Abstract
Mucoceles are benign, epithelial-lined mucous cysts. Commonly mucoceles form secondary to obstruction of a sinus outflow tract or from mucosal gland entrapment from chronic infection, inflammation, iatrogenic trauma, external trauma, or neoplasm. We present a rare case of a nasal mucocele in a 37-year old male arising from a remote history of maxillofacial trauma. To our knowledge, mucoceles associated with nasal bone fractures have not been reported in the literature.
1
Introduction
Patients with mucoceles frequently present due to complaints of frontal pressure, headaches, facial swelling, or visual disturbances . These symptoms correlate with the most common occurrence of mucoceles in the frontal and ethmoid sinuses. Mucosal entrapment or sinus outflow obstruction leads to the development of the locally expansile lesion. Increasing content of the mucocele will gradually alter the surrounding bony structures and has the potential for bony erosion. Here we describe a rare case of nasal mucocele associated with complex nasal bone and LeFort II fractures.
2
Case report
A 37-year-old male presented to our clinic with progressive external nasal swelling in the region of nasofrontal angle and nasal dorsum. He specifically noted his eyeglasses no longer fit across his nasal bridge. The patient also reported associated symptoms of increasing nasal congestion and hyposmia. He denied visual changes, facial pain, epistaxis, fevers, or clear rhinorrhea. Upon reviewing the patient’s history, he reported suffering facial fractures approximately nine years earlier during a work related accident. The mechanism of injury was described as blunt force trauma by a metal pipe dislodged from an industrial machine. Computed tomography (CT) scan at the time of injury revealed multiple facial fractures, including bilateral LeFort II, comminuted nasal bone, medial orbital wall, and comminuted maxillary dentoalveolar segment fractures. Shortly thereafter, the patient underwent uneventful open reduction and internal fixation with plating for the noted LeFort II. Orosurgical splints were used to stabilize the comminuted dento-alveolar segments. The nasal fractures were addressed with a rigid, external dorsal splint and internal nasal packing.
Upon presentation to our clinic nine years later, the external examination demonstrated widening of the upper vault on frontal view and blunting of the nasofrontal angle on profile. Palpation of the region revealed a soft mass that was mildly tender to palpation. Intranasal examination revealed a large amount of anterior and superior septal cartilage.
Further work-up included computed tomography (CT) of the sinuses and Magnetic Resonance Imaging (MRI) of the head to rule out intracranial communication as well as a Fine Needle Aspiration (FNA) of the mass. The CT sinus demonstrated a cyst-like mass enveloping the superior–anterior septum which displaced the nasal bones laterally. There was no significant sinus disease noted. The MRI with gadolinium defined a lesion confined to the superior aspect of the nasal cavity measuring approximately 2 × 3 × 2 cm. The lesion appeared hyperintense on T1 & T2-weighted images without evidence of intracranial extension ( Fig. 1 ). FNA cytology demonstrated mucoid material. History and workup were most consistent with the diagnosis of a nasal mucocele.
The option of an endoscopic approach for the removal of the mucocele was considered. However, the location of the mucocele resulted in tremendous difficulty for visualization and the complete removal of the lining via endoscopy, even with the use of seventy degree scope, was felt to be a suboptimal option. Thus, after extensive discussion, the patient elected for surgical removal of the mucocele via a direct, external approach using a shortened gull-wing incision. Intraoperatively, the mass was removed in its entirety from the surrounding structures ( Fig. 2 ). In addition, a septoplasty for bony and cartilaginous harvest was undertaken to reconstruct the operative defect. The harvested bony septum was fashioned to fit the defect in the nasal bones created by the mass and secured in place to the frontal bone with a titanium Y-plate ( Fig. 3 a ). The harvested cartilage was then morselized and draped over the bony reconstruction to minimize future contour irregularities as healing progressed ( Fig. 3 b). There were no operative or immediate post-operative complications. The final pathology of the mass revealed an inflammatory central nasal polyp with fragments of bone most consistent with a mucocele.
On post-operative follow-up the patient exhibited good signs of healing and has noted significant improvement in his nasal breathing and adequate fitting of his eyeglasses. He has remained asymptomatic and without recurrence of the mucocele.
2
Case report
A 37-year-old male presented to our clinic with progressive external nasal swelling in the region of nasofrontal angle and nasal dorsum. He specifically noted his eyeglasses no longer fit across his nasal bridge. The patient also reported associated symptoms of increasing nasal congestion and hyposmia. He denied visual changes, facial pain, epistaxis, fevers, or clear rhinorrhea. Upon reviewing the patient’s history, he reported suffering facial fractures approximately nine years earlier during a work related accident. The mechanism of injury was described as blunt force trauma by a metal pipe dislodged from an industrial machine. Computed tomography (CT) scan at the time of injury revealed multiple facial fractures, including bilateral LeFort II, comminuted nasal bone, medial orbital wall, and comminuted maxillary dentoalveolar segment fractures. Shortly thereafter, the patient underwent uneventful open reduction and internal fixation with plating for the noted LeFort II. Orosurgical splints were used to stabilize the comminuted dento-alveolar segments. The nasal fractures were addressed with a rigid, external dorsal splint and internal nasal packing.
Upon presentation to our clinic nine years later, the external examination demonstrated widening of the upper vault on frontal view and blunting of the nasofrontal angle on profile. Palpation of the region revealed a soft mass that was mildly tender to palpation. Intranasal examination revealed a large amount of anterior and superior septal cartilage.
Further work-up included computed tomography (CT) of the sinuses and Magnetic Resonance Imaging (MRI) of the head to rule out intracranial communication as well as a Fine Needle Aspiration (FNA) of the mass. The CT sinus demonstrated a cyst-like mass enveloping the superior–anterior septum which displaced the nasal bones laterally. There was no significant sinus disease noted. The MRI with gadolinium defined a lesion confined to the superior aspect of the nasal cavity measuring approximately 2 × 3 × 2 cm. The lesion appeared hyperintense on T1 & T2-weighted images without evidence of intracranial extension ( Fig. 1 ). FNA cytology demonstrated mucoid material. History and workup were most consistent with the diagnosis of a nasal mucocele.
