A pathologist’s perspective on mucocele of frontal sinus

CASE REPORT
AARTICLE
pathologist’s perspective on mucocele of frontal sinus – a case report
Shah Neha L1*, Upasham Pragati S2
1
Resident.Department of Pathology,D.Y.Patil school of Medicine, Nerul, NaviMumbai
2
Professor & Guide.Department of Pathology,D.Y.Patil school of Medicine, Nerul, NaviMumbai

ABSTRACT
We report a case of frontal paranasal sinus mucocele in a 30 year old female who presented with complaints of left
supra orbital mass since 15 days associated with tenderness. CT scan revealed minimally enhancing expansile cystic
lesion with patchy ground glass attenuation involving roof of left orbit and posterior wall of frontal sinus with fibrous
dysplasia. Endoscopic marsupialisation of the mucocele was performed and specimen was sent to histopathology
department. Based on the clinical, radiological and histopathological examination, the diagnosis of frontal paranasal
sinus mucocele was concluded and literature reviewed. Aim: we here by present this case considering its rarity and
to study the literature associated with it.

Key words: Mucocele, Paranasal sinus, fibrous dysplasia, supra orbital mass, cytokines

INTRODUCTION
A mucocele is an epithelial lined mucus
containing sac completely filling the sinus and
capable of expansion. It can affect the general
population but mostly from 4 th to 7th decade of
life. They present with soft, bluish and
transparent cystic swelling. 1 Paranasal sinus
mucocele were first described by Langeback in
1820. Rollet in early 1990s gave the name
‘mucocele.’ It is rare, slow growing, benign
intracranial pathology. A mucocele is formed by
obstruction of sinus ostium or a compartment of
separated sinus, this cause the cavity to be filled
with mucus or become airless. The lesion has a
multifactorial etiology involving anatomic
abnormality, inflammation, trauma, allergy,
previous surgery, fibrous dysplasia, ossifying
fibroma, osteoma, etc. 2
Since the frontal, ethmoid, sphenoidal and
maxillary sinus anatomically interface the orbit,
hence they can easily cause ophthalmic
manifestations like proptosis, blurring of vision,
orbital displacement, headache, etc. Sometimes
it can also lead to intracranial complications. 2
Fronto ethmoidal mucocele is the most common,
while sphenoid mucocele being the least
common. 1, 3 The fronto ethmoidal mucocele
often presents with an outward and downward
displacement of the orbital globe, fronto ethmoid
swelling, visual impairment, and headache. 4
*Corresponding Author:
Neha Shah,
Resident, Dept of Pathology,
D.Y.Patil school of Medicine,Nerul,
Navi Mumbai. Maharastra
Email: nehshah_culdoc@yahoo.com
40 Int J Int Med Res. 2015; 2(4): 40-42
Though mucocele can be diagnosed on CT scan
and MRI. It is important to distinguish mucocele
from the mucus retention cyst which is a sac
filled with fluid along the sinus lining which
does not expand or push into the surrounding
and therefore does not cause problem in most
cases. 5 Mainstay of management is surgery
ranging from functional endoscopic sinus
surgery to craniotomy, craniofacial exposure
with or without obliteration of sinus. 6
CASE HISTORY:
30 year old female presented in ophthalmology
OPD with a left supra orbital mass since 15 days
(mass size- 2 x 3 cm), clinically the mass
appeared to be cystic on palpation and was
tender. No complaints of any visual disturbance
or headache etc. The CT scan revealed a well-
defined minimally enhancing expansile cystic
lesion with patchy ground glass attenuation
involving roof of left orbit and posterior wall of
frontal sinus with fibrous dysplasia. MRI brain
and orbit also showed similar findings as of CT
scan. Based on these the differential diagnosis
of- fibrous dysplasia, Aneurysmal bone cyst and
mucocele of left frontal sinus were given.
Surgery was performed and specimen was sent
to histopathology section of our pathology
department.
Histopathological features: Gross specimen
showed multiple fragmented grey brown tissue
bits altogether measuring 3 x2 cm.
Microscopy: Sections studied through all
processed tissue bits shows epithelial lining of
e ISSN: 2393-9869 p ISSN: 2350-0360
 A pathologist’s perspective on mucocele of frontal sinus
the sinus with cystically dilated spaces filled
with mucin.
Based on these findings, diagnosis of mucocele-
frontal sinus was given.
Figure 1: H & E Section, 10 x view of
mucocele showing epithelial lining of sinus,
cartilage with few cystically dialated spaces
DISCUSSION
Majority of paranasal sinus mucocele present at
the age of 40-70yrs. Our case was seen in
slightly younger age group. 1 Paranasal sinus
mucocele occur in fronto ethmoid region (64%),
maxillary sinus (18.6%), sphenoidal sinus
(8.4%) and posterior ethmoid sinus (6.7%),
sphenoid (1%).In our case, the frontal sinus was
involved. 1,3 Fronto ethmoidal mucocele are the
most common as a result of complexity of its
drainage. 1 The natural development of sinus
mucocele is of gradual expansion and therefore
can invade into the vital structures in the
surrounding like other sinuses, orbit, clivus,
brain and skull and cause intra orbital (proptosis,
blurring of vision, displacement of globe, ocular
palsy) and intra cranial complications
(meningitis, subdural and brain abscess. 7
Theories of pressure erosion, cystic degeneration
of glandular tissue and active bone resorption
and regeneration are implicated in the
pathogenesis of mucocele. Bone resorbing
factors like leukotrines, PGE 2, HETES,
cytokines, interleukines, TNF α, E-selectin , I-
CAM and vascular adhesion molecule are found
in the mucosa of mucocele.Normally, new bone
formation is balanced by osteolysis. In
mucocele, the balance is just tipped in favour of
osteolysis facilitating expansion of lesion. 8,9
Various treatment options are available
depending upon the degree of extension ranging
from functional endoscopic sinus surgery to
external approach, craniotomy, craniofacial
41 Int J Int Med Res. 2015; 2(4): 40-42
exposure with or without obliteration of
sinus.[5]It is essential to differentiate mucocele
from the mucus retention cyst. It is a fluid filled
sac with a sinus lining but it cannot expand as
does the mucocele. In the differentials one must
also rule out mucopyocele, meningioma,
craniopharyngioma, hypophyseal tumours, optic
nerve glioma, intracranial chondroma, neoplastic
lesions of nasopharynx, sinus malignancy.
CONCLUSION
Symptoms of the currently reported case are
quite vague i.e. supra orbital mass and
tenderness since 15 days. Pre-operative
diagnosis was based on CT and MRI. The frontal
mucoceles are the commonest amongst various
paranasal sinus mucoceles and may have a
variable presentation. Rarely a supraorbital soft
tissue mass may be the presentation as in our
case. Through proper clinical examination,
timely and accurate histopathological
examination play an important role in
differentiating this lesion from the other sinus
related conditions and prevents the untoward
complications.
ACKNOWLEDGMENT
I thank the entire staff of the department of
pathology of D.Y. Patil School of Medicine,
nerul, Navi Mumbai for their support.
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42 Int J Int Med Res. 2015; 2(4): 40-42 e ISSN: 2393-9869 p ISSN: 2350-0360