Endoscopic sinus surgery for maxillary sinus mucoceles

Fatma Caylakli, Haluk Yavuz*, Alper Can Cagici* and Levent Naci Ozluoglu* Baskent University, Faculty of Medicine, Department of Otorhinolaryngology Head and Neck urgery, !nkara, "urkey author email corresponding author email* #ontri$uted e%ually Head & Face Medicine &''(, !&)doi*+',++-(.+/0(1+('21&1&) "he electronic version of this article is the complete one and can $e found online at* http*..333,head1face1med,com.content.&.+.&) 4eceived* &- Fe$ruary &''( !ccepted* ( eptem$er &''( 5u$lished*( eptem$er &''( 6 &''( #aylakli et al7 licensee BioMed #entral 8td, "his is an Open !ccess article distri$uted under the terms of the #reative #ommons !ttri$ution 8icense 9http*..creativecommons,org.licenses.$y.&,':, 3hich permits unrestricted use, distri$ution, and reproduction in any medium, provided the original 3ork is properly cited,

A"stract
#ackground Ma;illary sinus mucoceles are relatively rare among all paranasal sinus mucoceles, <ith the introduction of endoscopic sinus surgical techni%ues, rhinologic surgeons prefer transnasal endoscopic management of sinus mucoceles, "he aim of this study is to descri$e the clinical presentation of ma;illary sinus mucoceles and to esta$lish the efficacy of endoscopic management of sinus mucoceles,

$et%ods Bet3een &''= and &''>, +0 patients under3ent endoscopic sinus surgery for ma;illary sinus mucocele, "he presenting sign and symptoms, radiological findings, surgical management and need for revision surgery 3ere revie3ed, &esults "here 3ere eight males and si; females 3ith an age range of +0 to (>, "en patients complained of nasal o$struction, five of nasal drainage, five of cheek pressure or pain and one of proptosis of the eye and cheek s3elling, "he ma;illary sinus and ipsilateral ethmoid sinus involvement on computed tomographic studies 3as seen in 0 patients, Four patients had history of endoscopic ethmoidectomy surgery for ethmoid sinusitis and one had #ald3ell18uc operation in the past, ?thmoidectomy 3ith middle meatal antrostomy and marsupiali@ation of the mucocele 3as performed in all patients, 5ostoperative follo31up ranged $et3een - to 0- months, !ll patients had a patent middle meatal antrostomy and healthy ma;illary sinus mucosa, No patients need revision surgery, Conclusion "he most common causes of mucoceles are chronic infection, allergic sinonasal disease, trauma and previous surgery, An (0B of the patients of our study cause remains uncertain, ?ndoscopic sinus surgery is an effective treatment for ma;illary sinus mucoceles 3ith a favora$le long1term outcome,

#ackground
Mucoceles are $enign, locally e;pansile paranasal sinus masses, "hey are cyst1like structures lined $y the mucoperiosteum of the involved sinus C+,&D, Mucoceles are most commonly found in the frontal sinus, 3ith the ethmoid and sphenoid sinuses involved less fre%uently, Ma;illary sinus mucoceles are relatively rare, accounting for +'B or less of all paranasal sinus mucoceles descri$ed in the United tates or ?urope, Ho3ever, it is more commonly reported in Eapan, usually as a long term se%uel of #ald3ell18uc surgery C=,0D, Mucoceles are $elieved to form follo3ing o$struction of the sinus ostia, 3ith accumulation of fluid 3ithin a mucoperiosteal lined cavity, !s mucus continued to $e produced 3ithin the mucocele, it enlarges gradually, resulting in erosion and remodelling of the surrounding $one C+1(D, !lthough mucoceles are $enign, they can cause significant pathology as a result of their effects on surrounding vital structures,

mainly in the perior$ital region C/1)D, "he most common causes of mucoceles are chronic infection, allergic sinonasal disease, trauma, previous surgery and in some cases cause remains uncertain C+,&D, "he treatment of ma;illary mucoceles is surgical including e;ternal approaches, marsupiali@ation, #ald3ell18uc procedure and endoscopy C+10,)1++D, An the present study, a series of +0 patients 3ith ma;illary sinus mucoceles is reported, "he pathogenesis, clinical presentation, endoscopic surgical treatment and differential diagnosis of ma;illary mucocele 3ith other cystic e;pansile masses of the ma;illa and need for revision surgery 3ith revie3 of the literature is discussed,

$et%ods
"his study is a retrospective revie3 of +0 patients 3ith ma;illary sinus mucoceles treated at the Department of Otorhinolaryngology in Baskent University !dana "eaching and 4esearch Medical #enter $et3een &''= and &''>, Mucocele 3as defined in this study as a completely opacified ma;illary sinus 3ith evidence of e;pansion and.or $one erosion, "he diagnosis 3as $ased on physical e;amination, including nasal endoscopy, computed tomography 9#": and histopathologic findings, Only patients 3hose findings on histopathological study of the surgical specimen confirmed the preoperative diagnosis 3ere included in the present study, "he medical records 3ere revie3ed for patient demographics, presenting symptoms, preoperative #" findings, e;tent of operation, resolution of symptoms and need for revision surgery, Follo31up ranged from - to 0- months, "he surgical outcome 3as $ased on the patency of the middle meatal antrostomy, appearance of ma;illary sinus mucosa, resolution or persistence of presenting symptoms and need for revision surgery,

&esults
"here 3ere - males and ( females ranging from +0 to (> years, "3o patients had $ilateral, ( patients had left and ( patients had right ma;illary sinus mucoceles, On presentation, cheek pressure or pain 3as reported in > patients, nasal drainage in >, nasal o$struction or congestion in +', An addition, one patient had proptosis of the eye and cheek s3elling, He had no pro$lem 3ith his vision and mo$ility of the or$it in any direction, Four patients had history of endoscopic ethmoidectomy surgery for ethmoid sinusitis, One patient had #ald3ell18uc operation in the past, None of the patients had history of trauma and environmental allergy, Five patients had history of medical treatment for chronic sinusitis,

5reoperative #" imaging of the paranasal sinuses 3as performed in all patients, An all of them, completely opacified ma;illary sinuses 3ith homogenous cyst1like lesions 3ere seen and natural ostiums 3ere all o$structed causing the e;pansion of the sinuses 9Fig +, &, =:, "here 3as $ulging of the medial 3all of the ma;illary sinus in three patients, eroding the superior 3all and $ulging into the or$it in one patient, !nd four patients had mucosal thickening of the ethmoid sinuses, Figure '( #" scan sho3ing right opacified ma;illary sinus 3ith medial $ulging causing e;pansion of the sinus and o$struction of the right nasal cavity, Figure ( 4ight ma;illary mucocele eroding superior 3all of the sinus causing eye proptosis and cheek s3elling, Figure )( 4ight ma;illary mucocele causing $ulging of the uncinate process, !ll the patients under3ent endoscopic ethmoidectomy, middle meatal antrostomy and marsupiali@ation 3ith drainage of the mucocele, "he contents of the mucocele are evacuated 3ith a curved ma;illary sinus suction 3ithout the need to totally remove the mucocele lining, Histopathological reports revealed as mucocele lined 3ith pseudostratified columnar epithelium, "here 3ere no intraoperative or postoperative complications, Follo31up ranged from - to 0- months, !ll patients reported resolution of their symptoms and no patient re%uired revision surgery, !t the last follo31up visit the middle meatal antrostomy 3as noted to $e patent and the ma;illary sinus mucosa 3as o$served as normal in all patients 9"a$le +:, *a"le '( 5atient #haracteristics

+iscussion
Mucoceles of the paranasal sinuses are $enign, cyst1like, e;pansile lesions lined 3ith a secretory respiratory mucosa of pseudostratified columnar epithelium C+,&D, "hey are mucoid filled masses and develop after o$struction of the sinus ostium and drainage pattern, 3hich is confirmed $y the high incidence of mucoceles in the frontal sinus caused $y the variations of the nasofrontal duct C(,)D, Mucoceles gro3 slo3ly, 8und and Milroy proposed that the o$struction to sinus outflo3 in com$ination 3ith superimposed infection caused the release of cytokines from lymphocytes and monocytes, "he cytokine release 3ould stimulate fi$ro$lasts

to secrete prostoglandins and collagenases, 3hich in turn could stimulate $one resorption leading to e;pansion of the mucocele C+&D, Ma;illary sinus mucoceles are relatively rare accounting for less than +'B of paranasal sinus mucoceles, "here are numerous theories a$out origin and development of ma;illary sinus mucoceles, such as chronic infection, allergic sinonasal disease, trauma, previous surgery and in some cases cause remains uncertain, "hey are more prevalent in Eapan, 3here it is usually reported follo3ing #ald3ell18uc ma;illary sinusectomy C+,&,)D, Mucoceles that develop follo3ing #ald3ell18uc operations are presumed to form as a result of entrapped sinus mucosa, !lthough one of the theories a$out development of mucocele is chronic infection, Busa$a et al, compared the $acteriology of ma;illary sinus mucoceles to chronic sinusitis and reported that the data do not support infection as the main origin of nontraumatic ma;illary sinus mucocele C+=D, 5atients 3ith chronic sinusitis are treated 3ith oral anti$iotics preoperatively as in our patient group, During the postoperative period, they are follo3ed up for any symptom and.or need for revision surgery, An our series, > patients 9=(B: had previous surgery 9one #ald3ell18uc and 0 endoscopic ethmoid surgery:, $esides this ) patients 9(0B: had no kno3n pathology to cause ma;illary mucocele formation, Mucoceles of the ma;illary sinus have $een reported previously in the ma;illofacial literature C+01+/D, "he symptoms of mucoceles are related to their e;pansion and su$se%uent pressure on and o$struction of surrounding anatomic structures, !ntral mucoceles are commonly reported to present as painless $ulging of the cheek, Medial e;pansion of the 3all of the ma;illary sinus into the nasal cavity displaces the inferior tur$inate and causes the nasal o$struction C+-D, uperior e;pansion of the antrum into the inferior or$it can cause displacement of the or$ital contents and visual changes, Do3n3ard displacement into the area of the alveolus can even cause a loosening of teeth C/1)D, "he diagnosis of mucocele is made on the $asis of symptoms, imaging and surgical e;ploration and histological confirmation, "he most informative radiologic evaluation is computed tomography, #" scan 3ill sho3 mucocele as a homogenous lesion, 3hich is isodense 3ith $rain and no contrast enhancement, unless infected C+,>,+)D, "here are smooth clear1cut margins of $one erosions occurring in the sinus 3alls, An contrast, in malignancy the mass is likely to $e irregular in shape, 3ith erosion or destruction of the sinus 3alls, infiltration into the surrounding soft tissues and irregular margins of $one a$sorption, Magnetic resonance imaging is $est reserved for mucocele formation secondary to sinonasal tumors in 3hich lining mem$rane of the mucocele 3ill enhance after intravenous contrast C>,+/D, <hen the e;pansion and $one destruction are present the differential diagnosis includes $enign and malignant lesions of the paranasal sinuses, Benign lesions include neurofi$roma7 dermoid,

epidermoid, cementifying fi$roma7 angiofi$roma7 inverting papilloma and cylindrinoma, Malignant lesions include adenoid cystic carcinoma, plasmocytoma, em$ryonal rha$domyosarcoma, lymphoma, sch3annoma and tumours of dental origin C>,)D, An the a$sence of $one erosion, mucoceles must $e differentiated from several conditions, including retention cysts, chronic sinusitis, antrachoanal polyp and polyposis of the paranasal cavities C=,>,)D, 4etention cysts are common in the ma;illary sinus and may $e found on imaging studies in appro;imately )B of the population, "hey are thought to form due to o$struction of the ducts of seromucous glands in the sinus lining, 3hich results in an epithelium1lined cyst containing mucous or serous fluid, "hey develop under mucous mem$rane of the sinus that e;plains 3hy they are so thin13alled, 4adiographically, the cyst is a rounded, dome1shaped, soft tissue mass, most commonly situated on the flor of the ma;illary sinus7 it often contains clear, yello3ish fluid, Mucoceles are associated 3ith o$struction of the duct or natural ostium of any of the paranasal sinuses and gro3 under the periosteum, 5eriosteum contri$utes to construction of cystic 3all, as a result 3all of mucocele $ecomes thick and tough, "he gro3ing site of the mucocele is under the periosteum, 3hereas retention cysts gro3 under the mucosa of the sinus, "his e;plains thatFs 3hy retention cysts are non1e;panding, 3ell circumscri$ed, mucosa covered masses, 3hereas mucoceles e;hi$it an osteolytic capacity 3ith a tendency to e;pand along the path of least resistance C=,>,+/,&',&+D, !ntrachoanal polyp is thought to represent hypertrophic ma;illary sinus mucosa herniating into the nasal cavity through the natural or accessory ostia, Nasal o$struction is the most common presenting symptom and radiographically appears as an opacity of the involved sinus, "hey never erode $one C=,)D, Nasal polyps can $e single or multiple and may $e located in the sinus cavity or the nasal vault, "hey can cause e;pansion of the nasal cavity, $ut do not cause $ony erosion C)D, "he management of ma;illary sinus mucoceles is surgical, Historically, the recommended treatment is complete e;cision through an open approach that entails #ald3ell18uc sinusectomy, inferior nasoantral 3indo3 and removal of the mucocele lining, An cases in 3hich significant e;tension of the mucocele into the facial soft tissues is found, an open approach seems 3arrented, An cases in 3hich the mucocele is limited to the sinus or e;tends into the or$it or ethmoid sinus, endoscopic surgery to evacuate the mucocele contents and aerate.drain the mucocele cavity through a 3ide middle meatal antrostomy is a relia$le intervention modality C+,&,+',++D,

Conclusion
"here are numerous theories a$out origin and development of ma;illary sinus mucoceles, such as chronic infection, allergic sinonasal disease, trauma and previous

surgery, But, as in our series 3hich is (0B of the patients, cause remains uncertain, "he diagnosis is usually made $y #" imaging of the paranasal sinuses, ?ndoscopic sinus surgery is an effective treatment modality for ma;illary sinus mucocele 3ith favora$le long1term outcome,

Competing interests
"he author9s: declare that they have no competing interests,

Aut%ors, contri"utions
F# has drafted, prepared the design of the study and the manuscript, HG and #!# carried out the revie3 of the patientsF medical records and participated in design of the study, 8NO 3as involved in revising the article for intellectual content details, !ll authors read and approved the final manuscript,