Removal of a large maxillary sinus mucocele via Le Fort I osteotomy during orthognathic surgery: a case report

Abstract

Maxillary sinus mucoceles are uncommon expansile lesions resulting from impaired sinus drainage and mucus accumulation. We report a 19-year-old male with a large left maxillary sinus mucocele identified during planning for bimaxillary orthognathic surgery. Preoperative cone-beam computed tomography showed complete sinus occupation with extension into the nasal cavity and toward the nasopharynx. During the independently planned Le Fort I osteotomy, maxillary down-fracture provided direct access, allowing intact removal of the well-encapsulated lesion. Histopathological examination confirmed a mucocele. At 2-month follow-up, the patient had no nasal symptoms, and postoperative imaging demonstrated marked sinus re-aeration without radiographic evidence of residual or recurrent disease. When independently indicated, Le Fort I osteotomy may provide effective access for simultaneous management of selected extensive maxillary sinus mucoceles.