Tài liệu Mucoceles of the Paranasal Sinuses pdf

Anatomy and Development Clinical Features Treatment Case Presentations ¢ Epithelial lined mucous-containing sac completely filling a « 1725: Dezeimeris first described frontal mucoc

Anatomy and Development

Clinical Features Treatment Case Presentations

¢ Epithelial lined mucous-containing sac completely filling a « 1725: Dezeimeris first described frontal mucoceles

¢ Capable of expansion b symptoms

NH0) Rollett introd

* Most common lesion c sinuses

¢ First to develop in the

* 3 years

« 7 years to adolesceni Average volume 14.75 r Drains into middle meat

Nasal -: via maxillary ostium

Located in superior half of

lateral nasal wall

Development begins dur

4n month of fetal develo

Continue to grow throug

childhood until age 12

Average volume 15 ml

Drainage:

e Anterior: infundibul

ethmoid bulla

¢ Posterior: superior 1

¢ Frontal Sinuses

Frontal bone

Begins as evagination of frontal

IS 0S)

Development begins at 2

reaches adult size at 15-2

Variable development:

¢ 10% unilateral

° 5% rudimentary

¢ 4% absent

Drainage into frontal rec

« 2-20 mm In length

e Sinus lining:

Ciliated, pseudostratified,

columnar epItheliun

Mucous glands and gobl

cells > mucous blanket

“sol-gel” phase

e Sphenoid sinus

¢ In body of sphenoid bone

¢ No significant sinus at bir

¢ Development begins at 5 Final volume attained b years

Average volume: 7.5 ml Drainage:

¢ Sphenoethmoidal rec

e Frontal recess

¢ Marked variation in configuration and attachment of uncinate process

¢ Variable drainage patterr

a,

cS

¢ Pattern of clearance:

¢ Maxillary: floor 3 stellate pattern along walls

to natural ostium

R Superior

Frontal: inward flow | Turbinate medially > superior >

lateral > floor > fronta | Middle

Septum —\}

Inferior Turbinate

¢ Obstruction of sinus ostium or outflow tract

¢ Inflammation (ie Chronic sinusitis)

e Trauma

¢ Iatrogenic (eg FESS)

Mass/Tumour (eg Pol

¢ Obstruction of minor s

of paranasal sinus

¢ Eg Mucous retention c

34 or 4th decade

MCF ~ 7:1

10-15 years to develop

Frontal > ethmoid > m

¢ Fronto-ethmoidal ~65%

¢ Maxillary ~ 20%

¢ Sphenoid ~1-8%

Posterior ethmoid ~1-6'

Uncommon locations: r

¢ Slow expansion

¢ Patients asymptomatic for many years

« May take 10 years or mor

* Symptoms depend on Ic

of bony erosion

¢ In general:

¢ Headache and fa

¢ Facial swelling with

¢ Ocular and neurolog

¢ Bone resorption:

¢ Epithelium continues to secrete causing expansion of the mucocele sed pressure >

ation of bor osteolysis

¢ Local inflammation > s cytokines

¢ Fibroblasts > PGE

¢ Epithelial cells > T

¢ Cause osteoclastic bi resorption

resorption

bay

— osteoclast

* Rombaux ef al (Belgium, 2000):

¢ 178 mucoceles

¢ Primitive mucoceles: 3

¢ Post-traumatic: 2.1%

¢ Post-operative: 62.9%

* Incidence after FESS nc

¢ Most common clinically significant mucocele

* Classification (Har-El, 2001) Type 1: Limited to fr | Type2: Erontoethmoi Type 3: Erosion of po:

*® A Minmimal

¢ B Major int Type 4 — Erosion of an Type5 Erosion of bo’

*® A Minmimal

¢ B Major int

¢ Frontal headache (common) and/or deep nasa

¢ Frontal swelling +/ infecti

¢ Nasal obstruction and rt

* Neurologic:

¢ Destruction of posterior frontal sinus wall

¢ Decreased LOC

Confusion

Meningitis

CSF leak

¢ Rare lesion

¢ Extension:

¢ Superiorly into pituitary

¢ Posteriorly towards cliv'

eriorly into posterior

¢ Laterally into orbits

* Compression:

¢ Pituitary gland, optic chi

II-VI, brain

¢ Proptosis (common)

¢ Periorbital pain

¢ Displacement of globe downward and outward direction

Reduced ocular mobilit Diplopia

“mucous-retention” cyst

¢ Incidental finding

Rarely achieve sufficie Rarely require specific Spontaneous regressior

¢ General:

¢ Headache with occipital, vertex or deep nasal pain

¢ Ocular:

¢ Diplopia

¢ Visual field disturbance

« Vision loss

¢ Retro-orbital pain

¢ Neurologic:

¢ Decreased LOC

¢ Confusion

¢ Meningitis

¢ CSF leak

* CT scan provides excellent anatomical information ¢ MRI scan:

intracranial or intraorbite Loss of normal scallope 1"

Depression or erosion of m— -

¢ Majority show hyperinte

¢ Increased dehydration hyperintense

Surgery is required Traditionally preferable when there are intraorbital or

symptomatic mucopy

Goals

¢ Reintegration of affecte

Typically for fronto-et Techniques:

Ị l l ¢ External frontoethmoide

¢ Sinus exclusion with ob :

¢ Endoscopic

*® Indications:

¢ Acute infectious of frontal and ethmoid sinuses with orbital

extension

¢ Incision made near medial

medial canthal ligament a trochlea

N

¢ Mucoceles, pyoceles, cu

Ề ⁄ v

¢ Exposure for benign tun

skull base, or superior nz

Periosteum elevated to fronto-ethmoid

Sufure

Anterior ethmoid artery di

Lamina papyracea remove

ethmoidectomy performed

Frontal sinus opened in me

floor

Diseased tissue within sim

Large chute from frontal si

ethmoid cavity into the nos

+/- stent placement

Reidel procedure:

Entire anterior wall and floor

of frontal sinus removed

against posterior table

Significant deformity

Rarely if ever used

* 1894: described by Brieger

¢ Fat obliteration:

First described in 1950

Prevent recurrence

Associated with varying

necrosis and resorption

*® Indications:

Neoplasms

Fractures

Chronic frontal sinusitis

with orbital or intracrani

Killian procedure

¢ For tall sinuses in which disease cannot be remove through floor alone Floor and anterior wall removed

Supraorbital bony strut ( mm)

¢ Lothrop procedure:

¢ Unilateral or bilateral anterior ehtmoidectomy Interfrontal septum and s

connected High risk of cribriform

* Anosmia

¢ CSF leak

¢ Meningitis

Incisions:

¢ Coronal approach

¢ Midline forehead approac

¢ Brow incision

s Technique:

¢ Skin-tissue flap raised, of frontal sinus; die peoAem

preserving periosteum a

supraorbital nerves

¢ Technique:

¢ Periosteum incised and lifted off bone Ve FFE Make Wiper Bsikd bone lncion

along periosteal incision

supply to bone and periosteum

Bone cuts made to create

marked with template fre

Caldwell-view radiogra

¢ Technique:

¢ Mucosa lining stripped and plamond buctesd on inner surface drilling of cortical bone ` >

performed FONE SOS nasofrontal duct

inspected and cleaned

¢ Technique: Onotone ad alto compete bone tng

¢ Bone flap removed

¢ Disease in frontal sinus ) } yi ered

¢ Minimum 2 mm required to eliminate mucosal elements

¢ Mucosa lining stripped a

drilling of cortical bone

performed

¢ Minimum 2 mm

required to eliminate

mucosal elements

Subcutaneous adipose ft

¢ Bone flap replaced and fixed

¢ Once frontal recess reached,

mucosa is inverted dowr

¢ Skin closure Fat harvested from lowe

quadrant of the abdomer

over rectus muscle used

obliterate sinus cavity

Frontal recess is plugge

with fascia, muscle or be

Sinus s is = totally obliterated =

with adipose tissue

* Cranialization * Complications:

¢ Large portions of pos * Seroma

Abscess (0201101011:

sranmial:

¢ Intracranial complic

¢ Frontal craniotomy usua

¢ Extradural dead space re

¢ Oblteration of dead s CSE leaks

Meningitis Brain abscess

¢* Ocular: ¢ Nerve injury:

¢ Extraocular muscle injur ¢ Supraorbital nerves

¢ Osteomyelitis of bor ¢ Scar

¢ Depression or embo:

e¢ Recurrence

« 28 patients with combined approac ey * Opening enlarged witho

¢ Recurrence rate: 11 ¢ Lund (1991):

¢ Osteoplastic flaps fo mucociliary activity

¢ Conboy and Jones (2003 ¢ No facial scarring

* Contraindications (Rombaux et al, 2000)

* Absolute:

¢ Mucocele not accessi

¢ Mucocele located in

¢ Cutaneous fistula

¢ Relative:

¢ Loss of anatomical |

¢ Revision surgery for

previous external ap’

¢ Frontal recess steno

¢ Associated disease (

¢ Technique:

¢ Identification of anterior

ethmoid artery

¢ Posterior reference

¢ Frontal opening loca

mm ant€rIor

Frontal recess Lamina papyracea

Nasofrontal “beak”

cells

¢ Technique:

Enlargement

anteriorly and

anteriormedially to "

avoid accidental superior trbinate

intracranial entry plate

Anterior ethmoit

Drilled-out 365-6 2996" Nasi cells

Nasolacrimal sac

` Nasofrontal isthmus E— TL Agger nasi cells Lamina papyracea

‘of frontal sinus

Frontal recess enlarged Middle turbinate

‘Anterior ethmoidal a papyracea

s Technique:

¢ Polyps or polypoid mucosa cleared

Pa from frontal recess En al recess Agg )) \ Frontal recess aie:

Frontonasal duct

infundibulum

¢ Technique:

Cy Neos mn DEES cells removed

Nasofrontal

“beak”

Middle

nasi cells

Frontal sinus Agger nasi cells

¢ Technique:

¢ Mucosa covering posterior aspect of i oneal frontal sinus le 01A ý 3 andor 1 / preserved

Frontal sinus

Widely patent nasofrontal

Provides source of epithelialization

¢ Technique (Contd)

Floor of frontal sinus anterior to outflow tract removed

¢« Mucocele identified, ope

¢ Lining not curetted or re

+/- stent insertion

* Results:

¢ 178 patients with 3 r

« 97.9% successful

Lund et al; J Laryngol

¢ No recurrences in 20

¢ Mean follow-up 34 r

Results (Cont'd):

¢ Conboy and Jones; Clin Otolaryngol 28:207-210, 2003

¢ 68 mucoceles

* 66% endoscopic, 22

¢ Mean follow-up 6 ye

¢ Recurrences:

¢ 9% endoscopic gr

¢ 26% external or c

* Postoperative Care:

ntibiotics and saline spray

*_ Irrigation of stent

¢ Removal of stent 6-12 v

Results (Cont'd):

¢ Har-El; Laryngoscope 111:2131-2134, 2001

108 sinus mucoceles

66 frontal and front

12 sphenoid, 6 maxi 83% intraorbital exte 5% erosion of skull nsion; 31% maj extent larger than sir Follow-up: 1-13.5 ye Recurrence of fronta

Traditional teaching:

¢« Complete removal of mucocele lining

¢ Required external technic

Recent trend favourir Marsupialization for lar

¢ Long-term follow-up re

¢ Results of studies may n

¢ Follow-up in many serie

10

¢ Mucoceles may recur many years after surgery

* Recurrences may be as long as 49 years after initial surgery (Moriyama)

¢ “small, well-positioned mucoceles may be attempted first

endoscopically, but in the setting of massive mucoceles

¢ Recurrences should be facial skeleton, the mo

mOr€ aØø7€sSIVe Open t

“endoscopic transnasal

intracranially extended

invasive and can provid

wide marsupialization”

69 voM

Pituitary tumour removed 25 years ago

Follow-up MRI > inet

¢ No orbital or intracrania

Asymptomatic with no

Well postoperatively No sinus symptoms

No recurrence

W:2000 L:200 HU

¢ Dx: sphenoethmoidal mucocele

Treatment:

¢ Left functional endosco

¢ Uncinectomy

¢ Anterior ethmoidectom

¢« Posterior ethmoidectorm

Treatment (Cont d):

Marsupialization of posterior ethmoid cells Removal of anterior an inferior walls

Well postoperatively

Reduced pain

Vision still decreased

No recurrence at 4

months

73yoM History of chronic sinusitis Previous septoplasty

Admitted for nausea ar

headaches and diplopiz Previously on antibioti improvement in sympt

12

Discharged home

Returned to ER with

vomiting and dehydr

CT report:

* “area Ofcalciication

whether this 1s related

underlying meningior

free ee

progressive headache, nausea,

« Dx: sphenoethmoidal

mucocele

¢ Treatment:

¢ FESS Middle turbinate f expose large cystic fo:

Aspiration of purulen secretions Marsupialized Dehiscence of LP

* Repeat CT scan

13

Repeat MRI

Dx: Tuberculum sellae meningioma

¢ Involving:

¢ Pituitary gland

¢ Both cavernus sinu

¢ Compression of le

Endocrinology: no en

Ophthalmology: mild

Patient not interested 1

decompression

Dx: Right frontal mucocele

Treatment:

¢ Combined ENT, Ophtt

¢ Osteoplastic flap

* Browi

¢ Supraorbital nerve

¢ Template > osteo

¢ Roof of orbit and p

Mucocele lining ret

CS omy | Progressive proptosis of Tight eye

No visual deficits

Investigations:

¢ Large right front

lesion

¢ Extension into orbit an intracranial cavity

Treatment (Cont’ d)

¢ Osteoplastic flap:

¢ Dura dehiscent a

¢ Orbital roof defect

¢ Frontal recess plug

¢ Bone flap replaced

14

s Post-op

Accumulation of CSF under right forehead scalp

No rhinorrhea

Bed rest and aspiration of fluid

Persistent leak > lumbar drain

¢ Resolution of CSF leak

¢ No infection

¢ Discharge home

¢ Follow-up

¢ Well with no recurrence

¢ Treatment is surgical

Traditionally, complete removal advocated via external approach

Trend towards endoscopic management

External or combined approaches usually reserved for extensive

involvement or failed endoscopic attempt

Push towards endoscopic management of large intracranial

mucoceles

¢ Long term follow-up required to monitor for recurrence

Mucoceles most common lesion causing expansion of paranasal sinuses

Long asymptomatic progress When symptomatic, usually present with ocular symptoms +/- neurologic symptoms depending on location of expansion

Fronto-ethmoidal mucoceles most common

Caused by sinus obstruction secondary to chronic infection, surgery or trauma

15