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ARTICLES
Year : 1979  |  Volume : 27  |  Issue : 2  |  Page : 45-48

Fronto-ethmoidal mucocele as a cause of unilateral proptosis


Department of Ophthalmology and Otorhinolaryngology, Lok Nayak Jay Prakash Narayan Hospital and Maulana Azad Medical College, New Delhi, India

Correspondence Address:
D K Sen
V/4, M.A.M. College Campus, Kotla Road, New Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


PMID: 541032

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How to cite this article:
Sen D K, Puri N D, Majid A. Fronto-ethmoidal mucocele as a cause of unilateral proptosis. Indian J Ophthalmol 1979;27:45-8

How to cite this URL:
Sen D K, Puri N D, Majid A. Fronto-ethmoidal mucocele as a cause of unilateral proptosis. Indian J Ophthalmol [serial online] 1979 [cited 2019 Dec 10];27:45-8. Available from: http://www.ijo.in/text.asp?1979/27/2/45/31239

A mucocele of a para-nasal sinus is an accumulation of mucoid secretion and desqua­mated epithelium within the sinus with disten­tion of its walls and is regarded as a cyst like expansile and destructive lesion. If the cyst invades the adjacent orbit and continues to expand within the orbital cavity, the mass may mimic the behaviour of many benign growths primary in the orbit. In these circumstances the lesion is of concern to the ophthalmologists. More rarely such lesions may present with epiphora, sluggish pupillary reaction, myopia, optic neuritis, vitreous opacities, and catarac­tous changes of the lens[11].

The present paper reports two cases of frontoethmoidal mucoceles who attended. the eye out-patient department of Lok Nayak Jay Prakash Narayan Hospital, New Delhi, with unilateral proptosis. One of the cases was associated with a serous retinal detachment which is a rare event.


  Case Reports Top


Case 1 : W.C., 52-years-old male, was admitted with gradually progressive bulging of the left eye ball puffiness in the medial half of both upper and lower lids. The globe was pushed forwards, downwards and out wards by a painless, diffuse, non pulsatile, and non compressible, cystic swelling in the roof and inner wall of the orbit [Figure - 1]. The cough impulse was negative. for the past three years. There was no history of any nasal obstruction or epistaxis. On examination: Right eye was normal in all respects. Left Eye: there was The overlying skin was freely movable. On pressure there was no eggshell crackling in the periphery of the cyst. Nasolacrimal passages were patent. Adduction and elevation of the eye ball were restricted. Anterior and posterior segments of the globe were normal. Vision was 6/9 (Snellen's chart). Anterior and posterior rhinoscopic examination revealed mucopurulent dis­charge in the middle meatus of left nasal cavity. Routine laboratory investigations were within normal limits. X-ray, occipitofrontal view, showed markedly enlarged and distorted frontal sinus and ethmoidal air cells with destruction of superior-nasal wall of the orbit on the left side [Figure - 2]. The walls of the frontal sinuses lost their septate or scalloped configuration. The inter sinus septum was partly destroyed [Figure - 2]. A clinico­ radiological diagnosis of frontoethmoidal mucocele of the left side was made. An external frontoethmoidecto­my was decided upon. A curved incision on the skin was made along the superior nasal rim of the bony orbit. This incision was slightly higher than the approach preferred for superior orbitotomy. The periosteum was elevated. During dissection the cyst burst and the thick mucoid content was sucked out. The floor of the frontal sinus, inter sinus septum, and part of left ethmoidal air cells were found destroyed and converted into one large cavity. The dura of the anterior cranial fossa was seen bulging through the eroded posterior wall of the left frontal sinus. As the whole of the mucosa was unhealthy it was scraped away from the underlying bone. A neofrontonasal duct was created by making an opening in the middle meatus of the nose. A portex tube covered with a split thickness skin graft was passed through this opening into the sinus cavity and kept in place with anchoring stitches. The tube was removed after six weeks. The result was very satisfactory. The left eye ball returned to its normal position. Ocular movements became full. Visual acuity was 6/6. The cosmetic appearance of the face was excellent. The patient had no postoperative nasal obstruction or rhinorrhoea and the skin graft was seen to have taken well.

Case Report II

B.S., 40-years-old male, presented with slowly pro­gressive bulging of the left eye ball for the last 4 years and deterioration of eye sight on the same side for last 2 years. He did not have any nasal complaints. There was no history of trauma in the region of the eye or nose. On examination: Right eye was normal in all respects. On the left side there was a diffuse, nontender, noncompressible, cystic swelling similar to the one described in case number I was present. However, the eye ball here was displaced only forwards and outwards [Figure - 3]. The supraorbital margin was dehiscent in its medial portion. Movement of the eye ball was restricted in adduction only. The lacrimal sac was normal.

Anterior segment of the globe was normal. Vision was reduced to counting of fingers at a distance of 1 foot. Projection of rays was inaccurate in lower and inner quadrants. Fundus examination revealed old serous retinal detachment in the nasal and lower quad­rant with extensive degenerative changes and hole for­mations in the nasal retinal periphery. Retinoscopy revealed the eye to be emmetropic. X-ray findings were typical of frontoethmoidal mucocele. External frontoethmoidectomy was done. Here only the mucosa forming the anterior cyst wall was found unhealthy and, therefore, only this portion was scraped away. As in the previous case a neofrontonasal duct was created and kept patent by using a portex tube without any skin graft as in this case some parts of the mucous membrane lining the sinus cavity was healthy and therefore not removed. Postoperative course was uneventful. The tube was kept in place for 3 weeks. Final result was quite satisfactory. The eye was back to its normal position. The ocular movements were full. Since reti­nal detachment was quite old and visual prognosis was very poor no surgery for this condition was contemplat­ed. On subsequent follow-up there was no nasal com­plaint.


  Discussion Top


The exact mechanism underlying the development of a mucocele of the paranasal sinuses is unknown. Most of the authors believe this cystic dilatation of the sinuses to be secondary to obstruction of the nasal ostium [10],[8] as a result of recurrent bouts of inflam­mations, trauma[6], or repeated surgery in and around the nasal cavity and adjacent sinuses. Dabney[1] held that mucoceles arose as small cysts within the mucous membrane, which by continued growth finally obstruct­ed the ostium of the sinus. This view has not been widely agreed upon. However, it is likely that any of the circumstances may prevail in a particular case

The incidence of mucocele of the paranasal sinuses causing unilateral proptosis has been very variable depending upon the special interest of the investigators. Thus Bullock and Reeves[1] in a radiological series re­ported mucocele of the paranasal sinuses as the most common cause of unilateral proptosis. Whereas in the histological series of 877 cases of proptosis this condi­tion was not even listed as one of the causes because tissue from this lesion was never sent to the laboratory[9]. However, in a clinical series of 230 consecutive cases of unilateral expanding lesions of the orbit Reese found 6 cases[9]. In another clinical series of proptosis cases Henderson found this condition in a small (1.5%) per­centage of cases[5]. Our experience in this field reveals that in a balanced study mucocele of the paranasal sinu­ses responsible for proptosis has a low incidence (4%)[7].

Orbital symptomatology is influenced more by the specific area of bone erosion. Thus, in a large fronto­ethmoidal mucocele the clinical picture varies according to whether bone erosion occurs anteriorly or along the orbital roof near the apex. In the latter situation the condition may present at the early stages with blurring of vision or a defect in the visual field and at the late stage as a primary orbital tumour and cause considerable difficulty in arriving at a correct diagnosis especially when X-rays are negative for mucocele of the sinuses. There are cases wherein the true nature of the lesion is discovered by the ophthalmic surgeon for the first time during exploratory orbitotomy. Though the expanding mucocele produces pressure erosion of the bone walls destruction of its posterior or superior wall with expo­sure of the intracranial structures is very rare. Wilker­sontr reported one such case earlier. Dawes[3] encoun­tered only one case with similar finding out of 14 cases studied. It is interesting to note that one of our two cases had this rare finding. When the bony erosion occurs anteriorly the lesion may have to be differen­tiated from a lacrimal mucocele. The major part of the swelling in lacrimal mucocele is below the level of the medial palpebral ligament. Moreover, Lacrimal Sac mucocele rarely produces displacement of the globe; but if such displacement eventually occurs the globe is pushed up, laterally, and backwards.

The object of therapy is to remove the cyst comp­letely and restore the drainage from the occluded sinus into the nose. External frontoethmoidectomy is the treatment of choice[3],[11]. However, during surgery it is important to take care of the thin belly of the levator palpebrae superioris muscle that may be close to the dependent portion of the mucocele which has protruded into the orbit from the frontal sinus. A controversy exists whether or not the entire mucosal lining of the mucocele should be excised. Wilkerson[11] advocated excision of the entire mucosa even in cases where part of the mucosa was healthy. Others[3] feel that only the diseased mucosa need be removed retaining the healthy portions. We excised the entire mucosal lining, as the whole of it was diseased, in the first case. In the second case part of the mucosa was healthy and therefore this portion was retained. The result in both the cases were excellent. They have been followed for 12 months and are completely symptom free.


  Summary Top


Two cases of frontoethmoidal mucoceles presenting as unilateral proptosis are recorded. One case had destruction of the posterior sinus wall with duramater lying exposed in the sinus cavity which is a rare finding. The other case was associated with serous retinal detachment which has not been reported previously. Ex­ternal frontoethmoidectomy cured the condition and helped to restore the eyes to its normal position with full ocular movements.

 
  References Top

1.
Bullock, L.J. and Reeves, R.J. 1959, Amer. J. Roentgenol, 82, 290.  Back to cited text no. 1
    
2.
Dabney, V. 1921, Tr. Am Laryng. A. 43, 163 and 179.  Back to cited text no. 2
    
3.
Dawes, J.D.K. 1961, J. Laryng. 75, 297.   Back to cited text no. 3
    
4.
Gerber, 1909. Cited in 6.  Back to cited text no. 4
    
5.
Henderson, J. W. 1973, Orbital Tumours, P. 105-113. W.B. Saunders. Philadelphia.   Back to cited text no. 5
    
6.
Howarth, W.G. 1924. J. Laryng. 39, 265.  Back to cited text no. 6
    
7.
Mohan, H., Sen, D.K., and Gupta, D.K. 1968. Orient. Arch. Ophthal. 6, 271.  Back to cited text no. 7
    
8.
Neffson, A.H. 1957. Arch. Otolaryng, 66, 157.  Back to cited text no. 8
    
9.
Reese, A.B. 1963. Tumours of the Eye, 2nd. ed. p. 533. Hoeber, New York.  Back to cited text no. 9
    
10.
Thomson, St. C. and Negus, V.E. 1937. Diseases of the Nose and Throat, ed.4. p. 286. Appleton, Century, Crofts Inc., New York.  Back to cited text no. 10
    
11.
Wilkerson, W.W. 1945. Laryngoscope, 55, 294.  Back to cited text no. 11
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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