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Nasal septal mucocele in a child: A rare presentation
International Journal of Pediatric Otorhinolaryngology Extra 6 (2011) 414–415
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology Extra journal homepage: www.elsevier.com/locate/ijporl
Case report
Nasal septal mucocele in a child: A rare presentation M. Sinan Yilmaz *, Mehmet Guven, Mehmet Dicle Ministry of Health Sakarya Training and Research Hospital, Department of ORL, Adapazari, Sakarya, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 April 2011 Received in revised form 20 June 2011 Accepted 24 June 2011 Available online 23 July 2011
Paranasal sinus mucocele is a benign cystic lesions that usually affects adults and mostly occurs in the fronto-ethmoidal sinuses. It is very rare in children. Mucocele of the nasal septum is extremely rare. We report second case of septum mucocele in the literature occured in a 13-year-old boy presenting with bilateral nasal obstruction. The literature is reviewed. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric sinus mucoceles Nasal septum Endoscopic surgery
1. Introduction Mucoceles, which can pathologically be defined as encapsulated, mucoid filled masses, are benign, expansile chronic cystic lesions of the paranasal sinuses. It generally takes many years for them to become symptomatic. These lesions are thought to be secondary to an obstruction of the sinus ostium caused by an inflammation, trauma, fibrosis, previous surgery [1,2]. They are mostly seen in adults. In children, paranasal sinus mucoceles are rare and are thought to be related to cystic fibrosis [3–5]. Symptoms of the paranasal sinus mucoceles may vary depending on the size and location of the mucocele. Frontal sinus and ethmoid sinuses are the most frequent locations. They are seen rarely in the maxillary and sphenoid sinuses [1,2]. To our knowledge, there is only one reported case of a mucocele of the nasal septum in the literature [6] and we present the first case of a mucocele of the nasal septum occured in a child. 2. Case report A 13-year-old boy admitted to our clinic with one year history of bilateral nasal obstruction. He also reported nasal pain and headache. He had no smell disorders and denied any visual symptoms. He had no history of major maxillofacial trauma and nasal surgery. Anterior rhinoscopy revealed bilateral septal swelling prominently left septal valve region and maxillary crest lead to septum deviation to the right side. On his nasoendoscopic examination bilateral septal swelling that was more prominent on the left side and minimal adenoid
* Corresponding author at: Seker Mah. 884. Sok. No: 15/4 Adapazari, Sakarya, Turkey. Tel.: +9 02642817558; fax: +9 02642552105. E-mail address: [email protected] (M. Sinan Yilmaz). 1871-4048/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2011.06.004
hypertrophy detected. The rest of the otolaryngologic examination including cranial nerve examination and ophthalmic examination was normal. Computed tomography (CT) (Fig. 1) and magnetic resonance imaging (MRI) (Figs. 2 and 3) showed a large midline septal mass without intracranial extension. The patient underwent endoscopic drainage and total excision of the septal mucocele and endoscopic mini-septoplasty under general anaesthesia. There were no remnants of cartilage or bony septum identified within the septal mucocele. The mucocele was filled with mucoid fluid and there were no evidence of infection. The diagnosis of a mucocele was comfirmed histologically. After removing the nasal packings the patient was discharged 48 h postoperatively. He was symptom free over the next six months and there were no evidence of recurrence. 3. Discussion A mucocele is an epithelial-lined mucus-containing sac which fills a paranasal sinus. It can expand by bone resorption and new bone formation [1]. A mucocele is distinguished from a blocked sinus filled with trapped mucus by the dynamic process at the interface of the epithelium and bone [7]. It is generally caused by prior surgery of the paranasal sinus leading postoperatively to scarred occlusion of the ostium. Other predisposing factors are chronic sinusitis, craniofacial trauma, benign tumors and allergic rhinitis [3,8]. Paranasal sinus mucocele is a benign cystic lesions that usually affects adults. It is very rare in children. In the literature, it has been suggested that pediatric mucoceles occur predominantly in patients with cystic fibrosis [3–5] although some reports challenge this view. In Hartley and Lund’s series, no cystic fibrosis was diagnosed in seven patients and in Sciarretta et al.’s series none of the three patients was affected by cystic fibrosis [7,9]. In our case cystic fibrosis was not diagnosed.
M. Sinan Yilmaz et al. / International Journal of Pediatric Otorhinolaryngology Extra 6 (2011) 414–415
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Fig. 3. Magnetic resonance imaging coronal view showing a mass within the nasal septum.
Fig. 1. Coronal computed tomographic scan showing mucocele of the nasal septum.
intraseptal abscess should be considered. Radiological imaging techniques and nasoendoscopy are very useful in the differential diagnosis and management of the disease. The CT scan provides the surgeon with important information about the local bony anatomy which can be used in pre-operative planning. Paranasal sinus mucoceles can be differentiated from paranasal sinus tumors, soft tissue and dural inflammation visible on MRI [11]. Our patient underwent successful endonasal endoscopic surgery. Because of the lack of facial scarring and good results with minimal morbidity, this technique is deemed to be ideal for children and adolescents. Moreover this technique allows the operation to be performed under direct visualisation with minimum mucosal trauma and bleeding [2,12]. In conclusion, mucoceles are benign cystic lesions occurring in the paranasal sinuses that usually affects adults. It is very rare in children. They appear in uncommon locations of the facial skeleton rarely. We present a case of idiophatic nasal septal mucocele in a child which is not previously reported. Conflict of interest
Fig. 2. Magnetic resonance imaging axial view showing a midline septal mass.
The authors do not have any financial and/or personal relationships with other people or organisations that could potentially influence the work inappropriately. References
The frontal sinus is the commonest site of the paranasal sinus mucoceles (60 percent). It is followed by the ethmoid sinuses (30 percent). Only 10 per cent are found in the maxillary sinuses and rarely localized to the sphenoid sinus. In the literature some less common and unusual sites for mucoceles were reported. In their article Arrue et al. described mucoceles of the pterygomaxillary space, orbital floor, root of the nose and middle turbinate in a concha bullosa [10]. Up to date there is only one case of mucocele of the nasal septum occured as a result of patient’s previous nasal surgery was reported by Gall and Witterick [6]. To our knowledge this is second case of mucocele of the nasal septum and is the first case which is seen in a child. Furthermore in our case, there were no predisposing factor. Etiology of septal mucocele of our case is unclear. He had no history of previous nasal surgery, major craniofacial trauma or cystic fibrosis. Since it is seen together with the septum deviation we concluded that it could develop because of previous minor facial traumas. Septal mucoceles are very rare and occur as a midline septal mass leading to nasal obstruction. In the differential diagnosis of a mass in this region dermoid cyst, encephalocele, meningocele or
[1] V.J. Lund, Milroy CM. fronto-ethmoidal mucoceles: a histopathological analysis, J. Laryngol. Otol. 105 (1991) 921–923. [2] G. Har-El, Endoscopic management of 108 sinus mucoceles, Laryngoscope 111 (2001) 2131–2134. [3] R. Nicollas, F. Facon, I. Sudre-Levillain, C. Forman, S. Roman, J.M. Triglia, Pediatric paranasal sinus mucoceles: etiologic factors, management and outcome, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 905–908. [4] M. Di Cicco, D. Costantini, R. Padoan, C. Colombo, Paranasal mucoceles in children with cystic fibrosis, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 1407–1413. [5] R.J. Alvarez, N.J. Liu, G. Isaacson, Pediatric ethmoid mucocele in cystic fibrosis: longterm follow-up of reported cases, Ear Nose Throat J. 76 (1997) 539–543. [6] R. Gall, I. Witterick, Mucocele of the nasal septum, J. Otolaryngol. 31 (2002) 246–247. [7] B.E.J. Hartley, V.J. Lund, Endoscopic drainage of pediatric paranasal sinus mucoceles, Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 109–111. [8] H. Olze, C. Matthias, P. Degenhardt, Paediatric paranasal sinus mucoceles, Eur. J. Pediatr. Surg. 16 (2006) 192–196. [9] V. Sciarretta, E. Pasquini, G. Farnetti, A.R. Ceroni, Endoscopic treatment of paranasal sinus mucoceles in children, Int. J. Pediatr. Otorhinolaryngol. 68 (2004) 955–960. [10] P. Arrue, M. Thorn Kany, E. Serrano, F. Lacroix, J. Percodani, E. Yardeni, J.J. Pessey, C. Manelfe, Mucoceles of the paranasal sinuses: uncommon location, J. Laryngol. Otol. 112 (1998) 840–844. [11] G. Lloyd, V.J. Lund, L. Savy, D. Howard, Optimum imaging for mucoceles, J. Laryngol. Otol. 114 (2000) 233–236. [12] V.J. Lund, Endoscopic management of paranasal sinus mucoceles, J. Laryngol. Otol. 112 (1998) 36–40.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology Extra journal homepage: www.elsevier.com/locate/ijporl
Case report
Nasal septal mucocele in a child: A rare presentation M. Sinan Yilmaz *, Mehmet Guven, Mehmet Dicle Ministry of Health Sakarya Training and Research Hospital, Department of ORL, Adapazari, Sakarya, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 April 2011 Received in revised form 20 June 2011 Accepted 24 June 2011 Available online 23 July 2011
Paranasal sinus mucocele is a benign cystic lesions that usually affects adults and mostly occurs in the fronto-ethmoidal sinuses. It is very rare in children. Mucocele of the nasal septum is extremely rare. We report second case of septum mucocele in the literature occured in a 13-year-old boy presenting with bilateral nasal obstruction. The literature is reviewed. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric sinus mucoceles Nasal septum Endoscopic surgery
1. Introduction Mucoceles, which can pathologically be defined as encapsulated, mucoid filled masses, are benign, expansile chronic cystic lesions of the paranasal sinuses. It generally takes many years for them to become symptomatic. These lesions are thought to be secondary to an obstruction of the sinus ostium caused by an inflammation, trauma, fibrosis, previous surgery [1,2]. They are mostly seen in adults. In children, paranasal sinus mucoceles are rare and are thought to be related to cystic fibrosis [3–5]. Symptoms of the paranasal sinus mucoceles may vary depending on the size and location of the mucocele. Frontal sinus and ethmoid sinuses are the most frequent locations. They are seen rarely in the maxillary and sphenoid sinuses [1,2]. To our knowledge, there is only one reported case of a mucocele of the nasal septum in the literature [6] and we present the first case of a mucocele of the nasal septum occured in a child. 2. Case report A 13-year-old boy admitted to our clinic with one year history of bilateral nasal obstruction. He also reported nasal pain and headache. He had no smell disorders and denied any visual symptoms. He had no history of major maxillofacial trauma and nasal surgery. Anterior rhinoscopy revealed bilateral septal swelling prominently left septal valve region and maxillary crest lead to septum deviation to the right side. On his nasoendoscopic examination bilateral septal swelling that was more prominent on the left side and minimal adenoid
* Corresponding author at: Seker Mah. 884. Sok. No: 15/4 Adapazari, Sakarya, Turkey. Tel.: +9 02642817558; fax: +9 02642552105. E-mail address: [email protected] (M. Sinan Yilmaz). 1871-4048/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2011.06.004
hypertrophy detected. The rest of the otolaryngologic examination including cranial nerve examination and ophthalmic examination was normal. Computed tomography (CT) (Fig. 1) and magnetic resonance imaging (MRI) (Figs. 2 and 3) showed a large midline septal mass without intracranial extension. The patient underwent endoscopic drainage and total excision of the septal mucocele and endoscopic mini-septoplasty under general anaesthesia. There were no remnants of cartilage or bony septum identified within the septal mucocele. The mucocele was filled with mucoid fluid and there were no evidence of infection. The diagnosis of a mucocele was comfirmed histologically. After removing the nasal packings the patient was discharged 48 h postoperatively. He was symptom free over the next six months and there were no evidence of recurrence. 3. Discussion A mucocele is an epithelial-lined mucus-containing sac which fills a paranasal sinus. It can expand by bone resorption and new bone formation [1]. A mucocele is distinguished from a blocked sinus filled with trapped mucus by the dynamic process at the interface of the epithelium and bone [7]. It is generally caused by prior surgery of the paranasal sinus leading postoperatively to scarred occlusion of the ostium. Other predisposing factors are chronic sinusitis, craniofacial trauma, benign tumors and allergic rhinitis [3,8]. Paranasal sinus mucocele is a benign cystic lesions that usually affects adults. It is very rare in children. In the literature, it has been suggested that pediatric mucoceles occur predominantly in patients with cystic fibrosis [3–5] although some reports challenge this view. In Hartley and Lund’s series, no cystic fibrosis was diagnosed in seven patients and in Sciarretta et al.’s series none of the three patients was affected by cystic fibrosis [7,9]. In our case cystic fibrosis was not diagnosed.
M. Sinan Yilmaz et al. / International Journal of Pediatric Otorhinolaryngology Extra 6 (2011) 414–415
415
Fig. 3. Magnetic resonance imaging coronal view showing a mass within the nasal septum.
Fig. 1. Coronal computed tomographic scan showing mucocele of the nasal septum.
intraseptal abscess should be considered. Radiological imaging techniques and nasoendoscopy are very useful in the differential diagnosis and management of the disease. The CT scan provides the surgeon with important information about the local bony anatomy which can be used in pre-operative planning. Paranasal sinus mucoceles can be differentiated from paranasal sinus tumors, soft tissue and dural inflammation visible on MRI [11]. Our patient underwent successful endonasal endoscopic surgery. Because of the lack of facial scarring and good results with minimal morbidity, this technique is deemed to be ideal for children and adolescents. Moreover this technique allows the operation to be performed under direct visualisation with minimum mucosal trauma and bleeding [2,12]. In conclusion, mucoceles are benign cystic lesions occurring in the paranasal sinuses that usually affects adults. It is very rare in children. They appear in uncommon locations of the facial skeleton rarely. We present a case of idiophatic nasal septal mucocele in a child which is not previously reported. Conflict of interest
Fig. 2. Magnetic resonance imaging axial view showing a midline septal mass.
The authors do not have any financial and/or personal relationships with other people or organisations that could potentially influence the work inappropriately. References
The frontal sinus is the commonest site of the paranasal sinus mucoceles (60 percent). It is followed by the ethmoid sinuses (30 percent). Only 10 per cent are found in the maxillary sinuses and rarely localized to the sphenoid sinus. In the literature some less common and unusual sites for mucoceles were reported. In their article Arrue et al. described mucoceles of the pterygomaxillary space, orbital floor, root of the nose and middle turbinate in a concha bullosa [10]. Up to date there is only one case of mucocele of the nasal septum occured as a result of patient’s previous nasal surgery was reported by Gall and Witterick [6]. To our knowledge this is second case of mucocele of the nasal septum and is the first case which is seen in a child. Furthermore in our case, there were no predisposing factor. Etiology of septal mucocele of our case is unclear. He had no history of previous nasal surgery, major craniofacial trauma or cystic fibrosis. Since it is seen together with the septum deviation we concluded that it could develop because of previous minor facial traumas. Septal mucoceles are very rare and occur as a midline septal mass leading to nasal obstruction. In the differential diagnosis of a mass in this region dermoid cyst, encephalocele, meningocele or
[1] V.J. Lund, Milroy CM. fronto-ethmoidal mucoceles: a histopathological analysis, J. Laryngol. Otol. 105 (1991) 921–923. [2] G. Har-El, Endoscopic management of 108 sinus mucoceles, Laryngoscope 111 (2001) 2131–2134. [3] R. Nicollas, F. Facon, I. Sudre-Levillain, C. Forman, S. Roman, J.M. Triglia, Pediatric paranasal sinus mucoceles: etiologic factors, management and outcome, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 905–908. [4] M. Di Cicco, D. Costantini, R. Padoan, C. Colombo, Paranasal mucoceles in children with cystic fibrosis, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 1407–1413. [5] R.J. Alvarez, N.J. Liu, G. Isaacson, Pediatric ethmoid mucocele in cystic fibrosis: longterm follow-up of reported cases, Ear Nose Throat J. 76 (1997) 539–543. [6] R. Gall, I. Witterick, Mucocele of the nasal septum, J. Otolaryngol. 31 (2002) 246–247. [7] B.E.J. Hartley, V.J. Lund, Endoscopic drainage of pediatric paranasal sinus mucoceles, Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 109–111. [8] H. Olze, C. Matthias, P. Degenhardt, Paediatric paranasal sinus mucoceles, Eur. J. Pediatr. Surg. 16 (2006) 192–196. [9] V. Sciarretta, E. Pasquini, G. Farnetti, A.R. Ceroni, Endoscopic treatment of paranasal sinus mucoceles in children, Int. J. Pediatr. Otorhinolaryngol. 68 (2004) 955–960. [10] P. Arrue, M. Thorn Kany, E. Serrano, F. Lacroix, J. Percodani, E. Yardeni, J.J. Pessey, C. Manelfe, Mucoceles of the paranasal sinuses: uncommon location, J. Laryngol. Otol. 112 (1998) 840–844. [11] G. Lloyd, V.J. Lund, L. Savy, D. Howard, Optimum imaging for mucoceles, J. Laryngol. Otol. 114 (2000) 233–236. [12] V.J. Lund, Endoscopic management of paranasal sinus mucoceles, J. Laryngol. Otol. 112 (1998) 36–40.