Endocrine Abstracts

A case of frontal ethmoid sinus mucocele: a late complication of pituitary surgery?

Elaine Hui¹, Anjali Amin¹, Sandro Chiti-Batelli², Pooja Patel³, Nick Linton⁴ & Jonathan Valabhji¹

¹Department of Metabolic Medicine, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK; ²Department of Otolaryngology-Head-Neck Surgery, St Mary’s Hospital, London, UK; ³Department of Neurology, St Mary’s Hospital, London, UK; ⁴Department of Cardiology, St Mary’s Hospital, London, UK.

A 69-year-old Iraqi lady presented with a 4-day history of diplopia, headache and right eye swelling. She had a pituitary adenoma diagnosed in Beirut when she was 20 years old and underwent trans-frontal surgeries and radiotherapy twice and further transsphenoidal surgery in 1980. She was on prednisolone 2 mg+1 mg and thyroxine 50 mcg daily.

She initially presented to the ophthalmology clinic. Examination revealed a pupil-sparing 3rd nerve palsy of the right eye, with complete ptosis, proptosis and reduced visual acuity (6/9). She was referred to the medical team. CT head demonstrated a 2×1.5 cm homogeneous soft tissue mass in the medial aspect of the right orbit. MRI revealed a well-circumscribed mass arising within the anterior ethmoid air cells extending to the right frontal sinus. The pituitary fossa was enlarged but empty. IGF-1, prolactin and free T4 levels were normal. A multidisciplinary discussion involving radiologists, ophthalmologists, endocrinologists and otolaryngologists concluded that the MRI appearance was suggestive of a frontal ethmoid mucocele. Evacuation of the right frontal mucocele was performed by the otolaryngologists via endoscopic approach with antibiotics and steroid cover. She had complete resolution of the diplopia, ptosis and proptosis and visual acuity improved (6/6) post-operatively. Unfortunately, she had uncontrolled atrial fibrillation post-operatively and a positive troponin I of 0.09 μg/l (<0.04 μg/l). She was treated as acute coronary syndrome and subsequent coronary angiography did not show any significant coronary artery disease. She was discharged without further complication.

Mucoceles are slow-expanding cystic lesions with respiratory epithelium containing mucus caused by obstruction of sinus ostium¹. They can extend intraorbitally and intracranially². Mucocele formation is a rare complication of transsphenoidal surgery. There is no reported case following trans-frontal surgery. We reported a case of frontal ethmoid mucocele presented 50 years after trans-frontal surgery to a pituitary adenoma.

Reference: 1. Evans C. Aetiology and treatment of frontoethmoidal mucocele. J Laryngol Otol 1981 95 361–375.

2. Lai PC, Liao SL, Jou JR & Hou PK. Transcaruncular approach for the management of frontoethmoid mucoceles. Br J Ophthalmol 2003 87 699–703. doi: 10.1136/bjo.87.6.699.

Endocrine Abstracts (2008) 18 P17