Cholesterol granuloma of the posterior ethmoid sinus mimicking meningocele

Cholesterol Granuloma of the Maxillary Sinus Misdiagnosed as Nasal Polyp or Mucocele: Four Cases

ABSTRACT

Cholesterol granuloma is commonly found in the mastoid air cells but is rare in the paranasal sinuses. The most commonly affected sinuses are the frontal sinus, followed by the maxillary sinus. Cholesterol granuloma can be difficult to diagnose because clinical manifestations and radiologic findings are similar to those of other sinonasal disorders. The authors observed 4 cases of cholesterol granuloma that were preoperatively suspected to be nasal polyps or mucoceles. Here, the authors report on their clinical presentation and their successful treatment using the endoscopic sinus approach. These cases expand the current literature on cholesterol granuloma in the paranasal sinuses.

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.

Presence of cholesterol granuloma in the maxillary and ethmoid sinuses

INTRODUCTION

Although cholesterol granuloma associated with chronic middle ear disease is shown to be common in the mastoid antrum and air cells of the temporal bone (Leon et al., Arch Pathol Lab Med 126:217-219, 2002), its presence in the maxillary and ethmoid sinuses is rarely encountered. There are few cases reported regarding the incidence of cholesterol granuloma in these sinuses (Ko et al., Am J Otoryngol 27:370-372, 2006).

CASE

Here, we report a case of concomitant cholesterol granuloma in the maxillary and ethmoid sinuses of a 33-year-old man who underwent surgical excision.

DISCUSSION

Histopathological examination of the removed specimen revealed fragments of respiratory mucosa with cholesterol clefts surrounded by multinucleated foreign-body giant cells.