Cholesterol granuloma of the maxillary sinus: a case report

Abstract

Background

Cholesterol granuloma is not a common entity in the paranasal sinuses. It is a foreign body reaction to the cholesterol crystal deposition. Mostly associated with chronic middle ear diseases.

Case presentation

This article reports a case of cholesterol granuloma in the maxillary sinus. A 23-year-old Asian man presented with cough, nasal obstruction, and postnasal discharge. On endoscopy, there was a mass protruding from the right maxillary ostium. On computed tomograpy imaging, there was a polypoidal mass in the right maxillary sinus. Endoscopic sinus surgery was performed, the cholesterol granuloma was removed from the right maxillary sinus, and the tissue was submitted for histopathological examination, which showed foreign body giant cell reaction to cholesterol crystals.

Conclusion

Cholesterol granuloma of maxillary sinus is not common and often missed by clinicians. It is necessary to consider the cholesterol granuloma of maxillary sinus in the differential diagnosis sinonasal lesions. Histopathological analysis is required for confirmation and should be removed surgically. This case may help as a reference for clinician to approach these kinds of cases.

Background

Cholesterol granuloma is a histopathologic term describing cholesterol crystals with surrounding foreign body giant cells, foam cells, and macrophages filled with hemosiderin embedded in fibrous granulation tissue [1]. Cholesterol granuloma (CG) is most commonly seen in middle ear; other sites include mastoid process, apex of the temporal bone pyramid, breast, sella turcica, cerebellopontine angle, testis, lungs, brain, and kidneys [2]. It is unlikely seen in the maxillary sinus and is difficult to diagnose because of nonspecific symptoms at the time of presentation, which includes facial pain, yellowish nasal discharge, and unilateral nasal obstruction. The endoscopy showed a polypoid mass emerging from the ostiomeatal complex, and imaging showed a cyst-like or massive opacification of the maxillary sinus and bony erosion. These lead to the other differentials, such as mucocele, nonsecreting cysts, chronic sinusitis, and malignant pathology of the maxillary sinus [3]. The aim of this paper is to emphasize the uncommonness of cholesterol granuloma in the maxillary sinus of an adult and to consider it in the differential diagnosis for all sinonasal lesions.

Case presentation

A 23-year-old Asian male presented with complaints of postnasal discharge, irritation to the throat, cough, right nasal obstruction, and headache, which was on and off in nature. Computed tomography (CT) imaging showed a polypoidal mass in the right maxillary sinus and extending into anterior nasal cavity with widened ostium (Fig. 1).

Fig. 1

Showing soft tissue attenuation filling up right maxillary sinus and extending into the anteronasal cavity with widened ostium

Endoscopic sinus surgery was performed on the right maxillary sinus, and the specimen was sent for histopathological examination. Histopathological examination showed multiple gray–white soft tissues measuring 1 cm × 0.5 cm × 0.5 cm. In aggregate with the surface cut it was solid and gray–white to grey–yellow. On gross examination and on microscopy, the sections studied showed fibrocollagenous tissue lined by pseudostratified columnar respiratory epithelium.

Subepithelial tissue shows numerous cholesterol clefts surrounded by dense lymphoplasmacytic infiltrate with few multinucleated giant cells, hemosiderin laden macrophages, and congested blood vessels (Figs. 2 and 3). Cholesterol granuloma was confirmed postoperatively by the histopathological interpretation [4]. These pathologic findings were consistent with those of cholesterol granuloma. The postoperative course was favorable and uneventful.

Fig. 2

Numerous cholesterol clefts surrounded by dense lymphoplasmacytic infiltrates

Fig. 3

Numerous cholesterol clefts surrounded by dense lymphoplasmacytic infiltrates

Discussion

Cholesterol granuloma is not so common and unexpected finding in maxillary sinus, which is due to an uncommon tissue reaction to cholesterol crystals on the maxillary sinus and is often associated to chronic sinonasal diseases, trauma, and surgery in the area, which may cause focal bleed [5]. It has, been projected that one of the pathogenesis is hemorrhage and subsequent hemolysis along with accumulation of cholesterol granules [6]. Histopathological analysis is crucial for the final diagnosis of maxillary sinus cholesterol granuloma, as its clinical and radiographic characteristics are non-specific, and individually sinonasal diseases require specific approach [7,8,9,10]. Adequate therapy necessitates complete excision or wide drainage. Adequate therapy is succeeded by using an endoscopic approach.

Since its signs and symptoms are unspecific, it is necessary to consider the cholesterol granuloma in the differential diagnosis sinonasal lesions with definitive diagnosis and confirmed by the histopathological investigation.

Conclusion

The first faced case of cholesterol granuloma of maxillary sinus in this region with a current and updated literature review is presented here. Cholesterol granuloma of maxillary sinus is uncommon and often overlooked by clinicians. It is necessary to consider the cholesterol granuloma of maxillary sinus in the differential diagnosis sinonasal lesions. Confirmation is by the histopathological analysis and should be removed surgically. This case may act for a reference for clinician to approach these kinds of cases.