Mucoceles of Ethmoid and Sphenoid Sinus With Visual Disturbance Hiroshi
Moriyama, MD;
Hirohiko Hesaka, MD; Toshiro Tachibana, MD; Yoshio
the period from 1980 through 1989, we treated 25 (20 postoperative and five primary) cases of mucoceles of the posterior ethmoidal sinus and/or sphenoidal sinus accompanied by visual disturbances. The postoperative mucocele developed 15 to 25 years after initial surgery. Manifesta-
\s=b\ In
tions of mucoceles include headache, ophthalmalgia, double vision, and exophthalmos in addition to a decrease in visual acuity. The degree of improvement in visual acuity after an operation depends on visual acuity before the operation, the mode of development of the mucocele, and the time from onset of the disease until surgery. Opening the mucocele by an endonasal approach using an endoscope is recommended as the radical form of therapy. (Arch Otolaryngol Head Neck Surg. 1992;118:142-146) the
of mucoceles of posterior ethmoid The incidence low. Once they develop, sphenoid disturbances, of and
sinuses is
oc¬ impairment the eye, especially visual curs as the major symptom in many cases. It is especially important for this disease to be diagnosed and surgically treated as soon as possible. In general, many patients with mucoceles of the posterior sinuses show no nasal symp¬ toms and first visit a physician only when they have sub¬ of jective ophthalmologic symptoms. Thus, the diagnosis the
this disease tends to be
delayed. However, due to
re¬
diagnosis and the common use of to computed tomographic scans, it has become possibleeth¬ establish a diagnosis of mucoceles of the posterior moid and sphenoid sinuses early on. Furthermore, as a result of recent advances in endoscopie technology, it has become possible to perform endonasal treatment safely and correctly. It has also become possible to accurately observe the optic canal in the mucocele; we can, therefore, expect marked improvement in relief of symptoms by surgically opening the mucocele in the early stage of the cent
progress in image
disease. Nevertheless, even with surgery, the disease to a stage where no improvement can be achieved in the patient's visual acuity. The incidence of this disease is much higher in patients who have under¬ gone surgery on the paranasal sinus than it is in patients who have not. In other words, postoperatively muco¬ celes are found at a higher rate than they are primarily. Since 1980, we performed surgery on a mucocele of the posterior ethmoid or sphenoid sinuses in 25 patients who worsens
presented with visual disturbances as the primary symp¬ tom. These cases are presented and analyzed below. SUBJECTS AND METHODS
Subjects
The subjects of this study were 25 patients with a mucocele of the posterior ethmoid or sphenoid sinuses accompanied by vi¬ sual disturbances who underwent an operation between 1980 and 1989 (Table 1). These cases were analyzed for factors such as age, sex, age when the first nasal operation was performed, number of years after the first nasal operation, clinical symp¬ toms, surgical findings, and change in visual acuity. At the same time, the developmental mechanism of mucoceles was investi¬ gated. There were 20 cases of postoperative mucoceles (cases with a history of operation for sinusitis) and five cases without such a history; these were considered the primary mucoceles. The site of the mucocele was in the sphenoid sinus (Fig 1) in nine cases, the posterior ethmoid sinus in five cases, the posterior ethmoid sinus through the sphenoid sinus (Figs 2 and 3) in eight cases, and the anterior ethmoid sinus through the posterior eth¬ moid sinus (Fig 4) in three cases.
Age and Sex The age of the 25 subjects (15 men and 10 women) ranged from 11 to 69 years (mean age, 47.8 years). Patients with mucoceles postoperatively ranged in age from 30 to 69 years (mean age, 46.0 years). Cases of mucoceles postoperatively included a larger number of men (14) than women (six); in Japan, the incidence of paranasal sinus operation is generally higher in men than it is in women. However, Nugent et al1 found no difference in gender in the incidence of patients with mucoceles of the sphenoid si¬ nus, reporting a mean age of 42 years.
Operation and Years Passed After the Operation Patients with postoperative mucoceles generally underwent the first nasal operation at a young age (12 to 48 years) (mean age, 22.1 years). Ten patients underwent the first nasal operation during the second decade of life. In most cases, the first nasal operation had been performed by a transmaxillary sinus ap¬ proach, but sufficient opening of the ethmoid sinus was achieved in only a few cases. The time from the initial nasal op¬ eration to the first visit to our department was 15 years at the shortest and 45 years at the longest (mean, 23.9 years); the time from the initial operation to the first visit in 75% of cases was be¬ tween 15 and 25 years (Table 2). First Nasal
Signs and Symptoms Due to the anatomic relationship, the symptoms of this disease caused by mechanical pressure that the enlarged mucocele places on the orbit, orbital apex, optic nerve, and cranial base as well as diffusion of inflammation. Visual disturbance, therefore, is almost inevitable, and exophthalmos, double vision, head¬ ache, and ophthalmalgia also develop. Especially in cases with good pneumatization of the posterior paranasal sinuses, a decrease in visual acuity occurs early. Moreover, a report has are
Accepted
for publication May 9, 1991. From the Department of Otorhinolaryngology, The sity School of Medicine, Tokyo, Japan.
Jikei Univer-
Reprint requests to Department of Otorhinolaryngology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minatoku, Tokyo 105, Japan (Dr Moriyama).
Honda, MD
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Table 1.—Clinical Data of Patients With Duration From
Initial
Age, y/ Sex
a
Surgery Location Ago of Cyst
Years
Onset to
Mode of
Operation, wk
Onset
Mucocele of the Ethmoid
Change in Visual Acuity, min of Arc; Before, After
or
Sphenoid Sinus*
Other
0
Symptoms
mo
CD
PE
5
SD
FC (30 cm) 0.2 0 0.02
17
S
3
SD
HM HM
Pain in eye
52/M
38
4
HM HM
DV, exophthalmos,
69/M
45
PE, S PE, S
CD
4
GD
0.1 0.4
36/M
18
PE
8
GD
0.1 1.0
30/F 40/F
15
5
GD
0.06 1.2
21
PE, S PE, S
3
GD
0.01 1.0
42/M 41/F
25
PE, S
1
SD
0 0
25
PE
1 d
0.03 0.9
62/M
36
SD SD
36/M 41/F
20
S
17
PE
46/M
18
39/M
5
(stepwise)
52/M
20
52/M
20
44/M
27
PE
3
SD
0 0
52/M
30
S
2
GD
0.7 1.2
37/F
25
PE,
mo
GD
44/M
25
S
mo
SD
0 0
S
63/F
15
S
41/M
21
AE, PE
3d mo
GD
3
mo
CD
2 1
+
in eye
+ +
headache
+
+
Headache, pain
in eye
+ +
Pain in eye
+ +
Nasal root
pain
(stepwise)
0.5 1.0
Exophthalmos
0.01 0.01
Headache Nasal root pain Headache
LS 0.02
SD
0.3 1.0
mo
GD
0.3 1.0 0 0
6d 3
"Heavy" head Headache, pain
0 0
PE, S AE, PE PE, S
6
Nerve
Headache
2
SD
0
Exposure of
Optic
+ + +
+
Pain in eye
+
+
Pain in eye,
exophthalmos
67/F
S
3
SD
68/F
S
3y
GD
11/M
s
2
GD
(stepwise)
+
"Heavy" head
0.2 0.2
+
Headache
L:0.03, 1.2; R:0.8 1.2 0.3 0.6
DV, paralysis of sixth nerve 0.5 1.0 GD 10 d DV, exophthalmos AE, PE 61/F *AE indicates anterior ethmoid sinus; PE, posterior ethmoid sinus; S, sphenoid sinus; SD, sudden; GD, gradually; HM, hand movement; DV, double vision; FC, finger count; plus sign, optic nerve exposed; and minus sign optic nerve not exposed. s
68/F
1
CD
mo
,
Table 2.—Time From Initial Sinus
Age of Patient,
y
Surgery to First Visit No. of Cases
15-20
9
21-25
6
26-30
2
31+
3
been published showing that a broad area of the cranial base was lost due to expansion of the mucocele, and the mucocele extended intracranially and caused brain necrosis.2 Visual Disturbance.—The nature of the visual disturbance dif¬ fered among patients; some had severe disturbances, such as loss of eyesight, loss of the sense of light, and loss of recognition of move¬ ment of an object, while others had a mild degree of lowering of visual acuity (Table 1). The lowering of visual acuity occurred grad¬ ually in 12 patients, gradually, but stepwise, in three patients, and suddenly in 10 patients. The prognosis of visual disturbance is thought to be dependent on visual acuity preoperatively and the time from onset of the disease to the operation. In general, recovery is quite difficult in patients who presented with severe preopera¬ tive disturbances, such as blindness and loss of the sense of light and recognition of an object's movement. The prognosis in
relation to visual acuity is poor. Lundgren and Olin3 also stated that the prognosis is poor in patients who have already lost their eyesight before undergoing the operation. Relationship With the Mode of Onset of the Disease.—The severity of the visual disturbance is strong and the prognosis poor in cases of sudden onset. In patients in whom the distur¬ bance is moderate or mild and the onset of the disease is grad¬ ual, the recovery of visual acuity depends on the time from on¬ set of the disease to the operation. Improvement, therefore, is poor in patients who underwent an operation 1 to 2 months af¬ ter the onset of the disease. Nevertheless, even in patients with severe impairments such as blindness, recovery is possible if they undergo surgery as soon as possible after the appearance of the symptom, eg, within 24 hours. As a matter of course, usually no recovery can be expected if the eyeground findings include atrophy of the optic disc. McCarthy and Frenkel4 found that visual acuity lowered somewhat in 46 (64%) of 72 patients with sphenoid sinus mucoceles. These authors stated that the cause was pressure on the optic nerve and/or central artery and that no improvement could be achieved in more than half of pa¬ tients, even by means of an operation. Pain.—Nerves, eg, the trigeminal nerve, are stimulated by events such as inflammation of the paranasal sinus mucosa, change in paranasal sinus pressure, and contact of the nasal cavity mucosa, in turn causing the following symptoms: head¬ ache, ophthalmalgia, a "heavy" head, and nasal root pain. In
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3.—Axial computed tomographic scan of a 42-year-old man mucocele of the posterior ethmoid sinus through the sphenoid sinus (M) with destruction of bone around optic canal.
Fig
showing a
Fig 1. with
—
an
Coronal computed tomographic scan of an 11-year-old boy extensive sphenoidal sinus mucocele (M).
Fig 4.—Axial computed tomographic scan of a 52-year-old man with anterior through posterior ethmoid sinus mucocele (M).
an
RESULTS
Fig 2. —Coronal computed tomographic scan of a 52-year-old man showing a posterior ethmoid sinus mucocele (star) with bony de¬ struction of the
top of the sinus (arrow).
many cases, destruction of the anterior cranial base is seen. If the anterior cranial base is extensively lost, thereby widely exposing the dura mater, pain develops as the dura mater stretches due to expansion of the mucocele. In our study, pain, including headache and ophthalmalgia, was experienced by 16 (64%) of 25 patients. Nugent et al1 stated that pain was a common symptom in patients with a sphenoid mucocele; they reported pain in 71% of their patients. McCarthy and Frenkel4 also reported that pa¬ tients with sphenoid mucoceles had a high rate of pain (73%). Others.—Lundgren and Olin3 reported that a posterior paranasal sinus mucocele led to orbital apex syndrome, causing pa¬ ralysis of the oculomotor nerve and/or abducent nerve. Nugent et al1 also reported that paranasal sinus mucoceles cause a high rate of paralysis of the oculomotor nerve and/or abducent nerve. In our study, although paralysis of the abducent nerve was seen in one patient, the double vision reported by three patients was not due to paralysis of the nerve but, rather, was caused by ex¬ ophthalmos due to pressure from the mucocele.
Surgical Findings In our cases of mucoceles postoperatively, the develop¬ ment of the posterior paranasal sinus was generally good. the sphe¬ Especially in cases with good pneumatization ofthe noid sinus, the optic canal had projected inside sinus, and the bone wall of the optic canal was thin and had been resorbed, thereby exposing the optic nerve in various shapes (Figs 5 through 9). However, the optic nerve could
confirmed in the mucocele in four cases. The inter¬ nal carotid artery was exposed in one case (Fig 5). The an¬ terior wall of most mucoceles was thin and able to be readily excised. In some cases, nevertheless, the bone of the anterior wall had proliferated and became very thick, in spite of the fact that the posterior and superior walls of the mucocele had been absorbed, causing exposure of the optic nerve and dura mater. In addition, we treated pa¬ tients with two or three mucoceles. Therefore, a preoper¬ ative computed tomographic scan is important. not be
Treatment
absolutely indicated for a mucocele Surgical of the paranasal sinus. Opening the mucocele (with suffi¬ cient removal of its anterior and inferior walls) by an endo¬ nasal approach is therapeutic and can prevent recurrence in treatment is
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Fig 5. seen
The optic nerve (arrow) and carotid artery (star) can be in the sphenoid sinus mucocele of a 52-year-old man.
—
Fig 6. The optic nerve (arrow) is exposed in the mucocele of a 67-year-old blind woman.
sphenoid
—
Fig S. —Endoscopie view of exposed optic nerve (arrow).
a
62-year-old
man
with
an
Fig 9. —The optic nerve (arrow), lamina papyracea (asterisk), and dura mater (star) can be seen in the mucocele of a 40year-old woman who is recovering.
gion can be accurately identified, thereby enabling the sur¬ geon to perform the operation safely. In the case of a sphe¬
noid sinus mucocele, it is possible to open the anterior wall wide by using an via the olfactory cleavage as well as the conventional approach via the sphenoid sinus. When the visual field is restricted due to curvature of the nasal sep¬ tum, the most effective method is to correct the nasal septum before performing surgery on the mucocele.
approach
Fig 7. —Endoscopie view of a 41-year-old man in recovery with exposed optic nerve (arrow), lamina papyracea (aster¬
isk),
and dura mater (star).
all cases. Endonasal surgery places patients under minimal stress and can be performed on an outpatient basis. The en¬ donasal approach is an excellent method, allowing the sur¬ geon to clearly observe aspects of the visual field, ie, the optic canal and internal carotid artery. If the sinuses are carefully observed with an endoscope, the optic nerve and durai re-
Developmental Mechanism of Postoperative Mucocele In general, a postoperative mucocele develops 15 or more years after surgery of the paranasal sinus. This comes about due to postoperative cicatricial stenosis and/or infections and gradual changes in the surgical wound.5 Although the changes in the surgical wound after a paranasal sinus oper¬ ation differ as a function of the preoperative severity of the lesion and the surgical method employed (an ethmoid sinus incompletely treated [untreated lesions and ground lamella] undergoes granulation or fibrosis due to repeated local in¬ fections), an obstructive lesion eventually forms, even though the procedure may temporarily heal the sinus. Even in sinuses where sufficient cavitation has been
achieved,
a
closed cavity may be formed due to changes such as adhe¬ sion occurring over a long period of time after the surgery. Unresected ground lamellae, especially the ground lamellae of the middle turbinate, cause considerable problems. When
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the posterior ethmoid sinus is transmaxillarily treated with¬ out an endonasal approach, the outside of the ground lamella of the middle turbinate is opened while its inside re¬ mains insufficiently resected. If the middle turbinate devi¬ ates laterally, the excretion channel in the posterior ethmoid sinus becomes narrow, increasing the possibility of obstruc¬ tive lesions due to adhesions and/or infections. Conversely, isolation of the posterior ethmoid sinus can be prevented by sufficiently removing the ground lamella of the middle tur¬ In endonasal surgery, it is important to binate remove the ground lamella sufficiently. In one case, al¬ though the sphenoid sinus was opened as much as possible, within 1 year after the operation a septal wall was formed at the site of the original anterior wall of the sphenoid sinus, leaving only a narrow communicating channel. In this case, the morphologic appearance of the channel has remained ba¬ sically unchanged for over 5 years. In light of the abovementioned case, a predisposition to development of cicatri¬ cial stenosis and/or septal wall formation could be a factor in the development of a mucocele. Therefore, for prevention of a mucocele in the paranasal sinus, it is necessary to perform surgery to sufficiently excise the ground lamella and lamellae of the ethmoid sinus. It is also important for a long follow-up to account for changes in the surgical wound after an oper¬ ation for sinusitis.
endonasally.
COMMENT
general, it has been surmised that visual distur¬ bances due to a mucocele develop via one of two mech¬ anisms. In the first mechanism, the bone wall of the optic canal is absorbed as the mucocele expands and the optic nerve comes under direct pressure from the mucocele, In
ischemia and/or venous congestion. In the second mechanism, inflammation due to infection in the mucocele spreads via a region with bone loss or bone fissure and across the dura mater to the optic nerve, causing edema and/or a circulatory disorder. The ana¬ tomic uniqueness of the optic nerve is also thought to be involved in the development of visual disturbances. Be¬ cause vascular distribution to the optic nerve in the optic canal is less dense than it is in other regions,6 the optic nerve is thought to be readily impaired. Igai7 has written that, if the inflammation spreads to deeper regions of the brain, arachnoiditis is caused in the region of the optic chiasm and cerebrospinal fluid circulation is disturbed, worsening the visual disturbance. Igai7 has also written that it is possible to recover visual acuity by opening the region of the optic chiasm. The complication of arach¬ noiditis is generally accompanied by severe headache and fever and, occasionally, problems such as paralysis of the oculomotor nerve. Accordingly, if these signs or symp¬ toms are noted, arachnoiditis should be suspected. In this study, the optic nerve was not exposed in the mucocele in four cases. In these cases, we speculate that the cause of the decrease in visual acuity was a circulatory disorder due to twisting of the optic nerve in the orbit in response to pressure from the mucocele. We have also encountered patients who did not experience any abnor¬ malities of visual acuity or the visual field even though the optic canal had been lost, thereby extensively exposing the optic nerve in the mucocele. Therefore, it is surmised that relationships such as the thickness of the dura mater and the pattern of vascular distribution are also delicately related to visual disturbances. The mode and mechanism of the development of visual
thereby causing
disturbances are thought to be as follows: cases that show gradual development of decreased visual acuity are caused by circulatory disorders due to pressure by the mucocele; cases that show rapid loss of visual acuity are caused by the spread of infection and/or inflammation from the mucocele to the optic nerve. If mucoceles of the posterior paranasal sinuses are di¬ agnosed and operated on in the early stage of the disease, improvement in visual acuity is possible. However, many
patients experience only ophthalmologic symptoms; in this study, all patients visited ophthalmologists first. Therefore, a good understanding of this disease by oph¬
thalmologists, rather than by otorhinolaryngologists, is most important for early diagnosis, and the outcome of this disease is largely dependent on such diagnosis. CONCLUSION From 1980 though 1990, we surgically treated 25 cases of mucoceles of the posterior ethmoid sinus and/or sphenoid sinus accompanied by visual disturbances. These cases were reviewed and the following conclusions drawn. 1. There were 20 cases of postoperative mucoceles and five cases of primary mucoceles (mean age, 47.8
years).
2. Patients with mucoceles
postoperatively had un¬ the initial nasal between 15 and 30 years surgery dergone of age, and the mucocele developed postoperatively 15 to 25 years after the initial surgery. 3. The clinical manifestation of mucoceles includes headache, ophthalmalgia, double vision, and exophthal¬ mos in addition to a decrease in visual acuity. 4. Visual disturbances occur due to circulatory dis¬ orders caused by mechanical pressure on the optic nerve in the mucocele and/or the spread of inflammation to in¬ volve the optic nerve. 5. The degree of improvement in visual acuity after the operation depends on the visual acuity before the op¬ eration, the mode of development of the mucocele, and the time from onset of the disease until the operation. 6. Opening the mucocele by an endonasal approach using an endoscope is recommended as the radical form of therapy. 7. Postoperative mucoceles can be prevented by per¬ forming the first nasal operation so that the ground lamella and lamellae in the ethmoid sinus are completely resected. 1.
Nugent GR, Sprinkle
References P, Bloor BM.
Sphenoid
sinus
muco-
celes. J Neurosurg. 1970;32:443-451. 2. Close LG, O'Conner WE. Sphenoethmoidal mucoceles with intracranial extension. Otolaryngol Head Neck Surg.
1983;91:350-357. 3. Lundgren A, Olin T. Muco-pyocele of sphenoidal sinus or
posterior ethmoidal cells with special reference to apex orbital syndrome. Acta Otolaryngol. 1961;53:61-79. 4. McCarthy WL, Frenkel M. Visual loss as the only symptom of sphenoid sinus mucocele. Am J Ophthalmol. 1972;74:1134-1140. 5. Ashikawa R, Kasahara Y, Shigeta Y, et al. Exophthalmos due to postoperative paranasal sinus mucocele. ORL (Tokyo). 1972;15:671-682. 6. Matsuzaki H, Kitahara K, Horiuchi T,
et al. The study on the intracanal portion of the optic nerve: its morphology and function. Acta Soc Ophthalmol Jpn. 1985;89:132-161. 7. Igai J. Rhinogenous retrobulbar neuritis: pathogenetic problems and case reports. Jpn Rev Clin Ophthalmol. structure of the
1982;76:1345-1355.
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Moriyama, MD;
Hirohiko Hesaka, MD; Toshiro Tachibana, MD; Yoshio
the period from 1980 through 1989, we treated 25 (20 postoperative and five primary) cases of mucoceles of the posterior ethmoidal sinus and/or sphenoidal sinus accompanied by visual disturbances. The postoperative mucocele developed 15 to 25 years after initial surgery. Manifesta-
\s=b\ In
tions of mucoceles include headache, ophthalmalgia, double vision, and exophthalmos in addition to a decrease in visual acuity. The degree of improvement in visual acuity after an operation depends on visual acuity before the operation, the mode of development of the mucocele, and the time from onset of the disease until surgery. Opening the mucocele by an endonasal approach using an endoscope is recommended as the radical form of therapy. (Arch Otolaryngol Head Neck Surg. 1992;118:142-146) the
of mucoceles of posterior ethmoid The incidence low. Once they develop, sphenoid disturbances, of and
sinuses is
oc¬ impairment the eye, especially visual curs as the major symptom in many cases. It is especially important for this disease to be diagnosed and surgically treated as soon as possible. In general, many patients with mucoceles of the posterior sinuses show no nasal symp¬ toms and first visit a physician only when they have sub¬ of jective ophthalmologic symptoms. Thus, the diagnosis the
this disease tends to be
delayed. However, due to
re¬
diagnosis and the common use of to computed tomographic scans, it has become possibleeth¬ establish a diagnosis of mucoceles of the posterior moid and sphenoid sinuses early on. Furthermore, as a result of recent advances in endoscopie technology, it has become possible to perform endonasal treatment safely and correctly. It has also become possible to accurately observe the optic canal in the mucocele; we can, therefore, expect marked improvement in relief of symptoms by surgically opening the mucocele in the early stage of the cent
progress in image
disease. Nevertheless, even with surgery, the disease to a stage where no improvement can be achieved in the patient's visual acuity. The incidence of this disease is much higher in patients who have under¬ gone surgery on the paranasal sinus than it is in patients who have not. In other words, postoperatively muco¬ celes are found at a higher rate than they are primarily. Since 1980, we performed surgery on a mucocele of the posterior ethmoid or sphenoid sinuses in 25 patients who worsens
presented with visual disturbances as the primary symp¬ tom. These cases are presented and analyzed below. SUBJECTS AND METHODS
Subjects
The subjects of this study were 25 patients with a mucocele of the posterior ethmoid or sphenoid sinuses accompanied by vi¬ sual disturbances who underwent an operation between 1980 and 1989 (Table 1). These cases were analyzed for factors such as age, sex, age when the first nasal operation was performed, number of years after the first nasal operation, clinical symp¬ toms, surgical findings, and change in visual acuity. At the same time, the developmental mechanism of mucoceles was investi¬ gated. There were 20 cases of postoperative mucoceles (cases with a history of operation for sinusitis) and five cases without such a history; these were considered the primary mucoceles. The site of the mucocele was in the sphenoid sinus (Fig 1) in nine cases, the posterior ethmoid sinus in five cases, the posterior ethmoid sinus through the sphenoid sinus (Figs 2 and 3) in eight cases, and the anterior ethmoid sinus through the posterior eth¬ moid sinus (Fig 4) in three cases.
Age and Sex The age of the 25 subjects (15 men and 10 women) ranged from 11 to 69 years (mean age, 47.8 years). Patients with mucoceles postoperatively ranged in age from 30 to 69 years (mean age, 46.0 years). Cases of mucoceles postoperatively included a larger number of men (14) than women (six); in Japan, the incidence of paranasal sinus operation is generally higher in men than it is in women. However, Nugent et al1 found no difference in gender in the incidence of patients with mucoceles of the sphenoid si¬ nus, reporting a mean age of 42 years.
Operation and Years Passed After the Operation Patients with postoperative mucoceles generally underwent the first nasal operation at a young age (12 to 48 years) (mean age, 22.1 years). Ten patients underwent the first nasal operation during the second decade of life. In most cases, the first nasal operation had been performed by a transmaxillary sinus ap¬ proach, but sufficient opening of the ethmoid sinus was achieved in only a few cases. The time from the initial nasal op¬ eration to the first visit to our department was 15 years at the shortest and 45 years at the longest (mean, 23.9 years); the time from the initial operation to the first visit in 75% of cases was be¬ tween 15 and 25 years (Table 2). First Nasal
Signs and Symptoms Due to the anatomic relationship, the symptoms of this disease caused by mechanical pressure that the enlarged mucocele places on the orbit, orbital apex, optic nerve, and cranial base as well as diffusion of inflammation. Visual disturbance, therefore, is almost inevitable, and exophthalmos, double vision, head¬ ache, and ophthalmalgia also develop. Especially in cases with good pneumatization of the posterior paranasal sinuses, a decrease in visual acuity occurs early. Moreover, a report has are
Accepted
for publication May 9, 1991. From the Department of Otorhinolaryngology, The sity School of Medicine, Tokyo, Japan.
Jikei Univer-
Reprint requests to Department of Otorhinolaryngology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minatoku, Tokyo 105, Japan (Dr Moriyama).
Honda, MD
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Table 1.—Clinical Data of Patients With Duration From
Initial
Age, y/ Sex
a
Surgery Location Ago of Cyst
Years
Onset to
Mode of
Operation, wk
Onset
Mucocele of the Ethmoid
Change in Visual Acuity, min of Arc; Before, After
or
Sphenoid Sinus*
Other
0
Symptoms
mo
CD
PE
5
SD
FC (30 cm) 0.2 0 0.02
17
S
3
SD
HM HM
Pain in eye
52/M
38
4
HM HM
DV, exophthalmos,
69/M
45
PE, S PE, S
CD
4
GD
0.1 0.4
36/M
18
PE
8
GD
0.1 1.0
30/F 40/F
15
5
GD
0.06 1.2
21
PE, S PE, S
3
GD
0.01 1.0
42/M 41/F
25
PE, S
1
SD
0 0
25
PE
1 d
0.03 0.9
62/M
36
SD SD
36/M 41/F
20
S
17
PE
46/M
18
39/M
5
(stepwise)
52/M
20
52/M
20
44/M
27
PE
3
SD
0 0
52/M
30
S
2
GD
0.7 1.2
37/F
25
PE,
mo
GD
44/M
25
S
mo
SD
0 0
S
63/F
15
S
41/M
21
AE, PE
3d mo
GD
3
mo
CD
2 1
+
in eye
+ +
headache
+
+
Headache, pain
in eye
+ +
Pain in eye
+ +
Nasal root
pain
(stepwise)
0.5 1.0
Exophthalmos
0.01 0.01
Headache Nasal root pain Headache
LS 0.02
SD
0.3 1.0
mo
GD
0.3 1.0 0 0
6d 3
"Heavy" head Headache, pain
0 0
PE, S AE, PE PE, S
6
Nerve
Headache
2
SD
0
Exposure of
Optic
+ + +
+
Pain in eye
+
+
Pain in eye,
exophthalmos
67/F
S
3
SD
68/F
S
3y
GD
11/M
s
2
GD
(stepwise)
+
"Heavy" head
0.2 0.2
+
Headache
L:0.03, 1.2; R:0.8 1.2 0.3 0.6
DV, paralysis of sixth nerve 0.5 1.0 GD 10 d DV, exophthalmos AE, PE 61/F *AE indicates anterior ethmoid sinus; PE, posterior ethmoid sinus; S, sphenoid sinus; SD, sudden; GD, gradually; HM, hand movement; DV, double vision; FC, finger count; plus sign, optic nerve exposed; and minus sign optic nerve not exposed. s
68/F
1
CD
mo
,
Table 2.—Time From Initial Sinus
Age of Patient,
y
Surgery to First Visit No. of Cases
15-20
9
21-25
6
26-30
2
31+
3
been published showing that a broad area of the cranial base was lost due to expansion of the mucocele, and the mucocele extended intracranially and caused brain necrosis.2 Visual Disturbance.—The nature of the visual disturbance dif¬ fered among patients; some had severe disturbances, such as loss of eyesight, loss of the sense of light, and loss of recognition of move¬ ment of an object, while others had a mild degree of lowering of visual acuity (Table 1). The lowering of visual acuity occurred grad¬ ually in 12 patients, gradually, but stepwise, in three patients, and suddenly in 10 patients. The prognosis of visual disturbance is thought to be dependent on visual acuity preoperatively and the time from onset of the disease to the operation. In general, recovery is quite difficult in patients who presented with severe preopera¬ tive disturbances, such as blindness and loss of the sense of light and recognition of an object's movement. The prognosis in
relation to visual acuity is poor. Lundgren and Olin3 also stated that the prognosis is poor in patients who have already lost their eyesight before undergoing the operation. Relationship With the Mode of Onset of the Disease.—The severity of the visual disturbance is strong and the prognosis poor in cases of sudden onset. In patients in whom the distur¬ bance is moderate or mild and the onset of the disease is grad¬ ual, the recovery of visual acuity depends on the time from on¬ set of the disease to the operation. Improvement, therefore, is poor in patients who underwent an operation 1 to 2 months af¬ ter the onset of the disease. Nevertheless, even in patients with severe impairments such as blindness, recovery is possible if they undergo surgery as soon as possible after the appearance of the symptom, eg, within 24 hours. As a matter of course, usually no recovery can be expected if the eyeground findings include atrophy of the optic disc. McCarthy and Frenkel4 found that visual acuity lowered somewhat in 46 (64%) of 72 patients with sphenoid sinus mucoceles. These authors stated that the cause was pressure on the optic nerve and/or central artery and that no improvement could be achieved in more than half of pa¬ tients, even by means of an operation. Pain.—Nerves, eg, the trigeminal nerve, are stimulated by events such as inflammation of the paranasal sinus mucosa, change in paranasal sinus pressure, and contact of the nasal cavity mucosa, in turn causing the following symptoms: head¬ ache, ophthalmalgia, a "heavy" head, and nasal root pain. In
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3.—Axial computed tomographic scan of a 42-year-old man mucocele of the posterior ethmoid sinus through the sphenoid sinus (M) with destruction of bone around optic canal.
Fig
showing a
Fig 1. with
—
an
Coronal computed tomographic scan of an 11-year-old boy extensive sphenoidal sinus mucocele (M).
Fig 4.—Axial computed tomographic scan of a 52-year-old man with anterior through posterior ethmoid sinus mucocele (M).
an
RESULTS
Fig 2. —Coronal computed tomographic scan of a 52-year-old man showing a posterior ethmoid sinus mucocele (star) with bony de¬ struction of the
top of the sinus (arrow).
many cases, destruction of the anterior cranial base is seen. If the anterior cranial base is extensively lost, thereby widely exposing the dura mater, pain develops as the dura mater stretches due to expansion of the mucocele. In our study, pain, including headache and ophthalmalgia, was experienced by 16 (64%) of 25 patients. Nugent et al1 stated that pain was a common symptom in patients with a sphenoid mucocele; they reported pain in 71% of their patients. McCarthy and Frenkel4 also reported that pa¬ tients with sphenoid mucoceles had a high rate of pain (73%). Others.—Lundgren and Olin3 reported that a posterior paranasal sinus mucocele led to orbital apex syndrome, causing pa¬ ralysis of the oculomotor nerve and/or abducent nerve. Nugent et al1 also reported that paranasal sinus mucoceles cause a high rate of paralysis of the oculomotor nerve and/or abducent nerve. In our study, although paralysis of the abducent nerve was seen in one patient, the double vision reported by three patients was not due to paralysis of the nerve but, rather, was caused by ex¬ ophthalmos due to pressure from the mucocele.
Surgical Findings In our cases of mucoceles postoperatively, the develop¬ ment of the posterior paranasal sinus was generally good. the sphe¬ Especially in cases with good pneumatization ofthe noid sinus, the optic canal had projected inside sinus, and the bone wall of the optic canal was thin and had been resorbed, thereby exposing the optic nerve in various shapes (Figs 5 through 9). However, the optic nerve could
confirmed in the mucocele in four cases. The inter¬ nal carotid artery was exposed in one case (Fig 5). The an¬ terior wall of most mucoceles was thin and able to be readily excised. In some cases, nevertheless, the bone of the anterior wall had proliferated and became very thick, in spite of the fact that the posterior and superior walls of the mucocele had been absorbed, causing exposure of the optic nerve and dura mater. In addition, we treated pa¬ tients with two or three mucoceles. Therefore, a preoper¬ ative computed tomographic scan is important. not be
Treatment
absolutely indicated for a mucocele Surgical of the paranasal sinus. Opening the mucocele (with suffi¬ cient removal of its anterior and inferior walls) by an endo¬ nasal approach is therapeutic and can prevent recurrence in treatment is
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Fig 5. seen
The optic nerve (arrow) and carotid artery (star) can be in the sphenoid sinus mucocele of a 52-year-old man.
—
Fig 6. The optic nerve (arrow) is exposed in the mucocele of a 67-year-old blind woman.
sphenoid
—
Fig S. —Endoscopie view of exposed optic nerve (arrow).
a
62-year-old
man
with
an
Fig 9. —The optic nerve (arrow), lamina papyracea (asterisk), and dura mater (star) can be seen in the mucocele of a 40year-old woman who is recovering.
gion can be accurately identified, thereby enabling the sur¬ geon to perform the operation safely. In the case of a sphe¬
noid sinus mucocele, it is possible to open the anterior wall wide by using an via the olfactory cleavage as well as the conventional approach via the sphenoid sinus. When the visual field is restricted due to curvature of the nasal sep¬ tum, the most effective method is to correct the nasal septum before performing surgery on the mucocele.
approach
Fig 7. —Endoscopie view of a 41-year-old man in recovery with exposed optic nerve (arrow), lamina papyracea (aster¬
isk),
and dura mater (star).
all cases. Endonasal surgery places patients under minimal stress and can be performed on an outpatient basis. The en¬ donasal approach is an excellent method, allowing the sur¬ geon to clearly observe aspects of the visual field, ie, the optic canal and internal carotid artery. If the sinuses are carefully observed with an endoscope, the optic nerve and durai re-
Developmental Mechanism of Postoperative Mucocele In general, a postoperative mucocele develops 15 or more years after surgery of the paranasal sinus. This comes about due to postoperative cicatricial stenosis and/or infections and gradual changes in the surgical wound.5 Although the changes in the surgical wound after a paranasal sinus oper¬ ation differ as a function of the preoperative severity of the lesion and the surgical method employed (an ethmoid sinus incompletely treated [untreated lesions and ground lamella] undergoes granulation or fibrosis due to repeated local in¬ fections), an obstructive lesion eventually forms, even though the procedure may temporarily heal the sinus. Even in sinuses where sufficient cavitation has been
achieved,
a
closed cavity may be formed due to changes such as adhe¬ sion occurring over a long period of time after the surgery. Unresected ground lamellae, especially the ground lamellae of the middle turbinate, cause considerable problems. When
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the posterior ethmoid sinus is transmaxillarily treated with¬ out an endonasal approach, the outside of the ground lamella of the middle turbinate is opened while its inside re¬ mains insufficiently resected. If the middle turbinate devi¬ ates laterally, the excretion channel in the posterior ethmoid sinus becomes narrow, increasing the possibility of obstruc¬ tive lesions due to adhesions and/or infections. Conversely, isolation of the posterior ethmoid sinus can be prevented by sufficiently removing the ground lamella of the middle tur¬ In endonasal surgery, it is important to binate remove the ground lamella sufficiently. In one case, al¬ though the sphenoid sinus was opened as much as possible, within 1 year after the operation a septal wall was formed at the site of the original anterior wall of the sphenoid sinus, leaving only a narrow communicating channel. In this case, the morphologic appearance of the channel has remained ba¬ sically unchanged for over 5 years. In light of the abovementioned case, a predisposition to development of cicatri¬ cial stenosis and/or septal wall formation could be a factor in the development of a mucocele. Therefore, for prevention of a mucocele in the paranasal sinus, it is necessary to perform surgery to sufficiently excise the ground lamella and lamellae of the ethmoid sinus. It is also important for a long follow-up to account for changes in the surgical wound after an oper¬ ation for sinusitis.
endonasally.
COMMENT
general, it has been surmised that visual distur¬ bances due to a mucocele develop via one of two mech¬ anisms. In the first mechanism, the bone wall of the optic canal is absorbed as the mucocele expands and the optic nerve comes under direct pressure from the mucocele, In
ischemia and/or venous congestion. In the second mechanism, inflammation due to infection in the mucocele spreads via a region with bone loss or bone fissure and across the dura mater to the optic nerve, causing edema and/or a circulatory disorder. The ana¬ tomic uniqueness of the optic nerve is also thought to be involved in the development of visual disturbances. Be¬ cause vascular distribution to the optic nerve in the optic canal is less dense than it is in other regions,6 the optic nerve is thought to be readily impaired. Igai7 has written that, if the inflammation spreads to deeper regions of the brain, arachnoiditis is caused in the region of the optic chiasm and cerebrospinal fluid circulation is disturbed, worsening the visual disturbance. Igai7 has also written that it is possible to recover visual acuity by opening the region of the optic chiasm. The complication of arach¬ noiditis is generally accompanied by severe headache and fever and, occasionally, problems such as paralysis of the oculomotor nerve. Accordingly, if these signs or symp¬ toms are noted, arachnoiditis should be suspected. In this study, the optic nerve was not exposed in the mucocele in four cases. In these cases, we speculate that the cause of the decrease in visual acuity was a circulatory disorder due to twisting of the optic nerve in the orbit in response to pressure from the mucocele. We have also encountered patients who did not experience any abnor¬ malities of visual acuity or the visual field even though the optic canal had been lost, thereby extensively exposing the optic nerve in the mucocele. Therefore, it is surmised that relationships such as the thickness of the dura mater and the pattern of vascular distribution are also delicately related to visual disturbances. The mode and mechanism of the development of visual
thereby causing
disturbances are thought to be as follows: cases that show gradual development of decreased visual acuity are caused by circulatory disorders due to pressure by the mucocele; cases that show rapid loss of visual acuity are caused by the spread of infection and/or inflammation from the mucocele to the optic nerve. If mucoceles of the posterior paranasal sinuses are di¬ agnosed and operated on in the early stage of the disease, improvement in visual acuity is possible. However, many
patients experience only ophthalmologic symptoms; in this study, all patients visited ophthalmologists first. Therefore, a good understanding of this disease by oph¬
thalmologists, rather than by otorhinolaryngologists, is most important for early diagnosis, and the outcome of this disease is largely dependent on such diagnosis. CONCLUSION From 1980 though 1990, we surgically treated 25 cases of mucoceles of the posterior ethmoid sinus and/or sphenoid sinus accompanied by visual disturbances. These cases were reviewed and the following conclusions drawn. 1. There were 20 cases of postoperative mucoceles and five cases of primary mucoceles (mean age, 47.8
years).
2. Patients with mucoceles
postoperatively had un¬ the initial nasal between 15 and 30 years surgery dergone of age, and the mucocele developed postoperatively 15 to 25 years after the initial surgery. 3. The clinical manifestation of mucoceles includes headache, ophthalmalgia, double vision, and exophthal¬ mos in addition to a decrease in visual acuity. 4. Visual disturbances occur due to circulatory dis¬ orders caused by mechanical pressure on the optic nerve in the mucocele and/or the spread of inflammation to in¬ volve the optic nerve. 5. The degree of improvement in visual acuity after the operation depends on the visual acuity before the op¬ eration, the mode of development of the mucocele, and the time from onset of the disease until the operation. 6. Opening the mucocele by an endonasal approach using an endoscope is recommended as the radical form of therapy. 7. Postoperative mucoceles can be prevented by per¬ forming the first nasal operation so that the ground lamella and lamellae in the ethmoid sinus are completely resected. 1.
Nugent GR, Sprinkle
References P, Bloor BM.
Sphenoid
sinus
muco-
celes. J Neurosurg. 1970;32:443-451. 2. Close LG, O'Conner WE. Sphenoethmoidal mucoceles with intracranial extension. Otolaryngol Head Neck Surg.
1983;91:350-357. 3. Lundgren A, Olin T. Muco-pyocele of sphenoidal sinus or
posterior ethmoidal cells with special reference to apex orbital syndrome. Acta Otolaryngol. 1961;53:61-79. 4. McCarthy WL, Frenkel M. Visual loss as the only symptom of sphenoid sinus mucocele. Am J Ophthalmol. 1972;74:1134-1140. 5. Ashikawa R, Kasahara Y, Shigeta Y, et al. Exophthalmos due to postoperative paranasal sinus mucocele. ORL (Tokyo). 1972;15:671-682. 6. Matsuzaki H, Kitahara K, Horiuchi T,
et al. The study on the intracanal portion of the optic nerve: its morphology and function. Acta Soc Ophthalmol Jpn. 1985;89:132-161. 7. Igai J. Rhinogenous retrobulbar neuritis: pathogenetic problems and case reports. Jpn Rev Clin Ophthalmol. structure of the
1982;76:1345-1355.
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