Mucoceles in the paranasal sinuses involving the orbit: CT signs in 43 cases

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.

Frontoethmoidal Mucoceles: CT and MRI Evaluation

Paranasal sinus mucocele is an expanded, airless, mucus-filled sinus caused by obstruction of the sinus ostium. It is a benign slow growing epithelial lined lesion, bulging against adjacent anatomical structures, without infiltrating them. The purpose of our study is to describe the CT and MR findings in 19 patients (ten women, nine men, 18–72 years, mean age: 48.1) with surgically confirmed frontoethmoidal mucoceles between 1999–2005. CT scans displayed mucoceles as non enhancing soft tissue density lesions, generally isodense to the brain parenchyma, expanding the sinuses in most cases, eroding adjacent bones and extending intraorbitally or intracranially. Signal intensity in T2WI and T1WI MR images varied, but generally lesions had high signal intensity in T2WI and low to intermediate signal intensity in T1WI. Some of the lesions demonstrated regular linear peripheral enhancement after administration of contrast medium. The causes of mucoceles included mucosal thickening from chronic sinusitis, adhesions from previous operation in the nasal cavity, previous trauma, small nasal polyps and a small osteoma, while in six patients (31.5%) the cause of the mucocele remained unrecognized even after surgery. No underlying malignant tumor was found in any of the cases as the cause of obstruction. CT and MRI established the correct diagnosis in all patients. CT was more sensitive in determining bone erosions, while MRI had the advantage of multiplanar imaging and was much more sensitive for differentiating mucocele from a tumor on the basis of MR signal intensity characteristics. In conclusion, CT and MRI are the methods of choice for diagnosing mucoceles of the paranasal sinuses and are of major importance for the treatment plan. Each method seems to have its own advantages and should be used as complementary investigations of sinonasal pathology. Enhanced CT scan should only be performed in the absence or contraindication for enhanced MR imaging.

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

Chronic rhinosinusitis (CRS) can lead to serious long-term adverse sequelae, particularly if left untreated. The aim of this study was to describe a series of intracranial mucoceles (ICMs) that arose in the context of longstanding CRS combined with a review of the pertinent literature. A retrospective chart review was performed on all patients who developed ICMs in association with CRS between 2003 and 2012. The clinical presentation, radiographic features, surgical approach, intraoperative findings, and patient outcome were examined in the context of a literature review. Sixty-five cases of mucoceles were identified in patients with a history of CRS, of which seven (10.8%) were intracranial. Five patients were men and two were women with a mean age of 42.1 years. Headache, facial pressure, retro-orbital pain, and visual disturbances were the most common presenting symptoms. Five of the seven had previously undergone sinonasal surgery. Imaging studies showed ICMs involving the anterior cranial fossa, two of which were bilateral. Latency between onset of CRS and ICM detection ranged from 3 to 19 years (mean, 9.4 years). All patients underwent endoscopic transnasal drainage with three also requiring a concurrent, open neurosurgical procedure to access the intracranial component. There were no postoperative complications, and no recurrences were observed after a mean follow-up of 2.7 years. ICMs presenting as delayed complications of CRS are uncommon and constitute a surgical challenge. Open, external skull base approaches used in conjunction with transnasal endoscopic drainage procedures may be necessary to achieve successful management of this rare condition.

Maxillary air cyst

Pathologic dilatation of the maxillary sinus by air is a rare condition with unclear etiology. We present a case of a 17 year old male with a maxillary air cyst diagnosed by computed tomography. The CT demonstrated air-filled expansion of the maxillary sinus beyond the normal anatomical limits with associated cortical bone thinning. The case report highlights the pathognomonic computed tomography findings of this rare entity and discusses the perplexing nomenclature, proposed etiologies and various treatment options.

Complete loss of vision caused by a giant mucocele of the frontal sinus

The authors report the case of a 75-year-old man presenting with an exceptionally large giant posttraumatic mucocele of the frontal sinus years after a gunshot blast to the head. The lesion had grown so extensively that the right eye had shrunk and calcified, resulting in total monocular blindness, a complication that has been reported only once. To the best of our knowledge, it is the first time that a giant mucocele of such a large size is reported. We describe how the patient underwent surgical removal of this massive lesion, cranial base reconstruction, and a cosmetic oculoplastic procedure. The etiology, clinical presentation, and possible complications are reviewed, as well as the importance of a regular clinical follow-up and early surgical cure. Although the diagnosis and management of mucoceles are nowadays considered quite standard, the exceptional size of the lesion illustrated here emphasizes the destructive potential of such seemingly indolent lesions. Despite the benign histology of mucoceles, one should never underestimate their morbid potential or be lulled in delaying surgical cure. Large mucoceles should be removed as quickly as possible to prevent such unacceptable complications as permanent visual loss.

Giant Intradural Mucocele in a Patient with Adult Onset Seizures

A rare case of mucopyocele in a patient who presented with epileptic seizures is reported. The computed tomography scan (CT) and the magnetic resonance (MR) imaging revealed an intradural extension of a giant fronto-ethmoidal mucopyocele, eroding the cribriform plate and compressing both frontal lobes. The lesion was removed by craniotomy with elimination of the mass effect and reconstruction of the anterior skull base. An intracranial-intradural mucopyocele is an extremely rare cause of generalized convulsion as a presenting symptom, with only 6 cases reported in the literature. The total removal of the lesion associated with anterior fossa reconstruction is the treatment of choice.

Giant mucoceles of the frontal sinus: a series and review

Giant mucoceles of the frontal sinus are a rare pathology but their recognition is important in the differential diagnosis of paediatric proptosis and fronto-orbital lesions. Four patients with giant mucoceles of the frontal sinus were retrospectively analyzed. All the patients were females in the paediatric age group presenting with massive cosmetically unacceptable bony swelling in the frontal region along with unilateral extra-axial proptosis. Radiological imaging revealed giant mucoceles of the frontal sinus with extracranial, orbital and anterior cranial fossa extension. One patient had co-existent craniofacial fibrous dysplasia. Single stage surgery was performed in three patients and two-stage surgery in one. Fronto-orbital craniotomy, removal of the posterior wall of the sinus, obliteration of the sinus and its ostium, dural repair and remodeling cranioplasty were performed. Histopathological examination revealed mucoceles in all, and co-existant fibrous dysplasia in one patient. All the patients made excellent cosmetic recoveries with complete resolution of their visual symptoms. Their clinical presentation, radiological manifestations and treatment modalities are analyzed and an extensive review of the literature is presented. Our case of giant frontal mucocele associated with fibrous dysplasia is furthermore the first such report in the existing medical literature.

Giant mucocele of the frontal sinus

Giant mucocele of the frontal sinus is a rare pathology of benign entity caused by retention of mucous secretions in the sinus. It may expand and erode the surrounding structures such as bones and cerebral parenchyma. The authors describe a patient with frontal giant mucocele involving the orbit, the ethmoid, and intracranial portion of the dura. The main presenting symptoms were diplopia and proptosis. A computed tomography scan and magnetic resonance imaging were performed to permit differential diagnosis from other pathologies such as ossifying fibroma, fibrous dysplasia, and other neoplasms. A single stage maxillofacial and neurosurgical approach to treatment was taken consisting in the removal of the mucocele and reconstruction of the eroded bones with cranial bone grafts. The dura was repaired with temporalis muscle fascia sealed with fibrin glue. Two years after surgery, the patient shows no recurrence and satisfactory morphologic and functional results.

Orbital cysts of childhood—classification, clinical features, and management

There is little in the literature about the clinical spectrum of orbital cysts of childhood and no comprehensive classification has been proposed. The authors propose a classification of orbital cysts of childhood and review their clinical features, pathology, and management. The major categories in the classification include cysts of surface epithelium, teratomatous cysts, neural cysts, secondary cysts, inflammatory cysts, and noncystic lesions with cystic component. Cysts of the surface epithelium are further divided into simple epithelial cyst (epidermal, conjunctival, respiratory, and apocrine gland), and dermoid cyst (epidermal and conjunctival). Epidermal dermoid cyst (dermoid) is by far the most common orbital cystic lesion in children, accounting for over 40% of all orbital lesions of childhood and for 89% of all orbital cystic lesions of childhood that come to biopsy or surgical removal. Neural cysts include those associated with ocular maldevelopment (congenital cystic eye and colobomatous cyst) and those associated with brain and meningeal tissue (cephalocele and optic nerve meningocele). The most important secondary cyst is mucocele that can occur in children with cystic fibrosis. Inflammatory cysts are generally due to parasitic infestations and are more common in tropical areas of the world. Noncystic lesions that can have a cystic component include adenoid cystic carcinoma, rhabdomyosarcoma, lymphangioma, and others. Each type of cyst has rather characteristic, but not pathognomonic, clinical features. Computed tomography and magnetic resonance imaging can help differentiate a cystic lesion from a solid tumor, suggest the type of cyst, and help in planning management. The pathology varies with the cells that line the cyst and with the inflammatory agent. Management varies from local excision to observation, depending on the location and type of cyst. Orbital cysts of childhood can be classified into categories, based mainly on their histopathology. The clinical, radiologic, and histopathologic features can be correlated with the classification in order to better evaluate a child with a cystic lesion in the orbit.

Osteoma of the frontal sinus complicated by intracranial mucocele

We present a rare case of intracranial mucocele associated with frontal sinus osteoma in a patient suffering from generalized convulsion. The intracranial mucocele occurs as a complication of obstruction of sinus drainage caused by osteoma, but it is often diagnosed preoperatively as an intracranial or intracerebral cyst because of the rarity of these combined lesions in neurosurgical practice. However, once the mucocele extends intracranially, several other complications, including infections and/or a convulsion, can occur, indicating the necessity for surgical treatment. Moreover, the differentiation of the mucocele from the intracranial endodermal cyst predominantly depends upon its continuity with the intracranial osteoma portion or the sinus. Thus, knowledge of this rare lesion is important for accurate diagnosis and clinical management.

Intracranial spread of a giant frontal mucocele: case report

A giant mucocele eroded both the anterior and posterior wall of the frontal sinus and infiltrated the dura mater. Its extracranial growth caused a frontal bony prominence. The tumour and part of the dura were resected. A 12 x 6cm defect in the dura was repaired with a freeze-dried patch. A split-thickness bone graft from the right parietal region was used to repair the anterior frontal bony defect. The result one year later was satisfactory. Spiral computed tomography with thr ee-dimensional reconstructions excluded any recurrence of the tumour and showed good integration of bone grafts.

A giant intracranial mucocele associated with an orbitoethmoidal osteoma. Case report

The authors present a rare case of a giant intracranial mucocele associated with an orbitoethmoidal osteoma in a patient suffering from a generalized convulsive disorder. The broad pedicle of the osteoma had penetrated the cribriform plate and extended intracranially to form a nodular mass in the olfactory groove. The intracranial portion of the osteoma was surrounded by a mucocele. Both the cyst wall and multilayered intracystic septations of the mucocele were indented by layers of the osteoma. Although the extracranial portion adhered to the mucosa of the ethmoidal sinus, there were no signs of sinus obstruction. No direct communication other than the osteoma was identified between the mucocele and the ethmoidal mucosa. The large cerebral defect, which the mucocele occupied, communicated directly with the lateral ventricle without any intervening membranous structures. A frontal craniotomy is recommended for exposure of the lesion and plastic repair of the dural defect.

Mucoceles of the paranasal sinuses: uncommon location

Mucoceles are the most common lesions causing expansion of the paranasal sinuses. The sinuses most commonly involved are, in decreasing order of frequency, frontal sinus, ethmoid sinuses, maxillary sinus and sphenoid sinus. We reviewed 46 cases of surgically proven mucoceles and the purpose of this study was to report five cases of mucoceles in an uncommon location.

Intracranial mucoceles with midline fusion defects

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Life threatening intracranial complications of frontal sinus osteomas: report of two cases

Paranasal sinuses osteomas are known as biological benign tumours. However, due to the peculiar anatomical relationships, patients harbouring an osteoma within the frontal sinus are exposed to serious orbital and intracranial complications. We report two unusual cases of intracranial mucocoeles associated with frontal osteomas. In one of them, a superposed tension aerocoele required emergency surgery. Although aggressive treatment of asymptomatic osteomas is not warranted, these lesions must be carefully observed and resected as soon as they show clinical and/or radiological signs of progression. The physiopathological and clinical aspects are discussed.

Giant intracranial mucocele

A 21-year-old man was admitted to hospital because of recent anosmia and liquorrhoea. He also complained of moderate headache and concentration problems in the past few years. On CT scan and MRI scans a big subfrontal process was seen, partially solid and partially cystic. Neurosurgical and histological findings proved that the lesion was an osteoma of the anterior skull base, concomitant with an intradurally extending mucocele.

Mucoceles of the paranasal sinuses with intracranial and intraorbital extension: report of 28 cases

Twenty-eight patients received surgical treatment for a paranasal sinus mucocele with intracranial and/or intraorbital extension. The lesions were classified by site and extension: anterior without intracranial extension (Type 1), 7 patients; anterior with intracranial extension (Type 2), 11 patients; posterior midline without intracranial extension (Type 3), 5 patients; and posterior with intracranial extension (Type 4), 5 patients. The surgical approaches were: transnaso-orbital, transfrontonaso-orbital, transsphenoidal, transmaxillosphenoidal, and subfrontal transbasal; the choice depended on the site and extension of the lesion, with the aim of securing maximum exposure to ensure total removal of the lesion with its capsule. A transcranial approach was reserved for mucoceles possessing an intracranial extension or causing distension of the bone structures with optic pathway neurological symptoms. With a coronal or transfacial skin incision along the lines of the forehead, nose, and orbital muscles of expression and careful reconstruction, the patients' natural cast of features was spared or restored in a single operation.

Giant intracranial mucocele secondary to osteoma of the frontal sinuses: report of two cases and review of the literature

Two cases are reported in which the growth of an osteoma of the frontal sinuses led to the formation of a secondary lesion, an intracranial mucocele, with marked mass effect.

Sphenoid mucocele with intracranial invasion secondary to nasopharyngeal acinic cell carcinoma

We present a case of sphenoid mucocele with large invasion of the middle cranial fossa, secondary to a nasopharyngeal acinic cell carcinoma, occurring in a 52-year-old man. To the best of our knowledge, this association has not been reported so far. We discuss the importance of imaging techniques in delineating the relationship between the two lesions, as long as the clinical and therapeutic problems related both to sphenoid mucocele and acinic cell carcinoma.

Malignant neoplasia of the paranasal sinuses associated with mucocele

Paranasal sinus mucoceles are histologically benign and typically cause ophthalmic morbidity only after significant orbital extension. The authors describe seven patients who had both a mucocele and a malignant tumor in the same paranasal sinus and in whom the neoplasm was discovered incidentally during operation for mucocele. Although malignancy coexistent with paranasal sinus mucocele is uncommon, the association should be considered and appropriate biopsy specimens obtained if operation for mucocele is required.

Paranasal sinus mucocele: unusual MR manifestations at 1.5 T

The classic MR appearance of paranasal sinus mucoceles is due to its cystic composition. We present two cases of paranasal sinus mucocele that exhibit atypical signal characteristics. The morphology of this lesion, rather than its signal intensity, is paramount in establishing this diagnosis.

Computed tomographic evaluation of multiple mucocoeles of paranasal sinuses

There are some cases in which mucocoeles of the paranasal sinuses are multiple and their structures are complicated. When the mucocoeles are multiple, pre-operative evaluation is especially important for correct surgical management. We describe the usefulness of computed tomography for the evaluation of multiple mucocoeles of the paranasal sinuses.

Radiological evaluation of mucocoele of the paranasal sinuses

Ten cases of mucocoele of the para-nasal sinuses are reported. Plain X-ray findings were suggestive of the diagnosis in all cases. CT revealed a well defined homogeneous mass, isodense with brain, with expansion of the para-nasal sinuses and extension of the mass into the orbit or parasellar area in eight cases. Surgical confirmation was obtained in all cases.

CT of the paranasal sinuses

CT scanning has allowed the radiologist to image paranasal sinus disease with an accuracy and detail never before attainable. This information has made the imager an important member of the physician team that evaluates the operability and treatment planning of these patients. The protocol of the CT examination is discussed, the normal CT anatomy is reviewed and an approach to evaluating both inflammatory and malignant disease is presented.

Maxillary sinus mucocele. Report of an unusual case

The maxillary sinus mucocele occupying the entire sinus is rarely reported by dentists. This article discusses one such case diagnosed as an exceptionally large maxillary sinus cyst occupying the whole sinus. Unlike their findings in the medical literature, the authors were unable to find many similar cases reported in the dental literature. The location of these mucoceles necessitates the use of diagnostic radiographs, especially those of the panoramic type. Because etiology is still not fully understood after almost 100 years, the authors suggest and discuss four possible mechanisms of sinus mucocele formation and growth.