Case report: Fenestration is a logical and effective treatment for a large primordial cyst with a cholesterol granuloma

Fenestration is a logical and effective treatment 

Keywords 

Fenestration, cholesterol granuloma, odontogenic cyst, maxillary sinus, surgical excision, case report

Abstract 

A cholesterol granuloma (CG) is characterized by the presence of cholesterol crystals that cause a chronic granulomatous reaction in an enclosed space. It occurs most commonly in the head and neck region, particularly in the middle ear. Although CGs in the maxilla have also been reported, odontogenic cysts in conjunction with CGs in the maxilla are very rare. We herein present a case of a 72-year-old man who developed a large primordial cyst with a maxillary CG that extended into the maxillary sinus, nasal cavity, and infraorbital region, causing left-sided facial swelling and discomfort. We successfully controlled the symptoms and reduced the size of the lesion using the treatment approach for a common odontogenic cyst: fenestration followed by complete excision. This case suggests that fenestration is an effective technique to treat odontogenic cysts with CGs. Although the mechanisms underlying the pathogenesis and growth of CGs are still unknown, our report highlights a potential therapeutic approach for these lesions.

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Introduction 

A cholesterol granuloma (CG) is a histological lesion that causes a chronic granulomatous reaction in an enclosed space. The reaction is characterized by cholesterol crystals that form secondary to the deposition of hemosiderin and other blood products.1 The lesion is histopathologically defined by the presence of giant cells, plasma cells, lymphocytes surrounding cholesterol clefts, and hemosiderin deposits.2,3 Obstructed drainage and impaired ventilation are thought to be significant etiological factors of CGs

Discussion

In the head and neck region, CGs rarely occur in the mid-face region and maxillary sinus. However, more than 50 cases of CGs in the sinus were reported in the English language literature from 2005 to 2016.10 The most subjective symptoms of CGs are proptosis, orbital pain, headaches, nasal obstruction, and rhinorrhea.

The clinical features of CGs in the maxilla, including those of the maxillary sinus, are similar to the features of other cysts and inflammatory diseases of the maxilla and mandible, such as odontogenic keratocysts, ameloblastomas, and any other cyst.10 The diagnosis of CG is mainly based on clinical observation and diagnostic imaging.

The differential diagnoses of CG include other odontogenic cysts and tumors in the maxilla that are difficult to diagnose using diagnostic imaging. MRI of CGs reveals well-defined lesions with high signal intensity on T1- and T2-weighted images. However, it is difficult to confirm that such a lesion is a CG based only on MRI because it is similar to other cyst-like lesions.

In the present case, the size of the lesion significantly decreased after fenestration and biopsy. Fenestration is an effective approach to reduce the size of most if not all cysts, such as unicystic ameloblastoma, odontogenic keratocyst, and any other cystic lesion. Although there are a few reports on the recurrence of CG, complete removal of the CG tissue is necessary to prevent its recurrence. 

Surgical excision with curettage is a highly effective method of CG removal because it provides a low rate of recurrence without excessive bone removal. CGs in the maxillary sinus has been excised using the Caldwell–Luc procedure or endoscopic endonasal surgery, and irrespective of the approach, its recurrence rate has been consistently low.1

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