Endoscopic view of a mucocele in an infraorbital ethmoid cell (Haller cell).

A white, 37-year-old woman came to the office with a complaint of left-sided headaches. Despite earlier treatment with multiple antibiotics, antifungal medications, and endoscopic sinus surgery, she continued to experience persistent cephalalgia.

Computed tomography (CT) of the sinuses showed an opacification of the left ethmoid and infraorbital ethmoid cells (Haller cells) and a roundish mass within the Haller cells (figure, A). The remainder of the sinuses were clear of disease, and the antrostomy sites were patent. Nasal endoscopy with a 4-mm, 0[degrees] telescope revealed a mucosal thickening of the left ethmoid sinus and a widely patent middle meatal antrostomy (figure, B).

The patient underwent a left endoscopic ethmoidectomy with a left mini-Caldwell-Luc procedure in order to gain access to the opacified infraorbital ethmoid cell. A 30[degrees] telescope was passed through the mini-Caldwell-Luc opening, and the infraorbital ethmoid cell was visualized (figure, C). The Haller cell was resected and was found to contain a mucocele full of thick, yellow mucus (figure, D). Following this procedure, the patient has remained symptom-free for 9 months.

The 18th-century Swiss anatomist Albrecht von Haller described the ethmoid pneumatization of the inferior bony wall of the orbit. [1] A pneumatized infraorbital ethmoid cell is today called a Hailer cell. A diagnosis of a Haller cell cannot be made during transnasal endoscopy, because this cell is lateral to the lateral nasal wall. Haller cells make up the posterior and superior wall of the ethmoid infundibulum. When the Haller cells become enlarged, they can cause obstruction of the ethmoid infundibulum and lead to maxillary sinusitis. [2,3]

A diagnosis of Haller cell is easily made on coronal sinus CT, which is the primary means of diagnosing anatomic variations. The integrity of the surrounding lamina papyracea should be inspected to ensure the absence of any orbital fat dehiscence within the Haller cell. Cloudiness or a soft-tissue shadow should be looked for. If symptoms and findings persist, anterior rhinoscopy via a canine fossa or a mini-Caldwell-Luc approach should be performed and pathology should be removed. A transnasal telescopic approach does not show a lesion in the anterior-most position of a Haller cell.

In this case, we suspected that a mucocele was present in an infraorbital ethmoid cell, and this was confirmed by the sinus CT and by the mini-Caldwell-Luc approach. Haller cell mucocele or empyema with purulent secretions can cause a constant or episodic impingement of the ethmoid infundibulum. [4] It is important to identify Haller cells on the preoperative CT and to resect them if they are symptomatic.

From the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. E. Yanagisawa, Dr. Marotta, and Dr. K. Yanagisawa), and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, and the Section of Otolaryngology, Hospital of St. Raphael. New Haven (Dr. E. Yanagisawa and Dr. K. Yanagisawa).

References

(1.) von Haller A. First Lines of Physiology. Edinburgh: O. Penniman, 1803.

(2.) Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C. Decker, 1991.

(3.) Stackpole SA, Edelstein DR. The anatomic relevance of the Haller cell in sinusitis. Am J Rhinol 1997;11:219-23.

(4.) Stammberger H, Wolf G. Headaches and sinus disease: The endoscopic approach. Ann Otol Rhinol Laryngol Suppl 1988;134:3-23.