Cholesterol granuloma of the frontal bone

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.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Osteoplastic flap approach versus orbitotomy in case of orbitofrontal cholesterol granuloma

A 44-year-old man developed a slow-growing painless left superolateral orbital mass that extended into the frontal sinus with a complaint of ptosis. Magnetic resonance imaging revealed a heterogenous hyperintense lesion confined to the left frontal bone and superior orbit. The osteoplastic frontal sinus approach was performed to drain supraorbital cholesterol granuloma cyst and for curetting the capsule. Orbitofrontal cholesterol granuloma characteristically arises in the diploe of the superolateral frontal bone. The traditional approach for a primarily orbitofrontal cholesterol granuloma is the transorbital approach including anterior orbitotomy or lateral orbitotomy. However, the osteoplastic approach should be kept in mind as an alternative aprroach for the management of supraorbital lesions in patients with well-pneumatized frontal sinus.

Paranasal sinus cholesterol granuloma: systematic review of diagnostic and management aspects

BACKGROUND

Cholesterol granuloma (CG) is an expansile, cystic lesion most commonly observed in the temporal bone. CG is rarely encountered in the paranasal sinuses. Given its paucity in this region, the diagnostic and management aspects remain to be elucidated.

METHODS

Systematic review of the literature yielded 66 cases reported as individual data in 37 articles; an additional 69 cases were reported as aggregate data in 5 case series.

RESULTS

The mean age of the 135 patients was 43.8 years, with a male:female ratio of 5.6:1. The most common presenting symptoms were orbital (66%), followed by headaches (19.3%). The most common location for CG was the frontal sinus (60%), followed by maxillary (34.1%) and ethmoid (3.7%) sinuses. Computed tomography (CT) imaging was used in 84 patients (63.3%), with bone erosion being noted in 80% of cases. Magnetic resonance imaging (MRI) was reported in only 9 cases (6.7%); high signal on T1- and T2-weighted images was evident in 77.8% and 66.7%, of cases respectively. Surgical data was available on 65 cases; drainage was achieved by open and endoscopic techniques in 52 (80%) and 13 (20%) cases, respectively. Primary symptom improvement and CG cavity patency was achieved in 92% of cases at a mean follow-up of 34.5 months.

CONCLUSION

Paranasal sinus CG is most commonly observed in middle-aged males, arises in the frontal sinus, and typically presents with orbital symptoms. Both open and endoscopic techniques can be used with high success rate. The present study represents the first attempt in the literature to construct a clinical profile of this rare entity.

Recurrent orbitofrontal cholesterol granuloma in pediatric patient: case report and review of the literature

Orbitofrontal cholesterol granuloma is a rare entity which typically involves the lateral part of the supraorbital ridge. It causes progressive expansion and erosion of the inner and outer tables of the frontal bone. We describe a case of recurrent orbitofrontal cholesterol granuloma in a 17-year-old girl. In June 2002 this patient had originally presented to an eye clinic with a small palpable mass in the right superolateral orbit, limitation on upgaze, and progressive proptosis. MRI of the orbit revealed an intraorbital extraconal mass with smooth border, high signal on both T1- and T2-weighted magnetic resonance images. She underwent an anterior orbitotomy via a subbrow incision. The lesion was removed completely, and histopathological examination confirmed a cholesterol granuloma. She remained asymptomatic until her presentation in August 2005. On second admission (3 years later), she complained of a tender palpable mass in the superolateral aspect of the right orbit. Her right eye was 4 mm proptosed and 4 mm inferomedially displaced with limited elevation. The rest of the examination was normal. MRI of the orbit showed a large intraorbital but extraconal mass with smooth border, high signal on both T1- and T2-weighted images without enhancement after gadolinium injection. She underwent complete surgical excision by means of a bicoronal approach. Histopathological diagnosis revealed cholesterol granuloma. No recurrence of the lesion has been observed during the last 6 years following the second operation.

Recurrent orbital cholesterol granuloma

Cholesterol granuloma is an uncommon entity, occurring typically in the supero-temporal orbit. Recurrence has only rarely been reported. We describe a case of recurrent cholesterol granuloma in a 48-year-old-man to illustrate the clinical features of the condition, and to highlight the importance of complete resection to prevent recurrence.

[Cholesterol granuloma]

AIM OF THE STUDY

We report 2 cases (52 and 29-year-old men) of CG in the petrous apex we treated in 2004-2006. We also review the literature and discus the mechanism of development of CG and the treatment of this lesion.

MATERIAL AND METHODS

Cholesterol granuloma (CG) is a chronic inflammatory process with associated foreign body reaction to hemorrhage-related cholesterol crystals. Although CG is found in various organs the temporal bone is the most common site of detection. Numerous ethiopathological hypotheses have been proposed but most authorities support the concept of air cell tract blockage in well pneumatized petrous apex. Obstruction of the air cells leads to rupture of blood vessels and hemorrhage. Red blood cell degradation into cholesterol crystals produces a foreign body giant-cell reaction with progressive accumulation of typical brownish glistening fluid. Clinically, this lesion can produce sensorineural hearing loss, tinnitus, hemifacial spasm, facial numbness and trigeminal neuralgia. Cholesteatoma is the main lesion to distinguish from CG. On MRI studies, CG appears with a high signal on both T1- and T2-weighted sequences, cholesteatoma appear bright only on T2-weighted ones. Goal of the surgery is to create a drainage and ventilation of the affected area to prevent recurrence. Several alternative approaches to the petrous apex have been described.

RESULTS

12-18 months follow up shows no clinical signs of recurrence.