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.
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.
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.
Written by Dr. Sam Rizk