今日の臨床サポート

副鼻腔嚢胞

著者: 柳清 松脇クリニック品川

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2022/06/08
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
柳清 : 特に申告事項無し[2022年]
監修:森山寛 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 内視鏡下鼻内手術の術中写真を更新
  1. 外側にある上顎洞嚢胞に対してDALMA法(Direct approach to the anterior and lateral part of the maxillary sinus with an endoscope)を追加

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 副鼻腔嚢胞とは、副鼻腔に嚢胞が生じ、骨壁を圧排し、眼球変位、複視、頬部腫脹などを来す状態である。発生の機序は粘膜の肥厚や粘液腺の拡張など粘膜の慢性炎症、手術を含む外傷などにより副鼻腔が固有鼻腔との交通路の閉塞により生ずる。
  1. 副鼻腔嚢胞は原発性と続発性に大別される。
  1. 原発性嚢胞は原因となる明らかな既往症を持たないものである。
  1. 続発性嚢胞は誘因となる手術や外傷の既往があり、それに続発したと思われるものを指す。
  1. 嚢胞は貯留液の性状により、細菌感染を伴わない粘液嚢胞(mucocele)と細菌感染を伴う膿嚢胞(pyocele)に分けられる。
  1. 前頭洞、篩骨洞、上顎洞、蝶形骨洞の各副鼻腔に発生する。さらに各副鼻腔の境界部に発生する複合タイプや同時に複数の副鼻腔に発生するタイプ、そして両側性に発生するものもある。
  1. 発生頻度は欧米では前頭洞に最も多く(60~65%)、篩骨洞(20~25%)、上顎洞(10%)、蝶形骨洞(1~2%)の順になる。
  1. 日本では術後性上顎洞嚢胞の発生頻度が高いため、上顎洞が最も多く(78%)、次に前頭洞(10%)、篩骨洞(7%)、蝶形骨洞(5%)の順になる[1]
  1. 後部副鼻腔(後篩骨洞や蝶形骨洞)に発生すると視力障害を来すので、その場合、緊急手術が必要になる。
  1. いわゆる副鼻腔嚢胞とは別に副鼻腔の粘膜下に粘液が貯留する粘膜嚢胞がある。
 
  1. 副鼻腔嚢胞と洞内粘膜嚢胞とは病態が異なる(推奨度1)(参考文献:[2][3][4]
  1. 洞内粘膜嚢胞(mucosal retention cyst)は通常上顎洞の底にみられる。
  1. 上顎洞の粘液腺の腺管が閉塞して生じた貯留嚢胞と考えられている。
  1. 症状がなければ治療の必要はないが、大きくなると頬部痛や眼痛、蝶形骨洞に発生すれば頭痛などの症状が出ることがあるので、その場合は手術の対象となる。
  1. 内視鏡と手術器具の改良で低侵襲手術が可能になった。
  1. 追記:この疾患は脳ドックなどの健診で偶然発見されることも多く、脳外科や他科からの紹介で受診する例がときどきある。
 
副鼻腔嚢胞と洞内粘膜嚢胞とは病態が異なる。

a:前額断CTで左上顎洞内に粘膜嚢胞を認める。
b:粘膜嚢胞の上顎洞内視鏡所見
c:蝶形骨洞のMRI前額断所見。右蝶形骨洞内に水分濃度の嚢胞陰影を認める。
d:蝶形骨洞のMRI水平断所見。右蝶形骨洞内に水分濃度の嚢胞陰影を認める。

出典

img1:  著者提供
 
 
問診・診察のポイント  
問診:
  1. 鼻閉、鼻汁、嗅覚障害の有無

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文献 

E W Fisher, H B Whittet, C B Croft
Symptomatic mucosal cysts of the maxillary sinus: antroscopic treatment.
J Laryngol Otol. 1989 Dec;103(12):1184-6.
Abstract/Text Antroscopy has been shown to have a role in the diagnosis and treatment of antral disease. Four cases of 'non-secreting' benign antral cysts, each presenting with facial pain, were successfully treated using antroscopic techniques. The aetiology and management of these lesions is reviewed with the recommendation that antroscopic removal is the treatment of choice for all symptomatic cases, and for asymptomatic cases in which the diagnosis is in doubt.

PMID 2614239
P Eloy, S Vlaminck, M Jorissen, P Hellings, M Timmermans, J Daele, P Ransky, S Hassid, T Van Zele, C Bachert, A L Poirrier, B Bertrand
Type III frontal sinusotomy: surgical technique, indications, outcomes, a multi-university retrospective study of 120 cases.
B-ENT. 2011;7 Suppl 17:3-13.
Abstract/Text Draf in 1991. The procedure--which is also known as the modified endoscopic Lothrop procedure--aims to create the largest possible anteroposterior and lateral to lateral opening between both frontal sinuses and the nasal cavities. This requires the resection of the medial floor of both frontal sinuses, the intersinus septum and the superior nasal septum. The authors present a retrospective study including a cohort of 120 patients who underwent surgery in six Belgian university ENT departments. Mean follow-up was 24.6 months (range: 5-36 months). This paper describes the surgical procedure and reviews the indications, comorbidities, outcomes and complications of the type III frontal sinusotomy. Some correlations are also established with the data published in the worldwide literature. The authors conclude that the Draf III is a demanding procedure requiring considerable expertise in endoscopic sinus surgery. The procedure is effective with a success rate of 87.5%. Indeed, 12.5% of patients only experienced closure of the neoostium while 20% of all the patients had unchanged or worse symptomatology. The percentage of post-operative complications is 7.5%. All complications were managed successfully.

PMID 22338369
C F Lanzieri, M Shah, D Krauss, P Lavertu
Use of gadolinium-enhanced MR imaging for differentiating mucoceles from neoplasms in the paranasal sinuses.
Radiology. 1991 Feb;178(2):425-8. doi: 10.1148/radiology.178.2.1987603.
Abstract/Text The purpose of this study was to determine whether additional clinically useful information could be obtained from gadolinium-enhanced magnetic resonance (MR) imaging compared with the information obtained from nonenhanced MR imaging and computed tomography (CT). Therefore, the authors selected 41 patients, whose results at CT examinations demonstrated a variety of pathologic conditions of the paranasal sinuses, to undergo MR imaging both with and without the use of gadopentetate dimeglumine for contrast enhancement. In 22 of 35 cases of neoplasms and mucoceles occurring separately, the lesions were correctly differentiated by established MR signal criteria alone. However, 32 of these 35 cases were accurately differentiated when gadolinium-enhanced MR images were obtained. Six cases demonstrated co-existing neoplasm and mucocele: Gadolinium-enhanced MR enabled correct differentiation of five of these lesions, while unenhanced MR enabled correct differentiation of three. On the basis of these results, the authors conclude that the use of gadopentetate dimeglumine for contrast enhancement at MR imaging is useful for differentiating mucoceles from neoplasms in the sinonasal tract.

PMID 1987603
A Ruelle, R Pisani, G Andrioli
"Unusual" MRI appearance of sphenoid sinus mucocele.
Neuroradiology. 1991;33(4):352-3.
Abstract/Text The authors report a case of sphenoid sinus mucocele which exhibited unusual MRI features. However a review of the literature shows that these lesions may present with different MRI appearances probably related to the variability of the cyst content. Further series are needed for a better definition of the MRI behaviour of the lesions.

PMID 1922754
Tsuguhisa Nakayama, Daiya Asaka, Tetsushi Okushi, Mamoru Yoshikawa, Hiroshi Moriyama, Nobuyoshi Otori
Endoscopic medial maxillectomy with preservation of inferior turbinate and nasolacrimal duct.
Am J Rhinol Allergy. 2012 Sep-Oct;26(5):405-8. doi: 10.2500/ajra.2012.26.3791.
Abstract/Text BACKGROUND: Endoscopic medial maxillectomy (EMM) is a safe and effective procedure for treatment of inverted papilloma (IP) originating from the maxillary sinus. However, EMM usually removes the inferior turbinate and nasolacrimal duct. The inferior turbinate has a critical function in conditioning of the nasal airflow, and resection of the nasolacrimal ducts has a risk of epiphora. We developed a newly derived surgical technique, endoscopic modified medial maxillectomy (EMMM), which enables preservation of the inferior turbinate and nasolacrimal duct.
METHODS: A retrospective case series of six patients with IP and nine patients with mucoceles of the maxillary sinus after a Caldwell-Luc operation, who underwent surgery using the EMMM technique, were reviewed.
RESULTS: In patients with IP, there were no recurrences for a mean follow-up of 16.7 months. Eight of nine patients with mucoceles of the maxillary sinus showed patency. All patients showed preservation of the inferior turbinate. One patient with mucocele was referred for dacryocystorhinostomy because of epiphora.
CONCLUSION: EMMM produces access to the maxillary sinus identically to conventional EMM, despite preservation of the inferior turbinate and nasolacrimal duct.

PMID 23168157
Kazuhiro Omura, Kazuhiro Nomura, Satoshi Aoki, Nobuyoshi Otori, Yasuhiro Tanaka
Direct approach to the anterior and lateral part of the maxillary sinus with an endoscope.
Auris Nasus Larynx. 2019 Dec;46(6):871-875. doi: 10.1016/j.anl.2019.03.006. Epub 2019 Apr 4.
Abstract/Text OBJECTIVE: The Caldwell-Luc (CL) approach with a sublabial incision is used to manipulate the anterior wall of the maxillary sinus. Paresthesia is one of the major complications associated with the CL approach. We developed a new method, "direct approach to the anterior and lateral part of the maxillary sinus with an endoscope" (DALMA), that negates the need for a sublabial incision and minimizes dental paresthesia by reducing the risk of anterior superior alveolar nerve injury. This study aimed to describe how to perform the DALMA technique, and to review its effectiveness and associated complications.
METHODS: We retrospectively reviewed 10 patients who had received DALMA.
RESULTS: Ten patients underwent DALMA. The anterior superior alveolar nerve was identified in all patients. Access to the lateral side beyond the infraorbital canal and anterior wall of the maxillary sinus was achieved.
CONCLUSIONS: DALMA is a simple, effective, and minimally invasive technique that can be used as an alternative to CL with sublabial incision.

Copyright © 2019 Elsevier B.V. All rights reserved.
PMID 30955919
C Georgalas, F Hansen, W J M Videler, W J Fokkens
Long terms results of Draf type III (modified endoscopic Lothrop) frontal sinus drainage procedure in 122 patients: a single centre experience.
Rhinology. 2011 Jun;49(2):195-201. doi: 10.4193/Rhino10.153.
Abstract/Text OBJECTIVES: To assess the effectiveness and factors associated with restenosis after Draf type III (Endoscopic Modified Lothrop) frontal sinus drainage procedure.
DESIGN: Retrospective analysis of prospectively collected data.
PATIENTS: A hundred and twenty two consecutive patients undergoing Draf III procedure for recalcitrant chronic frontal rhinosinusitis (CRS) (71%), frontal sinus mucocoele (15%), benign frontal sinus tumours (9%) and cystic fibrosis with severe CRS (5%) were followed up for an average of 33 months.
OUTCOME MEASURES: Symptom burden (Visual Analogue Scale and Rhinosinusitis Outcome Measure), patency of neo-ostium and revision surgery.
RESULTS: At the end of follow up, ninety percent of patients had a patent neo-ostium, while 88% were either clinically better or completely asymptomatic. Thirty-nine patients required endoscopic revision surgery and 9 eventually underwent frontal sinus obliteration. Sixty percent of revision operations were performed during the first two years. RSOM showed a significant improvement in both general and nasal symptoms while on a VAS, headache improved significantly. The only factor weakly associated with re-stenosis was the presence of allergy. There were no major complications during any of the procedures.
CONCLUSION: Draf III Procedure is safe and effective for patients who have failed conventional frontal sinus procedures and a valid alternative to frontal sinus obliteration. Although the revision rate may appear to be quite significant, it can often be performed as an outpatient procedure and needs to be balanced against the reduced morbidity and the ease of follow-up.

PMID 21743876
Peter Anderson, Raj Sindwani
Safety and efficacy of the endoscopic modified Lothrop procedure: a systematic review and meta-analysis.
Laryngoscope. 2009 Sep;119(9):1828-33. doi: 10.1002/lary.20565.
Abstract/Text OBJECTIVES/HYPOTHESIS: The endoscopic modified Lothrop procedure (EMLP; also known as Draf III or frontal drillout) has recently gained popularity as a minimally invasive alternative to frontal sinus obliteration. This systematic analysis was designed to assess the safety and efficacy of the EMLP.
STUDY DESIGN: Literature review and meta-analysis.
METHODS: We performed a search of all English studies published from 1990 to 2008 that reported results from a minimum of five patients undergoing the EMLP. Of the 33 papers reviewed, 18 studies (evidence level II-2 or II-3) containing data from 612 patients met inclusion criteria.
RESULTS: The most common indications for EMLP were chronic frontal sinusitis (75.2%) and mucocele (21.3%). Patients had an average age of 47.9 years (range, 14-89 years) and were followed for 28.5 months postoperatively. Only 20.3% of procedures were performed without image-guidance. Stents were rarely used (6%). The rate of major and minor complications was <1% and 4%, respectively. No deaths were reported. A majority of patients were discharged within 24 hours. Postoperative endoscopic findings, qualitatively reported in 394 patients, demonstrated frontal sinus patency or partial stenosis in 95.9% at last follow-up. Where specifically assessed (n = 430 patients), improvement in symptoms was achieved in 82.2% of cases, with 16% reporting no significant change, and 1.2% reporting worsening of symptoms. The overall failure rate (requiring further surgery) of EMLP was 13.9% (85/612). Of the failures, 80% underwent revision EMLP, whereas 20% elected osteoplastic frontal sinus obliteration.
CONCLUSIONS: When performed by an experienced surgeon, EMLP is a safe and efficacious procedure that is well tolerated.

PMID 19554631
Shinya Morita, Kenji Mizoguchi, Keiji Iizuka
Paranasal sinus mucoceles with visual disturbance.
Auris Nasus Larynx. 2010 Dec;37(6):708-12. doi: 10.1016/j.anl.2010.04.002. Epub 2010 Jun 8.
Abstract/Text OBJECTIVE: Paranasal sinus mucoceles may cause visual disturbance in patients because of their close proximity to the orbit. We aimed to investigate visual prognosis to determine whether it is influenced by the interval before surgery and the severity of visual disturbance, and to heighten the physician's awareness of the occurrence of this disease.
METHODS: We retrospectively reviewed eight surgically treated patients with paranasal sinus mucoceles accompanied by visual disturbances between March 2005 and January 2009, and examined the visual acuity outcome of the patients.
RESULTS: Four patients with a mild visual acuity loss showed improvement after surgical drainage within 1 month after onset. Two patients with visual disturbances persisting for more than 1 year did not show postoperative improvements. Although two patient's preoperative visual acuity loss was worse than the ability to count fingers, they showed a remarkable improvement after surgery.
CONCLUSIONS: These results show the importance of diagnosing and treating paranasal sinus mucoceles with visual disturbance as soon as possible. In addition, the improvement of visual acuity can be expected if surgery is performed within 1 month after onset, and the patient's preoperative visual acuity loss is mild. However, if patients with severe visual acuity loss consult otolaryngologists at a later date, surgery may still be considered worthwhile.

Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.
PMID 20570455
T Yokoyama, S Inoue, J Imamura, T Nagamitsu, Y Jimi, S Katoh, H Kameda, S Abiko
Sphenoethmoidal mucoceles with intracranial extension--three case reports.
Neurol Med Chir (Tokyo). 1996 Nov;36(11):822-8.
Abstract/Text Three unusual cases of sphenoethmoidal mucoceles with rare intracranial extension are reported. A 64-year-old female presented with a 7-month history of right visual disturbance. Computed tomography (CT) and magnetic resonance (MR) imaging demonstrated a huge mass in the right middle fossa. She underwent right frontotemporal craniotomy. Postoperatively, her proptosis and cranial nerve dysfunction had improved markedly. A 53-year-old female complained of headache, nausea, and dizziness. CT and MR imaging revealed a cystic mass filling the right sphenoid sinus. The cystic lesion was evacuated through the transnasal approach. She was doing well postoperatively and has been asymptomatic. A 39-year-old male complained of headache, vomiting, and right visual disturbance. CT and MR imaging demonstrated a homogeneous mass occupying the sphenoid sinus. Sphenoidotomy exposed the cyst extending superiorly into the anterior cranial fossa. He recovered from the visual disturbances and has been asymptomatic since. MR imaging provides confirmation of the diagnosis of sphenoethmoidal mucocele and is important for preoperative evaluation.

PMID 9420437

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