INTRODUCTION

Cholesterol granuloma (CG) usually occurs in the ear rather than other places in the the head and neck. The clinical diagnosis is difficult to be found, so it is done over histopathological exam. It is generally considered that malaeration with hemorrhage into a cavity, which is normally ventilated and is the primary event in the development of this condition. It could be expected to be relatively frequent in the maxillary and frontal sinus, but only a few cases have been reported in the literature and only nine cases affecting the maxillary sinus have been diagnosed over the last 22 years, at the Royal National, Nose and Ear Hospital, (Gray's Inn Road, London) (1).

The main differential diagnosis in theses cases were mucoceles of the maxillary antrum, cysts arising within the sinus, or cysts of dental origin, and in those cases showing expansion or erosion of the maxillary sinus, malignant disease. Some patients may present with X-ray features, which may suggest the diagnosis of CG, but there were no specific X-ray findings which alerted the surgeon to the diagnosis pre-operatively (1). Surgical treatment consists of comprehensive removal of the lesion. In an overview of the literature, we found only 37 cases of CG sited in the maxillary sinus (1-15).


CASE REPORT

A 51 year-old Caucasoid male patient came to ENT appointment complaining of a permanent right-sided epiphora for the last 3 months, without any other symptoms. Previous consultations to ophthalmologist and allergist were fruitless. One week before ENT consultation he observed a clear and permanent right-sided nasal discharge. There was no past history of sinuses infections, but he referred to be a scuba diving enthusiast.

The ENT examination displayed a small tumor lesion, smooth, light red, sited on the middle concha, apparently arising from the maxillary sinus. CT of the paranasal sinuses revealed an extensive tumoral lesion, encapsulated, filling all the right maxillary sinus, anterior ethmoid and part of the ipsilateral nasal fossa (1,2).

We opted to remove the lesion combining a Caldwel-Luc procedure to the endonasal endoscopic assisted one, due to the great volume of the lesion and for convenient exploration of the floor of the orbit. During the surgery, it was observed that the encapsulated lesion was partially filled by a solid yellowish and viscous material and partially by liquid and clear material. The lesion was completely resected, but preserving the anatomical structures undamaged by the disease. The anatomopathological diagnosis was typical cholesterol granuloma (3). Such diagnosis is rarely suspected before surgery.

Figure 1. CT scan (coronal section) showing an extensive tumoral lesion, encapsulated, filling all maxillary sinus.


Figure 2. CT scan (axial section) showing the lacrimonasal duct compressed by the lesion.


Figure 3: The giant cells surround the clefts created by the cholesterol crystals (empty needle-shaped spaces).

DISCUSSION

Cholesterol granuloma (CG) is a granulomatous reaction to cholesterol crystals that have been precipitated in the tissues. It is commonly found in the mastoid antrum and the air cells of the middle ear. CG is not found in the nasal cavity but the closed cavities of the paranasal sinuses provide favorable conditions for its genesis (16), especially the maxillary and the frontal sinuses, which are the most common affected sites (1,2,3,17).

The pathogenesis of CG in the sinuses seems to be through hemorrhages inside these cavities, by liberation from degenerating tissue or by transudate.

The paranasal sinuses provide closed cavities with a long lymphatic drainage pathway and consequently slow drainage. This would give the time necessary for the cholesterol to dissociate and to precipitate as crystals and then initiate the granulomatous change (16).

CG is associated with mucosal hemorrhage, therefore, it could be expected to be relatively frequent in the maxillary and frontal sinus, but only few cases have been reported in the literature (3). In the literature is interesting the report of six cases of CG from the same region: Sivas, in Turkey (11). It is also interesting a report of CG associated to aspergilloma (13), and another to hypercholesterolemia (10). The clinical feature is non-specific and depends on the localization and extent in each individual case. Bone erosion may be seen in CG showing expansive growth (1,6,18,19).

In the present case we theorize if the disease could not have a causal relationship with minor hemorrhages produced by barotraumatic episodes consequent to the practice of scuba diving. However, the patient denied the occurrence of such events. It is impressive the paucity of symptoms in the presence of such voluminous expansive lesion (1). Epiphora was produced by compression of the lacrimonasal duct (2).

Radiological differential diagnosis includes mucocele, dentigerous cyst and voluminous mucous retention cysts and pseudo cysts. In the cases with bone erosion, a malignant disease should be considered. Histopathological examination is important and should be carried out on all specimens obtained from paranasal sinus surgery, because CG in the maxillary antrum could be mistaken for chronic sinusitis (11). The morphological aspect of CG is very typical, and avoids confusion with anything else (16). There is granulation tissue with foreign body-type giant cells. These giant cells surround the clefts created by the cholesterol crystals, and these clefts have the appearance of empty neddle-shaped spaces (3).

Treatment usually consists of removing the CG and restoring drainage of the affected sinus cavity. Radical operation seems to give absolute cure without any recurrence (3). However, for others, drainage and permanent aeration may be sufficient (9). It would be possible to achieve adequate therapy by using an endoscopic approach (9). After surgical removal of a CG there will seldom be a recurrence (16).

In the nine cases reported by Milton and Bickerton (1986), eight patients underwent a Caldwell Luc procedure and one patient had an intranasal antrostomy alone. The results of surgery were uniformly successful, some cases having been followed up for several years. MRI may be useful for follow up of treatment (9,20). The reported patient, in the 18th postoperative month is lesion free, asymptomatic and feeling good.


COMMENTS

We hypothesized that the cholesterol granuloma in this case could be related with possible episodes of barosinusitis with small and asymptomatic hemorrhages as a consequence of scuba diving.


REFERENCES

1. Milton CM, Bickerton RC. A review of maxillary sinus cholesterol granuloma. Brit J Oral Maxillofac Surg., 1986, 24:293-299.

2. Graham J, Michaels L. Cholesterol granuloma of the maxillary antrum. Clinical Otolaryngology, 1978;3:155.

3. Hellquist H, Lundgren J, Olofsson J . Cholesterol granuloma of the maxillary and frontal sinuses. ORL, 1984, 46:153-158.

4. Wolfson LR, Talmi YP, Halpern M, Levit I, Zohar Y, Gal R. Choleterol granulomas of the maxillary sinus presenting with nasal obstruction. Otolaryngol Head Neck Surg, 1993, 109:956-957.

5. Erpek G, Ustun H. Cholesterol granuloma in the maxillary sinus.Eur Arch Otorhinolaryngol, 1994, 251(4):246-247.

6. Marks SC, Smith DM. Endoscopic treatment of maxillary sinus cholesterol granuloma. Laryngoscope, 1995, 105:551-552.

7. Dilek FH, Kiris M, Ugras S. Cholesterol granuloma of the maxillary sinus. A case report. Rhinology, 1997, 35:140-141.

8. Kunt T, Ozturcan S, Egilmez R. Cholesterol granuloma of the maxillary sinus : six cases from the same region. J Laryngol Otol., 1998, 112(1):65-68.

9. Sarioglu S, Pabuccuoglu U, Arzu-Topal N. Cholesterol granuloma and aspergilloma of the maxillary sinus. Eur Arch Otorhinolaryngol, 2001, 258(2):74-76.

10. Kikuchi T, So E, Ishimaru K, Miyabe Y, Abe K, Kobayashi T. Endoscopic sinus surgery in cases of cholesterol granuloma of the maxillary sinus. Tohoku J Exp Med, 2002, 197(4):233-237.

11. Hellquist HB. Pathology of the nose and paranasal sinuses. London, Butterworths & Co, 1990.

12. Friedman I, Osborn DA . Pathology of granulomas of the nose and paranasal sinuses. Edinburgh, Churchill Livingstone, 1982, pp 23-35.

13. Wyler AR, Leech RW, Reynolds AF, Ojemann GA, Mead C. Cholesterol granuloma of the petrous apex. J Neurosurg., 1974, 41:765-768.

14. Bütler S, Grossenbacher R. Cholesterol granuloma of the paranasal sinus. J Laryngol Otol, 1989, 103:776-779.

15. Raveau V, Vignaux O, Marsot-Dupuch K. Cholesterol granuloma : review of the literature. Ann Radiol 1992;35:81-84.













1. Professor of the Otorhinolaryngology Department of the University State of Rio de Janeiro.
2. Lecturer of Otorhinolaryngology Department of the University State of Rio de Janeiro.
3. Resident of Otorhinolaryngology Department of Botafogo Clinic.

Institution: Otorhinolaryngology Department of the University State of Rio de Janeiro - Brazil

Roberto Meirelles
Mail address: Rua Siqueira Campos, 43 suite 1125 - Rio de Janeiro - RJ - Brazil - CEP: 22031-070 - Phone: (5521)25485543 - Fax: (5521)25492969 - E-mail : rocame@superig.com.br

Article received on May 24, 2005 and accepted with its corrections on October 09, 2005.