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Clinical Problem Solving: Radiology
June 2013

Radiology Quiz Case 2: Diagnosis

JAMA Otolaryngol Head Neck Surg. 2013;139(6):648. doi:10.1001/jamaoto.2013.3179b

Mucoceles of the paranasal sinuses are cystic lesions lined by respiratory epithelium and are believed to be caused by obstruction of a sinus ostium or obstruction of a mucus-secreting gland. This may lead to the accumulation of secretions into an expansile mass. Mucoceles may result from a distant history of trauma. Histologically, the cyst wall is composed of pseudostratified columnar epithelium with cilia.

This patient was taken to the operating room for an external rhinoplasty approach to resect the intranasal mass. As the mucoperichondrial septal flap was raised on the left side, thick white mucus was seen coming from the intraseptal mass. The secretions were evacuated, and a cystic, mucosal-lined cavity was entered with the fiber-optic endoscope (Figure 3 [MT indicates middle turbinate; S, septum] and Figure 4). Superior bowing of the bony septum to the right was noted, the result of the chronic pressure exerted by the mass. The wall of the cyst was removed with endoscopic equipment and sent for surgical pathologic and cytologic analysis, and cultures. The findings were consistent with a mucocele on gross examination. Final pathologic results were consistent with an intraseptal mucocele. Intraoperative assessment of the dorsal nasal bones revealed the previously noted widening, as well as significant thinning of the bone, making lateral osteotomies imprudent at that time. Delayed cosmetic rhinoplasty to narrow the nose, once healed, was deemed most appropriate.