Frontal sinus cholesteatoma with intracranial complication

Nasal sinuses cholesteatoma: case series and review of the English literature

BACKGROUND

Nasal sinus cholesteatomas are uncommon slow-growing lesions that are frequently misdiagnosed preoperatively. They can develop due to embryologic remnants or iatrogenic factors (surgical trauma or nasal sinus trauma). In addition, they can cause bone destruction resulting in intracranial or intraorbital complications as well as malignant change if neglected. Complete surgical removal is a must with strict postoperative follow-up.

MATERIALS AND METHODS

Three cases of nasal sinus cholesteatoma are reported. The first case was found inside the ethmoidal sinus, the second in the frontal sinus, and the third was found inside a concha bullosa. In all three cases, a wide endoscopic surgical excision was performed. Due to the lateral extension of the lesion, frontal sinus trephine was also used in the case of frontal sinus nasal cholesteatoma. In addition, a review of the English literature for the reported cases of nasal sinus cholesteatomas was conducted.

RESULTS

There were no reported recurrence or residual during strict postoperative follow-up for 2 years (by endoscopic examination and diffusion-weighted MRI with delayed postcontrast T1 images). A review of the English literature revealed 42 cases of nasal sinuses cholesteatomas (including the present three cases) (17 in the frontal sinus, 15 in the maxillary sinus, 5 in the ethmoid sinus, 3 in the sphenoid sinus, and 2 in a concha bullosa).

CONCLUSIONS

Although nasal sinus cholesteatomas are uncommon, they must be considered in the differential diagnosis of slow-growing nasal sinuses lesions. Preoperative CT scan and diffusion-weighted MRI are essential for proper diagnosis and to exclude other similar lesions, such as nasal sinus mucoceles, cholesterol granuloma, or neoplastic lesions. Wide complete surgical excision is necessary to avoid recurrence and facilitate postoperative follow-up. As with ear cholesteatoma, strict postoperative follow-up is required to detect recurrence or residual early and is performed by endoscopic examination, diffusion-weighted MRI, and delayed post-gadolinium T1 images.

Evolving Treatment of Frontal Sinus Cholesteatoma: A Case Report

INTRODUCTION

Cholesteatomas are lined by squamous epithelium, contain keratin debris, and can cause bony erosion. Although commonly found in the middle ear space and mastoid, cholesteatomas may develop in adjacent structures including the paranasal sinuses. Frontal sinus cholesteatoma (FSC) is a rare condition with fewer than 30 reported cases. The aims of this study are to describe the clinical presentation, diagnostic imaging, and endoscopic treatment of FSC and to review the literature focusing on the pathogenesis, diagnosis, and historical and contemporary treatments of FSC.

CASE PRESENTATION

A 45-year-old man presented with a 1-week history of right eyelid and forehead swelling. Results of computed tomography scans and magnetic resonance images revealed a right frontal sinus lesion of soft-tissue density with bony dehiscence along the superior orbit and posterior table. He underwent right-sided endoscopic sinus surgery at a tertiary care center in January 2017. Intraoperatively, the frontal sinus contained keratin debris suggestive of FSC. This suspicion was confirmed postoperatively by pathologic analysis after subtotal resection.

DISCUSSION

The pathogenesis of frontal sinus cholesteatoma varies based on its cause (congenital vs acquired). Clinical diagnosis remains challenging but is aided by nasal endoscopy, computed tomography, and magnetic resonance imaging. Historically, FSC has been managed by total extirpation through open approaches, which can entail substantial morbidity. With sophisticated endoscopic sinus instrumentation and image guidance, FSC can be successfully treated via an endoscopic approach. Serial débridements and washouts in an outpatient setting may adequately manage the residual disease in the postoperative period.

Frontal sinus cholesteatoma: a masquerading diagnosis

Cholesteatoma of the paranasal sinus is a very rare condition. As in the tympanomastoid region where cholesteatomas are a common entity, the paranasal sinus cholesteatomas also tend to erode the surrounding bony structures. Because of the extensive bony erosion, this condition often masquerades as a chronic granulomatous or a malignant lesion. Clinical presentation can be quite varied like facial deformities, visual and neurological deficits. Radiological findings are also non-specific making a preoperative diagnosis challenging. Histopathological examination is the only confirmatory investigation. We present a patient with frontal cholesteatoma who presented with forehead swelling of 1 month duration. Since the diagnosis could be obtained only intraoperatively, the patient required multiple surgeries. Frontal sinus cholesteatomas often require a combined endoscopic and external approach to ensure complete disease clearance. Periodic follow-up is essential to rule out recurrence.

Sphenoid Sinus Cholesteatoma-Complications and Skull Base Osteomyelitis: Case Report and Review of Literature

Introduction:

Cholesteatoma of the paranasal sinuses is uncommon. Its clinical characteristics are an expanding growth of the affected paranasal sinuses consisting of keratinizing squamous epithelium with bony wall destruction. Among involved paranasal sinuses, sphenoid sinus cholesteatoma is the least common.

Case presentation:

An 82-year-old female diabetic patient presented with subacute onset of fever after experiencing chronic progressive headaches for more than 20 years. Nasal endoscopy found purulent discharge from left sphenoethmoidal recess. Computed tomography (CT) scan of the paranasal sinus showed soft tissue lesions that totally filled the left sphenoid sinus with posterior and inferior wall destruction. There was no evidence of connection to the left mastoid cavity.

Management and outcome:

Left sphenoidotomy was performed. Histopathology revealed cholesteatoma. Two months after surgery, she became worse and CT showed extensive skull base destruction. The patient underwent bilateral sphenoidectomy and craniotomy with surgical debridement of osteomyelitis of the skull base. She received long-term intravenous ertapenam and sitafloxacin for treating drug-resistant Klebsiella infection. The osteomyelitis could not be controlled, and she died.

Discussion:

Progressive headache can be caused by an uncommon disease such as sphenoid sinus cholesteatoma, which is a surgical condition. Complicating osteomyelitis of the skull base requires extensive debridement surgery and should be anticipated.