Maxillary sinus mucocele. (Rhinoscopic Clinic).

A 48-year-old man came to us with right facial pressure and right nasal obstruction. Coronal computed tomography (CT) of the sinuses showed a complete opacification of the right maxillary sinus with expansion through the medial wall of the antrum (figure, A). Nasal endoscopy revealed the presence of a soft-tissue mass (a markedly swollen and anteriorly displaced uncinate process) in the nasal cavity that extended through the middle meatus (figure, B).

Powered endoscopic sinus surgery was performed, and the herniated maxillary sinus mucocele was opened with a microdebrider (figure, C). The dissection included excision of the intranasal portion of the mucocele (the swollen and displaced uncinate process), which resulted in wide marsupialization and adequate ventilation of the maxillary sinus portion of the mucocele. Postoperatively, the patient was asymptomatic, and nasal endoscopy showed a widely patent middle meatal antrostomy of the right maxillary sinus (figure, D) that provided excellent drainage and ventilation.

Paranasal sinus mucoceles are benign, mucus-filled lesions. Although their cause has not been clearly determined, they are known to be retention cysts that are lined with columnar or cuboidal epithelium. (1) They are most frequently found in the frontal and ethmoid sinuses. Their incidence in the maxillary sinus is less common, having been reported in only 3 to 10% of cases. (2) The typical radiographic appearance of mucoceles is a fully opacified sinus with evidence of rounded or ovoid expansion and bone erosion. (1,2)

The symptoms of mucoceles are related to their expansion and subsequent pressure on and obstruction of surrounding anatomic structures. Frontal and ethmoid mucoceles are often associated with headaches and sometimes with visual disturbances. Maxillary sinus mucoceles are more typically associated with symptoms of nasal obstruction, although visual disturbances have been reported. (1) Medial expansion of the wall of the maxillary sinus into the nasal cavity displaces the inferior turbinate and causes the nasal obstruction. Superior expansion of the antrum into the inferior orbit can cause displacement of the orbital contents and visual changes. Downward displacement into the area of the alveolus can even cause a loosening of teeth. (1)

Although mucoceles are benign, they can cause significant pathology as a result of their effects on surrounding vital structures of the orbit and skull base. In addition, local symptoms of sinusitis, nasal obstruction, and anosmia can occur. (2) Treatment has traditionally involved excision or marsupialization via an external approach. More recently, an endoscopic intranasal approach has been advocated. (3) The appropriate drainage and subsequent postoperative care of these lesions are essential to avoiding recurrence.

References

(1.) Jacobson AL, Lawson W, Biller HF. Bilateral pansinus mucocele with bilateral orbital and intracranial extension. Otolaryngol Head Neck Surg 1982;90:507-9.

(2.) Batsakis J, Sciubba J. Pathology. In: Blitzer A, Lawson W, Friedman WH, eds. Surgery of the Paranasal Sinuses. 2nd ed. Philadelphia: W.B. Saunders, 1991:119-59.

(3.) Kennedy DW, Senior BA. Endoscopic sinus surgery. A review. Otolaryngol Clin North Am 1997;30:313-30.

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn., and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa).