Mucous Cyst Formation After Rhinoplasty

The development of a deforming nasal-dorsal mass after rhinoplasty is a very rare and for the most part, an avoidable complication. The list of differential diagnoses for such a postoperative external nasal lesion ranges from simple soft tissue edema or hema­toma, which is usually temporary, to more serious lesions, such as lipogranulor epidermoid inclusion cysts, tumefactive cartilage proliferation, and mucous cysts, which can cause permanent deformities. Although various nasal tumors, infections, and granulomatous diseases are not specifically related to surgery, they should also be considered.

We report a case of an expanding nasal-dorsal mucous cyst that developed after a closed septorhinoplasty procedure. The cyst was related to sequestration of a mu-cosal-lined nasal bone that was not re­moved at the time of dorsal osteotomy. The nasal-dorsal mucocele and misplaced na­sal bone were managed through an exter­nal skin resection of the cystic mass and osteotomy of the nasal bone. The pa­tient's nasal-dorsal contour remained aes­thetically corrected at the 1-year postop­erative visit, with no evidence of recurrence of the mucous cyst.

A 33-year-old man with no significant medical history had previously under­gone 3 septorhinoplasty procedures at vari­ous outside institutions. After the last pro­cedure, performed over 2 years ago, he observed a gradually expanding mass over the dorsum of his nose. He also com­plained of persistent nasal obstruction and increased snoring. On physical examina­tion, it was noted that his nasal septum was moderately deviated to the right and that he had a cystic 2.0 X 2.5-cm upper nasal-dorsal mass Computed to­mography of the paranasal sinuses ini­tially revealed a moderately deviated septum with no evidence of sinusitis and a poorly defined soft tissue density calcifications along the superior nasal dor­sum. Antibiotic treatment and a short tapering course of oral prednisone v begun. I lowever, because of the poor defi­nition of the nasal mass on the computed tomographic scan, a subsequent D netic resonance imaging scan was ob­tained. The magnetic resonance imaging scan revealed a 1 X 2-cm proteinaceous cystic lesion just below and to the right ofthe nasofrontal suture, in contact with the superior aspect of the nasal hones. No fis­tula or dural contact was noted (Figure 2 and Figure 3).

The options were discussed with the patient, and the decision was made to per­form an open excision of the lesion, as well as revision septorhinoplasty. Intraopera-tively, a 2-cm horizontal midline inci­sion was made along a skin crease over­lying the nasal mass. The incision was carried subcutaneously, and a well-circumscribed 1.4 X 2.3-cm cystic mass. was noted to be firmly attached to the su­perior aspect of the right nasal bone, which was markedly displaced upward at the level of the nasofrontal suture line (Figure 4 and Figure 5). The mass was dissected from the nasal bone and surrounding na­sal-dorsal and glabellar soft tissue, and thedisplaced nasal bone was removed with an osteotome and a rasp, with good [ metic result. Within the complete cap­sule, a mucous-lined cavity was con-formed and noted to be filled with a thick yellowish liquid. Histopathologic findings confirmed a benign epithelial mucous cyst with a fragment of nor­mal cartilage and bone noted within the specimen.

COMMENT

The formation of a mucous cyst alter rhinoplasty is ex­ceedingly rare and should he considered a late soft tissue complication of septorbinoplasty. To our knowledge, fewer than 10 cases have been reported in the world literature to date.1-9 In all previous cases, the mucous cyst appeared sev­eral months to years after rhinoplasty. Sites described in­clude the glabellar region and the bony and cartilaginous nasal dorsum, as well as the area overlying the alar carti­lages. On exploration, a distinct capsule with no direct con­nection between the nasal mucosa and the cyst was re­ported in all cases. The most reasonable explanation for this phenomenon appears to be the proliferation of ectopic or displaced mucous membranes, acting as free grafts, caused by improper clearing of mucous epithelial remnants at­tached to bone or cartilage either in situ or as part of an autogenous graft. It is also hypothesized that cysts may de­velop by occlusion of sebaceous glands because of scar tis­sue formation.10 In our case, the cyst undoubtedly formed as a result of an incomplete osteotomy, with superior dis­placement and sequestration of the nasal bone and its at­tached mucous remnant.

Other entities that must also be considered in the differential diagnosis of the postrhinoplasty nasal-dorsal mass include rare cases of lipogranulomas (par­affinomas), which are thought to represent foreign body reactions to displaced lipid ointment from nasal pack­ings through intranasal incisions." Recently, 4 cases of tumelactive cartilage proliferation occurred after rhino­plasty in relation to morsellized dorsal cartilage im­plants.12 A case of multiple recurrent epidermoid inclu­sion cysts has also been reported and was thought to be related to implantation of epithelial tissue within scar tis­sue of the nasal skin by an original compound fracture of the nasal bones.13

There are various other nasal lesions that must be excluded, even though they are not related to surgery. Neoplastic lesions that can involve the nasal region in­clude squamous cell carcinoma, malignant melanoma, adenocarcinoma, sarcoma, and lymphoma. Benign pro­cesses, such as the congenital midline nasal masses (en-cephaloceles, gliomas, and dermoids), osteomas, lipomas, and even frontal sinus mucoceles, must also be considered. If an intranasal component exists, lesions such as inverting papillomas, juvenile nasopharyngeal angio­fibroma, and ethesioneuroblastoma must be excluded. Finally, certain granulomatous diseases (Wegener granu­lomatosis, sarcoidosis, and rhinoscleroma) and infec­tions (fungus, syphilis, and tuberculosis) may poten­tially present as a nasal mass. These entities should be able to be excluded with a careful physical examination, nasal endoscopy, anterior rhinoscopy, and radiographic studies. If any concern exists as to the possible diagno­sis, a biopsy should be considered.

Concerning treatment of the nasal-dorsal mucous cyst, depending on the size and location, complete exci­sion of the mucous cyst capsule and reconstruction of the surgical defect through an intranasal or open approach must be performed. The endonasal approach using intercartilaginous or intracartilaginous incisions of­lers limited exposure but has been used successfully by Shulman and Westreich,4 Flaherty et al,8 and Kotzur and Gubisch9 for mucous cysts invoking the lip and supra-tip regions. The open rhinoplasty approach with bilat­eral rim and transcolumellar incisions offers greater ex­posure and was used successfully by Zijlker and Vuyk7 for a supratip mucous cyst. Both of these approaches of­fer cosmetic advantages for interiorly placed and small masses. However, given our patient's 3 previous rhino­plasty procedures and the size and superior location of the mass, we opted lor a direct external cutaneous ap­proach to obtain a safe and maximal exposure, with good cosmetic result. Although the theoretical concerns of an external scar exist, this approach was also used success­fully by Kotzur and Gubisch for a mucous cyst below the glabella.

CONCLUSIONS

Postrhinoplasty nasal-dorsal mucous cyst formation is a preventable complication. Meticulous removal of all bony, cartilaginous, and mucous remnants is essential. Maintaining mucosal integrity during intranasal oste­otomy and completing all osteotomies are also impor­tant to prevent such postrhinoplasty complications as mucous cysts. Treatment of this unfortunate complica­tion is complete excision through an intranasal or open approach.