Intracranial mucocele formation in the context of longstanding chronic rhinosinusitis: A clinicopathologic series and literature review

A Real Headache: Intracranial Extension and Epidural Abscess As Complication of Chronic Mucocele

Mucoceles are benign lesions of salivary glands typically originating from the paranasal sinuses. Intracranial extension and superinfection of these lesions are rare but serious complications of chronic mucoceles. Here, we discuss a patient with a known mucocele, initially lost to follow-up, who presented three years later with headache, purulent rhinorrhea, and intracranial extension of his mucocele with development of an epidural abscess. This case highlights the potential complications of chronic, large mucoceles and emphasizes the importance of thorough evaluation in patients with facial abscesses in the setting of known sinus pathology. Any mucocele with signs of superinfection such as purulent rhinorrhea, abscess near the sinuses, or refractory symptoms should warrant cranial imaging. Mucoceles with evidence of intracranial extension require neurosurgical and/or otolaryngologic evaluation for evacuation and debridement to avoid neurologic injury or devastating infection.

Importance of MRI in the diagnosis of a rare intracranial mucocele associated with frontal paranasal osteoma: Case report and literature review

Osteomas and cystic mucoceles are well-known benign tumors, affecting the paranasal sinuses. However, the concomitant presence of both lesions represents a rare occurrence, with only a handful of reported cases. We report a case of a frontal sinus osteoma associated with an intracranial mucocele, in a 61-year-old male patient, with a 3-month history of intermittent headaches and subsequent generalized seizures. Post-contrast MRI showed a frontal heterogeneously enhanced lesion with an adjacent non-enhanced cyst. After surgical excision, histopathological examination established the diagnosis of osteoma with mucoid cyst. Mucoceles increase in size progressively and gradually. They are mostly asymptomatic, nevertheless, once they extend intracranially, complications like infections, seizures, or other neurological disturbances, may frequently occur, indicating the necessity for surgical treatment. Imaging modalities, in particular a head MRI is paramount while contemplating the differential diagnosis of a solid and cystic intracranial lesions, owing to its high sensitivity and specificity. The aim of this case report is to underscore the importance of considering intracranial mucoceles in the differential diagnosis of cystic lesions in the anterior cranial fossa when associated with a solid, possibly obstructing mass.

Partial resolution of chronic unilateral sinonasal obstructive disease in a cat using a temporary polyvinylchloride stent

Case summary

A 3-year-old male neutered domestic shorthair cat presented for further investigation of a swollen left eyelid and a hard, non-painful bony swelling over the left frontal sinus. Physical examination revealed no nasal discharge or airflow through the left nostril. A CT of the head revealed a left frontal sinus obstruction with expansile remodelling and osteolucency. Drainage of the frontal sinus obstruction was alleviated via placement of a temporary polyvinylchloride (PVC) stent that was left in place for 6 weeks. Purulent material removed from the frontal sinus returned a positive culture for Pseudomonas aeruginosa susceptible to marbofloxacin that was continued for 4 weeks, and for an additional 2 weeks after stent removal. A left-sided mucoid nasal discharge returned 3 months after removal of the stent. Repeat CT performed 20 months after surgery found the presence of a gas-filled frontal sinus and partial resolution in the amount of fluid within the mid and rostral nasal cavity. A repeat positive culture for P aeruginosa was also obtained. The exact cause of the chronic unilateral sinonasal obstruction remains unclear, but an underlying chronic rhinitis with secondary obstructive frontal sinusitis or sinus mucocoele with secondary nasal extension was suspected.

Relevance and novel information

Chronic rhinosinusitis in cats can be a challenging condition to treat and cure. This case illustrates the partial resolution of chronic unilateral sinonasal obstructive disease in a cat using a temporary PVC stent.

Giant frontal mucocele presenting with displacement of the eye globe

In this case, a 70-year-old female patient presented with large forehead swelling that occurred 2 years prior, with slow progressive enlargement that mimicked the behavior of a neoplasm. There was severe inferior displacement of the right orbital globe to the level of the nares. Brain computed tomography showed a large expansive lesion in the right frontal sinus with bony wall thinning without destruction or erosion. Brain magnetic resonance imaging showed high signal intensity of the contents in T1- and T2-weighted images with only peripheral enhancement after contrast administration. These features were consistent with a typical right frontal mucocele.

Imaging review of the anterior skull base

The anterior skull base (ASB) is intimately associated with the unique soft tissue subtypes of the nasal cavity, paranasal sinuses, orbits, and intracranial compartment. Pathology involving the ASB is rare but the causes are manifold and can be broadly subdivided into those intrinsic to the skull base and processes extending from below or above. Sinonasal pathology is the most commonly encountered and poses significant management challenges that rely heavily on accurate interpretation of the radiological findings. We illustrate the normal anatomy of the ASB and present a cross-sectional imaging review of the pathological entities that may be encountered, focusing on the specific features that will impact on clinical and surgical management.

Sphenoid Mucocele with Intracranial Extension: An Anatomic Perspective

BACKGROUND

Isolated sphenoid mucoceles are rare, but because of their close proximity to important vasculonervous structures, local extension may result in serious consequences.

CASE DESCRIPTION

A 47-year-old patient presented with headaches, meningismus, and a left homonymous lateral hemianopia. We report the atypical evolution of a posttraumatic sphenoid mucocele invading the sellar region and extending into the subarachnoid space with compression of the right optic tract, and we describe its surgical management. Further, with the aid of cadaveric specimens, we aim to analyze the precise pathway followed by the expanding collection from an anatomic perspective.

CONCLUSIONS

Anatomic knowledge of the sellar and parasellar regions is the key to understand the process of how sphenoid mucoceles may extend intracranially. Early endoscopic drainage with a large sphenoidotomy allows favorable outcomes and prevents serious consequences.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.