Endoscopic Marsupialization and Drainage of a Septated Sphenoid Sinus Mucocele in a Revision Skull Base Setting

Summary

This case report describes the endoscopic transnasal marsupialization of a septated sphenoid sinus mucocele in a revision case. It emphasizes landmark-based dissection, complete cavity unification, and safe drainage adjacent to critical skull base neurovascular structures.

Abstract

Sphenoid sinus mucoceles are rare lesions that account for less than 2% of all sinonasal mucoceles. In revision cases, surgery is more challenging because prior operations alter the normal anatomy and remove important surgical landmarks. A 79-year-old male presented with a headache 10 years after prior sphenoid surgery for fungal disease. Preoperative MRI showed a multiloculated, expansile sphenoid mucocele. Bony erosion involved the sellar floor and the right internal carotid artery (ICA) canal, with additional erosion of the mid-clivus. Endoscopic transnasal marsupialization was performed using the posterior choana and nasal septum as fixed landmarks to localize the sphenoid face. After entering the sphenoid sinus, the optic nerve prominence, ICA prominence, opticocarotid recess, and sella were identified on the posterior wall. A stepwise compartment-by-compartment approach was used to drain the mucocele and remove all septations under continuous visualization of these landmarks. The anterior sphenoid wall was completely removed to establish wide and durable drainage. All mucocele compartments were successfully drained. All posterior sphenoid landmarks were clearly identified. Bony dehiscence was noted at the sellar floor, mid-clivus, and right ICA canal. The dura was intact at all sites. No complications occurred. The headache improved after surgery. Follow-up confirmed a patent sphenoidotomy with no recurrence. This technique provides a safe and systematic approach to revision sphenoid mucocele surgery. It may be applied to other complex sphenoid lesions in which altered anatomy and skull-base dehiscence require careful landmark-based dissection.

Introduction

Sphenoid sinus mucoceles are rare, slowly expanding cystic lesions, accounting for less than 2% of all sinonasal mucoceles^1,2. They have high clinical importance due to their anatomical location and risk of severe complications^1,2. The sphenoid sinus has a close relationship with vital neurovascular structures, including the pituitary gland, optic nerves, internal carotid arteries (ICA), and cavernous sinuses^1,2. They usually develop in patients with previous sphenoid or transsphenoidal surgeri....

Protocol

This protocol was performed in compliance with the institutional guidelines for human research ethics. This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Taif University Ethical Committee (Approval No. HAPO-02-T-105).

1. Preoperative preparation and imaging review

1. Preoperative magnetic resonance imaging (MRI) of the paranasal sinuses and skull base was obtained and reviewed using T1- and T2-weighted panels. Lesion characteristics were identified, including mucocele content, septation pattern, and the full extent of sinus involvement.
2. All area....

Results

A 79-year-old male presented with a headache. He had no neurological deficits. He had undergone prior sphenoid surgery for fungal disease 10 years earlier. Magnetic resonance imaging demonstrated a multiloculated, expansile lesion centered in the sphenoid sinus, predominantly on the right, extending across the midline, with heterogeneous internal signal intensity and multiple internal septations (Figure 1A–B). Bony erosion involved the sellar floor and right ICA canal. The p.......

Discussion

This case illustrates key principles for the safe endoscopic management of a sphenoid sinus mucocele in a revision setting. Revision sphenoid surgery is more challenging than primary surgery. Prior operations cause altered anatomy, scarring, and bony remodeling^11,12. The middle and superior turbinates may have been removed. The sphenoid ostia are often stenosed or obliterated^11,12. Prior sphenoid fungal d.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Bipolar Forceps 23 cm, bayonet, 1.2 mm	Karl Storz	28163BPL	Bipolar diathermy, Hemostasis
BLAKESLEY  Nasal Forceps, size 4, 11 cm	Karl Storz	456004	Sphenoid rostrum removal; straight tissue removal
Centricity PACS System	GE HealthCare	7.0 SP2.01	MRI images view
Curette, 2 mm, working length 13 cm	Karl Storz	28164KLH	For  dissection, Exposure
FREER Elevator, double-ended	Karl Storz	474000	Mucoperiosteal flap elevation; mucocele entry
GELFOAM Absorbable Gelatin Sponge	Pfizer	09-0353-01	Gelatin sponge packing and hemostasis
HOPKINS Telescope, 0°, ø 4 mm, length 18 cm	Karl Storz	28132 AA	Primary endoscope for all phases
HOPKINS Telescope, 30°, ø 4 mm, length 18 cm	Karl Storz	28132 BA	Angled view into sphenoid sinus and lateral recesses
HOPKINS Telescope, 45°, ø 4 mm, length 18 cm	Karl Storz	28132 FA	Angled view into sphenoid sinus and lateral recesses
Insulated Cannula for Suction & Coagulation, 3 mm, WL 16 cm	Karl Storz	28164 MXB	Suction diathermy, Hemostasis
Insulated Cannula for Suction & Coagulation, curved, 2.5 mm	Karl Storz	28164 MXA	Suction diathermy, Hemostasis
Kerrison Punch, upbiting 60°, 2 mm, WL 17 cm	Karl Storz	28164 MKB	Sphenoid bone removal and sphenoidotomy widening
Kerrison Punch, upbiting 60°, 3 mm, WL 17 cm	Karl Storz	28164 MKC	Sphenoid bone removal and sphenoidotomy widening
Nasal Forceps, through-cutting, jaws angled up 45°	Karl Storz	28164 UB	Angled through-cutting; septation near ICA
NasoPore nasal dressing	Stryker	5400-020-108ITL	Resorbable packing and hemostasis at end of case
Neurosurgical Cottonoid Patties, X-ray detectable	Integra / Codman	801407	Intra-oprative packing and hemostasis
Scalpel Blade No. 15	Bard-Parker	371615	Killian incision
Scalpel Handle No. 3	Bard-Parker	371030	Holds No. 15 blade
Suction Tube, straight, 9 Charr., WL 15 cm	Karl Storz	28164 XG	Straight suction for mucocele contents drainage, large bore
Suction Tube, tip curved upwards, 8 Charr.	Karl Storz	28164 XC	Curved suction; lateral recess aspiration
Throughcutting Forceps, 18 cm, straight	Karl Storz	28164GS	Straight through-cutting; septation removal