대한비과학회

(1)

－ 75 －

KISEP Case Reports J Rhinol 6((((1)))), 1999

A Case of a Sphenoid Sinus Mucocele Protruding into Both Nasal Cavities：：：：Transnasal Endoscopic Marsupialization

Yong Bae Lee, M.D., Kyung Chul Lee, M.D., Jeong Woo Lee, M.D. and Sung Min Jin, M.D.

ABSTRACT

A sphenoid sinus mucocele is a rare condition that causes a variety of symptoms by creating pressure on important contiguous neurological and vascular structures. The lesion is difficult to diagnose due to the subtlety of its symptoms, but careful radiological evaluation, with CT and MRI, for example, can help to provide a correct assessment. Transnasal endoscopic surgery can poten- tially deliver dramatic reduction in the operative morbidity of surgery for paranasal sinus mucoceles by offering an approach that is minimally invasive under local anesthesia. We experienced a 37-year-old male patient with a large sphenoid sinus mucocele protruding into both nasal cavities. The patient was treated with transnasal endoscopic marsupialization.

KEY WORDS：Sphenoid sinus mucocele·Transnasal endoscopic marsupialization.

INTRODUCTION

A paranasal sinus mucocele is a cystic condition that affects the frontal and ethmoid sinuses and, in rare cases, the sphenoid sinus.¹⁾ Its symptoms are variable mainly due to pressure placed on the neurological and vascular structures around the sphenoid sinus. In many cases, the disease is discovered only after the lesion has progressed considerably.

Recent advancement in radiological evaluation met- hods, such as Computerized Tomography and Magnetic Resonance Imaging, have made the disease easier to diagnose, while innovations in functional endoscopic sinus surgery have helped to reduce postoperative complications and enabled more precise postoperative observations.

We conducted a transnasal endoscopic marsupialization on a large sphenoid sinus mucocele extruding toward both nasal cavities, causing the expansion of bony erosion in the sphenoid sinus walls without placing pressure on the optic nerve and trigeminal nerve. Our postoperative ob-

servations indicate complete removal of the lesion, eli- mination of the symptoms and no further complications.

CASE REPORT

A 37-year-old male patient visited the otorhinolary- ngology department of the hospital on March 3, 1998, complaining of mucopurulent rhinorrhea, hyposmia and headache, which had lasted for the previous six months.

He also reported that he had been suffering from obstruction of both nasal cavities for about 25 years but had been never received medical treatment for it. An exam- ination of his past history and family history provided no relevant information. Observation via anterior rhin- oscopy and transnasal endoscopy indicated an extruded cystic mass located between the nasal septum and the middle turbinate in both nasal cavities (Fig. 1). An ext- ernal ocular muscle movement test showed visual acuity to be normal, and results of blood and biochemistry te- sts and urinalysis were also normal.

Computerized tomography of the paranasal sinuses indicated expanded soft tissue density with bony erosion extending toward both nasal cavities in the sphenoid sinus, but there was no pressure on the intraocular rectus muscle or the optic nerve. Soft tissue density was also found in both ethmoid sinuses and in the left maxillary sinus (Fig. 2). T1-weighted and T2-weighted magnetic Department of Otolaryngology, Kangbuk Samsung Hospital,

School of Medicine, Sungkyunkwan University, Seoul, Korea Address correspondences and reprint requests to Kyung-Chul Lee, M.D., Department of Otolaryngology, Kangbuk Samsung Hospital, 108 Pyung-dong, Chongro-gu, Seoul 110-102, Korea Tel：82-2-2001-2268, Fax：82-2-2001-2273

Accepted for publication on February 20, 1999

(2)

76 / J Rhinol 6(1), 1999

resonance imaging indicated a cystic mass of high-signal intensity extruding toward both nasal cavities from the sphenoid sinus (Fig. 3). The posterior and inferior part of the cystic mass, however, produced intermediate- signal intensity, suggesting a solid form of the abscess in the density.

A marsupialization was conducted on the patient on March 16, 1998, under local anesthesia mixed with 2%

lidocaine and 1：100,000 epinephrine. The first incision was made, using a transnasal endoscope, on the anterior wall of the cystic mass extruding to the left nasal cavity between the nasal septum and the middle turbinate. After the incision, a yellowish-green mucoid discharge was drained, and the anterior wall of the sphenoid sinus was widened. Polyposis was removed from both ethmoid sinuses, and the left maxillary sinus ostium was widened for removal of the purulent secretion in the left maxillary sinus. Bleeding was minimal during the surgery, and the left side of the sphenoid sinus and both nasal cavities were packed with Merocel^®. In a germiculture test during surgery, Group D nonstrep-tococcus were cultured and showed sensitivity to the Augmentin^® used before the surgery. The nasal cavity packing was removed one day after the surgery, and the patient was treated with irrigation of both nasal cavities two times a day and any blood clots or fibrin clots found were removed. Showing a marked improvement in symptoms, the patient was discharged from the hospital on the fifth postoperative day. However, the patient returned one month after the operation, complaining of nasal obstruction on both si- des and purulent rhinorrhea. Computerized tomography of the paranasal sinuses at that time yielded findings that suggested a recurrence of the polyposis. The CT showed no abnormal mass lesions in the sphenoid sinus but there

Fig. 3. Preoperative T1-weighted axial MRI (A) and T2-weighted axial MRI (B) show high-signal intensities bulging out into the posterior nasal cavity.

Fig. 2. A preoperative axial view of the paranasal sinuses with CT shows the soft-tissue density (*) expanding to both nasal ca- vities from the sphenoid sinus.

Fig. 1. Preoperative endoscopic findings show a cystic mass (*) protruding between the left nasal septum (S) and the middle turbinate (MT).

IT：inferior turbinate

A AA

A BBBB

(3)

Lee et al：Sphenoid Sinus Mucocele / 77

was soft tissue density in both ethmoid and maxillary sinuses (Fig 4). On May 18, 1998, polyposis was removed from both ethmoid sinuses using a transnasal endoscope and both maxillary sinus ostia were widened. Fol- low-up observations over eight months showed no signs of recurrence.

DISCUSSION

Mucoceles of the paranasal sinuses is a cystic disease caused by obstruction of the natural ostia and can affect people regardless of age or gender. The disease occurs mainly in the frontal sinus (65%-70%) or the ethmoid sinus (30-40%), and is in rare cases found in the maxillary and sphenoid sinuses.¹⁾ The sphenoid sinus is located in the very center of the sinuses and is not a main pa- thway of normal respiration, so it is rarely exposed to pathologic bacteria. As well, the frequency of sphenoid sinus mucocele is very low, because there are few mucus- secreting cells in the sphenoid sinus.²⁾³⁾ At the microsc- opic level, the sphenoid sinus consists of normal pseu- dostratified ciliated columnar epithelium which includes goblet cells and may show atrophy or erosion due to pressure from the mucocele.⁴⁾ The mechanisms of sphenoid sinus mucocele include obstruction of the ostia and the secretory duct and submucosal edema.⁵⁾⁶⁾ Our case inv- olved obstruction of the sphenoid sinus ostium by ethmoid sinus polyposis.

The clinical symptoms of a sphenoid sinus mucocele include pressure on the surrounding areas due to expansion of the cyst, possibly resulting in headache, oculo- motor palsy, exophthalmosis, diplopia and blindness.⁷⁾⁸⁾ In approximately 40% of cases, nasal obstruction is also

a symptom. Paranasal sinusitis, endocrine disorder, facial nerve palsy and trigerminal nerve paralysis are also as- sociated with the disease in some cases.⁹⁾ In our case, no other symptoms other than the nasal obstruction was found, which may be due to the fact that the cyst, extruding toward both nasal cavities, created only slight pressure on the surrounding areas.

In a computerized tomography of the paranasal sinuses, the mucocele is similar to brain tissue in density and is homogeneous low-density. Because the mucocele is a vascular lesion, there is no attenuation caused by contrast.

Calcification is found in 5% of cases.¹⁰⁾¹¹⁾ In the early stages of a mucocele, magnetic resonance imaging of the paranasal sinuses indicates a high-signal intensity only with T2WI due to the extrusion’s highly liquid form, while in cases of a well-progressed mucocele, the high- signal intensity is found with both T1WI and T2WI, due to a high level of glycoprotein.¹²⁾ This helps to dif- ferentiate the diagnosis of tumor and mucocele, which is often difficult with CT.

At present, transnasal endoscopic marsupialization is widely used for the removal of cysts because the procedure does not damage the sphenoid sinus mucosa or its surrounding areas and because it helps to avoid intracranial complications even in cases of serious bony defect or intrusion into the intracranial. During the procedure, the drainage path of the sinus should be well maintained to prevent obstruction of the artificially created ostium during the healing process.^14-16) Kennedy et al.¹⁷⁾ reported treating 15 out of 18 patients suffering from paranasal sinus mucocele with transnasal endoscopic marsupialization without encountering recurrence or complications 42 months after the operation. In our case, we conducted the transnasal endoscopic marsupialization through the left-side nasal cavity because the extrusion was larger in the left-side than in the right-side cavity. Polyposis was removed from both ethmoid sinuses, but revision endoscopic sinus surgery was conducted on both ethmoid polyposis three months after the operation due to recurrence.

REFERENCES

1) Lundgren A, Olin T. Mucopyocele of sphenoid sinus or posterior ethmoid cells with special reference to apex orbital syndrome. Acta Otolaryngol 1961;53:61-79.

2) Kron TK, Johnson CM. Diagnosis and management of the opaci- fied sphenoid sinus. Laryngoscope 1983;93:1319-27.

3) Wyllie JW, Kern EB, Djalilian M. Isolated sphenoid lesions. Lar- Fig. 4. A postoperative axial view of the paranasal sinuses with

CT shows no abnormal mass lesion in the sphenoid sinus.

(4)

78 / J Rhinol 6(1), 1999

yngoscope 1973;83:1252-65.

4) Bodric GE. Cystic lesion of the orbit. In Principle and Practice of Ophthalmology WB Saunders company Vol 3 1994;1900-3.

5) Jing BS, Goeppert H, Close LG. Computerized tomography of paranasal sinus neoplasms. Laryngoscope 1978;88:1485-503.

6) Sellars SL, De Villiers JC. The sphenoid sinus mucocele. J Lary- ngol Otol 1981;95:493-502.

7) Cho JH, Kwun YS, Won YS, Suh BD. A Sphenoid Mucocele with Bilateral Ophthalmic Symptoms. Korean J Otolaryngol 1998;41:

266-9.

8) Lee JJ, Ha HB, Na IG, Park KY, Park MS, Lee SC. A case of mucocele of the sphenoid sinus causing sudden onset of blindness and hyperprolactinemia. Korean J Otolaryngol 1989;32:730-4.

9) Shikowitz MJ, Goldstein MN, Stegnjajic A. Sphenoid sinus mucocele masquerading as a skull base malignancy. Laryngoscope 1986;96:1405-10.

10) Lidov M, Behin F, Som PM. Calcified sphenoid mucocele. Arch Otolaryngol Head Neck Surg 1990;116:718-20.

11) Toriumi DM, Sykes JM, Russel EJ, Morganstein SA. Sphenoeth- moid mucocele with intracranial extention: Radiologic diagnosis.

Otolaryngol Head Neck Surg 1988;98:254-7.

12) Stankiewicz JA. Sphenoid sinus mucocele. Arch Otolaryngol Head Neck Surg 1989;115:735-740.

13) Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith MM. Endoscopic sinus surgery for mucoceles: A viable alternative.

Laryngoscope 1989;99:885-95.

14) Seok YS, Jung KY, Lee SH, Choi JO. Sphenoid sinus mucocele.

Korean J Rhinol 1996;3:87-91.

15) Park CW, Kim SG, Koh KM, Kim KR, Lee HS. Endoscopic treatment of paranasal sinus mucoceles. Korean J Otolaryngol 1996;

39:29-34.