Mucous retention cyst causing pain of the infraorbital nerve BRADFORD K. ENCE, MD, and DAVID S. PARSONS, MD, San Antonio, Texas

Mucous retention cysts are common in the maxillary sinuses and are most often asymptomatic. They are usually an incidental finding on examination of sinus or dental radiographs, where they are seen as a dome-

From the Department of Otolaryngology-Head and Neck Surgery, Wilford Hall USAF Medical Center, Lackland AFB. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force or the Department of Defense. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery. New Orleans, La.• Sept. 24-28, 1989. Received for publication Sept. 23. 1989; revision received Feb. 17. 1990; accepted Feb. 19. 1990. Reprint requests: David S. Parsons, MD, Department of Otolaryngology-Head and Neck Surgery, Wilford Hall USAF Medical Center. Lackland AFB, TX 78236·5300.

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shaped mass ansmg from the floor of the maxillary sinus. We present the case of a patient with unilateral pain in the distribution of the infraorbital nerve. Endoscopic examination revealed a large retention cyst suspended from the nerve within the maxillary sinus. After removal of the cyst, the patient had complete resolution of her symptoms. The pathophysiology and diagnosis are discussed, along with the generally accepted management of mucous retention cysts. This case is presented because of its interesting symptom, the unusual location within the sinus, and the excellent visualization obtained through the sinus endoscopes . CASE REPORT An otherwise healthy 33-year-old woman with a long history of infrequent sinusitis was referred after 6 months of persistent right maxillary sinus pain. She had previously been treated with multiple courses of antibiotics without response. Numerous sinus radiographs consistently demonstrated a

Fig. 1. waters view radiograph demonstrates right-sided, smooth, soft tissue-densi1y mass In the maxillary antrum .

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Fig. 2. Coronal computed tomographic scan demonstrates ovoid soft tissue mass in the lateral aspect of rig ht maxillary antrum.

in the superolateral aspect of the right maxillary sinus ( Fig. 2) . There was no evidence of bony erosion , and the most likely radiologic diagnosis was a benign mucous retention cyst. Examination revealed a normal nasal cavity without masses, purulence, or bleeding. Head and neck examinati on was only remarkable for mild tenderness to palpation and percussion over the anterior surface of the maxillary sinus and infraorbital foramen . Sensation in the distribution of the infraorbital nerve was intact. There was no evidence of dental disease . The patient was taken to the operating theater because of the unusual symptom of pain. Sinus endo scopes of varying angles were passed through a puncture in the canine fossa, and excellent visualization was obtained of a large, fluidfilled sac suspended from a dehiscent infraorbital nerve ( Fig. 3). By way of a Caldwell -Luc approach, the cyst was carefull y removed while preserving the nerve . The remaining contents of the maxillary sinus were entirely normal. Pathologic examination of the specimen revealed a cyst lined by pseudostratified columnar respiratory epithelium and a thin stroma of fibrovascular tissue ( Fig. 4). The patient did well after operation and has had complete resolution of her pain for the 12 months of her follow-up .

Fig. 3. Mucous retention cyst suspended from the infraorbital nerve in the right maxillary sinus. viewed through aD-degree 4 mm sinus endoscope.

DISCUSSION

smooth mass in the lateral portion of the right maxillary sinus (Fig. I). On referral to the otolaryngology department at Wilford Hall USAF Medical Center, a computed tomographic scan demonstrated the same round, soft tissue-density mass

The mucous retention cysts is a well-known entity. Almost all otolaryngologists have been confronted with a sinus radiograph demon strating the classic domeshaped mass in the maxillary sinus. These cases have been treated by the primary physician with antibiotics

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Volume 103 Number 6 December 1990

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Fig . 4. Photomicrograph demonstrates the retention cyst wall lined by normal respiratory epithelium. (Hematoxylin-eosin stain; original magnification x 400.)

to no avail. The otolaryngologist must decide what needs to be done diagnostically and therapeut ically. Paparaella' has stated that the mucous retention cyst is the most common solitary benign lesion of the maxillary sinus. The pathologic definition of the mucous retention cyst is an epithelium-lined cyst containing serous or mucinous fluid that develops because of ductal blockage of a seromucinous gland in the antral mucosa .' Some authors have proposed invagination of the mucosa into the underlying connective tissue as another mechanism for cyst formation.' Mucous retention cysts are also known as benign mucosal cysts, antral retention cysts, retention cysts of the maxillary antrum, mesothelial cysts , and mucosal antral cysts. The mucous retention cyst almost always manifests in the maxillary sinus, although it has been reported in all of the other paranasal sinuses. The etiology is not known, but it is most likely an inflammation or infection that precipitates the obstruction of the duct. These lesions are not usually expansile and do not erode the bone of the sinus . The retention cyst needs to be distinguished from the mucocele, which represents an accumulation of secretions behind a blocked ostium of a sinus and results in slow, progressive expansion of the sinus . Eventual bony erosion is common. The frontal and ethmoid sinuses are the most common sites, although about 10% have been reported in the maxillary sinus." Other important

distinctions include those between retention cysts and pseudocysts, polyps , tumors, and extrinsic masses. The pseudocyst appears much like the mucous retention cyst but seems to be an accumulation of fluid underneath the periosteal layer of the maxillary sinus . The outside layer is therefore pseudostratified columnar epithelium and the inner lining of the sac is fibrous connective tissue . Halstead' suggested that dental infections may be related to the accumulation of this fluid. Gardner argues that the most commonly seen lesion is actually the pseudocyst and not the mucous retention cyst. The cyst described here was histologically more consistent with the diagnosis of mucous retention cyst. Incidence of the benign mucous retention cyst can be estimated from large series of sinus and dental x-ray films. Incidences of 1.4% to 9.6% have been reported . Ruprecht et al." found an incidence of 2.6% on reviewing 1685 dental radiographs . Symptoms are usually absent. Occasional reports of a full sensation or of pain are scattered through the literature. Whiner? has recently proposed an association of dehiscence of the infraorbital nerve within the maxillary sinus with "atypical facial pain ." He found this dehiscence in 4% of the patients examined endoscopically; half of these patients displayed symptoms in the nerve's distribution. We do not know the mechanism of pain in our patient, whether it was from the dehiscence or from the tension and stretching the cyst caused.

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The resolution of symptoms after careful removal of the cyst supports the latter cause. Diagnosis of the mucous retention cyst is usually made with a high level of confidence from plain sinus radiographs or by computed tomographic scan. Absence of bony erosion, best demonstrated by computed tomographic scan, supports the diagnosis. Considering the benign nature of the lesion, radiographic diagnosis is probably adequate in cases that are typical without other symptoms or signs. With the advent of sinus endoscopes. visualization through an antrostomy is a simple office procedure and a very practical option. Management has been and continues to be conservative observation. Despite this watchful waiting, Gothberg et al. 8 have reported resolution in only five of 13 cases (38%), and Halstead" reports resolution in only four of 17 cases (l 0%). If diagnosis is uncertain. as when the patient atypically exhibits symptoms, exploration and either biopsy or removal are indicated. Once the lesion has been visualized endoscopically, it may be removed transnasally or through the canine fossa. In our case an initial attempt was made to remove the cyst through a trocar placed in the canine fossa using Takahashi forceps alternating with a sinus endoscope. Surgical instruments not available, such as malleable forceps, would have allowed the removal of the cyst through a middle meatus antrostomy. This would be the technique of choice today. Removal of the cyst will most likely be curative. and thus stripping of the normal sinus mucosa is not indicated.

CONCLUSION

Mucous retention cysts are common in the maxillary sinuses but rarely cause symptoms. A patient was referred with pain in the distribution of the infraorbital nerve. A cyst was found suspended from a dehiscent infraorbital nerve within the maxillary sinus. The pain was judged to be a result of tension and stretching of the nerve. Diagnosis of a mucous retention cyst is usually radiographic and treatment is usually simple. If the diagnosis is in doubt, the safest management of the condition is exploration and removal to rule out more aggressive lesions. REFERENCES

I. Paparella MM. Mucosal cyst of the maxillary sinus: diagnosis and management. Arch Otolaryngol 1963;77:650-7. 2. Miles DA. Glass BJ. Langlais RP. Cyst of the maxillary antrum. Report of an unusual case. Oral Surg Oral Med Oral Pathol 1984;57:225-9. 3. Gardner DG. Pseudocysts and retention cysts of the maxillary sinus. Oral Surg Oral Med Oral Pathol 1984;58:561-5. 4. Sorn PM. Shugar JMA. Antral mucoceles: a new look. J Cornput Assist Tomogr 1980;4:484-8. 5. Halstead CL. Mucosal cysts of the maxillary sinus: report of 75 cases. J Am Dent Assoc 1973;87:1435-41. 6. Ruprecht A, Batniji S, El-Ncweihi E. Mucous retention cyst of the maxillary sinus. Oral Surg Oral Med Oral Pathol 1986;62:72831.

7. Whittet HB. Facial pain resulting from dehiscence of the infraorbital nerve within the maxillary sinus [Abstract). OroLARYNGOL HEAD NECK SURG 1989;101:219. 8. Gothberg KA, Little JW. King DR, Bean LR. A clinical study of cysts arising from the mucosa of the maxillary sinus. Oral Surg 1976;41:52-8.

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Mucous retention cyst causing pain of the infraorbital nerve.

Mucous retention cyst causing pain of the infraorbital nerve BRADFORD K. ENCE, MD, and DAVID S. PARSONS, MD, San Antonio, Texas Mucous retention cyst...
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