Pneumocele of the Maxillary Sinus Report of
a
Case
Murray D. Morrison, MD, FRCS(C); Stanley Barry R. Maber, MD \s=b\ The first two cases of
pneumocele of maxillary sinus have been recently published.1 The expanded antrum produced a different initial complaint in each case. A third case, with yet another initial problem, middle ear effusion, is now reported. The roentgenographic and operative findings and the therapeutic effect of decompression by antrostomy would suggest that this is a specific disease entity, presumably due to a check valve obstruc-
the
tion of the sinus ostium.
(Arch Otolaryngol 102:306-307, 1976) of the maxillary sinus is a term introduced by Noyek and Zizmor1 in two recent reports of patients with this unusual condition.2 The first initially had pain in the maxillary area on ascent during an airplane flight,1 and the second had facial swelling and slight proptosis.2 The patient described in the present report had yet another initial problem, Eustachian tube obstruction and serous otitis media.
Pneumocele
REPORT OF A CASE A 45-year-old man initially sought attention in December 1974 with pain, fullness, and loss of hearing involving the left ear. These symptoms came on shortly after landing from a long distance trip in a commercial jet aircraft. Because of the persistence of his symptoms, the patient consulted a physician, who made a diagnosis of aerotitis media and inserted a tympanostomy tube. A short time later, the patient developed otorrhea, for which systemic antibiotic therapy was begun. The tube was subse-
Accepted
for publication Nov 11, 1975. From the departments of surgery (otolaryngology) and radiology, University Hospital, Saskatoon, Saskatchewan, Canada. Reprint requests to the Division of Otolaryngology, University Hospital, Saskatoon, Saskatchewan, Canada S7N 0W8 (Dr Morrison).
P.
Tchang, MD, FRCP(C);
quently removed with the reappearance of decreased hearing and fullness in this ear.
In February 1975, a silicone elastomer tube was reinserted into the left tympanic membrane. At the same time, a left antral lavage was carried out. It was impossible to irrigate this sinus due to resistance, but with insertion of a second cannula, the resistance disappeared and the returned fluid was clear. At this time, it was also noted that the left middle turbinate appeared to be abnormally large. Our initial examination disclosed the continued presence of a silicone elastomer tympanostomy tube, located posteroinferiorly. On anterior rhinoscopy, the left middle turbinate was small and displaced superiorly and medially against the septum by a mass bulging into the nose from the lateral nasal wall, just above the inferior turbinate. This mass was bony hard around its base, but very soft and cyst-like over the dome. The remainder of the otolaryngological examination results were within normal limits. Notably, there was no palpable abnormality in the superior gingival buccal sulcus, nor was there any apparent displacement of the eye. Past history revealed that the patient had a nasal septal operation performed in 1960. Plane radiograms and tomograms of the sinuses show an extremely large left maxillary sinus that is hyperlucent. The pneumatization of the left maxillary sinus is extraordinary, expanding in every direction, laterally into the zygomatic process, and inferiorly into the alveolar process (Fig 1 to 3). The medial expansion is the most striking, with encroachment on most of the left nasal cavity and widening of the left ethmomaxillary sinus angle (Fig 1 and 3). There is also erosion of a short segment of the anterior cortical margin on the inferior lateral wall (Fig 4). The patient was subsequently admitted to the hospital, and the left maxillary antrum was explored through a Caldwell\x=req-\ Luc approach. The sinus mucosa was thin
Downloaded From: http://archotol.jamanetwork.com/ by a UQ Library User on 06/21/2015
and healthy in appearance and the cavity contained air only. The sinus cavity was obviously grossly distended. A nasal antral window was fashioned, and a portion of the mucosa bulging into the nose was removed so that the nasal mass could be redisplaced toward the sinus. One month postoperatively, the patient's nose appeared normal and the obstruction was relieved. Four months later, the tympanostomy tube extruded sponta¬ neously and there has been no recurrence of the middle ear effusion. His nose remains clear.
COMMENT Pneumoceles have been described elsewhere in relation to soft tissues, and have been generally regarded as epithelial-lined cavities containing air as a result of a pathologic communica¬ tion with a source of air. Pneumocele of the maxillary sinus differs in that it represents abnormal expansion of a bony cavity that is air-containing in the normal state. Pneumocele of the maxillary sinus has previously been described, and the authors propose that the pathogenesis involves a physiologic block to rapid equilibration of intrasinus air pres¬ sure through the major sinus ostium due to some physical abnormality that produces a one-way check valve mech¬ anism. Repeated air trapping second¬ ary to such events as sneezing or autoinflation could, over a period, produce chronic distention of the sinus as the result of a net positive intra¬ sinus air pressure. This explanation seems to be plausible, and, in fact, it is difficult to conceive of any other mechanism that might account for the findings associated with this condi¬ tion. In differentiating this condition, one must first exclude the possibility that these findings represent a nor¬ mal variant. It has been established that the maxillary sinuses usually
develop symmetrically. Slight
asym¬
metry is
plasia
not uncommon, but hypomay be difficult to differen¬
tiate from
underdevelopment second¬ previous sinusitis or trauma.3·4 Asymmetry due to a slight degree of overdevelopment does occur and has ary to
as an extension of into the zygomatic or alveolar processes of the maxilla.'·7' A
been described
pneumatization
Fig 1.—Anteroposterior tomogram delineating expanded maxil¬ lary sinus, with medial expansion as well as widened ethmoidomaxillary angle well shown (upper arrows). Inferolateral extension of maxillary sinus is also delineated (lower arrows).
Fig 2.—This lateral tomogram of the maxillary sinus delineates the superior, posterior, and inferior extensions (arrows) to better advantage.
Fig 3.—Axial projection demonstrates overexpanded
Fig 4.—Waters projection, showing hyperlucent and overdevel¬ oped left maxillary sinus with bony erosion in anterior aspect of inferolateral wall (short arrow). Long arrow points to posterior aspect of inferolateral wall.
left
antrum, particularly its medial aspect (arrows).
unilateral
excessively pneumatized maxillary sinus, occurring as a normal variant, has not yet been convincingly
described in the literature." It would seem reasonable to con¬ clude that, in our case, the Eustachian tube obstruction and middle ear effu¬ sion were the result of the expanding maxillary sinus causing compression of peritubal tissues via the infratem¬ poral fossa. The roentgenographic and
maxillary
operative findings, in association with the therapeutic effect of decompres¬ sion, would all of this
entity.
seem
being
a
to argue in favor
specific disease
References Noyek AM, Zizmor J: Pneumocele of the maxillary sinus. Arch Otolaryngol 100:155-156, 1.
1974. 2. Zizmor J, Bryce M, Schaffer SL, et al: Pneumocele of the maxillary sinus: A second case
Downloaded From: http://archotol.jamanetwork.com/ by a UQ Library User on 06/21/2015
report. Arch Otolaryngol 101:387-388, 1975. 3. Yanagisawa E, Smith HW: Normal Radiographic anatomy of the paranasal sinuses. Otolaryngol Clin North Am 6:429-457, 1973. 4. Samuel E: Clinical Radiology of the Ear, Nose, and Throat. London, HK Lewis & Co, Ltd, 1952. 5. Keats TE: An atlas of normal roentgen variants that may simulate disease, in Atlas of the Paranasal Sinuses. Chicago, Year Book
Medical Publishers, 1974. 6. Kohler A, Zimmer EA: Borderlands of the Normal and Early Pathologic Skeletal Roentgenology, ed 3. New York, Grune & Stratton, 1968, p 231.
a
Case
Murray D. Morrison, MD, FRCS(C); Stanley Barry R. Maber, MD \s=b\ The first two cases of
pneumocele of maxillary sinus have been recently published.1 The expanded antrum produced a different initial complaint in each case. A third case, with yet another initial problem, middle ear effusion, is now reported. The roentgenographic and operative findings and the therapeutic effect of decompression by antrostomy would suggest that this is a specific disease entity, presumably due to a check valve obstruc-
the
tion of the sinus ostium.
(Arch Otolaryngol 102:306-307, 1976) of the maxillary sinus is a term introduced by Noyek and Zizmor1 in two recent reports of patients with this unusual condition.2 The first initially had pain in the maxillary area on ascent during an airplane flight,1 and the second had facial swelling and slight proptosis.2 The patient described in the present report had yet another initial problem, Eustachian tube obstruction and serous otitis media.
Pneumocele
REPORT OF A CASE A 45-year-old man initially sought attention in December 1974 with pain, fullness, and loss of hearing involving the left ear. These symptoms came on shortly after landing from a long distance trip in a commercial jet aircraft. Because of the persistence of his symptoms, the patient consulted a physician, who made a diagnosis of aerotitis media and inserted a tympanostomy tube. A short time later, the patient developed otorrhea, for which systemic antibiotic therapy was begun. The tube was subse-
Accepted
for publication Nov 11, 1975. From the departments of surgery (otolaryngology) and radiology, University Hospital, Saskatoon, Saskatchewan, Canada. Reprint requests to the Division of Otolaryngology, University Hospital, Saskatoon, Saskatchewan, Canada S7N 0W8 (Dr Morrison).
P.
Tchang, MD, FRCP(C);
quently removed with the reappearance of decreased hearing and fullness in this ear.
In February 1975, a silicone elastomer tube was reinserted into the left tympanic membrane. At the same time, a left antral lavage was carried out. It was impossible to irrigate this sinus due to resistance, but with insertion of a second cannula, the resistance disappeared and the returned fluid was clear. At this time, it was also noted that the left middle turbinate appeared to be abnormally large. Our initial examination disclosed the continued presence of a silicone elastomer tympanostomy tube, located posteroinferiorly. On anterior rhinoscopy, the left middle turbinate was small and displaced superiorly and medially against the septum by a mass bulging into the nose from the lateral nasal wall, just above the inferior turbinate. This mass was bony hard around its base, but very soft and cyst-like over the dome. The remainder of the otolaryngological examination results were within normal limits. Notably, there was no palpable abnormality in the superior gingival buccal sulcus, nor was there any apparent displacement of the eye. Past history revealed that the patient had a nasal septal operation performed in 1960. Plane radiograms and tomograms of the sinuses show an extremely large left maxillary sinus that is hyperlucent. The pneumatization of the left maxillary sinus is extraordinary, expanding in every direction, laterally into the zygomatic process, and inferiorly into the alveolar process (Fig 1 to 3). The medial expansion is the most striking, with encroachment on most of the left nasal cavity and widening of the left ethmomaxillary sinus angle (Fig 1 and 3). There is also erosion of a short segment of the anterior cortical margin on the inferior lateral wall (Fig 4). The patient was subsequently admitted to the hospital, and the left maxillary antrum was explored through a Caldwell\x=req-\ Luc approach. The sinus mucosa was thin
Downloaded From: http://archotol.jamanetwork.com/ by a UQ Library User on 06/21/2015
and healthy in appearance and the cavity contained air only. The sinus cavity was obviously grossly distended. A nasal antral window was fashioned, and a portion of the mucosa bulging into the nose was removed so that the nasal mass could be redisplaced toward the sinus. One month postoperatively, the patient's nose appeared normal and the obstruction was relieved. Four months later, the tympanostomy tube extruded sponta¬ neously and there has been no recurrence of the middle ear effusion. His nose remains clear.
COMMENT Pneumoceles have been described elsewhere in relation to soft tissues, and have been generally regarded as epithelial-lined cavities containing air as a result of a pathologic communica¬ tion with a source of air. Pneumocele of the maxillary sinus differs in that it represents abnormal expansion of a bony cavity that is air-containing in the normal state. Pneumocele of the maxillary sinus has previously been described, and the authors propose that the pathogenesis involves a physiologic block to rapid equilibration of intrasinus air pres¬ sure through the major sinus ostium due to some physical abnormality that produces a one-way check valve mech¬ anism. Repeated air trapping second¬ ary to such events as sneezing or autoinflation could, over a period, produce chronic distention of the sinus as the result of a net positive intra¬ sinus air pressure. This explanation seems to be plausible, and, in fact, it is difficult to conceive of any other mechanism that might account for the findings associated with this condi¬ tion. In differentiating this condition, one must first exclude the possibility that these findings represent a nor¬ mal variant. It has been established that the maxillary sinuses usually
develop symmetrically. Slight
asym¬
metry is
plasia
not uncommon, but hypomay be difficult to differen¬
tiate from
underdevelopment second¬ previous sinusitis or trauma.3·4 Asymmetry due to a slight degree of overdevelopment does occur and has ary to
as an extension of into the zygomatic or alveolar processes of the maxilla.'·7' A
been described
pneumatization
Fig 1.—Anteroposterior tomogram delineating expanded maxil¬ lary sinus, with medial expansion as well as widened ethmoidomaxillary angle well shown (upper arrows). Inferolateral extension of maxillary sinus is also delineated (lower arrows).
Fig 2.—This lateral tomogram of the maxillary sinus delineates the superior, posterior, and inferior extensions (arrows) to better advantage.
Fig 3.—Axial projection demonstrates overexpanded
Fig 4.—Waters projection, showing hyperlucent and overdevel¬ oped left maxillary sinus with bony erosion in anterior aspect of inferolateral wall (short arrow). Long arrow points to posterior aspect of inferolateral wall.
left
antrum, particularly its medial aspect (arrows).
unilateral
excessively pneumatized maxillary sinus, occurring as a normal variant, has not yet been convincingly
described in the literature." It would seem reasonable to con¬ clude that, in our case, the Eustachian tube obstruction and middle ear effu¬ sion were the result of the expanding maxillary sinus causing compression of peritubal tissues via the infratem¬ poral fossa. The roentgenographic and
maxillary
operative findings, in association with the therapeutic effect of decompres¬ sion, would all of this
entity.
seem
being
a
to argue in favor
specific disease
References Noyek AM, Zizmor J: Pneumocele of the maxillary sinus. Arch Otolaryngol 100:155-156, 1.
1974. 2. Zizmor J, Bryce M, Schaffer SL, et al: Pneumocele of the maxillary sinus: A second case
Downloaded From: http://archotol.jamanetwork.com/ by a UQ Library User on 06/21/2015
report. Arch Otolaryngol 101:387-388, 1975. 3. Yanagisawa E, Smith HW: Normal Radiographic anatomy of the paranasal sinuses. Otolaryngol Clin North Am 6:429-457, 1973. 4. Samuel E: Clinical Radiology of the Ear, Nose, and Throat. London, HK Lewis & Co, Ltd, 1952. 5. Keats TE: An atlas of normal roentgen variants that may simulate disease, in Atlas of the Paranasal Sinuses. Chicago, Year Book
Medical Publishers, 1974. 6. Kohler A, Zimmer EA: Borderlands of the Normal and Early Pathologic Skeletal Roentgenology, ed 3. New York, Grune & Stratton, 1968, p 231.
