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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 24  |  Issue : 2  |  Page : 208-210

Scuba Diver Presenting with a Giant Sphenoid Sinus Mucocele


Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission27-Feb-2022
Date of Decision11-Mar-2022
Date of Acceptance12-Mar-2022
Date of Web Publication10-Aug-2022

Correspondence Address:
Prof. (Dr) Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_32_22

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  Abstract 


Isolated sphenoid sinus mucocele is an uncommon clinical entity. Expanding mucocele in the sphenoid sinus may affect vital structures such as the optic nerve, internal carotid artery, and other adjacent structures. Hence, barotrauma causing sphenoid sinus mucocele may result in serious neurological disorders including headache and vision disturbances. The patient urgently requires treatment of endoscopic marsupialization of the sphenoid sinus mucocele. Here, a 35-year-old male diver presented with acute headache and was diagnosed as sphenoid mucocele by computed tomography scan and magnetic resonance imaging. He was treated immediately with oral corticosteroids, nasal decongestants, and antibiotics. Then, he underwent endoscopic transnasal sphenoidotomy and marsupialization of the mucocele. A high index of suspicion is needed to get such a rare clinical entity like sphenoid mucocele when a diver presents with a headache and/or visual problem.

Keywords: Barotrauma, diver, headache, sphenoid sinus mucocele


How to cite this article:
Swain SK. Scuba Diver Presenting with a Giant Sphenoid Sinus Mucocele. J Mar Med Soc 2022;24:208-10

How to cite this URL:
Swain SK. Scuba Diver Presenting with a Giant Sphenoid Sinus Mucocele. J Mar Med Soc [serial online] 2022 [cited 2022 Dec 1];24:208-10. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/2/208/353652




  Introduction Top


Scuba diving-related injuries of the head-and-neck region are common and account for approximately 80% of all diving injuries.[1] Development of the sphenoid sinus mucocele in a diver is a rare manifestation.[1] Mucoceles are uncommon cystic lesions of the paranasal sinuses that are thought to occur by obstruction of the sinus ostium.[2] Scuba diving may result in barotrauma of the paranasal sinus that results in mucocele of the sphenoid sinus. There are several theories for the development of paranasal sinus mucoceles such as congenital, traumatic, iatrogenic, infectious, and inflammatory causes.[2] Barotrauma is an important cause for the development of mucocele. The frontal sinus is most commonly affected by the barotrauma, likely due to the anatomic restrictions and variations of narrow frontal recess, which connects sinus to anterior ethmoids.[3] Other sinuses such as maxillary, ethmoid, and sphenoid sinuses are affected with mucoceles less frequently than frontal sinus.[3] Here, this case reports presentation with sphenoid mucocele in a diver due to barotrauma.


  Case Report Top


A 35-year-old male scuba diver attended the outpatient department of otolaryngology with complaints of headache for 3 days after scuba diving approximately 60 feet below sea level. He had two previous episodes of headache occurring after diving 3 and 6 months before the presentation but resolved after he underwent a decompression scuba diving maneuver. He had also right-side nasal obstruction. He had a history of sinusitis 3 months back and has undertaken medical treatment. He was evaluated with proper history taking examination for decompression sickness (DCS), arterial gas embolism, carbon monoxide poisoning, envenomation, dehydration, hyperbaric triggered migraine, and different barotraumas. There were no such complications associated with patient after diving by proper evaluation in emergency department before coming to otolaryngology outpatient department. He had no history of vision problems. He had no history of fever, vomiting, and neck rigidity. Anterior rhinoscopy showed normal findings. Diagnostic nasal endoscopy revealed no evidence of sinusitis and any anatomical anomalies in the nasal cavities. His extraocular movements of eye were normal with no evidence of proptosis. Computed tomography (CT) scan of the nose and paranasal sinus revealed a large mucocele in the sphenoid sinus without any evidence of bony erosion [Figure 1]. Magnetic resonance imaging (MRI) revealed normal intracranial and adjacent vital structures to the sphenoid sinus. He was immediately started conservative treatment with oral steroids, antibiotics, and nasal decongestants. He underwent trans-sphenoidal marsupialization of the mucocele in the sphenoid sinus under general anesthesia. During surgery, the sphenoid ostium was widened using upward biting and straight biting forceps under endoscopic visualization. The anterior and inferior walls of the sphenoid sinus were sufficiently removed for adequate drainage to the sphenoethmoidal recess and also for avoiding recurrence. Postoperative follow-up was done at 1 week, 1 month, 3 and 6 months. In a follow-up visit, the patient was relieved from headaches after performing endoscopic marsupialization. Diagnostic nasal endoscopy revealed a patent ostium and clear sphenoid cavity in all patients.
Figure 1: Computed tomography scan of the paranasal sinus (axial cut) showing a large sphenoid sinus mucocele

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  Discussion Top


Paranasal sinus barotrauma occurs due to pressure differences in the sinuses from diving and can result from the improper technique of diving, defective equipment, or diving with congested sinonasal tract.[4] The proposed etiopathology for sphenoid mucocele, in this case, is due to the depth of water into which the diver was submerged leading to acute expansion of the sphenoid mucocele. Sphenoid sinus barotrauma may occur in association with obstruction of the sinus drainage in the setting of rapidly changing ambient pressure.[4] Sphenoid sinus ostia obstruction can happen due to several sinonasal diseases but is most commonly associated with acute or chronic rhinosinusitis.[2] The first case of sinus barotrauma by diving was documented in an Australian Navy environment.[5] That case had presented with headache and epistaxis. Paranasal sinus barotrauma in divers may be associated with middle ear barotrauma.[6] The severity of the barotrauma in a person is usually associated with the size of the sinus ostia, cavities, and rate of ambient pressure alteration. When the mucosal linings of the sinus of a diver are subjected to a relative vacuum during the descent, mucosal edema, serosanguinous exudates, and submucosal hematoma occur.[7] Sphenoid sinus mucoceles are an uncommon clinical entity associated with diving but potentially life-threatening due to proximity to the dehiscent internal carotid artery and morbid due to optic nerve. Resorption and/or erosion of the bony wall of the sphenoid sinus cause rapid expansion of the sphenoid sinus mucocele and involve adjacent vital structures. It may sometimes cause optic nerve compression by expanded sphenoid mucocele. Parallel increasing of recreational divers, clinicians often confront with more number of driving-related cases.[8]

Good history taking and clinical examination are helpful to rule out the causes of headache and its severity. For a dive physician, the dive profile like depth, bottom-time, decompression stoppages, gas mixture, and equipment condition are vital for diagnosis. Site of headache, type pf headache, presence of neck rigidity, and associated symptoms of fever and vomiting are helpful for early diagnosis of this clinical entity. The sphenoid sinus mucocele has varied clinical presentations. Headache is the most common symptom of sphenoid sinus mucocele and it should be differentiated from other causes of headaches such as ophthalmological causes like acute angle-closure glaucoma or neurological causes like raised intracranial pressure.[9] Isolated sphenoid sinus barotrauma may manifest with retro-orbital/occipital pain with the absence of significant nasal discharge.[4] Headache in a scuba diver, postdive is one of the most common presentations seen by a marine medicine specialist or a dive physician. There are multiple causes for this but it is axiomatic to believe that or any headache in a diver within 36 h of surfacing from a dive is related to diving illness unless proven otherwise. This is because DCS is a great imitator or masquerader like HIV, Lyme's disease, infectious endocarditis,  Brucellosis More Details, sarcoidosis, tuberculosis.[9] Sometimes, such a patient may present with epistaxis.[4] Sphenoid sinus mucocele can affect vision by compression with vessels leading to vascular compromise or spread of inflammation/infection to the optic nerve.[9] Visual loss can be found in 20%–50% of cases.[10] The other common symptom in sphenoid sinus mucocele is a nonaxial proptosis.[11] However, proptosis was not seen in our case. Other clinical manifestations include extraocular motility abnormalities, nasal congestion, optic neuropathy, and less commonly ophthalmoplegia and orbital cellulitis.[2] It may be complicated with meningitis or cerebral empyema. The diagnosis is often based on diagnostic nasal endoscopy findings and CT or MRI scanning.[12] A CT scan of the nose and paranasal sinuses is an excellent diagnostic tool for finding the sphenoid sinus mucocele with intracranial involvement, which is an important step for the management of the mucoceles. On CT scan, the mucocele appears a hypodense, nonenhancing mass that fills and expands the sphenoid sinus. An MRI is useful for sphenoid sinus mucocele with intracranial and optic nerve involvement. MRI is a superior investigation tool for identifying the relationship of the mucoceles to the adjacent soft tissue and in distinguishing from other soft tissue lesions.[13] The signal intensity of T1WI and T2WI is dependent upon the viscosity and fluid present in the mucocele. On T2W1, the sphenoid sinus mucocele is hyperintense due to its high-water content. As time progresses, the intensity may reduce because of inspissations. In contrast, T1Wis have less signal intensity initially, but with the absorption of water and raised protein concentration over time, a more viscous mucocele alters from an isointense to hyperintense components.[14] The recovery of vision loss is poor if the patient of sphenoid sinus mucocele presents with sudden onset of vision loss or visual acuity is no light perception preoperatively.[2] However, 55.5%–62.5% of the patients show resolution of the optic neuropathy with sphenoid sinus mucocele after surgery.[2] The recovery of vision loss/optic neuropathy depends on the duration and amount of compression on the optic nerve.[15] A high index is required in cases of recurrent headache postdive. In the extant case, the imaging such as CT scan and MRI can be done to confirm the diagnosis of sphenoid sinus mucocele.

Early diagnosis and treatment are important for preventing the sphenoid mucocele such as to prevent permanent visual loss. The treatment of sphenoid sinus mucocele is usually surgical. After the advent of the endoscopic technique, endoscopic marsupialization of the mucocele has gained popularity. Nasal decongestants, oral steroids, and antibiotics can be started while awaiting surgical intervention. The steroid with nasal decongestants helps reduce osteal inflammation that allows drainage and decompression of the mucocele. The oral steroid is also helpful for drainage and decompression of the mucoceles. The intravenous steroid is beneficial for rapid recovery as it is a higher dosage and earliest onset of action. However, caution must be used when mucocele is associated with possible infection. The surgical intervention is the effective mode of intervention for early improvement of the symptoms. The important method for preventing sphenoid sinus barotrauma in diving is abstention from diving at the time of upper respiratory tract infection, particularly in rhinitis or sinusitis.[4] Other preventive measures include avoidance of smoking and other nasal irritants, adopting a feet-first position on the descent, and using frequent and appropriate equalization techniques.[7] In case of scuba diving, some precautions are a must like avoiding consumption of alcohol, tobacco, and caffeine during diving. Divers may return for diving within 6 weeks of treatment provided imaging shows resolution of the sinus opacification and also resolution of factors like sinonasal polyps, infections, or inflammation.[15]


  Conclusion Top


Scuba divers have a significant potential for causing complications like sphenoid sinus mucocele. Otorhinolaryngologists and diving medicine experts should understand the etiopathology and management of diving-related complications of sphenoid mucocele. It is important to have a high index of suspicion for sphenoid sinus mucocele as a differential diagnosis in scuba divers with severe headaches and/or acute visual impairment. Endoscopic transnasal marsupialization of the mucocele is the ideal treatment option for sphenoid sinus mucocele developed by diving.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Klingmann C, Praetorius M, Baumann I, Plinkert PK. Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up. Otol Neurotol 1977;42:593-9.  Back to cited text no. 1
    
2.
Soon SR, Lim CM, Singh H, Sethi DS. Sphenoid sinus mucocele: 10 cases and literature review. J Laryngol Otol 2010;124:44-7.  Back to cited text no. 2
    
3.
Lynch JH, Deaton TG. Barotrauma with extreme pressures in sport: From scuba to skydiving. Curr Sports Med Rep 2014;13:107-12.  Back to cited text no. 3
    
4.
Bourolias C, Gkotsis A. Sphenoid sinus barotrauma after free diving. Am J Otolaryngol 2011;32:159-61.  Back to cited text no. 4
    
5.
Fagan P, McKenzie B, Edmonds C. Sinus barotrauma in divers. Ann Otol Rhinol Laryngol 1976;85:61-4.  Back to cited text no. 5
    
6.
Swain SK, Shajahan N, Mohapatra A. Middle ear barotrauma and facial baroparesis in underwater diving – A scoping review. J Mar Med Soc 2020;22:118-22.  Back to cited text no. 6
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Edmonds CB, Bennett M, Lippmann J, Mitchell S, editors. Diving and Subaquatic Medicine. 5th ed. Florida: CRC Press; 2015. p. 865.  Back to cited text no. 7
    
8.
Gonnermann A, Dreyhaupt J, Praetorius M, Baumann I, Plinkert PK, Klingmann C. Otorhinolaryngologic disorders in association with scuba diving. HNO 2008;56:519-23.  Back to cited text no. 8
    
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Friedman A, Batra PS, Fakhri S, Citardi MJ, Lanza DC. Isolated sphenoid sinus disease: Etiology and management. Otolaryngol Head Neck Surg 2005;133:544-50.  Back to cited text no. 9
    
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Kim YS, Kim K, Lee JG, Yoon JH, Kim CH. Paranasal sinus mucoceles with ophthalmologic manifestations: A 17-year review of 96 cases. Am J Rhinol Allergy 2011;25:272-5.  Back to cited text no. 10
    
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Ajaiyeoba A, Kokong D, Onakoya A. Clinicopathologic, ophthalmic, visual profiles and management of mucoceles in blacks. J Natl Med Assoc 2006;98:63-6.  Back to cited text no. 11
    
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Giovannetti F, Filiaci F, Ramieri V, Ungari C. Isolated sphenoid sinus mucocele: Etiology and management. J Craniofac Surg 2008;19:1381-4.  Back to cited text no. 12
    
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Swain SK, Munjal S. Otitic barotrauma causing facial baroparesis. Arch Trauma Res 2020;9:197-9.  Back to cited text no. 13
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14.
Kao HW, Lo CP, Hsu YC, Chiu YC, Hsiao CH, Chen CY. Sphenoid sinus mucocele presenting with optic canal syndrome. J Med Sci 2006;26:061-4.  Back to cited text no. 14
    
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Levy J, Monos T, Puterman M. Bilateral consecutive blindness due to sphenoid sinus mucocele with unilateral partial recovery. Can J Ophthalmol 2005;40:506-8.  Back to cited text no. 15
    


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