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Ask UsMucous Retention Cyst: How to Address?
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Dr. A. asks:I have a patient with missing molars on the right side of the maxilla. Upon evaluation of his CT scan I discovered a lesion consistent in appearance with mucous retention cyst.
The lesion occupies over 50% of the right maxillary sinus. I referred the patient for surgical removal of the lesion with ENT specialist. The ENT refused to do the surgery. She stated that according to ENT guidelines this kind of lesion does not require any treatment if asymptomatic, and that success of sinus graft will not be at any risk as a result of present problem since the nature of the lesion is not infectious.
I didn’t found any literature addressing this issue and would like to have an expert opinion or referral to some publication.
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10 Responses to “ Mucous Retention Cyst: How to Address? ”
your ent is correct.
Ignore it. It will be elevated with the membrane and have no consequence as to the success of the surgery.
Dr. Michael Pikos recommends removal of the MRC if a sinus graft is being done. Call him at his office in Palm Harbor, Florida to get his opinion.I would take his word over the ENT. At his grafting course he recommends removal if it is in the area. Compressing the cyst will do more harm than good.
Dear Dr. A,
I to would be cautious when approaching a case like this. I can only speak from personal experience, I think Daren Rosen advice isnt off base, you can lift in cases like these and it may not be a problem. However these days I air more toward Dr. Michael Weinberg point of view. I had one bad experience doing an open sinus lift in a patient with a nice sized MRC. I ended up perfing into it and ultimately removing it, which left behind a sizeable perforation. Needless to say I am a little more cautious when I approach these cases.
Dr. Wienberg, I agree with you, Dr Pikos probably has alot more insight and experience then a ENT when it comes to sinus grafting and implants and cases such as these.
Hope thats helpful
I agree with your ENT about the assessment; however, I would tend to remove the cyst if it had the potential to block the ostium. If the size of the graft (membrane elevation) is such that the ostium is occluded, the infundibulum would no longer be patent and could lead to acute problems.
While it may not be routine to remove all of them, in my opinion it totally depends on graft size and lesion size.
The MRC is not an issue by it self as DR Daren Rosen pointed out its asymptomatic usually and you may ignore it.
There is one thing you must evaluate and that is whether the mucous retention cyst may block the sinus drainage after the membrane is elevated.
This might happen in only extreme cases - that is when the MRC is big and the amount of membrane elevation is also large.
I think your ENT is a wonder doctor. i wonder how you can see what it is on just a rx. There should be a differential diagnosis even if it seems the most obvious possibility. I have had an experience with a third molar that looked like an normal cyst but after removal by the surgeon it turned to be a rare form of cancer with an jaw resection in the end. So Iam very carefull to let those things left when I start surgery. I just want to know if it is that innocent as it looks like on a radiograft. At the end you are responsable after your surgery and not the ENT!
Three common inflammatory disease entities that involve the maxillary sinus are mucocele, retention cyst (RC), and antrochoanal polyp (ACP). Nontraumatic maxillary sinus mucocele (MSM) is commonly thought to form after obstruction of the sinus ostium, with accumulation of fluid. Secondary infection can lead to its rapid expansion. So far, the exact pathogenesis of RC and ACP is not very well understood. Formerly, the traditional treatment of MSM, RC, and ACP has been exenterative surgery, typically through a Caldwell Luc approach, with complete excision of the disease and underlying sinus lining. Retention cysts are common in the maxillary sinus and may be found on imaging studies in approximately 9% of the population. Retention cysts are thought to form because of obstruction of the ducts of seromucous glands in the sinus lining, which results in an epithelium-lined cyst containing mucous or serous fluid. Most maxillary sinus retention cysts are asymptomatic and do not require treatment. However, some patients may complain of ipsilateral cheek pressure and pain. Establishing a relationship between cheek symptoms and maxillary RC is difficult. Surgery may be needed for such patients with ipsilateral symptoms for both diagnostic and therapeutic purposes. Maxillary sinus exploration with complete excision of the RC has been advocated by many ENT specialists. Mucoceles are caused by obstruction of the sinus ostium and behave like an abscess. Drainage through a middle meatal antrostomy is adequate. Removal of the sinus lining should be avoided. On the other hand, RC and ACP are caused by disease in the sinus lining. Complete excision of the lesion and the underlying lining is necessary. Diseases that originate from the floor or anterior wall of the maxillary sinus are difficult to access through the middle meatal antrostomy and therefore are likely to recur. Endoscopic sinus surgery is adequate for some cases and may be offered as initial treatment. A recurrent retention cyst can be managed by repeated marsupialization in the office, whereas ACP recurrence requires Caldwell Luc operation that affords a more complete removal of the disease and the surrounding sinus lining. The possibility that ACP represents a subset of RC with accelerated growth that continues to enlarge and later protrudes through the natural or accessory maxillary sinus ostia are plausible but difficult to prove. Any attempt on open sinus surgery in order to lift its floor by grafting must at least be undertaken 4-6 months after the endoscopic surgical eradication of the RCs provided that that the patient proves to be symptom-free and there is no sign of recurrence on his/her CT imaging.
I do not understand why the ENT doc did not remove the cyst for you. In my practice I do it myself. In 20 years I have not had a problem. I also do a great deal of craniofacial reconstruction so this is nothing for me to do or I find a ENT that has come balls.
To: Jeff West
Very funny! did you mean some instead of come?
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