Turkish boy with a 3-year history of nasal obstruction. A computed tomography scan showed a well-defined soft tissue density lesion, seemingly originating in the region of the middle concha and was suggestive of a middle concha mucocele. The mass was removed by endoscopic sinus surgery.

CONCLUSIONS

In the case of a child presenting with nasal obstruction, mucocele should be remembered in the differential diagnosis of intranasal tumors. Computed tomography and magnetic resonance imaging are helpful in making the diagnosis and endoscopic nasal surgery has proven successful in the treatment.

Cystic fibrosis chronic rhinosinusitis: a comprehensive review

BACKGROUND

Advances in the care of patients with cystic fibrosis (CF) have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research focusing on therapeutic strategies for CF-associated chronic rhinosinusitis (CRS) lags behind the evidence-based approaches currently used for pulmonary disease.

METHODS

This review evaluates the available literature and provides an update concerning the pathophysiology, current treatment approaches, and future pharmaceutical tactics in the management of CRS in patients with CF.

RESULTS

Optimal medical and surgical strategies for CF CRS are lacking because of a dearth of well-performed clinical trials. Medical and surgical interventions are supported primarily by level 2 or 3 evidence and are aimed at improving clearance of mucus, infection, and inflammation. A number of novel therapeutics that target the basic defect in the cystic fibrosis transmembrane conductance regulator channel are currently under investigation. Ivacaftor, a corrector of the G551D mutation, was recently approved by the Food and Drug Administration. However, sinonasal outcomes using this and other novel drugs are pending.

CONCLUSION

CRS is a lifelong disease in CF patients that can lead to substantial morbidity and decreased quality of life. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

[Pediatric mucoceles: clinical aspects and therapeutic approaches]

INTRODUCTION

Paranasal sinuses mucoceles are extremely rare in children and adolescents. The objective of this study was to assess their clinical presentations and the contribution of endoscopic surgery in their management.

MATERIAL AND METHODS

we retrospectively reviewed 11 children with paranasal sinus mucoceles who were managed during a period of 15 years (1995-2009).

RESULTS

The mean age was 11.8 years with a sex ratio of 2.66. One patient had a history of nasal polyposis surgery. The symptomatology was dominated by ophthalmological complains. The ethmoïd sinus was the main localization. Orbital extension was found in eight cases, pyomucocele in one case. The surgical management was endoscopic (nine cases), and by an external approach (two cases). Two cases of recurrence were assessed. The mean follow-up was 22.3 months.

DISCUSSION

Paranasal sinuses mucocele is exceptional in children. Cystic fibrosis is the main etiologic factor. The symptoms depend on the location and size of the mucocele. The treatment is surgical and most authors prefer the endoscopic approach.

Cystic Fibrosis: Brazilian ENT Experience

Most published studies about Cystic Fibrosis (CF) are European or North American. There are still few publications about the characteristics of fibrocystic populations in developing countries. The incidence of cystic fibrosis (CF) in Brazil varies among different regions (1 : 10,000 in Minas Gerais, 1 : 9,500 in Paraná, 1 : 8,700 in Santa Catarina, and 1 : 1600 in Rio Grande do Sul). The prevalence of the DF508 mutation also varies according to population: 33% in Sao Paulo, 49% in Rio Grande do Sul, 27% in Santa Catarina, and 52% in Minas Gerais. Cough and nasal obstruction are the most common symptoms. The variation in nasal polyposis prevalence may be explained by population genotypic characteristics in a country that spans a continent. Findings on nasal endoscopy and computed tomography (CT) have better correlation than do this information compared with surgical and clinical history. Microbiologic studies suggest a high level of early contamination of the airways. Sensorineural hearing loss (SNHL) occurs in these patients as a result of ototoxic antibiotics. The data compiled in this paper is useful, but also lead to the general agreement that more research would be welcome due to the unique characteristics of this country.

Image guidance systems for minimally invasive sinus and skull base surgery in children

OBJECTIVE

The use of image guidance for sinonasal and skull base surgery has been well-characterized in adults but there is limited information on the use of these systems in the pediatric population, despite their widespread use. The aim of this study is to evaluate the use of image guidance systems to facilitate an endoscopic minimally invasive approach to sinonasal and skull base surgery in a pediatric population.

METHODS

A retrospective cohort study was performed at a tertiary pediatric hospital. Thirty-three children presented with complications of sinusitis, tumors, traumatic, or congenital lesions of the skull base and underwent endoscopic surgery using image guidance from March 2000 to April 2007. Patient variables including diagnosis, extent of disease, and complications were extracted from paper and computer charts. Additional surgical variables including set-up time, accuracy, surgeon satisfaction index and number of uses per case were also reviewed.

RESULTS

Twenty-eight patients (85%) underwent sinonasal surgery and five (15%) underwent skull base surgery. Indications included infectious complications of acute sinusitis (N=15), neoplasms (N=12), choanal atresia (N=4), and cerebrospinal fluid leak (N=2). Thirty-one patients (94%) required only one procedure. No surgical complications were reported. Surgeon satisfaction, mean accuracy and number of uses per procedure increased over time (p<0.05).

CONCLUSIONS

Image guidance systems are safe and effective tools that facilitate a minimally invasive approach to sinonasal and skull base surgery in children. Consistent with adult literature, usage and surgeon comfort increased with experience. The additional anatomical information obtained by image guidance systems facilitates a minimally invasive endoscopic approach for sinonasal and skull base pathologies.

Ethmoid mucocele presenting as an orbital mass

This is a case of an 11-year-old male with an ethmoid sinus mucocele who presented to our emergency department with an orbital mass. This mucocele was most likely related to an ipsilateral orbital subperiosteal abscess that required endoscopic drainage 9 years ago. Mucoceles are mucus-filled, epithelial-lined sacs that slowly develop in the paranasal sinuses when sinus drainage is obstructed by inflammatory processes, trauma, or prior surgery. They are rare in children and should be suspected in patients with progressive headache or orbital complaints.

[Mucoceles of the paranasal sinuses]

INTRODUCTION

Paranasal sinus mucocoele is a benign pseudocystic lesion, which may originate from any sinus cavities when their natural ostia are blocked. Raising mucocoele in frontal, ethmoid or sphenoid sinus causes headache, disorders of eye mobility and deformities of forehead or orbit.

AIM OF THIS STUDY

was clinical analysis of treatment results taking into consideration the method of surgical treatment.

MATERIAL AND METHOD

Presented material consists of 42 patients (39 adults and 3 children), 22 females and 20 males, in the age from 8 to 76 treated at Department of Otolaryngology of Medical University of Gdansk in the years from 1995 to 2005 for paranasal sinuses mucocoele.

RESULTS

Fronto-ethomidal mucocoele was found in 22 (52.4%) patients, ethmoidal--in 10 (23.8%), frontal--in 4 (9.5%), spheno-ethmoidal--in 4 (9.5%) and maxillar in 2 (4.8%) patients. 14 (33.3%) cases were primary and 28 (66.7%) secondary of mucocoeles. The most frequent symptoms of frontal or ethmoidal mucocoele were: headache, lacrimation, deformity of orbit, blepharoedema, and diplopia. Sphenoethmoidal and maxillar mucocoele caused mostly nose obstruction and severe headache. Destruction of sinuses and orbital bony wall was found in 16 patients (38.1%), and in 9 of them (21.4%) there were in medial wall of orbit, in 3 (7.1%)--in inferior wall of frontal sinus, in 3 (7.1%)--in anterior wall of frontal sinus, and in 1 (2.3%) in anterior wall of maxillary sinus. In 3 patients (97.1%) with fronto-ethmoidal mucocoele as the consequence of disease the development of empyema was observed. Endoscopic intranasal treatment was applied in 9 patients (21.4%) with fronto-ethmoidal, spheno-ethmoidal and maxillar mucocoele. Complete recovery was observed in 30 (71.4%) patients, recurrence was noted in 12 (28.6%) and these patients were operated from extranasal approach.

CONCLUSIONS

Paranasal sinuses mucocoele is found when natural ostia of sinuses are blocked after prior operation. They cause destruction of bony walls of sinuses. Extranasal approach is an optimal method of treatment in extended mucocoele and their complications.

Nasal and paranasal sinus endoscopy, computed tomography and microbiology of upper airways and the correlations with genotype and severity of cystic fibrosis

OBJECTIVE

Many studies have assessed clinical and functional aspects of lower airway affections in cystic fibrosis. Conversely, few studies have been performed to assess the clinical and functional affections of upper airways. The objective of the present study was to correlate the variables obtained by nasal and paranasal sinuses endoscopy, paranasal sinus laboratory and computed tomography (CT) scan findings, and to check the association with severity and genotype of cystic fibrosis patients.

METHODS

Clinical and laboratory study of 50 patients with cystic fibrosis at a university center. All patients were submitted to CT scan, nasal and paranasal endoscopy and bacterioscopy of maxillary sinus, trachea and oropharynx secretion. Severity of cystic fibrosis was assessed by Shwachman score and the most frequent genetic mutations were identified.

RESULTS

The prevalence of polyposis in the studied population was 36% and it was greater among homozygote for DeltaF 508. Shwachman score was correlated with age (p=0.003). The genotype was correlated with presence of nasal polyposis (p=0.006). There was no association between affections in CT scan and severity of cystic fibrosis (CF). Patients presented high prevalence of early colonization of Pseudomonas aeruginosa.

CONCLUSIONS

Sinus disease in CF patients presents several clinical, endoscopic and tomographic affections. Although most of them are not correlated with severity and disease genotype, severity of CF is correlated with age and presence of polyposis is genotype-dependent.