Cholesterol Granuloma of the Frontal Sinus Complicated by Mycetoma: A Rare Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for submitting your case report titled “Cholesterol granuloma of the frontal sinus complicated by mycetoma: a rare case report.” The manuscript addresses a unique and clinically relevant presentation. The case is clearly of academic interest and adds value to the limited literature on the coexistence of cholesterol granuloma and fungal infection in the frontal sinus.

I do, however, have several suggestions to help improve the clarity and scientific rigor of the manuscript:

• Line 35: Please clarify that the dehiscence refers to the interface between the bone marrow and pneumatized cell, so readers do not need to seek additional sources to understand the proposed mechanism.

• Line 40: The incidence data cited from reference 3 is not clearly found in that source, and it dates back to 1984. Please either clarify where the incidence is stated or replace it with a more recent reference that includes epidemiological data.

• Figures 1 and 2: Please include a detailed radiological description of the lesion. For the MRI, specify whether the images are T1- or T2-weighted, and indicate whether contrast was used. Ideally, MRI cuts should include T1, T2, and post-contrast T1. Additionally:

  • Figure 2b appears to be an axial cut, not sagittal as stated—please correct this.

  • The provided images do not seem to account for the reported inferior oblique muscle deficit. Please review and ensure there is no reporting discrepancy.

  • If any radiological signs suggestive of a fungal ball were present, please describe them.

• Figure 3: The asterisks in panels C and E should be clearly explained in the figure legend. Also, please identify key anatomical landmarks in the surgical images to better guide the reader.

• Table 2: Please clarify whether the table is summarizing only case reports and excluding case series. References 5 and 6 include a combined total of 153 cases, yet Table 2 features only 11. This distinction should be made explicit in the table’s title or footnote.

• Lines 124–130: Consider adding a brief discussion of the radiological features typically seen in fungal balls, and how these were (or were not) reflected in this case.

With these clarifications and additions, the manuscript will more accurately and clearly present the case and its significance. I look forward to the revised version.

Author Response

• Line 35: Please clarify that the dehiscence refers to the interface between the bone marrow and pneumatized cell, so readers do not need to seek additional sources to understand the proposed mechanism.

This specific topic has been clarified (lines 34-35)

 

• Line 40: The incidence data cited from reference 3 is not clearly found in that source, and it dates back to 1984. Please either clarify where the incidence is stated or replace it with a more recent reference that includes epidemiological data.

We updated references about epidemiology  3. Li K.L.; Agarwal V.; et al. Surgical approaches to the petrous apex. World J Otorhinolaryngol Head Neck Surg. 2020 Jun 3;6(2):106-114. doi: 10.1016/j.wjorl.2019.11.002. PMID: 32596655; PMCID: PMC7296478.

This article is dated 2020 and it confirms epidemiology data.

 

• Figures 1 and 2: Please include a detailed radiological description of the lesion. For the MRI, specify whether the images are T1- or T2-weighted, and indicate whether contrast was used. Ideally, MRI cuts should include T1, T2, and post-contrast T1. Additionally:
• Figure 2b appears to be an axial cut, not sagittal as stated—please correct this.
• The provided images do not seem to account for the reported inferior oblique muscle deficit. Please review and ensure there is no reporting discrepancy.
• If any radiological signs suggestive of a fungal ball were present, please describe them.

Additional data about radiology were included for better explanation, mistake about figure 2b was corrected. We also identified landmarks in all figures.

 

• Figure 3: The asterisks in panels C and E should be clearly explained in the figure legend. Also, please identify key anatomical landmarks in the surgical images to better guide the reader.

Landmarks were identified and marked in all figures and a more complete description was added, in order to a better comprehension and orientation

 

• Table 2: Please clarify whether the table is summarizing only case reports and excluding case series. References 5 and 6 include a combined total of 153 cases, yet Table 2 features only 11. This distinction should be made explicit in the table’s title or footnote

We decided to remove table 2, as the article presented is a case report rather than a literature review

 

• Lines 124–130: Consider adding a brief discussion of the radiological features typically seen in fungal balls, and how these were (or were not) reflected in this case We added a short discussion about fungus ball’s radiological features on CT and MRI images, but in the case presented, radiological findings weren’t correlated to fungus ball suspicion, which was confirmed only intraoperatively (fig 3 F)

Reviewer 2 Report

Comments and Suggestions for Authors

1. The manuscript presents-as Authors state- a "rare" case report of cholesterol granuloma in frontal sinus, however, this condition is not that rare when it comes to sinus location, as it was described in literature previously:

Al-Mousa A, Tarifi AA, Shtaya A, Ghanem IM. Transglabellar resection of frontal sinus cholesterol granuloma extending cranially through cecum foramina: Technical note. Surg Neurol Int. 2023 Jul 7;14:238. doi: 10.25259/SNI_316_2023. PMID: 37560594; PMCID: PMC10408640.

Li R, Ren M, Wang W, Li R, Zhang L, Liu L. Orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles: report of two cases. BMC Ophthalmol. 2023 Mar 13;23(1):98. doi: 10.1186/s12886-023-02842-3. PMID: 36915085; PMCID: PMC10010065.

Kavarthapu S. Cholesterol granuloma of the maxillary sinus: a case report. J Med Case Rep. 2024 Sep 6;18(1):426. doi: 10.1186/s13256-024-04561-9. PMID: 39237973; PMCID: PMC11378435.

Abdelkarim AZ, Fereir A, Elzayat AM, Lozanoff S, Paudyal S. Cholesterol Granuloma in the Maxillary Sinus: A Rare Presentation Associated With an Odontogenic Cyst. Cureus. 2023 Aug 6;15(8):e43041. doi: 10.7759/cureus.43041. PMID: 37680430; PMCID: PMC10482362.

Therefore, the novelty of the manuscript topic should be considered average.

2. English language of the manuscript must be improved. From simple misspelling and multiple errors, that occur even in the first paragraph in the name of the disease (Abstract section line 14 "cholesterin"), to grammar errors (eg. line 18 "who underwent to neuro-navigated surgery" should be changed to "who underwent neuro-navigated surgery"; line 34 "It's supposed that this lesion originates" should be changed for "It's suspected that this lesion originates") and stylistic errors (eg line 40 no bracket for the reference 1). All manuscript should be scanned and rewritten with better English.

3. Case report should be presented in more official way, for example when referring to the patient, authors should avoid pronouns like "her". Patient should be described as "80 years-old female patient" rather than "her" or "woman". Avoid using pronouns like "our ED"-line 50 or "our patient"- line 80 in Discussion paragraph, "our case"-line 105 in Discussion paragraph.

4. Figure 1 resolution could be improved.

5. The course of the treatment and presentation of the case should be considered good and the photos from endoscopic procedure improve the general merit and reception of the manuscript.

6. The Discussion paragraph looks too much like literature review, when the manuscript is in fact case report. I suggest erasing Table 1 and Table 2 and lines from 86-93-it does not have any substantive input into discussion.

 

Comments on the Quality of English Language

As already stated, English language of the manuscript must be improved. From simple misspelling and multiple errors, that occur even in the first paragraph in the name of the disease (Abstract section line 14 "cholesterin"), to grammar errors (eg. line 18 "who underwent to neuro-navigated surgery" should be changed to "who underwent neuro-navigated surgery"; line 34 "It's supposed that this lesion originates" should be changed for "It's suspected that this lesion originates") and stylistic errors (eg line 40 no bracket for the reference). All manuscript should be scanned and rewritten with better English.

Author Response

• The manuscript presents-as Authors state- a "rare" case report of cholesterol granuloma in frontal sinus, however, this condition is not that rare when it comes to sinus location, as it was described in literature previously: Al-Mousa A, Tarifi AA, Shtaya A, Ghanem IM. Transglabellar resection of frontal sinus cholesterol granuloma extending cranially through cecum foramina: Technical note. Surg Neurol Int. 2023 Jul 7;14:238. doi: 10.25259/SNI_316_2023. PMID: 37560594; PMCID: PMC10408640. Li R, Ren M, Wang W, Li R, Zhang L, Liu L. Orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles: report of two cases. BMC Ophthalmol. 2023 Mar 13;23(1):98. doi: 10.1186/s12886-023-02842-3. PMID: 36915085; PMCID: PMC10010065.Kavarthapu S. Cholesterol granuloma of the maxillary sinus: a case report. J Med Case Rep. 2024 Sep 6;18(1):426. doi: 10.1186/s13256-024-04561-9. PMID: 39237973; PMCID: PMC11378435.Abdelkarim AZ, Fereir A, Elzayat AM, Lozanoff S, Paudyal S. Cholesterol Granuloma in the Maxillary Sinus: A Rare Presentation Associated With an Odontogenic Cyst. Cureus. 2023 Aug 6;15(8):e43041. doi: 10.7759/cureus.43041. PMID: 37680430; PMCID: PMC10482362. Therefore, the novelty of the manuscript topic should be considered average.

The first two articles had been cited in this paper and both stated this kind of lesion as “relatively rare”(Li et al). However, we preventively changed in “uncommon” instead of rare (line 39).

 

2. English language of the manuscript must be improved. From simple misspelling and multiple errors, that occur even in the first paragraph in the name of the disease (Abstract section line 14 "cholesterin"), to grammar errors (eg. line 18 "who underwent to neuro-navigated surgery" should be changed to "who underwent neuro-navigated surgery"; line 34 "It's supposed that this lesion originates" should be changed for "It's suspected that this lesion originates") and stylistic errors (eg line 40 no bracket for the reference 1). All manuscript should be scanned and rewritten with better English.

Errors were corrected and global English was improved

 

3. Case report should be presented in more official way, for example when referring to the patient, authors should avoid pronouns like "her". Patient should be described as "80 years-old female patient" rather than "her" or "woman". Avoid using pronouns like "our ED"-line 50 or "our patient"- line 80 in Discussion paragraph, "our case"-line 105 in Discussion paragraph.

We improved the general style of the presentation, in order to present the case in a more official way

 

4. Figure 1 resolution could be improved.

Resolution was improved in all figures. Landmarks were identified and marked in all figures and a more complete description was added, in order to a better comprehension and orientation

 

5. The course of the treatment and presentation of the case should be considered good and the photos from endoscopic procedure improve the general merit and reception of the manuscript.

 

6. The Discussion paragraph looks too much like literature review, when the manuscript is in fact case report. I suggest erasing Table 1 and Table 2 and lines from 86-93-it does not have any substantive input into discussion.

We decided to remove table 2, as the article presented is a case report rather than a literature review. We kept Table 1 and previous citations from literature reviews for a more complete description of the disease, according to our opinion

Reviewer 3 Report

Comments and Suggestions for Authors

Line 14, 20
Is this a spelling error? Cholesterin?

Line 40:
Spelling error: occurrence1

Line 50 and 51:
Would you be able to clarify the duration of symptoms?
Was there any ophthalmology assessment performed for this patient?Do include resluts if significant.

Figure 1 and 2:
Please provide indicators or arrows that indicate the abnormality seen on the image.
In figure 2, indicate which is right and left.
Elaborate more on the descriptions for both figures 1 and 2.

Line 60:
Please elaborate more on the intraoperative findings during surgery.

Line 61:
I would like to clarify what does 'double left frontoethmoidal mucocele' mean?

Figure 3:
Please provide indicators or markers which refer to the normal anatomy during the intraoperative procedure.
What does the asterisk indicate?
Elaborate more on the abnormalities seen in these pictures.

Figure 4:
Please include markers/arrows in the picture to help readers orientate themselves.

Line 87:
Authors is in capitalised A.

Table 2:
Indicate full name of abbreviated terms: M, F, RX, CT, MRI, RESS, RMN
Spelling error?: exophtalmoses

This case discusses a patient with dual pathology of the paranasal sinus. 
It would be of value to the readers if you could add discussion on the natural progression of this disease and potential complications of paranasal sinus cholesterol granuloma if left untreated.

Author Response

• Line 14, 20. Is this a spelling error? Cholesterin?

This was a spelling error we missed out and it was corrected in “cholesterol granuloma”

• Line 40: Spelling error: occurrence1

This was a spelling error we missed out and it was corrected

• Line 50 and 51: Would you be able to clarify the duration of symptoms? Was there any ophthalmology assessment performed for this patient?

We added some information (lines 53-56)  “Headache had been persistent for the previous six months, with progressive worsening, while ocular symptoms had appeared over the preceding three weeks. The patient had been referred to the Emergency Department by the ophthalmologist she had consulted for diplopia, who had excluded primary ocular disease.”. The ophthalmologist’s medical report was not available, and the information we obtained was derived from the patient’s medical history.

• Figure 1 and 2: Please provide indicators or arrows that indicate the abnormality seen on the image. In figure 2, indicate which is right and left.
  Elaborate more on the descriptions for both figures 1 and 2.

Landmarks were identified with asterisks and arrows and marked in all figures and a more complete description was added, in order to a better comprehension and orientation

• Line 60: Please elaborate more on the intraoperative findings during surgery.

We added some information about intraoperative findings in lines 85-88: The patient underwent bilateral endoscopic sinus surgery (ESS) and endoscopic frontal sinusotomy via a Draf IIb approach. Neuronavigation was used to facilitate access to the left ethmoid and frontal sinuses, where a cystic mass resembling a mucocele occupying the entire sinus and extending close to orbital lamina papyracea (Figure 3).

• Line 61: I would like to clarify what does 'double left frontoethmoidal mucocele' mean?

In order to avoid incomprehension, we replaced this sentence with “a double mucocelic sac filled with thick, clay-like material occupying the entire sinus and extending close to orbital lamina papyracea (line 87). Radiological images also suggested two adjacent mucoceles (line 82)

• Figure 3: Please provide indicators or markers which refer to the normal anatomy during the intraoperative procedure. What does the asterisk indicate?
  Elaborate more on the abnormalities seen in these pictures.

Landmarks were identified with asterisks and arrows and marked in all figures and a more complete description was added, in order to a better comprehension and orientation. Asterisk in figure 3 marks medial wall of the left orbita.

 

• Figure 4: Please include markers/arrows in the picture to help readers orientate themselves.

Landmarks were identified with asterisks and arrows and marked in all figures and a more complete description was added, in order to a better comprehension and orientation

• Line 87: Authors is in capitalised A.

This was a spelling error we missed out and it was corrected

• Table 2:
  Indicate full name of abbreviated terms: M, F, RX, CT, MRI, RESS, RMN
  Spelling error?: exophtalmoses

We decided to remove table 2, as the article presented is a case report rather than a literature review

 

• This case discusses a patient with dual pathology of the paranasal sinus. 
  It would be of value to the readers if you could add discussion on the natural progression of this disease and potential complications of paranasal sinus cholesterol granuloma if left untreated.

We added more information  lines 186-192: Furthermore, both cholesterol granuloma and FB may mimic mycetoma [39], underscoring the need for an accurate differential diagnosis, particularly in the presence of bone erosion and sinus involvement. If left untreated, both conditions tend to enlarge, causing bone erosion and subsequent extension to adjacent structures, which may result in complications such as debilitating headache, proptosis, visual impairment, and displacement of the ocular globe, as observed in the presented case. We also enhanced the importance of neuronavigation, especially in challenging cases.