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Nasal septal cyst: A rare phenomenon
Auris Nasus Larynx 36 (2009) 96–99 www.elsevier.com/locate/anl
Nasal septal cyst: A rare phenomenon A.C. Leong *, H.R. Sharp Department of Otorhinolaryngology – Head and Neck Surgery, William Harvey Hospital, Ashford, Kent TN24 0LZ, United Kingdom Received 11 October 2007; accepted 19 May 2008 Available online 7 July 2008
Abstract Introduction: Well-recognized complications of nasal septal surgery i.e. septoplasty or submucous resection (SMR), include septal haematoma, infection, septal perforation and external nasal deformity. Nasal septal cysts are extremely rare in rhinology. Objectives: To discuss the underlying aetiological theories, management and strategies for prevention of this very rare complication of a commonly performed rhinological procedure such as SMR. Case report: We describe a case of a nasal septal cyst several years after an SMR had been performed, which was excised using an open rhinoplasty approach that has not previously been described for this purpose. Conclusion: Entrapment of free nasal mucosal remnants or inward folding of incised septal mucosa in the submucosal space is postulated as the cause of this phenomenon, leading to the development of this type of ‘‘inclusion’’ cyst. Postoperative nasal packing, especially if traumatic, may exacerbate this. We recommend that anterior nasal packing should be used only if necessary, and packs inserted with care, possibly under endoscopic guidance. # 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Nasal septal cyst; Septoplasty; Nasal packing
1. Introduction Submucous resection (SMR), first described by Freer and Killian in 1902, is widely performed to manage deviation of the nasal septum in symptomatic patients, as it is relatively easy to perform and provides satisfactory results. The complication rate is low but may include septal haematoma and subsequent abscess, septal perforation and nasal deformity. Cyst formation in the nasal septum is a very rare phenomenon in rhinological practice. We present a case which occurred 10 years after the original SMR procedure.
2. Case report A 43-year old male presented with a 4-month history of progressive headaches and bilateral nasal obstruction. * Corresponding author. Tel.: +44 1233 633331x86234; fax: +44 1277 864135. E-mail address: [email protected] (A.C. Leong).
Rhinologic examination revealed a large, smooth-surfaced mass occluding the right nasal passage. Ten years previously, the patient had undergone SMR, which was followed by 24 h of postoperative nasal packing with bismuth iodoform paraffin paste (BIPP)-impregnated ribbon gauze. As traditionally performed by otolaryngologists in the United Kingdom, BIPP packing was inserted with the help of a pair of Tilley’s forceps and Thudicum’s nasal speculum, as a continuous piece in gradually decreasing lengths along the floor of the nose in stepwise fashion until the nasal passage was securely filled. Ten days following surgery, he was readmitted with severe epistaxis due to secondary infection, which required repeat bilateral nasal packing with BIPP gauze and the administration of intravenous antibiotics. The packs were removed after 72 h and the patient discharged without obvious short-term consequences. Nasal examination at outpatient follow-up 6 weeks later was reported as unremarkable and the patient discharged from further ENT review. At the time of re-presentation, an MRI scan showed a large cystic mass in the right nasal passage without any intracranial
0385-8146/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2008.05.006
A.C. Leong, H.R. Sharp / Auris Nasus Larynx 36 (2009) 96–99
97
Fig. 2. (a) CT (axial) shows an isodense nasal mass originating from the right side of the nasal septum and bowing the underlying cartilage in a convex fashion into the left nasal passage. No bony erosion is seen. Paranasal sinuses were clear and (b) CT shows the septal mass filling the right nasal passage in the coronal plane. Fig. 1. (a) MRI (T1-weighted sagittal) shows a septal mass with low signal intensity (arrow) and (b) MRI (T2-weighted axial) shows a mass of high signal intensity, filling the right nasal passage, compatible with a nasal septal cyst (arrow).
communication (Fig. 1a and b). The CT scan revealed that the cystic mass originated from the nasal septum, and was confined to the right side of the cartilaginous septum, with the underlying cartilage bowed in a convex manner into the left nasal passage (Fig. 2a and b). An open rhinoplasty approach was used to excise the septal cyst. This involved a small stairstep columellar incision with separation of the medial crura of the alar cartilages, subsequent elevation of the columellar flap and careful dissection onto the anterior septal margin. During subperichondrial dissection into the anterior
portion of the quadrate cartilage, the cyst ruptured due to its extremely thin wall containing fluid under pressure. Brown mucoid content was aspirated. The remaining cystic structure was extirpated as one specimen (Fig. 3) by dissecting the cystic wall away from the underlying concave septal cartilage, and dividing the upper lateral cartilages from the dorsal septum to allow complete circumferential visualization and dissection around the cyst. The quadrate cartilage was largely intact despite the quoted nature of the previous surgery, with only a small deficiency in the inferior cartilage and without evidence of a septal perforation. No nasal packing was required, but silastic splints were inserted to promote mucosal healing.
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A.C. Leong, H.R. Sharp / Auris Nasus Larynx 36 (2009) 96–99
Fig. 3. The nasal septal cyst after excision.
Histopathological examination revealed that the cystic wall consisted of respiratory epithelium with chronically inflamed granulation tissue and keratin. Bacterial culture was negative. The patient made a good immediate postoperative recovery, and the silastic splints were removed at 1 week. At 6 months’ follow-up, there was a well-healed mucosal surgical site without any sign of recurrence. The patient also reports that his headaches have completely resolved since the cyst was excised.
3. Discussion While nasal dorsal cysts and mucocoeles of the septum have been described after rhinoplasty, [1,2] nasal septal cysts occurring after SMR are extremely rare. It would appear unlikely for the straightforward procedure of an uncomplicated submucous resection to be the only contributor to the pathogenesis of a nasal septal cyst, especially in view of the fact that the phenomenon of nasal septal cyst is so rare. If the surgical procedure was the culprit, then nasal septal cyst would be expectedly more common. Only two other cases have been reported in the literature: the first required deroofment by lateral rhinotomy, which resulted in cyst rupture; while the second had a pre-existing septal perforation, and was excised via an endoscopic approach only after aspiration of cystic fluid made it possible for endoscopic access [3,4]. Employing an open rhinoplasty approach in our case has not previously been described to remove a nasal septal cyst. It provides a more cosmetic alternative to lateral rhinotomy, while facilitating access to the entire cystic structure under direct vision. One possible explanation for nasal septal cyst formation is that chronic rhinitis may stimulate the mucosal epithelium of the postoperative septal space to undergo cystic degeneration [3]. However, entrapment of free nasal mucosal remnants or inward folding of incised septal
mucosa in the postoperative septal space is postulated to be the more likely cause, leading to the development of an ‘‘inclusion’’ or ‘‘retention’’ cyst phenomenon. Both theories may explain the relatively long interval between the original SMR surgery and re-presentation, as the accumulation of secretions within the blocked postoperative septal space gradually leads to the formation and expansion of a cyst. The act of sneezing leading to herniation of nasal mucosa into the subcutaneous space has been suggested to explain nasal dorsal cyst formation after rhinoplasty, and perhaps a similar mechanism of mucosal implantation exists with nasal septal cyst development after SMR [5]. However, if so, then one would expect nasal cyst formation after SMR to be more common. The characteristics of a nasal septal cyst are thought to be more similar to those of a postoperative maxillary cheek cyst after a Caldwell-Luc operation, with both entities consisting of respiratory epithelium and developing as a delayed complication many years after the original surgery [6]. Residual mucosa, antral haematoma and postoperative infection are important factors in the formation of postoperative cheek cyst. We postulate that the action of postoperative nasal packing, especially if traumatic, may inadvertently exacerbate the entrapment of free mucosal remnants in the submucosal space, precipitating the development of an ‘‘inclusion’’ cyst. Although the use of nasal packing was not clarified in the first reported case, the original surgery in the second case was complicated by postoperative epistaxis requiring repeated nasal packing, specifically with BIPP [3,4], and our case also involved several episodes of postoperative nasal packing. The bismuth constituent of BIPP itself may have a contributory role in the pathogenesis of nasal septal cyst as it has been reported to cause allergic hypersensitivity reactions, albeit in ear surgery, [7] which may have incited a further degree of inflammation of these entrapped mucosal remnants. In addition, BIPP has the potential to initiate a foreign body reaction which may result in giant cell granuloma formation [8]. The differential diagnosis of a nasal septal cyst includes haematoma and abscess of the nasal septum, and congenital midline masses, such as nasal dermoid cysts, meningoencephaloceles and gliomas. Septal haematoma and abscess are usually preceded by a history of recent trauma or surgery, and their contents are obviously different. Although dermoid cysts are rare and commonly present as external nasal masses visible in early childhood, some may present intranasally with intracranial communication. Other rare tumours such as minor salivary tumours (i.e. pleomorphic adenoma) and schwannoma may also present in the nasal septum. Therefore preoperative assessment with CT and MRI is mandatory to ascertain the possibility of intracranial involvement, as well as to evaluate bony erosion and nature of contents within the mass. In view of the likely aetio-pathology, nuances of surgical technique during septal surgery are worth re-evaluation. Strategies involve keeping the mucosal lining intact,
A.C. Leong, H.R. Sharp / Auris Nasus Larynx 36 (2009) 96–99
meticulously removing all free mucosal debris from the operative site and ensuring that the incised septal mucosa does not fold inwards. The use of carefully placed septal quilting, as well as through-and-through mucosal apposition sutures in the event of tears in the mucosal flaps, may augment this process. Finally, anterior nasal packing should be used only if necessary, and packs inserted with care, possibly under endoscopic guidance.
References [1] Holt GR, Garner ET, McLarey D. Postoperative sequelae and complications of rhinoplasty. Otolaryngol Clin North Am 1987;20:853–76.
99
[2] Romo 3rd T, Rizk SS, Suh GD. Mucous cyst formation after rhinoplasty. Arch Facial Plast Surg 1999;1:208–11. [3] Chiang CH, Juan KH, Kuo WR, Tai CF, Wu JR. Nasal septal cyst—a case report. Kaohsiung J Med Sci 1996;12:256–9. [4] Cincik H, Gungor A, Mutlu H, Cekin E. Nasal septal cyst: a case report. Kulak Burun Bogaz Ihtis Derg 2006;16:87–90. [5] McGregor M, O’Connor GB, Saffier S. Complications of rhinoplasty. I. Skin and subcutaneous tissues. J Int Coll Surg 1958;30:179–85. [6] Kaneshiro S, Nakajima T, Yoshikawa Y, Iwasaki H, Tokiwa N. The postoperative maxillary cyst: report of 71 cases. J Oral Surg 1981;39:191–8. [7] Lim P, Hughes R, Oates J. Hypersensitive allergic reactions to bismuth iodoform paraffin paste following ear surgery. J Laryngol Otol 1998;112:335–7. [8] Miller W, Ripley JF. Foreign body potential of the consitituents of BIPP: an analysis. Br Dent J 1974;137:278.
Nasal septal cyst: A rare phenomenon A.C. Leong *, H.R. Sharp Department of Otorhinolaryngology – Head and Neck Surgery, William Harvey Hospital, Ashford, Kent TN24 0LZ, United Kingdom Received 11 October 2007; accepted 19 May 2008 Available online 7 July 2008
Abstract Introduction: Well-recognized complications of nasal septal surgery i.e. septoplasty or submucous resection (SMR), include septal haematoma, infection, septal perforation and external nasal deformity. Nasal septal cysts are extremely rare in rhinology. Objectives: To discuss the underlying aetiological theories, management and strategies for prevention of this very rare complication of a commonly performed rhinological procedure such as SMR. Case report: We describe a case of a nasal septal cyst several years after an SMR had been performed, which was excised using an open rhinoplasty approach that has not previously been described for this purpose. Conclusion: Entrapment of free nasal mucosal remnants or inward folding of incised septal mucosa in the submucosal space is postulated as the cause of this phenomenon, leading to the development of this type of ‘‘inclusion’’ cyst. Postoperative nasal packing, especially if traumatic, may exacerbate this. We recommend that anterior nasal packing should be used only if necessary, and packs inserted with care, possibly under endoscopic guidance. # 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Nasal septal cyst; Septoplasty; Nasal packing
1. Introduction Submucous resection (SMR), first described by Freer and Killian in 1902, is widely performed to manage deviation of the nasal septum in symptomatic patients, as it is relatively easy to perform and provides satisfactory results. The complication rate is low but may include septal haematoma and subsequent abscess, septal perforation and nasal deformity. Cyst formation in the nasal septum is a very rare phenomenon in rhinological practice. We present a case which occurred 10 years after the original SMR procedure.
2. Case report A 43-year old male presented with a 4-month history of progressive headaches and bilateral nasal obstruction. * Corresponding author. Tel.: +44 1233 633331x86234; fax: +44 1277 864135. E-mail address: [email protected] (A.C. Leong).
Rhinologic examination revealed a large, smooth-surfaced mass occluding the right nasal passage. Ten years previously, the patient had undergone SMR, which was followed by 24 h of postoperative nasal packing with bismuth iodoform paraffin paste (BIPP)-impregnated ribbon gauze. As traditionally performed by otolaryngologists in the United Kingdom, BIPP packing was inserted with the help of a pair of Tilley’s forceps and Thudicum’s nasal speculum, as a continuous piece in gradually decreasing lengths along the floor of the nose in stepwise fashion until the nasal passage was securely filled. Ten days following surgery, he was readmitted with severe epistaxis due to secondary infection, which required repeat bilateral nasal packing with BIPP gauze and the administration of intravenous antibiotics. The packs were removed after 72 h and the patient discharged without obvious short-term consequences. Nasal examination at outpatient follow-up 6 weeks later was reported as unremarkable and the patient discharged from further ENT review. At the time of re-presentation, an MRI scan showed a large cystic mass in the right nasal passage without any intracranial
0385-8146/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2008.05.006
A.C. Leong, H.R. Sharp / Auris Nasus Larynx 36 (2009) 96–99
97
Fig. 2. (a) CT (axial) shows an isodense nasal mass originating from the right side of the nasal septum and bowing the underlying cartilage in a convex fashion into the left nasal passage. No bony erosion is seen. Paranasal sinuses were clear and (b) CT shows the septal mass filling the right nasal passage in the coronal plane. Fig. 1. (a) MRI (T1-weighted sagittal) shows a septal mass with low signal intensity (arrow) and (b) MRI (T2-weighted axial) shows a mass of high signal intensity, filling the right nasal passage, compatible with a nasal septal cyst (arrow).
communication (Fig. 1a and b). The CT scan revealed that the cystic mass originated from the nasal septum, and was confined to the right side of the cartilaginous septum, with the underlying cartilage bowed in a convex manner into the left nasal passage (Fig. 2a and b). An open rhinoplasty approach was used to excise the septal cyst. This involved a small stairstep columellar incision with separation of the medial crura of the alar cartilages, subsequent elevation of the columellar flap and careful dissection onto the anterior septal margin. During subperichondrial dissection into the anterior
portion of the quadrate cartilage, the cyst ruptured due to its extremely thin wall containing fluid under pressure. Brown mucoid content was aspirated. The remaining cystic structure was extirpated as one specimen (Fig. 3) by dissecting the cystic wall away from the underlying concave septal cartilage, and dividing the upper lateral cartilages from the dorsal septum to allow complete circumferential visualization and dissection around the cyst. The quadrate cartilage was largely intact despite the quoted nature of the previous surgery, with only a small deficiency in the inferior cartilage and without evidence of a septal perforation. No nasal packing was required, but silastic splints were inserted to promote mucosal healing.
98
A.C. Leong, H.R. Sharp / Auris Nasus Larynx 36 (2009) 96–99
Fig. 3. The nasal septal cyst after excision.
Histopathological examination revealed that the cystic wall consisted of respiratory epithelium with chronically inflamed granulation tissue and keratin. Bacterial culture was negative. The patient made a good immediate postoperative recovery, and the silastic splints were removed at 1 week. At 6 months’ follow-up, there was a well-healed mucosal surgical site without any sign of recurrence. The patient also reports that his headaches have completely resolved since the cyst was excised.
3. Discussion While nasal dorsal cysts and mucocoeles of the septum have been described after rhinoplasty, [1,2] nasal septal cysts occurring after SMR are extremely rare. It would appear unlikely for the straightforward procedure of an uncomplicated submucous resection to be the only contributor to the pathogenesis of a nasal septal cyst, especially in view of the fact that the phenomenon of nasal septal cyst is so rare. If the surgical procedure was the culprit, then nasal septal cyst would be expectedly more common. Only two other cases have been reported in the literature: the first required deroofment by lateral rhinotomy, which resulted in cyst rupture; while the second had a pre-existing septal perforation, and was excised via an endoscopic approach only after aspiration of cystic fluid made it possible for endoscopic access [3,4]. Employing an open rhinoplasty approach in our case has not previously been described to remove a nasal septal cyst. It provides a more cosmetic alternative to lateral rhinotomy, while facilitating access to the entire cystic structure under direct vision. One possible explanation for nasal septal cyst formation is that chronic rhinitis may stimulate the mucosal epithelium of the postoperative septal space to undergo cystic degeneration [3]. However, entrapment of free nasal mucosal remnants or inward folding of incised septal
mucosa in the postoperative septal space is postulated to be the more likely cause, leading to the development of an ‘‘inclusion’’ or ‘‘retention’’ cyst phenomenon. Both theories may explain the relatively long interval between the original SMR surgery and re-presentation, as the accumulation of secretions within the blocked postoperative septal space gradually leads to the formation and expansion of a cyst. The act of sneezing leading to herniation of nasal mucosa into the subcutaneous space has been suggested to explain nasal dorsal cyst formation after rhinoplasty, and perhaps a similar mechanism of mucosal implantation exists with nasal septal cyst development after SMR [5]. However, if so, then one would expect nasal cyst formation after SMR to be more common. The characteristics of a nasal septal cyst are thought to be more similar to those of a postoperative maxillary cheek cyst after a Caldwell-Luc operation, with both entities consisting of respiratory epithelium and developing as a delayed complication many years after the original surgery [6]. Residual mucosa, antral haematoma and postoperative infection are important factors in the formation of postoperative cheek cyst. We postulate that the action of postoperative nasal packing, especially if traumatic, may inadvertently exacerbate the entrapment of free mucosal remnants in the submucosal space, precipitating the development of an ‘‘inclusion’’ cyst. Although the use of nasal packing was not clarified in the first reported case, the original surgery in the second case was complicated by postoperative epistaxis requiring repeated nasal packing, specifically with BIPP [3,4], and our case also involved several episodes of postoperative nasal packing. The bismuth constituent of BIPP itself may have a contributory role in the pathogenesis of nasal septal cyst as it has been reported to cause allergic hypersensitivity reactions, albeit in ear surgery, [7] which may have incited a further degree of inflammation of these entrapped mucosal remnants. In addition, BIPP has the potential to initiate a foreign body reaction which may result in giant cell granuloma formation [8]. The differential diagnosis of a nasal septal cyst includes haematoma and abscess of the nasal septum, and congenital midline masses, such as nasal dermoid cysts, meningoencephaloceles and gliomas. Septal haematoma and abscess are usually preceded by a history of recent trauma or surgery, and their contents are obviously different. Although dermoid cysts are rare and commonly present as external nasal masses visible in early childhood, some may present intranasally with intracranial communication. Other rare tumours such as minor salivary tumours (i.e. pleomorphic adenoma) and schwannoma may also present in the nasal septum. Therefore preoperative assessment with CT and MRI is mandatory to ascertain the possibility of intracranial involvement, as well as to evaluate bony erosion and nature of contents within the mass. In view of the likely aetio-pathology, nuances of surgical technique during septal surgery are worth re-evaluation. Strategies involve keeping the mucosal lining intact,
A.C. Leong, H.R. Sharp / Auris Nasus Larynx 36 (2009) 96–99
meticulously removing all free mucosal debris from the operative site and ensuring that the incised septal mucosa does not fold inwards. The use of carefully placed septal quilting, as well as through-and-through mucosal apposition sutures in the event of tears in the mucosal flaps, may augment this process. Finally, anterior nasal packing should be used only if necessary, and packs inserted with care, possibly under endoscopic guidance.
References [1] Holt GR, Garner ET, McLarey D. Postoperative sequelae and complications of rhinoplasty. Otolaryngol Clin North Am 1987;20:853–76.
99
[2] Romo 3rd T, Rizk SS, Suh GD. Mucous cyst formation after rhinoplasty. Arch Facial Plast Surg 1999;1:208–11. [3] Chiang CH, Juan KH, Kuo WR, Tai CF, Wu JR. Nasal septal cyst—a case report. Kaohsiung J Med Sci 1996;12:256–9. [4] Cincik H, Gungor A, Mutlu H, Cekin E. Nasal septal cyst: a case report. Kulak Burun Bogaz Ihtis Derg 2006;16:87–90. [5] McGregor M, O’Connor GB, Saffier S. Complications of rhinoplasty. I. Skin and subcutaneous tissues. J Int Coll Surg 1958;30:179–85. [6] Kaneshiro S, Nakajima T, Yoshikawa Y, Iwasaki H, Tokiwa N. The postoperative maxillary cyst: report of 71 cases. J Oral Surg 1981;39:191–8. [7] Lim P, Hughes R, Oates J. Hypersensitive allergic reactions to bismuth iodoform paraffin paste following ear surgery. J Laryngol Otol 1998;112:335–7. [8] Miller W, Ripley JF. Foreign body potential of the consitituents of BIPP: an analysis. Br Dent J 1974;137:278.