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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 40-43

Sphenoid sinus cholesterol granuloma with orbital complications: a case report


1 Department of Otorhinolaryngology, Royal Medical Services, Amman, Zarqa Jordan
2 Department of Histopathology, Royal Medical Services, Amman, Zarqa Jordan
3 Department of Ophthalmology, Royal Medical Services, Amman, Zarqa Jordan
4 Faculty of Medicine, Hashemite University, Zarqa Jordan

Date of Submission29-Nov-2019
Date of Acceptance07-May-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
MD Qais Aljfout
PO Box 1643, Tareq Amman, 11947
Zarqa Jordan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajr.pajr_17_19

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  Abstract 


Cholesterol granulomas are benign lesions that affect many parts of the body. Although they are benign, their expansile properties might affect important neighborhood structures which is an associated risk. Paranasal sinuses are rare locations to be affected. A case of sphenoid sinus cholesterol granuloma with orbital complications is presented. The study places emphasis on preoperative examination, radiological evaluation, and endoscopic management, and we recommend including cholesterol granulomas in the differential diagnosis of cystic lesions in paranasal sinuses.

Keywords: cholesterol granuloma, endoscopic, orbital, sphenoid


How to cite this article:
Aljfout Q, Al-Ruhaibeh M, Dahoun L, Al-Shawayat W, Qais S. Sphenoid sinus cholesterol granuloma with orbital complications: a case report. Pan Arab J Rhinol 2020;10:40-3

How to cite this URL:
Aljfout Q, Al-Ruhaibeh M, Dahoun L, Al-Shawayat W, Qais S. Sphenoid sinus cholesterol granuloma with orbital complications: a case report. Pan Arab J Rhinol [serial online] 2020 [cited 2020 Jul 7];10:40-3. Available from: http://www.PAJR.eg.net/text.asp?2020/10/1/40/288575




  Introduction Top


Cholesterol granuloma of the paranasal sinuses is one of the rare encounters in otorhinolaryngology practice. It describes a lesion that is characterized by the presence of what is known as cholesterol clefts associated with cholesterol crystals accompanied by a foreign body reaction in a closed cavity [1],[2],[3]. It can affect the middle ear, petrous apex, breast, lung, kidney, liver, and other parts of the body[1].

Clinical findings are not specific, and imaging usually reveals an expanding cystic mass lesion and it can help in the diagnosis[4]. In this paper, we present a case of sphenoid sinus cholesterol granuloma with orbital complications.


  The Case Top


A 32-year-old woman was referred to our clinic by an ophthalmologist who had evaluated her for severe headache and left periorbital pain for many years, and her symptoms increased in the last few months. Her complaints were associated with left eye decreased vision. Initial evaluation in the ophthalmology clinic showed decreased visual acuity on the left eye 6/12. An MRI was requested for both the brain and orbit, which showed an expansile lesion in the area of sphenoid sinuses 4.5 × 5 cm with upward displacement of the sella and compression of left optic nerve. The lesion showed isointense signal on T1 and hyperintense signal on T2 [Figure 1], and the radiologist's impression was a sphenoid sinus mucocele; with this report, the patient was sent to our clinic. Her past medical history was unremarkable with no history of trauma or sinonasal surgery. Her examination showed mild left eye exophthalmos; endoscopic examination of the nose was unremarkable. Computed tomography scan of paranasal sinuses was requested and showed expansile 4.5 × 5 cm cystic lesion of the sphenoid sinuses mostly representing the sphenoid sinus mucocele [Figure 2]. The patient was sent back to the ophthalmologist with specific request to evaluate color vision and visual fields. Reevaluation showed affected color vision on the left 5/16 and visual field defect in the superior temporal quadrant. Situation was explained to the patient and she gave consent for endoscopic approach for management of this lesion, which mostly represents a mucocele both clinically and radiologically. At the time of surgery, a careful dissection to the anterior wall of the sphenoid revealed an unusual wall for this cystic lesion [Figure 3]. Therefore, we decided to use a spinal needle to do aspiration which revealed a straw color thin fluid [Figure 4]. The diagnosis of the mucocele was disregarded and continued our work carefully to open the lesion. Part of the anterior wall was removed and it revealed a cleft full of crystals [Figure 5] and [Figure 6]. At this moment, the diagnosis of cholesterol granuloma was made and waited a confirmation by the histopathologist. Drainage procedure was done where the anterior wall of the sphenoid sinus was removed. Few days later, histopathology report confirmed chronic inflammation and fibrosis with cholesterol cleft in keeping with the clinical diagnosis of cholesterol granulomas [Figure 6] and [Figure 7]. The patient's headache and periorbital pain disappeared completely, but her vision did not improve, and she is still followed up in our clinic with no recurrence.
Figure 1: (a) Coronal sinus T1 MRI; (b) coronal sinus T2 MRI; (c) sagittal sinus T1 MRI; (d)] sagittal sinus T2 MRI.

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Figure 2: (a) Coronal sinus computed tomography scan; (b) sagittal sinus computed tomography scan.

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Figure 3: Anterior wall of the cystic lesion.

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Figure 4: Fluid aspirated from the cystic lesion.

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Figure 5: Cholesterol crystals inside the cystic lesion.

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Figure 6: Sphenoid sinus after removal of crystals.

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Figure 7: Histopathology view of cholesterol granuloma showing the fibrous tissue with cholesterol crystals.

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  Discussion Top


Cholesterol granuloma of paranasal sinuses is a rare disease. Maxillary sinus followed by the frontal sinus are mostly affected; ethmoid sinuses and sphenoid are much less affected. In otorhinolaryngology practice, the middle ear and petrous apex are the usual affected sites. Although the exact pathogenesis is not known, the most accepted theory suggested that in an obstructed sinus whatever the cause, inflammatory, traumatic, or surgical, pressure changes lead to obstruction of drainage pathways of venous and lymphatic vessels which may lead to hemorrhage. The breakdown of the erythrocyte membrane leads to leakage of lipid components of the red blood cell and this in the presence of lymphatic obstruction leads to the formation of cholesterol crystals and their esters[5],[6] and this result in foreign body reaction to the crystals[7]. The most important factor in cholesterol granuloma formation is a closed cavity with hemorrhage and exudates inside[8]., According to literature reports 11% of cases had prior history of surgery and 14% had history of trauma[9].

Men are more affected than women with a male to female ratio of 3:1, and most people affected are in their fourth and fifth decades of life.

The clinical diagnosis is usually challenging in cases of cholesterol granuloma of paranasal sinuses; the presenting symptoms are not specific; nasal obstruction, periorbital pain, headache, and proptosis are among the most reported[9] and symptoms differ according to the site and degree of expansion of the lesion. Clinical and endoscopic examination are not pathognomonic. It may show a polyp or even a benign mass.

Imaging is helpful in the diagnosis of cholesterol granuloma; computed tomography scan usually reveals an expansile cystic lesion that causes bone erosion and compressing adjacent structures[9]. This picture is not diagnostic, and it cannot be distinguished from the mucocele, which is the most common lesion., On the other hand, MRI shows an expanding lesion with well-defined margins. The lesion usually gives hyperintense signal on T1 and T2 images[10]. In our case, the lesion did not show a hyperintense signal on T1 which made mucocele the preoperative diagnosis, since mucoceles show hypointense or isointense signal on T1 and hyperintense signal on T2[11]. This is not a stranded rule, as the degree of intensity depend on water, protein, or blood content of the lesion[11].

Cholesterol granuloma is treated through surgical drainage procedures. At present, endoscopic approaches are the most used to drain and ventilate the affected sinuses[12],[13]. While in the past, different open approaches were used to drain the lesion according to the sinus affected, for example, Caldwell-Luc or lateral rhinotomy approaches[14],[15]. The recurrence is rare and is reported to be less than 4% with all recurrences happening after the open approach[9].


  Conclusion Top


Cholesterol granuloma should be included in the differential diagnosis of an expanding cystic lesion of paranasal sinuses. Its MRI characteristics are distinguishable but not pathognomonic, and endoscopic surgery is the best approach.

Acknowledgements

The authors certify that they have obtained all appropriate patient consent forms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Almada CB, Fonseca DR, Vanzillotta RR, Pires FR. Cholesterol granuloma of the maxillary sinus. Braz Dent J 2008; 19:171–174.  Back to cited text no. 1
    
2.
Hwang DJ, Chung YS, Jun SY, Kim YJ, Lee JY, Park IW, et al. A case of compressive optic neuropathy caused by sphenoid sinus cholesterol granuloma. Jpn J Ophthalmol 2009; 53:441–442.  Back to cited text no. 2
    
3.
Nakagawa T, Asato R, Ito J. Cholesterol granuloma of the posterior ethmoid sinus mimicking meningocele. Acta Otolaryngol Suppl 2007; 557:47–50.  Back to cited text no. 3
    
4.
Marco M, Ida C, Luigi PF, Giampiero M, Domenico L, et al. Cholesterol granuloma of the frontal sinus: a case report. Case Rep Otolaryngol 2012; 2012:515986.  Back to cited text no. 4
    
5.
Graham J, Michaels L. Cholesterol granuloma of the maxillary antrum. Clin Otolaryngol Allied Sci 1978; 3:155–160.  Back to cited text no. 5
    
6.
Leon ME, Chavez C, Fyfe B, Nagorsky MJ, Garcia FU. Cholesterol granuloma of the maxillary sinus. Arch Pathol Lab Med 2002; 126:217–219.  Back to cited text no. 6
    
7.
Niho M. Cholesterol crystals in the temporal bone and the paranasal sinuses. Int J Pediatr Otorhinolaryngol 1986; 11:79–95.  Back to cited text no. 7
    
8.
Bulter S, Grossenbacher R. Cholesterol granuloma of the paranasal sinuses. J Laryngol Otol 1989; 103:776–779.  Back to cited text no. 8
    
9.
Durgam A, Batra PS. Paranasal sinus cholesterol granuloma: systematic review of diagnostic and management aspects. Int Forum Allergy Rhinol 2013; 3:242–247.  Back to cited text no. 9
    
10.
Shykon ME, Trotter MI, Morgan DW, Reuser TTQ. Cholesterol granuloma of the frontal sinus. J Laryngol Otol 2002; 116:1041–1043.  Back to cited text no. 10
    
11.
Lloyd G, Lund VJ, SavyL, Howard D, et al. Optimum imaging for mucoceles. J Laryngol Otol 2000; 114:233–236.  Back to cited text no. 11
    
12.
Cassano M, Pennella A, Taranto FD, Limosani P. Cholesterol granuloma of the maxillary sinus in a young patient with associated neurosurgical pathology. Int J Pediatr Otorhinolaryngol Extra 2009; 4:129–133.  Back to cited text no. 12
    
13.
Rath-Wolfson L, Talmi YP, Halpern M, et al. Cholesterol granulomas of the maxillary sinus presenting with nasal obstruction. Otolaryngol Head Neck Surg 1993; 109:956–958.  Back to cited text no. 13
    
14.
Hellquist H, Lundgren J, Olofsson J. Cholesterol granuloma of the maxillary and frontal sinuses. ORL J Otorhinolaryngol Relat Spec 1984; 46:153–158.  Back to cited text no. 14
    
15.
Gatland DJ, Youngs RP, Jeffrey IJ. CholesteroL granuloma of the maxillary antrum. J Otolaryngol 1988; 17:131–133.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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