What are the symptoms of a sphenoid sinus mucocele that require surgical drainage through endoscopic sinus surgery (ESS) for treatment?

From the Guidelines

Surgical drainage through endoscopic sinus surgery is the primary treatment for symptomatic sphenoid sinus mucoceles, as it provides the most effective way to relieve symptoms and prevent complications. Patients typically present with headaches, visual disturbances, diplopia, and occasionally cranial nerve deficits due to the mucocele's expansion and compression of surrounding structures. Preoperative evaluation includes CT and MRI imaging to assess the extent of the mucocele and its relationship to critical structures like the optic nerve and carotid artery, as recommended by the ACR Appropriateness Criteria for sinonasal disease 1.

The surgical procedure involves creating a wide sphenoidotomy to marsupialize the mucocele, removing its contents, and establishing permanent drainage. This approach is supported by the European Position Paper on Rhinosinusitis and Nasal Polyps, which suggests that endoscopic surgery can be successfully undertaken in patients with chronic rhinosinusitis who do not respond to medical treatment 1. Postoperatively, patients require saline irrigations (240-480mL twice daily) and may need a short course of oral antibiotics like amoxicillin-clavulanate (875/125mg twice daily for 7-10 days) if infection is present.

Intranasal steroids such as fluticasone (2 sprays per nostril daily) are often prescribed to reduce inflammation, as they are a mainstay of treatment for chronic rhinosinusitis 1. Follow-up endoscopic examinations are essential at 1 week, 1 month, and 3 months post-surgery to ensure the surgical opening remains patent. This approach is effective because it addresses the underlying pathology by establishing permanent drainage while preserving mucosa and minimizing complications compared to traditional open approaches, which carried higher risks of cerebrospinal fluid leaks and neurovascular injuries. Key considerations in the management of sphenoid sinus mucoceles include:

• Preoperative evaluation with CT and MRI imaging
• Endoscopic sinus surgery to establish permanent drainage
• Postoperative care with saline irrigations and intranasal steroids
• Follow-up endoscopic examinations to ensure the surgical opening remains patent.

From the Research

Symptoms of Sphenoid Sinus Mucocele

• The symptoms of a sphenoid sinus mucocele can vary, but common symptoms include:
  • Headache, which was the most frequent symptom in 9 out of 12 patients in one study 2
  • Visual disorders, such as ocular symptoms, which were present in 50% of patients in another study 3
  • Nasal discharge and facial pain, which were also reported by patients in the studies 2, 3
• The symptoms can be insidious and may progress to more severe complications if left untreated, such as monocular blindness, as reported in one case 4

Diagnosis and Treatment

• Diagnosis of a sphenoid sinus mucocele is typically based on a combination of:
  • Clinical evaluation, including nasoendoscopy
  • Imaging studies, such as computed tomography (CT) and magnetic resonance imaging (MRI) scans
• Treatment of a sphenoid sinus mucocele usually involves surgical drainage, which can be performed using an endoscopic approach, as described in several studies 4, 2, 5, 6, 3
• The endoscopic approach is considered the gold standard for treatment, as it allows for effective drainage and restoration of respiratory function, with minimal complications and high patient compliance 5