Orbital Mucocele

Description
Orbital mucocele can occur when sinus mucoceles cannot naturally drain through the nose. Instead, they grow and slowly invade adjacent orbital tissues.

Generally arising from the ethmoid or frontal sinuses, orbital mucoceles are mucous or fluid filled cysts which can displace the eye. Frontal sinus mucoceles can force the eye down, ethmoid tumors will push the eye out and maxillary lesions can elevate or push the eye in. Lastly, orbital mucoceles originating in the sphenoid sinus can compress the optic nerve resulting in loss of vision.

Symptoms
Patients with mucocele of the orbit, typically have a history of facial trauma or chronic sinus disease. They tend to be in their mid 40's or older. They can have painless proptosis, or complain of headaches, double vision, or loss of vision.

Diagnosis
Though magnetic resonance imaging (MRI) can be consistent with a mucous or serous fluid-filled tumor, a drainage procedure is typically required and found to be diagnostic. The mucoid or serous fluid (which is found to make up the mucocele) should be sent for culture and sensitivity as well as cytologic examination. Mucoceles can be infected. In those cases, the choice of antibiotics can depend on cultures taken during surgery.

These magnetic resonance imaging (MRI) studies demonstrate displacement of the optic nerve, a bright T1 tumor image, and a variably bright T2 tumor image. The tumor is noted to involve the orbit, the ethmoid and frontal sinuses.

Computed axial tomography demonstrates displacement of the medial rectus muscle (MR), as well as erosion and obliteration of portions of the orbital roof (black arrows). Note that the orbital portion of the mucocele is partially encased in bone. This is characteristic of mucocele. The rectus muscles and optic nerve are labeled.

Intraoperative transnasal video photography is presented to show the mucocele cavity (arrow) after ethmoidectomy (photograph courtesy of Steven Schaefer, MD)

Treatments
The treament of mucocele of the orbit is surgical. It is best to have a combination of an ophthalmic and ENT surgeons. Treatment involves removal of as much of the cyst and its lining as possible. This usually requires an orbitotomy and sinusectomy. It is most important to re-establish or create a new drainage pathway for the mucous to exit the nose.

Intraoperative transnasal video photography is presented to show the mucocele cavity (arrow) after ethmoidectomy (photograph courtesy of Steven Schaefer, MD)

Additional Info
Case Example: A 63 year old male was referred to The New York Eye Cancer Center with a 6 month history of progressive painless proptosis of the right eye.

Despite this large orbital tumor with optic nerve displacement, the patient was 20/20 OU, he had no visual field defect, and no signs of optic neuropathy. A complete medical survey was initiated and the patient was cleared for surgery. A combination of anterior orbitotomy and transnasal ethmoidectomy were performed to evacuate the mucous and allow for future drainage.

Though recurrence is possible, this surgery is typically curative. We recommend sending the mucoid contents for culture and sensitivity and cytopathology.

Related Links
Orbital Mucocele Literature

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