Pneumocele of the A Second Case
Maxillary Sinus
Report
Judah Zizmor, MD; Michael
Bryce, MD; Sylven L. Schaffer, MD, DDS; Arnold
M.
Noyek, MD, FRCS(C),
The term pneumocele refers to an expansile bone destructive air containing cyst-like lesion involving the sinus cavity proper, presumably due to obstruction of the major sinus ostium. It differs from pneumoceles described previously that have all been air pockets beyond a para-
struction of the major sinus ostium. The maxillary sinus is lined by nor¬ mal mucosa.
nasal air sinus due to
a
abnormal fistulous communication, rather than expansion of the sinus cavity itself. In adding this second case to the literature we believe that this rare lesion may be encountered from time to time, and should be considered when an expanded maxillary antrum Is found to contain air rather than fluid or soft tissue content. an
encountered sinus disease referred to as pneu¬ was de¬ mocele of the scribed by Noyek and Zizmor.1 It is the purpose of this paper to report a second but more extensive case. The term maxillary pneumocele re¬ fers to an expansile, air containing cyst-like lesion involving the max¬ illary antrum. Its walls have been ex¬ panded and thinned presumably by long-term air trapping due to ob-
Anewly entity, maxillary sinus,
REPORT OF A CASE A 13-year-old girl was seen initially with chief complaint of facial swelling on the right of approximately three months dura¬ tion. The mother's initial observation was that "more of the white of the eye" was visible on upward gaze. The patient was seen previously else¬ where, and the mother was told that a na¬ sal mass on the right was present. Intranasal biopsy results showed normal mucosa. The child has experienced a moderate degree of nasal obstruction on the right, without pain or purulent discharge. There were no antecedent dental symptoms, and the child did not experience diplopia, al¬ though a slight exophthalmos on the right was
present.
According to the mother, the child was a persistent, vigorous, and forceful nose blower. At no time did she experience cheek pain on nose blowing. She had un¬ dertaken airplane flights five years and one year prior to treatment, but at no time had she experienced sinus pressure symp¬ toms in conjunction with these airplane flights. Past history was normal. The patient born in the United States and had had neither previous facial trauma nor nasal surgery, other than a recent intranasal was
Accepted
for publication Dec 21, 1974. From Cornell University Medical Center, Manhattan Eye, Ear and Throat Hospital, and New York Hospital, Cornell University Medical Center, New York (Dr. Zizmor); the Department of Otolaryngology, Manhattan Eye, Ear and Throat Hospital (Drs. Bryce and Schaffer); and the University of Toronto and Mount Sinai and Sunnybrook Hospitals, Toronto (Dr. Noyek). Reprint requests to the Ear, Nose and Throat Associates, 99 Avenue Rd, Suite 207, Toronto M5R 2G5, Ontario, Canada (Dr. Noyek).
biopsy. Physical examination
was
essentially
within normal limits except for the pres¬ ence of a slight ocular proptosis on the right. The right cheek was larger and more prominent than the left. The right na¬ soantral wall was expanded medially toward the nasal septum. The right middle
FACS
meatus and infundibulum
parently
were
absent, ap¬
obliterated by the expanded na¬ soantral wall. The inferior turbinate re¬ tained its shape only in its anterior third; the posterior two thirds was fused in a con¬ tinuous shell-like structure with the over¬ sized middle turbinate. The nasal cavity was extremely narrow but still present. The right middle turbinate appeared dis¬ placed medially toward the nasal septum; its mucosa was thinned, but felt firm. The usual erectile tissue of the inferior margin of the middle turbinate was atrophied. No intranasal tumor mass was seen. The nasopharynx was clear. No occlusal abnor¬ malities were detected. An ophthalmologic consultation con¬ firmed the presence of a mild exophthalmos. The roentgenographic findings on con¬ ventional sinus roentgenography and an¬ teroposterior tomography are shown in Fig 1 and 2. The Waters view demonstrates an expanded hyperlucent maxillary sinus on the right. Its bony walls are thinned and expanded. The anteroposterior tomogram shows a hyperlucent and greatly expanded right maxillary antrum, and displacement and thinning of its medial, lateral, and su¬ perior bony walls. Bone destruction is sug¬ gested in the antral roof and in the na¬ soantral wall. The expanded antral lucency encroaches on the nasal septum and on the lower third of the right orbit. The ethmomaxillary angle and the alveolar pro¬ cess are greatly widened. A Caldwell-Luc procedure on the right was carried out under general anesthesia. Normal antral mucous membrane was en¬ countered. There was expansion of all sinus walls including the prelacrimai, zy¬ gomatic, and alveolar recesses. The na¬ soantral wall and the roof of the antrum were paper thin but not dehiscent. No defi-
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Fig 2.—An anteroposterior tomogram demonstrates the gener¬ alized hyperlucency of the expanded right maxillary antrum and the displacement and thinning of ¡ts medial, lateral, and superior bony walls (arrows). Bone destruction is suggested in the com¬ mon antral roof-orbital floor and in the nasoantral wall. Expanded right maxillary antrum encroaches on the nasal septum, and the lower third of the right orbit. Ethmomaxillary angle is broadened. Expanded antrum encroaches on the ethmoid labyrinth. Alveolar recess is widened, and the dental roots are well profiled by air.
Fig 1 —Waters view demonstrates an expanded hyperlucent right maxillary sinus. The sinus Is of much greater volume than the opposite antrum; its walls are thinned and expanded and an area of bone destruction is suggested in the common roof of antrum-orbital floor (arrows).
nite maxillary ostial disorder was encoun¬ tered. The sinus contained only air. A nasoantral window with a large nasal mucosal flap was formed. Part of the shell¬ like middle turbinate in its middle and an¬ terior thirds was removed along with the paper-thin adherent nasoantral wall to which it was fused. This resulted in a widely patent nasoantral window in the general area of the middle meatus. The postoperative course has been un¬ eventful.
COMMENT
The possible theories of pathogen¬ esis and the suggestion of long-term positive pressure air-trapping have been presented.1 Basically, a mecha¬ nism of long-term air-trapping is suggested, with a physiologic or path¬ ologic block occurring at the level of the natural maxillary sinus ostium. Various forms of intracranial and extracranial air cysts or pneumoceles or pneumatoceles have been described from time to time.2 3 However, all of these lesions that have involved the paranasal air sinuses have in common
the presence of
an
abnormal fistulous
communication, due mor,
trauma,
or
to infection, tu¬ surgery, between a
normal sinus cavity and an extrasinus pathologic abnormality. These cyst¬ like expansions of the sinuses have filled with air under pressure, result¬ ing from a valve mechanism, due to a loss of integrity of the lining mu¬ cosa or mucoperiosteum of the af¬ fected paranasal sinus secondary to an extrasinus disease process. These lesions are, therefore, quite different pathologically from the pneumocele described now and in a previous re¬
port.1
Clinically, this case has a more ex¬ treme example of sinus enlargement and displacement of bony walls than the case described previously.1 Our patient also had facial asymmetry and slight proptosis, and ipsilaterai nasal obstruction. These symptoms would reflect the expansion of the maxillary antrum with encroachment on surrounding structures. In both cases, a Caldwell-Luc procedure was
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/17/2015
carried out and
inspection revealed air-containing sinus lined by normal mucosa. An adequate nasoan¬ tral window was created to provide only
an
ventilation of the sinus and relief of
air-trapping.
It is now believed that substantial sinus wall displacement could be dealt with, where indicated, by surgical fracture or osteotomy with restora¬ tion of relatively normal anatomic configuration. This was not deemed necessary in the second case as diplo¬ pia had not occurred, and the facial skeleton was considered to be still
growing. References 1. Noyek AM, maxillary sinus.
Zizmor J: Pneumocele of the Arch Otolaryngol 100:155-156,
1974. 2. Dandy WE:
Pneumocephalus (intracranial pneumatocele or aerocele). Arch Surg 12:949-982, 1926. 3. Killian H:
Pneumatopathien, Neue Deutsche Chirurgie. Ferdinand Enke, Stuttgart, Germany, 1939.
Maxillary Sinus
Report
Judah Zizmor, MD; Michael
Bryce, MD; Sylven L. Schaffer, MD, DDS; Arnold
M.
Noyek, MD, FRCS(C),
The term pneumocele refers to an expansile bone destructive air containing cyst-like lesion involving the sinus cavity proper, presumably due to obstruction of the major sinus ostium. It differs from pneumoceles described previously that have all been air pockets beyond a para-
struction of the major sinus ostium. The maxillary sinus is lined by nor¬ mal mucosa.
nasal air sinus due to
a
abnormal fistulous communication, rather than expansion of the sinus cavity itself. In adding this second case to the literature we believe that this rare lesion may be encountered from time to time, and should be considered when an expanded maxillary antrum Is found to contain air rather than fluid or soft tissue content. an
encountered sinus disease referred to as pneu¬ was de¬ mocele of the scribed by Noyek and Zizmor.1 It is the purpose of this paper to report a second but more extensive case. The term maxillary pneumocele re¬ fers to an expansile, air containing cyst-like lesion involving the max¬ illary antrum. Its walls have been ex¬ panded and thinned presumably by long-term air trapping due to ob-
Anewly entity, maxillary sinus,
REPORT OF A CASE A 13-year-old girl was seen initially with chief complaint of facial swelling on the right of approximately three months dura¬ tion. The mother's initial observation was that "more of the white of the eye" was visible on upward gaze. The patient was seen previously else¬ where, and the mother was told that a na¬ sal mass on the right was present. Intranasal biopsy results showed normal mucosa. The child has experienced a moderate degree of nasal obstruction on the right, without pain or purulent discharge. There were no antecedent dental symptoms, and the child did not experience diplopia, al¬ though a slight exophthalmos on the right was
present.
According to the mother, the child was a persistent, vigorous, and forceful nose blower. At no time did she experience cheek pain on nose blowing. She had un¬ dertaken airplane flights five years and one year prior to treatment, but at no time had she experienced sinus pressure symp¬ toms in conjunction with these airplane flights. Past history was normal. The patient born in the United States and had had neither previous facial trauma nor nasal surgery, other than a recent intranasal was
Accepted
for publication Dec 21, 1974. From Cornell University Medical Center, Manhattan Eye, Ear and Throat Hospital, and New York Hospital, Cornell University Medical Center, New York (Dr. Zizmor); the Department of Otolaryngology, Manhattan Eye, Ear and Throat Hospital (Drs. Bryce and Schaffer); and the University of Toronto and Mount Sinai and Sunnybrook Hospitals, Toronto (Dr. Noyek). Reprint requests to the Ear, Nose and Throat Associates, 99 Avenue Rd, Suite 207, Toronto M5R 2G5, Ontario, Canada (Dr. Noyek).
biopsy. Physical examination
was
essentially
within normal limits except for the pres¬ ence of a slight ocular proptosis on the right. The right cheek was larger and more prominent than the left. The right na¬ soantral wall was expanded medially toward the nasal septum. The right middle
FACS
meatus and infundibulum
parently
were
absent, ap¬
obliterated by the expanded na¬ soantral wall. The inferior turbinate re¬ tained its shape only in its anterior third; the posterior two thirds was fused in a con¬ tinuous shell-like structure with the over¬ sized middle turbinate. The nasal cavity was extremely narrow but still present. The right middle turbinate appeared dis¬ placed medially toward the nasal septum; its mucosa was thinned, but felt firm. The usual erectile tissue of the inferior margin of the middle turbinate was atrophied. No intranasal tumor mass was seen. The nasopharynx was clear. No occlusal abnor¬ malities were detected. An ophthalmologic consultation con¬ firmed the presence of a mild exophthalmos. The roentgenographic findings on con¬ ventional sinus roentgenography and an¬ teroposterior tomography are shown in Fig 1 and 2. The Waters view demonstrates an expanded hyperlucent maxillary sinus on the right. Its bony walls are thinned and expanded. The anteroposterior tomogram shows a hyperlucent and greatly expanded right maxillary antrum, and displacement and thinning of its medial, lateral, and su¬ perior bony walls. Bone destruction is sug¬ gested in the antral roof and in the na¬ soantral wall. The expanded antral lucency encroaches on the nasal septum and on the lower third of the right orbit. The ethmomaxillary angle and the alveolar pro¬ cess are greatly widened. A Caldwell-Luc procedure on the right was carried out under general anesthesia. Normal antral mucous membrane was en¬ countered. There was expansion of all sinus walls including the prelacrimai, zy¬ gomatic, and alveolar recesses. The na¬ soantral wall and the roof of the antrum were paper thin but not dehiscent. No defi-
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/17/2015
Fig 2.—An anteroposterior tomogram demonstrates the gener¬ alized hyperlucency of the expanded right maxillary antrum and the displacement and thinning of ¡ts medial, lateral, and superior bony walls (arrows). Bone destruction is suggested in the com¬ mon antral roof-orbital floor and in the nasoantral wall. Expanded right maxillary antrum encroaches on the nasal septum, and the lower third of the right orbit. Ethmomaxillary angle is broadened. Expanded antrum encroaches on the ethmoid labyrinth. Alveolar recess is widened, and the dental roots are well profiled by air.
Fig 1 —Waters view demonstrates an expanded hyperlucent right maxillary sinus. The sinus Is of much greater volume than the opposite antrum; its walls are thinned and expanded and an area of bone destruction is suggested in the common roof of antrum-orbital floor (arrows).
nite maxillary ostial disorder was encoun¬ tered. The sinus contained only air. A nasoantral window with a large nasal mucosal flap was formed. Part of the shell¬ like middle turbinate in its middle and an¬ terior thirds was removed along with the paper-thin adherent nasoantral wall to which it was fused. This resulted in a widely patent nasoantral window in the general area of the middle meatus. The postoperative course has been un¬ eventful.
COMMENT
The possible theories of pathogen¬ esis and the suggestion of long-term positive pressure air-trapping have been presented.1 Basically, a mecha¬ nism of long-term air-trapping is suggested, with a physiologic or path¬ ologic block occurring at the level of the natural maxillary sinus ostium. Various forms of intracranial and extracranial air cysts or pneumoceles or pneumatoceles have been described from time to time.2 3 However, all of these lesions that have involved the paranasal air sinuses have in common
the presence of
an
abnormal fistulous
communication, due mor,
trauma,
or
to infection, tu¬ surgery, between a
normal sinus cavity and an extrasinus pathologic abnormality. These cyst¬ like expansions of the sinuses have filled with air under pressure, result¬ ing from a valve mechanism, due to a loss of integrity of the lining mu¬ cosa or mucoperiosteum of the af¬ fected paranasal sinus secondary to an extrasinus disease process. These lesions are, therefore, quite different pathologically from the pneumocele described now and in a previous re¬
port.1
Clinically, this case has a more ex¬ treme example of sinus enlargement and displacement of bony walls than the case described previously.1 Our patient also had facial asymmetry and slight proptosis, and ipsilaterai nasal obstruction. These symptoms would reflect the expansion of the maxillary antrum with encroachment on surrounding structures. In both cases, a Caldwell-Luc procedure was
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/17/2015
carried out and
inspection revealed air-containing sinus lined by normal mucosa. An adequate nasoan¬ tral window was created to provide only
an
ventilation of the sinus and relief of
air-trapping.
It is now believed that substantial sinus wall displacement could be dealt with, where indicated, by surgical fracture or osteotomy with restora¬ tion of relatively normal anatomic configuration. This was not deemed necessary in the second case as diplo¬ pia had not occurred, and the facial skeleton was considered to be still
growing. References 1. Noyek AM, maxillary sinus.
Zizmor J: Pneumocele of the Arch Otolaryngol 100:155-156,
1974. 2. Dandy WE:
Pneumocephalus (intracranial pneumatocele or aerocele). Arch Surg 12:949-982, 1926. 3. Killian H:
Pneumatopathien, Neue Deutsche Chirurgie. Ferdinand Enke, Stuttgart, Germany, 1939.
