Case Report
A giant frontoethmoid mucocele with intracranial extension
Scottish Medical Journal 2015, Vol. 60(1) e1–e3 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014561949 scm.sagepub.com
¨ mit Is¸k1, Selc¸uk Arslan1, Erhan Arslan2 and Abdu¨lcemal U Su¨leyman Baykal3
Abstract Mucoceles are mucus-containing cysts lined by epithelium. Although benign, they may show expansive growth and remain undiagnosed until symptoms due to compression of surrounding structures arise. We report a rare case of frontoethmoid mucocele with intracranial extension in an 80-year-old woman with complaints of headache, right diplopia and proptosis. A right frontoorbital craniotomy was performed, and a mucocele in the frontal sinus extending into the frontal lobe and orbit was totally removed. The patient was successfully treated without any complication. The two-year followup results were satisfactory. Magnetic resonance imaging excluded any recurrence of the mucocele. Combined intranasal and transcranial approach is necessary to treat giant frontoetmoid mucoceles with intracranial extension.
Keywords Ethmoid sinus, frontal sinus, mucocele, intracranial extension, paranasal sinus
Introduction
Case report
Mucocele is generally described as the accumulation of mucus secretions in paranasal sinuses the ostia of which are obstructed by inflammation, fibrosis, trauma, previous surgery, anatomical anomaly, polyps or bone tumours.1,2 Mucoceles are slow-growing and locally aggressive lesions caused by the failure of draining properties of the mucous epithelium of the sinus.3 Even though mainly a rhinologic condition, it may generate orbital symptoms, including proptosis, visual disorder, headache and, on occasion, a palpable mass. Mucoceles commonly occur in frontal and ethmoid sinuses, but intracranial extension is unusual.4 Despite their histologically benign characteristics, mucoceles can cause erosion of the bony sinus walls and may extend to the orbital and intracranial structures. Further, they can lead to life-threatening conditions such as mucopyocele, pneumocephalus, brain abscess and gross mass effect.1,5 We present a case of giant frontoethmoid mucocele with intracranial extension and discuss surgical approaches and the necessity of combined approach in our case.
An 80-year-old woman was admitted to our department with the complaints of frontal headache, right diplopia and proptosis. The symptoms had grown slowly for two years and then rapidly worsened in the previous two months. On ophthalmologic examination, her visual acuity was normal but the ocular mobility in upward gaze was limited. No other neurological symptoms were present. Magnetic resonance imaging (MRI) revealed a 6 6-cm sized heterogeneous mass originating from right frontoethmoid area with intermediate signal intensity. The mass extended to the floor of the anterior cranial fossa and displaced the right orbit 1
M.D., Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Turkey 2 M.D., Department of Neurosurgery, School of Medicine, Giresun University, Turkey 3 M.D., Department of Neurosurgery, School of Medicine, Karadeniz Technical University, Turkey Corresponding author: ¨ niversitesi, Tıp Faku¨ltesi KBB AD., Selc¸uk Arslan, Karadeniz Teknik U Kalkınma Mah., 61080 Trabzon, Tu¨rkiye. Email: [email protected]
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Scottish Medical Journal 60(1)
Figure 1. Coronal (a) axial (b) and sagittal (c) sections on magnetic resonance imaging showing mucocele with extension into the right orbit and intracranial space, compressing the right frontal lobe.
anterolaterally. MRI showed marked extension of the lesion intracranially and extracranially (Figure 1). The preoperative diagnosis was a mucocele of the frontoethmoid sinuses. The patient underwent surgical excision of the lesion. Bicoronal incisions and unilateral frontoorbital craniotomy was performed, and the extradural localisation of the mucocele was observed. Opening the mucocele revealed thick mucopurulent fluid and thickened mucosa. Intraoperatively, we detected that the posterior and inferior wall of the frontal sinus had been eroded, and the right orbit and anterior cranial fossa had been invaded. We totally removed the soft, yellow-grey mucocele with its wall over the dura mater through a combined intranasal and transcranial approach. During the procedure, a dural laceration occurred and it was sutured primarily. After the operation, the patient was free of her complaints such as diplopia and severe proptosis. Histopathologic examination confirmed the diagnosis of mucocele. In the follow-up visits, endoscopic examinations were performed. The postoperative course was uneventful. The MRI at two months postoperatively showed no recurrence (Figure 2). Two years after the surgery, the patient had no symptoms except mild proptosis.
Discussion Mucoceles are benign and expansive lesions that occur most commonly in the frontal and ethmoid sinuses.6–8 Gradually over a period of time, there is considerable expansion of the sinus with thinning of the bony walls. Further expansion then takes place at the expense of surrounding structures. These lesions occur in men and women in the same proportion, and the highest incidence is between the ages of 30 and 40 years. In our case, the pathogenesis of the frontoethmoid mucocele was unclear, but it probably resulted from recurrent
infections when the present state of sinonasal mucosa was considered. The clinical symptoms of the frontoethmoid mucocele range from none to incapacitating headache and visual disturbance. There is an array of clinical symptoms due to compression of neighbouring anatomic structures. The clinical manifestation of mucoceles largely depends on their anatomic site involved. However, the onset of symptoms is insidious. The patient with frontoethmoid mucocele may develop frontal headache, facial asymmetry or swelling. Symptoms due to compression of the orbit such as pain, proptosis, diplopia, reduced ocular movement and impaired visual acuity may also occur. The erosion of the posterior wall of the frontal sinus can lead to meningitis, meningoencephalitis, pneumocephalus, brain abscess, seizures or cerebrospinal fistula.5,6 Our patient had typical symptoms as proptosis, frontal headache and limited ocular mobility in upward gaze. Both MRI and computerised tomography (CT) imaging can confirm the diagnosis, but CT of the paranasal sinuses has great value in the evaluation of bony structures. The surgical treatment of frontal mucocele may vary from functional endoscopic sinus surgery to craniotomy with or without obliteration of the sinus.9,10 Endoscopic sinus surgery is the treatment of choice for a non-invasive frontal mucocele but aggressive surgery is indicated for highly invasive lesions.11 The most common management is radical extirpation of the invasive mucocele, and obliteration using gelfoam, muscle graft and fibrin glue when the posterior wall of the frontal sinus is eroded and the dura is involved. Intradural invasion of the mucocele require resection of the involved dura and duraplasty using pericranium or galea graft and fibrin glue. Vascularised local flaps using pericranium or galea are very useful in avoiding contamination of the anterior cranial fossa. The
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Figure 2. Sagittal (a) and coronal (b) magnetic resonance imaging at two months postoperatively.
remaining defects of the anterior wall must be restructured with autologous bone or alloplastic materials.
Conclusions Mucoceles with intracranial extension are often reported by otolaryngologists and neurosurgeons. Mucoceles occur frequently in the frontal and anterior ethmoid sinuses and may rarely grow into the orbit and anterior cranial fossa. In patients with undue intracranial extension in whom drainage is not possible, the lesion must be removed via craniofacial approach. Collaboration among the otolaryngology, ophthalmology and neurosurgery departments is important in the preoperative assessment. Author’s contributions AU¨I: selection of case, writing this article and proof reading; SA: report of text, literature search; EA: literature search; SB: helping to review of article and with alterations.
Patient consent A signed consent form is available.
Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Manaka H, Tokoro K, Sakata K, et al. Intradural extension of mucocele complicating frontoethmoid sinus osteoma: case report. Surg Neurol 1998; 50: 453–456. 2. Nakajima Y, Yoshimine T, Ogawa M, et al. A giant intracranial mucocele associated with an orbitoethmoidal osteoma. Case report. J Neurosurg 2000; 92: 697–701. 3. Bahadır O, Arslan S, Arslan E, et al. Sphenoid sinus mucocele presenting with unilateral visual loss: a case report. B-ENT 2011; 7: 65–68. 4. Suri A, Mahapatra AK, Gaikwad S, et al. Giant mucoceles of the frontal sinus: a series and review. J Clin Neurosci 2004; 11: 214–218. 5. Nakayama T. Giant pyocele in the anterior intracranial fossa—case report. Neurol Med Chir 1998; 38: 499–502. 6. Cansiz H, Yener M, Guvenc MG, et al. Giant frontoethmoid mucocele with intracranial extension: case report. Ear Nose Throat J 2003; 82: 50–52. 7. Kawaguchi S, Sakaki T, Okuno S, et al. Giant frontal mucocele extending into the anterior cranial fossa. J Clin Neurosci 2002; 9: 86–89. 8. Chiarini L, Nocini PF, Bedogni A, et al. Intracranial spread of a giant frontal mucocele: case report. Br J Oral Maxillofac Surg 2000; 38: 637–640. 9. Weitzel EK, Hollier LH, Calzada G, et al. Single stage management of complex fronto-orbital mucoceles. J Craniofac Surg 2002; 13: 739–745. 10. Ichimura K, Ohta Y, Maeda YI, et al. Mucoceles of the paranasal sinuses with intracranial extension-postoperative course. Am J Rhinol 2001; 15: 243–247. 11. Khong JJ, Malhotra R, Wormald PJ, et al. Endoscopic sinus surgery for paranasal sinus mucocoele with orbital involvement. Eye 2004; 18: 877–881.
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A giant frontoethmoid mucocele with intracranial extension
Scottish Medical Journal 2015, Vol. 60(1) e1–e3 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014561949 scm.sagepub.com
¨ mit Is¸k1, Selc¸uk Arslan1, Erhan Arslan2 and Abdu¨lcemal U Su¨leyman Baykal3
Abstract Mucoceles are mucus-containing cysts lined by epithelium. Although benign, they may show expansive growth and remain undiagnosed until symptoms due to compression of surrounding structures arise. We report a rare case of frontoethmoid mucocele with intracranial extension in an 80-year-old woman with complaints of headache, right diplopia and proptosis. A right frontoorbital craniotomy was performed, and a mucocele in the frontal sinus extending into the frontal lobe and orbit was totally removed. The patient was successfully treated without any complication. The two-year followup results were satisfactory. Magnetic resonance imaging excluded any recurrence of the mucocele. Combined intranasal and transcranial approach is necessary to treat giant frontoetmoid mucoceles with intracranial extension.
Keywords Ethmoid sinus, frontal sinus, mucocele, intracranial extension, paranasal sinus
Introduction
Case report
Mucocele is generally described as the accumulation of mucus secretions in paranasal sinuses the ostia of which are obstructed by inflammation, fibrosis, trauma, previous surgery, anatomical anomaly, polyps or bone tumours.1,2 Mucoceles are slow-growing and locally aggressive lesions caused by the failure of draining properties of the mucous epithelium of the sinus.3 Even though mainly a rhinologic condition, it may generate orbital symptoms, including proptosis, visual disorder, headache and, on occasion, a palpable mass. Mucoceles commonly occur in frontal and ethmoid sinuses, but intracranial extension is unusual.4 Despite their histologically benign characteristics, mucoceles can cause erosion of the bony sinus walls and may extend to the orbital and intracranial structures. Further, they can lead to life-threatening conditions such as mucopyocele, pneumocephalus, brain abscess and gross mass effect.1,5 We present a case of giant frontoethmoid mucocele with intracranial extension and discuss surgical approaches and the necessity of combined approach in our case.
An 80-year-old woman was admitted to our department with the complaints of frontal headache, right diplopia and proptosis. The symptoms had grown slowly for two years and then rapidly worsened in the previous two months. On ophthalmologic examination, her visual acuity was normal but the ocular mobility in upward gaze was limited. No other neurological symptoms were present. Magnetic resonance imaging (MRI) revealed a 6 6-cm sized heterogeneous mass originating from right frontoethmoid area with intermediate signal intensity. The mass extended to the floor of the anterior cranial fossa and displaced the right orbit 1
M.D., Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Turkey 2 M.D., Department of Neurosurgery, School of Medicine, Giresun University, Turkey 3 M.D., Department of Neurosurgery, School of Medicine, Karadeniz Technical University, Turkey Corresponding author: ¨ niversitesi, Tıp Faku¨ltesi KBB AD., Selc¸uk Arslan, Karadeniz Teknik U Kalkınma Mah., 61080 Trabzon, Tu¨rkiye. Email: [email protected]
Downloaded from scm.sagepub.com at University of Otago Library on July 3, 2015
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Scottish Medical Journal 60(1)
Figure 1. Coronal (a) axial (b) and sagittal (c) sections on magnetic resonance imaging showing mucocele with extension into the right orbit and intracranial space, compressing the right frontal lobe.
anterolaterally. MRI showed marked extension of the lesion intracranially and extracranially (Figure 1). The preoperative diagnosis was a mucocele of the frontoethmoid sinuses. The patient underwent surgical excision of the lesion. Bicoronal incisions and unilateral frontoorbital craniotomy was performed, and the extradural localisation of the mucocele was observed. Opening the mucocele revealed thick mucopurulent fluid and thickened mucosa. Intraoperatively, we detected that the posterior and inferior wall of the frontal sinus had been eroded, and the right orbit and anterior cranial fossa had been invaded. We totally removed the soft, yellow-grey mucocele with its wall over the dura mater through a combined intranasal and transcranial approach. During the procedure, a dural laceration occurred and it was sutured primarily. After the operation, the patient was free of her complaints such as diplopia and severe proptosis. Histopathologic examination confirmed the diagnosis of mucocele. In the follow-up visits, endoscopic examinations were performed. The postoperative course was uneventful. The MRI at two months postoperatively showed no recurrence (Figure 2). Two years after the surgery, the patient had no symptoms except mild proptosis.
Discussion Mucoceles are benign and expansive lesions that occur most commonly in the frontal and ethmoid sinuses.6–8 Gradually over a period of time, there is considerable expansion of the sinus with thinning of the bony walls. Further expansion then takes place at the expense of surrounding structures. These lesions occur in men and women in the same proportion, and the highest incidence is between the ages of 30 and 40 years. In our case, the pathogenesis of the frontoethmoid mucocele was unclear, but it probably resulted from recurrent
infections when the present state of sinonasal mucosa was considered. The clinical symptoms of the frontoethmoid mucocele range from none to incapacitating headache and visual disturbance. There is an array of clinical symptoms due to compression of neighbouring anatomic structures. The clinical manifestation of mucoceles largely depends on their anatomic site involved. However, the onset of symptoms is insidious. The patient with frontoethmoid mucocele may develop frontal headache, facial asymmetry or swelling. Symptoms due to compression of the orbit such as pain, proptosis, diplopia, reduced ocular movement and impaired visual acuity may also occur. The erosion of the posterior wall of the frontal sinus can lead to meningitis, meningoencephalitis, pneumocephalus, brain abscess, seizures or cerebrospinal fistula.5,6 Our patient had typical symptoms as proptosis, frontal headache and limited ocular mobility in upward gaze. Both MRI and computerised tomography (CT) imaging can confirm the diagnosis, but CT of the paranasal sinuses has great value in the evaluation of bony structures. The surgical treatment of frontal mucocele may vary from functional endoscopic sinus surgery to craniotomy with or without obliteration of the sinus.9,10 Endoscopic sinus surgery is the treatment of choice for a non-invasive frontal mucocele but aggressive surgery is indicated for highly invasive lesions.11 The most common management is radical extirpation of the invasive mucocele, and obliteration using gelfoam, muscle graft and fibrin glue when the posterior wall of the frontal sinus is eroded and the dura is involved. Intradural invasion of the mucocele require resection of the involved dura and duraplasty using pericranium or galea graft and fibrin glue. Vascularised local flaps using pericranium or galea are very useful in avoiding contamination of the anterior cranial fossa. The
Downloaded from scm.sagepub.com at University of Otago Library on July 3, 2015
Is¸k et al.
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Figure 2. Sagittal (a) and coronal (b) magnetic resonance imaging at two months postoperatively.
remaining defects of the anterior wall must be restructured with autologous bone or alloplastic materials.
Conclusions Mucoceles with intracranial extension are often reported by otolaryngologists and neurosurgeons. Mucoceles occur frequently in the frontal and anterior ethmoid sinuses and may rarely grow into the orbit and anterior cranial fossa. In patients with undue intracranial extension in whom drainage is not possible, the lesion must be removed via craniofacial approach. Collaboration among the otolaryngology, ophthalmology and neurosurgery departments is important in the preoperative assessment. Author’s contributions AU¨I: selection of case, writing this article and proof reading; SA: report of text, literature search; EA: literature search; SB: helping to review of article and with alterations.
Patient consent A signed consent form is available.
Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Manaka H, Tokoro K, Sakata K, et al. Intradural extension of mucocele complicating frontoethmoid sinus osteoma: case report. Surg Neurol 1998; 50: 453–456. 2. Nakajima Y, Yoshimine T, Ogawa M, et al. A giant intracranial mucocele associated with an orbitoethmoidal osteoma. Case report. J Neurosurg 2000; 92: 697–701. 3. Bahadır O, Arslan S, Arslan E, et al. Sphenoid sinus mucocele presenting with unilateral visual loss: a case report. B-ENT 2011; 7: 65–68. 4. Suri A, Mahapatra AK, Gaikwad S, et al. Giant mucoceles of the frontal sinus: a series and review. J Clin Neurosci 2004; 11: 214–218. 5. Nakayama T. Giant pyocele in the anterior intracranial fossa—case report. Neurol Med Chir 1998; 38: 499–502. 6. Cansiz H, Yener M, Guvenc MG, et al. Giant frontoethmoid mucocele with intracranial extension: case report. Ear Nose Throat J 2003; 82: 50–52. 7. Kawaguchi S, Sakaki T, Okuno S, et al. Giant frontal mucocele extending into the anterior cranial fossa. J Clin Neurosci 2002; 9: 86–89. 8. Chiarini L, Nocini PF, Bedogni A, et al. Intracranial spread of a giant frontal mucocele: case report. Br J Oral Maxillofac Surg 2000; 38: 637–640. 9. Weitzel EK, Hollier LH, Calzada G, et al. Single stage management of complex fronto-orbital mucoceles. J Craniofac Surg 2002; 13: 739–745. 10. Ichimura K, Ohta Y, Maeda YI, et al. Mucoceles of the paranasal sinuses with intracranial extension-postoperative course. Am J Rhinol 2001; 15: 243–247. 11. Khong JJ, Malhotra R, Wormald PJ, et al. Endoscopic sinus surgery for paranasal sinus mucocoele with orbital involvement. Eye 2004; 18: 877–881.
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