CASO CLÍNICO

 

Post-traumatic mucocele of the maxillary sinus

Mucocele del seno maxilar post-traumático

 

 

 

E. Charro-Huerga¹, J. Ferreras Granado², I. Vázquez Mahía, J.L. López-Cedrún³

1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial del Complejo Hopitalario Universitario de La Coruña. España

Correspondence

 

 

 

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ABSTRACT

Mucoceles of the paranasal sinuses are benign lesions but they can be destructive because they cause bone resorption. The location in a maxillary sinus and a traumatic origin are uncommon. We report a case of mucocele of the maxillary sinus 28 years after facial trauma. We analyzed the etiopathogenesis, diagnosis, and treatment of this type of lesions.

Key words: Mucocele; Maxillary sinus; Post-trauma.

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RESUMEN

Los mucoceles de los senos paranasales son lesiones benignas pero con un considerable potencial destructivo por la reabsorción ósea que pueden generar. La localización en el seno maxilar es muy poco frecuente así como el origen postraumático. Presentamos el caso de un mucocele de seno maxilar tras 28 años después de un traumatismo facial. Analizamos la etiopatogenia, el diagnóstico y el tratamiento de este tipo de lesiones.

Palabras clave: Mucocele; Seno maxilar; Postraumático.

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Introduction

Mucoceles of the paranasal sinuses are described as cystic, expansive lesions lined by epithelium and filled with mucous secretion as a result of obstruction of the drainage orifice of the paranasal sinuses. ^1,2 Although paranasal mucoceles are benign, they are potentially destructive because they can cause resorption of the surrounding bone by raising the pressure on the bone.³

The most frequent location of paranasal mucocele is the fronto-ethmoidal complex, followed by the sphenoid sinus. It occurs only rarely in the maxillary sinus. In the maxillary sinus, the most frequent origin of mucocele is prior surgery; mucocele secondary to facial fracture is extraordinarily rare.¹

We report a case of mucocele of the maxillary sinus secondary to maxillo-malar fracture that the patient experienced 28 years earlier. We analyzed the etiopathogenesis, incidence, symptoms, diagnosis, and treatment of maxillary mucocele.

 

Clinical case

A 55-year-old man was referred to our clinic by the ophthalmology department for exophthalmia secondary to a tumor of the right maxillary sinus.

The patient’s history included a right maxillo-malar fracture 28 years earlier, in which reduction and wire fixation of the fracture of the infraorbital rim and frontomalar buttress was performed.

In the ophthalmologic examination we found exophthalmia, vertical dystopia of the ocular globe, and ophthalmoplegia of the vertical gaze. A lack of projection of the infraorbital rim allowed the palpation of a soft mass at this level.

In orthopantomography, the relation between the mass and teeth was not evident. CT (Figs. 1 and 2) revealed a well delimited, soft tissue mass approximately 3.5 cm wide in the right maxillary sinus, with bone remodeling, destruction of the orbital floor, and displacement of the inferior rectus muscle, causing secondary exophthalmia.

The operation consisted of excision of the lesion with extraction of the subciliary fixation wires (Fig. 3) and reconstruction with a Medpor prosthesis (Figs. 4 and 5) of the damaged maxillomalar complex (infraorbital rim, orbital floor, and frontomalar buttress).

Histopathologic study confirmed the diagnosis of maxillary mucocele (Fig. 6).

The evolution of the patient was satisfactory, with good ocular motility, no diplopia, and an acceptable aesthetic result (Fig. 7). At the most recent follow-up visit three years later, the outcome continues to be satisfactory without recurrence or complications.

 

Discussion

Mucoceles of the paranasal sinuses are due to ostial obstruction with mucous accumulation and gradual expansion of the sinus cavity.

A series of predisposing etiopathogenic factors can be divided into intrinsic and extrinsic.² The intrinsic factors are those that increase mucous viscosity, such as cystic fibrosis. Among the extrinsic factors described are polyps, tumors, and septal deviations. Trauma is the most frequent cause of maxillary mucocele, especially surgical trauma and, in extremely infrequent cases, middle facial fracture.

Among the causes of predisposing surgical trauma are difficult tooth extractions,¹ orthognathic surgery,⁴ and the Cadwell-Luc intervention. ^4,5

The Cadwell-Luc intervention is described in the literature as the most common extrinsic cause of maxillary mucocele. It develops 10 to 30 years after the procedure and is infrequent in Europe and the U.S., but relatively common in Japan.^1,5 It is speculated that this probably is due to the high prevalence of maxillary sinusitis, especially before and after World War II, which at this time was treated by means of the Cadwell-Luc procedure due to the unavailability of antibiotics. ¹ Nevertheless, authors like Hasegawa⁵ have speculated about a racial anatomic predisposition.

In the literature reviewed, we found few cases secondary to direct trauma to the middle third of the face.^3,6,7 It is the least common of the predisposing factors described.^3,6,8 In these patients the pathophysiology varies with respect to other mucoceles because ostial drainage remains patent. Mucous sequestration of a sinus zone occurs, which becomes encapsulated and stops draining.³

Clinically, mucoceles have an insidious and painless course in most cases,³ accompanied by swelling, facial deformity, and chin edema. Sometimes, herniation into the adjacent cavities occurs, such as the orbit in the case reported, which may cause dystopia, exophthalmia, and diplopia. However, orbital involvement is infrequent. Kaneshiro⁹ reports it in 1.4% and Hasegawa⁷ in 7% of all post-traumatic maxillary mucoceles reviewed.

Imaging studies, such as the Waters projection will reveal partial or total opacity of the sinus. In conjunction with a detailed interview, this will lead to the diagnosis. CT shows thinning and erosion of the maxillary walls, together with the absence of enhancement of the lesion after contrast is administered. This will serve us in the differential diagnosis with retention cysts and malignant lesions of the maxilla, respectively.^1,3

Histologically, a respiratory type epithelium lining the cyst is observed that sometimes has evolved to squamouscell metaplasia.¹

The treatment of these lesions is simple exeresis. In surgery, mucoceles are firm masses filled with fluid that sometimes can be purulent. In this case we refer to it as mucopyocele, but it is generally sterile.¹ We should always use the least invasive approach possible and ensure that the entire lesion is removed. Most authors^10-12 confirm the advantages of an endoscopic approach whenever possible, and emphasize its scant invasiveness and short recovery time; however, its limitation with respect to secondary bone reconstruction is important.³

In our case, total exeresis was performed and the malar projection and floor of the orbit were reconstructed through a subciliary approach. The endoscopic approach was ruled out due to the need for reconstruction of the maxillo-malar complex and the intraoral approach was ruled out to preserve the maximum sterility possible and to avoid contamination with germs from the oral cavity.

Some authors, such as Hasewaga,⁵ do not think that the continuity of the orbital floor has to be restored if it is affected. However, we think that reconstruction is important to obtain good aesthetic and functional ocular motility result.

 

 

Correspondence:
Esther Charro Huerga
Servicio de Cirugía Oral y Maxilofacial.
Complejo Hospitalario Universitario de La Coruña. España
Hopital Materno Infantil
As Xubias de Arriba 84, 15006
e-mail: esch26@hotmail.com

Received: 16.07.08
Accepted: 28.01.09

 

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