Ophthalmic considerations in fronto-ethmoidal mucocoeles

The Clinical and Radiologic Features Affecting the Ocular Symptoms in Patients With Paranasal Sinus Mucoceles Involving the Orbit

INTRODUCTION

Paranasal sinus (PNS) mucoceles may involve orbit and have ophthalmic manifestations. The objective of this study was to investigate the clinical and radiological features affecting the ophthalmic manifestations in patients with PNS mucoceles involving the orbit.

METHODS

Fifty-two patients underwent endoscopic sinus surgery for PNS mucoceles with orbital involvement were investigated. Ophthalmic manifestations included exophthalmos, ocular pain, diplopia, visual disturbance. The correlation between ocular symptoms and the mucocele volume, origin site of mucocele, and the involvement of extraocular muscles or optic nerve were evaluated.

RESULTS

Ophthalmic manifestations were significantly higher in the anterior ethmoid and frontal sinus involvement. Exophthalmos was significantly increased in the involvement of anterior ethmoid sinus, frontal sinus, and superior group ocular muscles, but decreased in the mucocele of maxillary sinus. Ocular pain was significantly lower in the involvement of anterior ethmoid sinus, frontal sinus, and superior group ocular muscle. Diplopia showed no significant differences among clinical and radiological parameters. Visual disturbance was significantly higher in the involvement of posterior ethmoid sinus and sphenoid sinus. The volume of mucocele, relation to optic nerve, adjacent bony change, and duration of ocular symptom had no significant effect on ocular symptoms in patients with PNS mucoceles involving the orbit.

CONCLUSION

The volume of mucocele did not affect the ophthalmic manifestations in patients with PNS mucoceles involving the orbit. Exophthalmos, ocular pain, and visual disturbance were significantly correlated with the involved sinus of PNS mucoceles.

Eyeball deviation by orbital mucocele after midface sinus injury

A mucocele is an epithelium-lined, mucus-filled cavity in the paranasal sinuses. Mucocele may develop due to scarring and obstruction of the sinus ostium caused by midface sinus trauma, such as orbital bone fracture or endoscopic sinus surgery. The authors report two cases of orbital mucocele as complications following midface sinus injury (endoscopic sinus surgery in one case, and orbital fracture repair in the other). In both cases, imaging studies showed a large orbital mucocele accompanied by bony erosion and orbital wall remodeling, compressing the ocular muscle. Using an open approach, the lesion was excised and marsupialized. The symptoms resolved, and the postoperative eyeball position was normal. Orbital mucocele may cause serious complications such as ocular symptoms, orbital cellulitis, osteomyelitis, and the formation of an abscess with the potential to invade the brain. Therefore, surgeons should consider the possibility of mucocele as a late complication of surgery and initiate an immediate work-up and surgical treatment if needed.

Paranasal Sinus Mucoceles: Modern Management

As a result of the introduction of endoscopic sinus surgery, together with improvements in diagnostic radiology, it is now possible to marsupialize the majority of paranasal sinus mucoceles. We present a review of our management of 34 consecutive mucoceles, of which 22 were approached endoscopically. We discuss the presenting features and radiological findings in these patients, and the surgical techniques employed. At review, two patients have had a recurrence; both had previously had drainage of their mucocele by an external approach. One was then managed by further external surgery and the other endoscopically. There were no significant complications following endoscopic surgery with a follow-up of 6 months to 3 years. We suggest what should be the contraindications to an endoscopic approach.

Anatomic relationship of the first olfactory neuron and trochlea: cadaveric study with surgical implications

BACKGROUND

Iatrogenic injury to the trochlea is a potential complication of the Draf III or endoscopic modified Lothrop procedure; however, the location of the trochlea from within the sinus cavity has yet to be clearly characterized. We performed the first cadaveric study assessing the position of the trochlea in relation to the first olfactory neuron, a commonly identified landmark during the Draf III procedure.

METHODS

Thirteen external dissections of the trochlea were performed on 7 disarticulated cadaveric heads via an extended Lynch type incision. An endoscopic Draf III procedure was then performed on all cadavers. A burr hole was then created at the trochlear fovea. A straight vector between the trochlear attachment and the ipsilateral first olfactory neuron was then created. The vector was then viewed from within the sinuses using a 30-degree endoscope. The endoscope was maneuvered to create an upright midline view centered on the olfactory neurons. An image was subsequently captured and analyzed using ImageJ software to calculate a vector angle. The linear distance between the 2 structures was also recorded.

RESULTS

Relative to the first olfactory neuron, the trochlea was found to be 19.52 ± 4.68 mm away and at an angle of 39.42 ± 8.54 degrees in the anterolateral, superior direction along the frontal bone.

CONCLUSION

We report the first anatomical dissection characterizing the position of the trochlea relative to the ipsilateral first olfactory neuron. Intraoperative recognition of this relationship during Draf III procedures can prevent potential injury to the trochlea.

Frontoethmoidal Mucoceles: CT and MRI Evaluation

Paranasal sinus mucocele is an expanded, airless, mucus-filled sinus caused by obstruction of the sinus ostium. It is a benign slow growing epithelial lined lesion, bulging against adjacent anatomical structures, without infiltrating them. The purpose of our study is to describe the CT and MR findings in 19 patients (ten women, nine men, 18–72 years, mean age: 48.1) with surgically confirmed frontoethmoidal mucoceles between 1999–2005. CT scans displayed mucoceles as non enhancing soft tissue density lesions, generally isodense to the brain parenchyma, expanding the sinuses in most cases, eroding adjacent bones and extending intraorbitally or intracranially. Signal intensity in T2WI and T1WI MR images varied, but generally lesions had high signal intensity in T2WI and low to intermediate signal intensity in T1WI. Some of the lesions demonstrated regular linear peripheral enhancement after administration of contrast medium. The causes of mucoceles included mucosal thickening from chronic sinusitis, adhesions from previous operation in the nasal cavity, previous trauma, small nasal polyps and a small osteoma, while in six patients (31.5%) the cause of the mucocele remained unrecognized even after surgery. No underlying malignant tumor was found in any of the cases as the cause of obstruction. CT and MRI established the correct diagnosis in all patients. CT was more sensitive in determining bone erosions, while MRI had the advantage of multiplanar imaging and was much more sensitive for differentiating mucocele from a tumor on the basis of MR signal intensity characteristics. In conclusion, CT and MRI are the methods of choice for diagnosing mucoceles of the paranasal sinuses and are of major importance for the treatment plan. Each method seems to have its own advantages and should be used as complementary investigations of sinonasal pathology. Enhanced CT scan should only be performed in the absence or contraindication for enhanced MR imaging.

[Clinical and surgical evaluation of patients with mucocele in the Conde de Valenciana Ophthalmology Institute]

PURPOSE

Mucoceles are cystic lesions, resulting from an obstruction in the paranasal sinuses and an accumulation of mucus, causing enlargement of the affected paranasal sinus. The signs and symptoms depend on the affected sinus. Treatment consists of surgical resection. The purpose of this study was to describe the clinical presentation of patients with mucocele, and also to describe the surgical results with our mucocele resection in patients treated in our institution over the last 10 years.

METHODS

All patients with a diagnosis of mucocele over the last 10 years and treated in our institution were included. An analysis was performed on the symptoms, surgical technique, and results.

RESULTS

Frontoethmoidal sinus mucoceles were the most common. Both eyes were affected but with no significant statistical differences. The median age at presentation was 52 years old, with no difference between both genders. The time to seek medical attention was shorter in frontal mucoceles. Proptosis was the most common symptom. Complications during surgery were reported in just one patient. Recurrence was reported in 12% of patients.

DISCUSSION

Our results correlate with those in the literature. We reported satisfying results with our technique, avoiding sinus obliterations, with a recurrence of 12% versus 6% reported in previous studies. We believe that our technique is safe and accessible for ophthalmologists in mucoceles treatment.

Transcutaneous medial canthal tendon incision to the medial orbit

PURPOSE

The surgical approach to the medial orbit allows superior exposure of the medial orbital wall and nasal bones, extending to the orbital apex, with excellent cosmetic results.

METHODS

This is a retrospective database study of all patients (N = 98) undergoing a transcutaneous medial canthal tendon incision in practice during 2009. This 1.5- to 2.0-cm incision is made just anterior to, in the same plane as, and shaving the anterior ramus of the medial canthal tendon. After exposing the origin of the anterior ramus of the medial canthal tendon, the periorbita along with the attached medial canthal tendon is elevated, exposing the entire medial orbital wall from the orbital strut to the trochlea. Anterior dissection allows access to the nasal bones to the dorsum of the nasal bridge. The parameters studied in this report were the complication rates (including scarring requiring revision, telecanthus, diplopia related to the technique, and injury to the optic nerve or other orbital structures) and photographic evidence of the final cosmetic result of this approach.

RESULTS

During 2009, 173 surgical procedures were performed through the transcutaneous medial canthal tendon incision. The procedures comprised 89 fracture repairs of the nasal or ethmoid complex, 2 naso-orbito-ethmoid fracture repairs, 4 cases of isolated nasal fracture repair, 37 medial wall decompressions for ophthalmic Graves disease, 13 cases of subperiosteal abscess drainage, and 28 dacyrocystorhinostomies using a slightly modified incisional position. The inferior oblique was not cut or released in any of these cases. There were no observed cases of medial canthal webbing, injury to orbital structures, telecanthus, optic neuropathy, or iatrogenically induced diplopia related to the technique. By definition, the authors' follow-up time is limited to less than 2 years in each case; however, all complications, which the authors have considered for this report, would have been readily observable in this postoperative period.

CONCLUSIONS

The small incision, transcutaneous medial canthal approach offers excellent and safe exposure of the medial wall, nose, and the orbital apex. The authors differentiate this transcutaneous medial canthal tendon incision from the less cosmetically acceptable, larger and more anterior Lynch incision. This medial canthal tendon incision has, and continues to be, a workhorse in the authors' approach to the medial orbit and nose while offering unparalleled exposure with an excellent safety and complication profile.

Superior oblique muscle palsy after frontal sinus mini-trephine

OBJECTIVE

The aim of this study is to present a case of superior oblique muscle dysfunction after a frontal sinus mini-trephine.

METHODS

This is a case report of an 18-year-old woman where a mini-trephination approach and endoscope were used to open and marsupialize a symptomatic, opacified type IV cell within the left frontal sinus. After surgery, the patient developed a persisting diplopia; a left superior oblique muscle palsy was diagnosed. Nine cadaveric dissections of the trochlea were undertaken to clarify mechanisms for potential trochlear damage.

RESULTS

Cadaveric dissection reveals that the trochlea is more than a simple pulley; it is a complex structure in close proximity to the orbital rim. The superior oblique tendon telescopes and is surrounded by a vascular sheath that could be easily traumatized.

CONCLUSION

Damage to the trochlea could occur, as the periosteum is elevated from bone or during healing. Alternatively, prolonged traction on soft tissue near the trochlea could cause swelling of the vascular sheath, fibrosis, and hypomobility of the superior oblique tendon. Careful siting of the incision for external frontal sinus surgery as well as careful retraction of skin flaps and periosteal elevation are all techniques used, which should reduce the risk of damage to the trochlea.

Bilateral asymmetrical mucoceles of the paranasal sinuses with unilateral orbital complications

We report the rare occurrence of bilateral asymmetrical mucoceles of the paranasal sinuses that resulted in a unilateral orbital complication. The patient was a 47-year-old woman who presented with complaints of diplopia, blurred vision, and protrusion of her right eye that had progressed over a period of several months following an upper respiratory tract infection. Computed tomography detected the presence of two large, asymmetrical mucoceles. The lesion on the right involved the frontal and ethmoid sinuses, and the one on the left involved the ethmoid sinus. The mucoceles were locally expansile and had eroded the surrounding bony structures on the right. The expansile nature of the right-sided mass had displaced the right orbit, which was the cause of the vision deterioration. Transnasal endoscopic surgery was performed to excise and marsupialize the mucoceles. This modality was preferred over conventional open surgery because it affords good visualization, it is safe, and it is a less morbid procedure. The patient's recovery was uneventful, and she was discharged home on the third postoperative day. On continuing follow-up, her vision had improved, her intraocular pressure had returned to normal, and her orbits were in their normal position. Based on our literature search, no case of bilateral frontal and ethmoid sinus mucoceles has been previously reported.

Unusual case of frontoethmoid mucopyocele with intracranial and orbital extension

A case report of rare occurrence of frontoethmoid mucopyocele with Intracranial and orbital extension with complete recovery after endoscopic surgery.

Ophthalmic manifestations of paranasal sinus mucocoeles

PURPOSE

To investigate the ophthalmic manifestations of paranasal sinus mucocoeles.

METHODS

A retrospective study of all patients (1992-1998) diagnosed with paranasal sinus mucocoeles. All patients had a CT scan.

RESULTS

Of the 45 patients, only 3 (6.7%) did not have ophthalmic symptoms or signs. The most common (64.4%) presenting feature was peri-orbital swelling, often associated with pain and tenderness. Other presenting features included diplopia, proptosis, hypoglobus, diplopia, decreased colour vision, epiphora, facial swelling and nasal polyps. The frontal sinus was the most commonly (70%) involved site.

CONCLUSIONS

Paranasal sinus mucocoeles present most commonly with ophthalmic symptoms and signs. Patients with this condition are therefore highly likely to present initially to the ophthalmology department. Awareness of the aetiology of this condition is important so that appropriate and timely referral is made to the otolaryngologists to ensure appropriate management of this condition.

Management of frontoethmoidal mucoceles with orbital extension: is primary orbital reconstruction necessary?

PURPOSE

Sinus mucoceles with orbital extension are often managed primarily by an otolaryngologist to relieve the sinus obstruction. In this study, a series of patients was examined to determine whether or not reconstruction of the orbit was necessary at the time of the initial sinus surgery from the perspective of an orbital surgeon often involved in the comanagement of orbital complications of sinus mucoceles.

METHODS

A retrospective interventional case series of 5 patients with frontoethmoidal mucoceles comanaged by otolaryngology and oculoplastics. We reviewed symptoms, clinical findings, course, and treatment of our patients and reviewed the literature regarding management options for frontoethmoidal mucoceles.

RESULTS

In extended follow-up, clinical resolution of presenting orbital symptoms and radiographic evidence of reformation of the bony orbit was noted without the need for orbital reconstruction at the time of the initial sinus surgery for a sinus mucocele with orbital extension.

CONCLUSIONS

A specific subset of sinus mucoceles with orbital extension may resolve by primary sinus surgery alone. A decision on the relative merits of orbital surgery at the time of primary sinus surgery should be made on a case-by-case basis.

Ophthalmic manifestations of paranasal sinus mucoceles

BACKGROUND

Paranasal sinus mucoceles are mucus-containing cysts caused by obstruction of the sinus orifice. Although such mucoceles originate in the paranasal sinuses, they are usually only associated with ophthalmic and not rhinologic symptoms. The purpose of this study was to demonstrate the presence of ophthalmic manifestations in patients with paranasal sinus mucoceles, and to discuss the possible mechanisms and prognosis for such manifestations.

METHODS

Medical records for 41 patients with paranasal sinus mucoceles, who presented with ophthalmic complaints at our department over a 10-year period (1989-1999), were reviewed retrospectively. For analysis of the relationships between ophthalmic complaints and the affected paranasal sinuses, we considered the paranasal sinuses as anterior and posterior.

RESULTS

Proptosis (n = 19), periorbital pain (7), and impairment of ocular mobility (5), were common manifestations associated with mucoceles in the anterior paranasal sinuses (25 patients), while blurred vision (n = 9) and impairment of ocular mobility (3) were frequently associated with mucoceles in the posterior paranasal sinuses (11 patients). Ophthalmic complaints resolved in 38 of 41 patients (92.7%) after operation.

CONCLUSION

The clinical ophthalmic manifestations of paranasal sinus mucoceles correlated with the paranasal sinuses involved (i.e. anterior or posterior). Because of cranial nerve involvement, mucoceles in the posterior paranasal sinuses had a worse prognosis than those in the anterior paranasal sinuses.

Volumineuse mucocèle frontale à extension orbito-palpébrale

INTRODUCTION

A mucocele is an unusual benign cystic tumor, frequently seen in the adult and affecting mucous sinuses that expand the orbit by bone destruction. It is caused by a lack of sinus aeration; surgical treatment consists in cyst extirpation and sinus drainage.

DESCRIPTION

A 72-year-old man, without a history of sinus disease, presented a voluminous mucocele of the right frontal sinus that had begun 3 years before, with superior eyelid and orbit expansion hiding and pushing the eye to the downside and the outside. The cyst was surgically removed via the external approach without sinus drainage because of a lack of technical means resulting from the total destruction of the anterior and severe thinning of the posterior wall of the right frontal sinus with dura mater exposure. After surgery, the patient recovered visual function without diplopia, and normal eyelid and ocular motility. However, the right eye is abnormally sized a bit downside.

CONCLUSION

A mucocele of the frontal sinuses can show major superior eyelid development with a low risk of trochlea injury during surgery, a possibility particularly if the destruction of the anterior wall of the frontal sinuses is opened ahead of the orbit septum. Sinus drainage was not undertaken for our patient because of the substantial destruction of the posterior wall of the frontal sinus, with a high risk of infection.

Fronto-orbital mucoceles: our experience

Frontal sinus mucoceles are rare benign neoplasms that can result in bony erosion extending from the borders of the sinus into the orbital cavity. The authors report the fronto-orbital mucoceles they have observed in the last 8 years. The authors used an "open surgery" approach in 12 fronto-orbital mucoceles, characterized by an osteoplastic frontal flap, through a coronal incision or Lynch incision. In this way, they were able to expose the frontal sinus and to remove completely the mucocele from the periorbita. Only one recurrence is reported 2 years after surgery. Excellent aesthetic results have been reached in all cases. In the literature, many different positions are reported for the treatment of mucoceles. The endoscopic surgery of the paranasal sinuses has become the procedure of choice for mucoceles of maxillary, ethmoidal, and sphenoidal sinuses. However, few authors have recommended the endoscopic approach for frontal mucoceles. The indications and limitations of endoscopic and "open" surgery are critically discussed in the light of the authors' personal experience and current literature.

Mucocele frontoetmoidal: relato de casos e revisão da literatura

As mucoceles dos seios paranasais são lesões císticas de revestimento epitelial com conteúdo mucóide, que apresentam crescimento lento com características expansivas e de reabsorção óssea. Eventualmente, podem comprometer as estruturas nobres adjacentes como a órbita e a cavidade intracraniana. Acredita-se que sua etiologia esteja ligada à obstrução do óstio de drenagem do seio paranasal envolvido. Podem causar dor facial, cefaléia, obstrução nasal, diplopia, diminuição da acuidade visual, deslocamento do globo ocular, edema facial ou até mesmo meningite, dependendo da área anatômica comprometida. Acomete mais freqüentemente os seios frontal e etmoidal anterior, sem prevalência de sexo. O diagnóstico é realizado através de exames de imagem, sendo a tomografia computadorizada o exame de eleição, embora em algumas ocasiões a ressonância magnética esteja indicada. Atualmente a abordagem endoscópica paranasal é o acesso cirúrgico de primeira escolha, por ser menos invasiva e apresentar menor morbidade. Este estudo relata dois casos de mucocele frontoetmoidal com extensão orbitária, abordados por via endoscópica endonasal. Os resultados comprovaram a segurança e eficiência deste acesso cirúrgico.

Transcaruncular approach for the management of frontoethmoid mucoceles

AIMS

To present transcaruncular medial orbitotomy as the preferred approach to manage frontoethmoid mucoceles.

METHODS

11 patients with frontoethmoid mucoceles received transcaruncular orbitotomy from 2000 to 2002 at the National Taiwan University Hospital. The incision was made through the caruncle to explore the medial wall periosteum. Then the periosteum was opened and extended to provide adequate surgical field exposure. Frontoethmoid mucoceles could be viewed and removed directly. A transnasal drainage tube was inserted before closure of the caruncle wound.

RESULTS

The mean follow up period was 12 (SD 9.1) months (range 1-26). Both functional recovery and cosmetic outcome were excellent. There was no recurrence of mucoceles. One patient complained of diplopia, which subsided after 2 months.

CONCLUSION

Transcaruncular orbitotomy provides a wide exposure and a safe access to the medial orbital extraperiosteal space. Furthermore, there is less damage to skin and muscle layer and less manipulation of other ocular adnexal structures, such as medial canthal tendon and lacrimal sac. It can be an excellent approach for the management of frontoethmoid mucoceles.

Endoscopic management of paranasal sinus mucocoeles

Mucocoeles of the paranasal sinuses are relatively uncommon and in the past have been generally treated by an external surgical approach. Forty-eight mucocoeles in the frontal, fronto-ethmoidal and sphenoidal sinuses have been treated during the last five years, 20 by an entirely endonasal endoscopic approach and 28 by a combination of an external procedure and an endoscopic approach. There were no recurrences in the endoscopic group, with a mean follow-up of 34 months whilst three recurrences occurred in the combined external and endoscopic group which had a mean follow-up of 44 months. This may reflect the complexity and severity of concomitant disease. If a wide marsupialization can be achieved by an entirely endoscopic approach there are a number of advantages, notably a lack of facial scarring in children and young adults.

Endoscopic Management of a Large Ethmoid Mucocele

We present a patient complaining of severe proptosis and diplopia, who had a large ethmoid mucocele. The patient was treated with endoscopic surgical drainage. He had complete resolution of all symptoms. There is no evidence of recurrence at six months follow-up.