Cholesterol Granuloma of Maxillary Sinus

7/31/2019 Cholesterol Granuloma of Maxillary Sinus

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Cholesterol Granuloma of Maxillary Sinus

INTRODUCTION

Cholesterol granuloma (CG) usually occurs in the ear rather than other places in the the

head and neck. The clinical diagnosis is difficult to be found, so it is done over

histopathological exam. It is generally considered that malaeration with hemorrhage into

a cavity, which is normally ventilated and is the primary event in the development of thiscondition. It could be expected to be relatively frequent in the maxillary and frontal sinus,

but only a few cases have been reported in the literature and only nine cases affecting the

maxillary sinus have been diagnosed over the last 22 years, at the Royal National, Nose

and Ear Hospital, (Gray's Inn Road, London) (1).

The main differential diagnosis in theses cases were mucoceles of the maxillary antrum,

cysts arising within the sinus, or cysts of dental origin, and in those cases showingexpansion or erosion of the maxillary sinus, malignant disease. Some patients may

present with X-ray features, which may suggest the diagnosis of CG, but there were no

specific X-ray findings which alerted the surgeon to the diagnosis pre-operatively (1).Surgical treatment consists of comprehensive removal of the lesion. In an overview of the

literature, we found only 37 cases of CG sited in the maxillary sinus (1-15).

CASE REPORT

A 51 year-old Caucasoid male patient came to ENT appointment complaining of apermanent right-sided epiphora for the last 3 months, without any other symptoms.

Previous consultations to ophthalmologist and allergist were fruitless. One week before

ENT consultation he observed a clear and permanent right-sided nasal discharge. There

was no past history of sinuses infections, but he referred to be a scuba diving enthusiast.

The ENT examination displayed a small tumor lesion, smooth, light red, sited on the

middle concha, apparently arising from the maxillary sinus. CT of the paranasal sinuses

revealed an extensive tumoral lesion, encapsulated, filling all the right maxillary sinus,

anterior ethmoid and part of the ipsilateral nasal fossa (1,2).

We opted to remove the lesion combining a Caldwel-Luc procedure to the endonasalendoscopic assisted one, due to the great volume of the lesion and for convenient

exploration of the floor of the orbit. During the surgery, it was observed that the

encapsulated lesion was partially filled by a solid yellowish and viscous material andpartially by liquid and clear material. The lesion was completely resected, but preserving

the anatomical structures undamaged by the disease. The anatomopathological diagnosis


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was typical cholesterol granuloma (3). Such diagnosis is rarely suspected before surgery.

Figure 1. CT scan (coronal section) showing an extensive tumoral lesion, encapsulated,

filling all maxillary sinus.

Figure 2. CT scan (axial section) showing the lacrimonasal duct compressed by the

lesion.

mri show very high signal


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Figure 3: The giant cells surround the clefts created by the cholesterol crystals (empty

needle-shaped spaces).

DISCUSSION

Cholesterol granuloma (CG) is a granulomatous reaction to cholesterol crystals that havebeen precipitated in the tissues. It is commonly found in the mastoid antrum and the air

cells of the middle ear. CG is not found in the nasal cavity but the closed cavities of the

paranasal sinuses provide favorable conditions for its genesis (16), especially the


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maxillary and the frontal sinuses, which are the most common affected sites (1,2,3,17).

The pathogenesis of CG in the sinuses seems to be through hemorrhages inside these

cavities, by liberation from degenerating tissue or by transudate.

The paranasal sinuses provide closed cavities with a long lymphatic drainage pathwayand consequently slow drainage. This would give the time necessary for the cholesterol todissociate and to precipitate as crystals and then initiate the granulomatous change (16).

CG is associated with mucosal hemorrhage, therefore, it could be expected to be

relatively frequent in the maxillary and frontal sinus, but only few cases have beenreported in the literature (3). In the literature is interesting the report of six cases of CG

from the same region: Sivas, in Turkey (11). It is also interesting a report of CG

associated to aspergilloma (13), and another to hypercholesterolemia (10). The clinical

feature is non-specific and depends on the localization and extent in each individual case.Bone erosion may be seen in CG showing expansive growth (1,6,18,19).

In the present case we theorize if the disease could not have a causal relationship withminor hemorrhages produced by barotraumatic episodes consequent to the practice of

scuba diving. However, the patient denied the occurrence of such events. It is impressive

the paucity of symptoms in the presence of such voluminous expansive lesion (1).Epiphora was produced by compression of the lacrimonasal duct (2).

Radiological differential diagnosis includes mucocele, dentigerous cyst and voluminous

mucous retention cysts and pseudo cysts. In the cases with bone erosion, a malignantdisease should be considered. Histopathological examination is important and should be

carried out on all specimens obtained from paranasal sinus surgery, because CG in the

maxillary antrum could be mistaken for chronic sinusitis (11). The morphological aspectof CG is very typical, and avoids confusion with anything else (16). There is granulation

tissue with foreign body-type giant cells. These giant cells surround the clefts created by

the cholesterol crystals, and these clefts have the appearance of empty neddle-shaped

spaces (3).

Treatment usually consists of removing the CG and restoring drainage of the affected

sinus cavity. Radical operation seems to give absolute cure without any recurrence (3).However, for others, drainage and permanent aeration may be sufficient (9). It would be

possible to achieve adequate therapy by using an endoscopic approach (9). After surgical

removal of a CG there will seldom be a recurrence (16).

In the nine cases reported by Milton and Bickerton (1986), eight patients underwent a

Caldwell Luc procedure and one patient had an intranasal antrostomy alone. The results

of surgery were uniformly successful, some cases having been followed up for severalyears. MRI may be useful for follow up of treatment (9,20). The reported patient, in the

18th postoperative month is lesion free, asymptomatic and feeling good.


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COMMENTS

We hypothesized that the cholesterol granuloma in this case could be related with

possible episodes of barosinusitis with small and asymptomatic hemorrhages as aconsequence of scuba diving.

Cholesterol Granuloma of Maxillary Sinus

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