Abstract
Cholesteatoma is a relatively common disease entity within the middle ear cavity, but it is rarely found in the paranasal sinuses. We describe a rare case of cholesteatoma in the maxillary sinus of an elderly man presenting with recurrent sinus infections and nasal obstruction refractory to medical treatment. The patient was treated using functional endoscopic sinus surgery with successful removal of the cholesteatoma. He has no recurrence of the cholesteotoma at a 13 year follow-up. We review the literature and history on maxillary cholesteatomas and discuss the theories on the pathogenesis of cholesteatoma formation. We propose functional endoscopic sinus surgery with maxillary antrostomy and marsupialization of the cholesteatoma as a primary treatment option for a maxillary cholesteatoma.
1
Introduction
Cholesteatoma is a relatively common disease entity within the middle ear cavity, but it is rarely found in the paranasal sinuses. A review of the English literature reported less than 30 cases of a cholesteatoma in a paranasal sinus . Of these limited cases, the most common location was the frontal sinus, followed by the ethmoid sinus, and finally the maxillary sinus . Paranasal cholesteatomas are generally unilateral . The origin of the term cholesteatoma traces back to Müller who in 1838 described the presence of cholesterol crystals in a cavity lined with squamous epithelium and filled with layers of dense, squamated keratin . This term is a misnomer as Virchow noted in 1854 that cholesterol is not an essential component of this entity . More appropriate terminology that is used to refer to a cholesteatoma is keratoma, keratocyst, epidermoid tumor, or epidermoid cyst .
2
Case report
A 72-year-old Caucasian male presented with recurrent sinus infections. No facial deformity was noted. He complained of chronic nasal obstruction and post nasal drip with colored mucopus. He had been treated with antibiotics, steroids, nasal sprays, and irrigation with no improvement of symptoms. The CT scan showed right maxillary sinus opacification consistent with nasal polyposis and erosion of the right medial maxillary wall. As medical treatment failed to control the symptoms, the patient opted for surgery. Functional endoscopic sinus surgery was performed and a mass was visualized eroding the right medial wall of the maxillary sinus with purulent material and keratinaceous debris present. The mass was biopsied and specimens were sent to pathology, which revealed keratinaceous material consistent with cholesteatoma as well as some filamentous organisms, possibly Actinomyces. A middle meatal antrostomy with marsupialization of the cholesteatoma and removal of maxillary sinus debris were carried out. Infected bone pertaining to the ethmoid sinus, sphenoid sinus, and frontal recess was also observed, so endoscopic ethmoidectomy, sphenoidotomy, and frontal recess dissection were performed. The patient has not had a recurrence of his cholesteotoma since his surgery 13 years ago, although he is still a chronic sinus sufferer who requires medical therapy.
2
Case report
A 72-year-old Caucasian male presented with recurrent sinus infections. No facial deformity was noted. He complained of chronic nasal obstruction and post nasal drip with colored mucopus. He had been treated with antibiotics, steroids, nasal sprays, and irrigation with no improvement of symptoms. The CT scan showed right maxillary sinus opacification consistent with nasal polyposis and erosion of the right medial maxillary wall. As medical treatment failed to control the symptoms, the patient opted for surgery. Functional endoscopic sinus surgery was performed and a mass was visualized eroding the right medial wall of the maxillary sinus with purulent material and keratinaceous debris present. The mass was biopsied and specimens were sent to pathology, which revealed keratinaceous material consistent with cholesteatoma as well as some filamentous organisms, possibly Actinomyces. A middle meatal antrostomy with marsupialization of the cholesteatoma and removal of maxillary sinus debris were carried out. Infected bone pertaining to the ethmoid sinus, sphenoid sinus, and frontal recess was also observed, so endoscopic ethmoidectomy, sphenoidotomy, and frontal recess dissection were performed. The patient has not had a recurrence of his cholesteotoma since his surgery 13 years ago, although he is still a chronic sinus sufferer who requires medical therapy.
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