A case of frontal ethmoid sinus mucocele: a late complication of pituitary surgery
Elaine Hui, Anjali Amin, Sandro Chiti-Batelli, Pooja Dassan, Nick Linton & Jonathan Valabhji
A 69-year-old 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 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. She had complete resolution of the diplopia, ptosis and protosis 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.
Mucocele is a slow-expanding cystic lesion with respiratory epithelium containing mucus caused by obstruction of sinus ostium and can extend intraorbitally and intracranially. It is a rare complication of transsphenoidal surgery. We report a case of frontal ethmoid mucocele presented 50 years after trans-frontal surgery to a pituitary adenoma.