Endoscopic management of 108 sinus mucoceles

The Relationship Between Destruction Sites and Clinical Findings in Diffuse Paranasal Sinus Mucoceles

Objective

This study aimed to investigate that complicated mucoceles of paranasal sinuses and their clinical presentation, complications of relations with size, destructions areas, extension limits in affected patients.

Materials and methods

A retrospective review was performed on patients who were diagnosed and treated as paranasal sinus mucoceles at ENT department from 2002 to 2013 years. Patients' demographic data, mucoceles location, symptoms, surgical approach and complications were evaluated.

Results

The study group included 9 male and 10 female patients with a mean age of 45,0 years (range, 12-76 years). This case series include fronto-ethmoidal complex (52,6%), followed by frontal (26,3%), maxillary (15,7%) and sphenoid sinus mucoceles (5,2%). Endoscopic sinus surgery (ESS) was performed on 11 patients (57.8%); endoscopic procedures included marsupialization through an infundibulotomy, associated with an anterior ethmoidectomy and maxillary sinus antrostomy. Four patients (21%) underwent an external surgical procedure. 8 patients (42%) were treated by a combination of both endoscopic and external approaches such as trephination of the anterior wall of the frontal sinus, osteoplastic flap approach, Caldwell-Luc operation, anterior craniotomy and Lynch procedure. Complications occurred only in 2 cases (10.5%).

Conclusion

The majority of patients with extensive paranasal sinus mucoceles exhibited ophthalmologic and intracranial symptoms. A satisfactory outcome can be achieved after surgical treatment of both endoscopic and external approaches.

Combined upper lid skin crease and endoscopic approach to frontal sinus mucocoeles

PURPOSE

This case series describes the ophthalmic manifestations of frontal sinus mucoceles and reports the long-term surgical outcomes of a combined endoscopic and upper-lid skin crease drainage approach carried out jointly with otorhinolaryngology.

METHODS

We present a retrospective case review of 18 orbits and 15 patients presenting with frontal sinus mucocoeles, all of whom underwent drainage via an adapted anterior orbitotomy approach between January 2015 and July 2023. Data collection included preoperative and postoperative examination findings (visual acuity, extraocular motility, lid retraction, and lagophthalmos), mucocoele recurrence, cosmetic satisfaction, and surgical complications. Patients were followed up for an average of 22 months.

RESULTS

All patients underwent successful frontal mucocoele drainage via a modified anterior orbitotomy and simultaneous endonasal approach. At presentation, three (20%) had extraocular restriction leading to diplopia, and six (40%) had proptosis in the eye adjacent to the mucocoele. One patient presented acutely with no light perception in the affected eye due to compressive optic neuropathy. All patients who had reduced extraocular motility before surgery regained full motility post-operatively. Treatment was successful in all cases, and there was no documented mucocoele recurrence during follow-up. Satisfactory aesthetic outcomes were achieved in all cases. Reported complications included temporary forehead numbness and ptosis of the affected eyelid, which resolved without intervention.

CONCLUSION

The modified anterior orbitotomy approach to frontal mucocoeles allows optimal frontal sinus access and mucocoele treatment while preserving cosmesis.

Orbital Apex Syndrome Secondary to Huge Primary Ethmoidal Sinus Mucocele: A Case Report

Ethmoidal sinus mucoceles are benign expansile lesions that may progressively invade the orbit causing optic nerve compression and its nearby structures. We report a rare case of primary ethmoidal sinus mucocele instigating orbital apex syndrome. A 40-year-old man presented with right eye (RE) progressive blurring of vision with diplopia for 2 weeks. It was preceded by right-sided facial pain for 3 months. Clinical examination revealed RE proptosis with multiple cranial nerves palsy involving right cranial nerves II, III, IV, V, and VI, suggestive of right orbital apex syndrome. Magnetic resonance imaging (MRI) demonstrated right eye proptosis and right ethmoidal mucocele with intracranial and right intraorbital extension compressing the right medial rectus and optic nerve. The patient underwent an uncomplicated endoscopic sinus surgery resulting in a return to normal appearance and function post-operation. Thus, ethmoidal mucoceles are benign and curable with early recognition and intervention.

Mucoceles of Paranasal Sinuses: A Single Centre Experience

Describe experience of managing paranasal sinus mucoceles, with either endoscopic endonasal approach (EESS) or combined external with EESS approach. Retrospective study done at SDMCMS&H, between 2007 and 2019, on patients undergoing surgical excision of mucocele. Results described as mean, median, mode, percentages. Twenty-one patients were included, with male to female ratio (0.75:1), mean age (42.95 years). Commonest presentation were facial pain (42.85%),visual symptoms (28.57%), headache (23.80%). Signs included, proptosis (52.38%), facial deformity (23.80%). Imaging: showed frontal mucoceles (42.85%), fronto-ethmoid (38.09%), ethmoid (14.28%), sphenoid (4.76%). Orbital extension in 42.85%, sinusitis (33.33%), skull base erosion (23.80%). EESS or combined external and EESS approach (61.90%, 38.09% respectively) were performed. Complete excision of mucocele wall done. Recurrence in two cases(average-2.5 years),revision surgery performed without further recurrences. Either EESS or combined external and EESS approach used based on site and extension of mucoceles. Complete peeling of mucocele wall without obliteration of the sinus cavity was the mode of surgical management in all cases.

The Endoscopic Management of Different Pediatric Frontal Sinus Pathologies

Background.The paranasal sinuses in pediatrics can harbor a wide variety of pathologies. With the present literature being composed of case studies only, this entity is quite understudied. Objectives. This article aims to study the clinical presentation, diagnosis, and endoscopic management of six different rare frontal sinus pathologies in pediatrics, which include extensive allergic fungal sinusitis, mucoceles, osteoma, superior sagittal sinus thrombosis, CSF leak, and subdural empyema. Methods. We retrospectively studied all pediatric patients with frontal sinus pathologies presenting to our center, King Fahad Specialist Hospital, Dammam, Saudi Arabia, from the period of 2006 to 2020. Results. A total of 8 patients presented to our hospital with different frontal sinus pathologies. 5 of them were males, and 3 were females with an age of presentation ranging from 7 to 17 years. The diagnosis and localization were performed through computerized tomography without contrast and magnetic resonance imaging, when indicated. All cases were primarily managed with endonasal endoscopic approaches successfully without complications and with no recurrence evident upon follow-up. Conclusion. In this case series, six different frontal sinus pathologies were managed by an endoscopic approach, with excellent recovery and no recurrence upon follow-up demonstrated. This approach enabled excellent visualization of the pathologies, accurate localization, adequate drainage, and repair or grafting when needed.

Burkholderia Cepacia Causes Frontal Mucopyocele with Anterior Cranial Fossa Extension: A Novel Case Report

Introduction:

Burkholderia cepacia complex (Bcc) is a group of gram-negative bacilli that have rarely been isolated in the ear, nose and throat region in immunocompetent patients. Bcc show resistance to most available antibacterial drugs.

Case Report:

We present the case of an immunocompetent 31-year-old male reporting a pulsating headache with right supraorbital swelling associated with exophthalmos. A brain CT scan showed an expansive giant cystic lesion occupying the right frontal sinus, extending to the anterior cranial fossa. Management and outcome: drainage with the resecting of the floor of the frontal sinus from the orbital plate of the ethmoid bone to the nasal septum (Draf IIb) was performed with wide marsupialization of the mucopyocele. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis was used to identify the isolate. MRI 1 and 12 months after surgery showed complete lesion removal. The patient was followed for 12 months with complete recovery of symptoms.

Conclusion:

Paranasal sinuses disease with cranial expansion and orbital complications constitutes an emergency. For the first time in the literature, Bcc was isolated in the frontal sinus, extending into the anterior cranial fossa, in an immunocompetent patient. An endoscopic surgical approach with microbiological identification and management by appropriate antibacterial drug treatment seems to be the key to success.

Endoscopic Intranasal Marsupialization of the Isolated Mucocele in the Inferior Orbit

ABSTRACT

Isolated intraorbital mucocele without anatomical communication between the sinus and orbital cavity, and all orbital walls are intact is rare. It may lead to many orbital symptoms including proptosis, diplopia, orbital pain. Traditionally, many cases of typical paranasal sinus mucocele are successfully treated with endoscopic marsupialization. Most of the isolated intraorbital mucoceles were treated with complete removal of the mucocele via an external approach. However, there are many disadvantages of the external approach, and a case of isolated intraorbital mucocele in medial orbit treated by endoscopic intranasal marsupialization was reported. Here, the authors report a case of isolated orbital mucocele in inferior orbit treated by endoscopic intranasal marsupialization.

Combined Surgical Approach in the Treatment of Oculoorbital Complications of Frontal Sinus Mucocele: A Case Report

Paranasal sinus mucoceles are benign cystic masses filled with mucous content. Mucoceles are locally destructive, causing pressure on sinus walls with their resorption, allowing them to spread on adjacent structures causing local, orbital or intracranial complications. They are most commonly found in frontal sinuses.

The aim of this report is to present case of oculo-orbital complications of frontal sinus mucocele, with focus on treatment using combined surgical approach.

A 75-year old female patient with frontal sinus mucocele which led to destruction of orbital roof and occurrence of complications in form of orbital cellulitis and palpebral abscess was successfully treated with a combination of external frontoethmoidectomy and endoscopic sinus surgery. After initial incision of the upper eyelid abscess with drainage of purulent content, modified external frontoethmoidectomy was performed using preformed defect of orbital roof. Finally, using endoscopic sinus surgery, natural drainage of anterior group of paranasal sinuses was achieved.

Various endoscopic and open approaches have been described in mucocele treatment. In this case we showed that the combined surgical approach in the treatment of frontal sinus mucoceles with destruction of sinus floor and appearance of oculo-orbital complications, provides an effective treatment and allows natural drainage of anterior group of sinuses.

'A Down and Out Eye': Case Report of a Primary Ethmoid Mucocele

Paranasal sinus mucoceles are benign, locally expansile masses of the paranasal sinuses that are lined by epithelial cells. They result from obstruction of sinus ostia. The close proximity of paranasal sinus mucoceles to the orbit and skull base predisposing the patient to significant morbidity. We describe the case of a previously healthy 23-year-old gentleman presenting with a five-day history of unilateral (left) eye pain and swelling with an obvious deformity. There was also no history of trauma or prior surgery. He underwent a CT sinus, which showed near complete opacification of the left anterior ethmoid sinus with bony destruction and obvious displacement of the orbit both laterally and anteriorly. This was assessed as to be in keeping with an ethmoid mucocele. Endoscopic marsupialization has become the preferred surgical approach over obliterative procedures for the treatment of paranasal sinus mucoceles. Primary ethmoid mucocele is an uncommon entity, especially in the absence of prior ear, nose and throat (ENT) complaints, and therefore should remain an important differential when a patient presents with a unilateral swelling causing proptosis.

The endonasal endoscopic management of pediatric lateral frontal mucocele

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Frontal mucoceles in children are rare.

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A child with lateral frontal mucocele with no known etiology.

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This shows the usefulness of image-guided endoscopic sinus surgery.

Objectives

The aim of this report is to show the usefulness of endoscopic sinus surgery in management of lateral frontal mucocele in pediatric patient.

Case presentation

A 14 years old girl presented with right frontal bone depression and headache. CT and MRI showed lateral mucocele occupying the right frontal sinus. The patient was managed successfully by image-guided endoscopic sinus surgery and she was well after two years follow up.

Discussion & conclusion

Frontal mucoceles in children are rare. We report a rare case of a child with lateral frontal mucocele with no known etiology, treated successfully by image-guided endoscopic sinus surgery with no recurrence after two years follow-up. This case shows the usefulness of image-guided endoscopic sinus surgery in treatment of lateral frontal mucocele in children.

Ophthalmic Presentation of Undiagnosed Sinonasal Masses

AIMS

To evaluate clinical features of patients who first present with orbital symptoms and signs due to undiagnosed sinonasal pathology.

PATIENTS AND METHODS

Retrospective chart review for patients seen at Moorfields Eye Hospital between 1969 and 2020. Patient demographics and clinical features were reviewed.

RESULTS

Four hundred and forty-eight patients (250 males; 56%) presented to ophthalmologists with undiagnosed sinonasal pathologies, the patients attending at an average age of 47 years and having first symptoms at an average age of 46 years. The commonest presenting symptoms were proptosis (153 patients; 34%), orbital ache or pain (133; 31%), periorbital swelling (130; 29%), and diplopia (98; 22%). Eighty-seven patients (20%) had a corrected acuity of 6/18 or worse, and 66 (16%) had an ipsilateral relative afferent pupillary defect. There was 2.3 mm relative exophthalmos (median 2 mm; range 0-17 mm) in patients with unilateral disease, an orbital mass was palpable in 218 patients (49%), ocular movements were reduced in 252/448 (56%), and nonaxial displacement of the globe was recorded in 296/424 (74%). The commonest pathologies were sinus mucoceles (38%), sinus carcinoma (11%), and granulomatous polyangiitis (10%). Multivariate regression analysis of mass lesions identified periorbital pain (odds ratio, 6.0; 95% confidence interval, 1.7-21.5; P = 0.005) and reduced motility (odds ratio, 3.2; 95% confidence interval, 1.1-9.0; P = 0.03) as features most predictive for undiagnosed sinonasal malignancy.

CONCLUSION

This study describes a large group of patients in whom unknown midfacial masses presented initially to the ophthalmologist: Mucoceles and sinonasal malignancy were the commonest lesions, and nonaxial globe displacement-particularly inferolateral, lateral, or upward-is commonly associated with sinonasal pathology. Pain and reduced ocular movements significantly favor a malignant, rather than benign, tumor.

Partial resolution of chronic unilateral sinonasal obstructive disease in a cat using a temporary polyvinylchloride stent

Case summary

A 3-year-old male neutered domestic shorthair cat presented for further investigation of a swollen left eyelid and a hard, non-painful bony swelling over the left frontal sinus. Physical examination revealed no nasal discharge or airflow through the left nostril. A CT of the head revealed a left frontal sinus obstruction with expansile remodelling and osteolucency. Drainage of the frontal sinus obstruction was alleviated via placement of a temporary polyvinylchloride (PVC) stent that was left in place for 6 weeks. Purulent material removed from the frontal sinus returned a positive culture for Pseudomonas aeruginosa susceptible to marbofloxacin that was continued for 4 weeks, and for an additional 2 weeks after stent removal. A left-sided mucoid nasal discharge returned 3 months after removal of the stent. Repeat CT performed 20 months after surgery found the presence of a gas-filled frontal sinus and partial resolution in the amount of fluid within the mid and rostral nasal cavity. A repeat positive culture for P aeruginosa was also obtained. The exact cause of the chronic unilateral sinonasal obstruction remains unclear, but an underlying chronic rhinitis with secondary obstructive frontal sinusitis or sinus mucocoele with secondary nasal extension was suspected.

Relevance and novel information

Chronic rhinosinusitis in cats can be a challenging condition to treat and cure. This case illustrates the partial resolution of chronic unilateral sinonasal obstructive disease in a cat using a temporary PVC stent.

Etiologies of Proptosis: A review

Proptosis, the protrusion of the eyeball from the orbit, results from a wide variety of pathologies that can be vision- or life-threatening. Clinical history, associated physical exam findings, and imaging features are all crucial in establishing the underlying etiology. The differential diagnosis is broad, and includes infectious, inflammatory, vascular, and neoplastic entities that range from benign and indolent, to malignant and aggressive. While treatment varies significantly based on the disease process, all are aimed at preserving vision, salvaging the globe, preventing disfigurement, and reducing mortality. Both internists and general ophthalmologists should be familiar with the causes of proptosis in order to initiate the work-up for, and appropriately triage, affected patients.

Sphenoid Mucocele: A Complication of Skull Base Reconstruction with Nasoseptal Flap-A Critical Review and Our Experience

The evolution of expanded endoscopic skull base surgery has enabled development of minimally invasive approaches for resection of large skull base tumors with the nasoseptal flap proving to be an indispensable tool in skull base reconstruction. We here present our experience of sphenoid mucocele development after skull base reconstruction with the nasoseptal flap along with a comprehensive review of the limited literature on the same. With the expanding scope of endoscopic skull base surgery, the nasoseptal flap is increasingly being used for reconstruction. Despite adherence to standard recommendations and use of meticulous technique during flap placement, the potential risk of mucocele formation under the flap should always be borne in mind. In our experience, displacement of the flap pedicle could lead to ostial obstruction and mucocele formation. Hence, in addition to meticulous technique, a close follow up of such patients via nasal endoscopy or imaging is important to further our knowledge and understanding of the long-term effects and complications of this flap.

Frontal pyomucocoele as forehead swelling in a five-year-old girl

Mucocoeles are slow-growing, locally aggressive, mucus-containing cysts, lined by epithelium, which, when infected, are called pyomucocoeles. We present the case of a five-year-old girl who presented with a frontal pyomucocoele requiring decompression and adequate antibiotics.

Intraseptal Mucocele as a Long-term Complication of Revision Septorhinoplasty: A Case Report and Review of a Rare Entity

Paranasal sinus mucoceles are benign, expansive, cystic lesions which arise from retention of mucus secretions. They arise primarily in the setting of cystic degeneration of the sinus mucosa or secondarily in the setting of obstruction of the sinus ostium due to mucosal trauma or chronic inflammation. Septal mucoceles are rare. Only 10 cases to our knowledge have previously been reported. Patients are exclusively male, in their middle years, usually with a history of nasal trauma or nasal surgery. Nasal obstruction followed by headache present for 3 months to a year are the most common presenting symptoms. Here, we present a case of septal mucocele with dystrophic bone formation in a 57-year-old man arising 35 years after open septorhinoplasty treated successfully with total excision via an endoscopic, endoseptal approach. A review of the available literature was conducted to provide a consolidated update on diagnosis and management.

Transnasal frontal intersinus septum takedown for frontal sinus pyocele

INTRODUCTION

The open frontal intersinus septum takedown (FISST) technique was first described in 1976. We describe our experience with an endoscopic transnasal approach to manage a frontal sinus pyocele arising from an obstructed frontal sinus outflow tract due to anterolateral thigh flap reconstruction of a maxillectomy defect.

CASE REPORT

A 40-year-old lady experienced upper eyelid swelling and purulent nasal discharge 3 weeks after undergoing a left extended medial maxillectomy with free anterolateral thigh flap reconstruction. A computed tomography (CT) scan revealed total opacification of the left frontal sinus. There was no improvement with intravenous antibiotics and she underwent a surgery, whenshe was found intraoperatively to have a frontal sinus pyocele, which was then drained. She then underwent an endoscopic transnasal FISST to ventilate the left frontal sinus via the contralateral frontal recess with good results. A CT scan performed 3 months postoperatively showed a widely patent interfrontal sinus septal window and right frontal outflow tract with no disease recurrence.

DISCUSSION

The FISST is a useful technique to manage unilateral frontal sinus disease by taking advantage of the contralateral outflow tract when the ipsilateral frontal recess is obstructed.

Implication of frontal sinus mucocele's location and intrasinus septation

Mucocele of paranasal sinuses commonly affects frontal or frontoethmoidal air cells. With the evolution of endoscopic sinus surgery, the endoscopic marsupialisation has become the standard of care for these lesions. However, the external approach still has a role in selected cases of frontal sinus mucocele. The location of the mucocele and its communication with the natural outflow tract of the frontal sinus are some of the critical factors to be considered while choosing the surgical approach. We have discussed the management of three cases of frontal mucoceles having different locations and one of them having intervening septa. We emphasise that the successful management of far laterally located mucoceles and those with laterally situated septation require an external approach in conjunction with endoscopic marsupialisation.

Mucocele development after endoscopic sinus surgery for nasal polyposis: A long-term analysis

The aim of the present study was to determine the prevalence of long-term mucocele development after functional endoscopic sinus surgery (FESS) for nasal polyposis, to search for a statistical relationship with preoperative variables and to analyze the management of this complication. A retrospective analysis of 153 patients who underwent FESS for nasal polyposis, with a minimum of 7 years of follow-up, was performed. Mucocele diagnosis was based on regular clinical and radiologic evaluation. Univariate and multivariate statistical analysis was performed. The postoperative mucocele rate was 13.1% (20 patients). The mean delay between surgery and mucocele diagnosis was 6.25 years. A high preoperative Lund-Mackay score (>19) was a risk factor for postoperative mucocele (p = 0.04). Asthma and aspirin intolerance did not increase the risk of this complication. Endoscopic marsupialization of mucoceles was successful in 19 patients, with only one recurrent frontal mucocele. One patient required external approaches for two frontal mucoceles. In conclusion, mucocele risk after FESS for nasal polyposis is significant, especially in case of a high preoperative Lund-Mackay score (>19). Long-term clinical follow-up is recommended, imaging being prescribed based on symptoms or abnormal findings on clinical examination. Endoscopic marsupialization is very effective, but frontal mucoceles are more likely to recur.

Mucocele: Clinical Characteristics and Outcomes in 46 Operated Patients

Introduction  Paranasal sinus mucocele is a benign, expansive lesion associated with paranasal sinus obstruction. It affects mostly adults, and is most common in the frontal and ethmoidal sinuses.

Objective  To evaluate outcomes in patients undergoing surgical treatment for paranasal sinus mucocele.

Methods  Retrospective review of medical records of patients treated for paranasal sinus mucocele at the ENT department of a tertiary care hospital between 2005 and 2016.

Results  Forty-six patients underwent surgical treatment of paranasal sinus mucocele. The mean age was 50.1 years, and 56.5% were male. The most prevalent symptom was pain, and the frontal sinus was most commonly affected. The vast majority of patients (89.1%) underwent endoscopic sinus marsupialization; 10.9% required combined open and endoscopic access. Seven recurrences occurred.

Conclusion  Sinus mucocele is an expansive disease that primarily affects the frontal sinus of adult patients. In most cases, endoscopic surgery is an effective treatment modality.

Modified endoscopic inferior meatal fenestration with mucosal flap for maxillary sinus diseases

Introduction

This is a novel minimally invasive surgical method for maxillary sinus mucoceles and antrochoanal polyps.

Aim

To describe a modified technique of inferior meatal fenestration with a mucosal flap for maxillary sinus diseases and to present a case series of subjects who underwent this procedure. The novel surgical technique and indications for this approach are also discussed.

Material and methods

The authors analyzed data from 32 cases involving patients who underwent resection of maxillary sinus mucoceles and antrochoanal polyps via modified endoscopic inferior meatal fenestration with a mucosal flap in the period from January, 2011 to January, 2016. The group included 19 men and 13 women, and the patients’ mean age was 36.2 years (range: 11–56 years). Preoperative and postoperative imaging studies were available in all cases and were reviewed.

Results

Thirty-two cases are included in this study. The appearance of nasal and (or) maxillary sinus mucosa was observed in the follow-up at 1 month, 3 months and 6 months using endoscopes. Postoperative computed tomography was performed for only 9 patients in this study. The mean follow-up period was 56 (range: 10–82) months in these cases. All patients had an uneventful post-operative period. Postoperative symptoms were relieved gradually for 1 to 2 weeks after the operation. No patients experienced recurrent symptoms related to the mucocele. Mucocele and polyps recurrence was not observed. No patient showed re-stenosis and obstruction of the nasal cavity, facial pain or numbness during follow-up.

Conclusions

Maxillary sinus mucoceles and antrochoanal polyps are completely excised via modified endoscopic inferior meatal fenestration with a mucosal flap. It could keep the nasal lateral wall intact.

Intracranial abscess formation following sphenoid sinus occlusion with nasoseptal flap skull base reconstruction: A cautionary tale

The formation of an intracranial abscess secondary to sphenoid sinus occlusion after nasoseptal flap skull base reconstruction has not been previously described. We report such a case that occurred at our institution in a 23-year-old man who underwent flap reconstruction for a cerebrospinal fluid leak. We determined that occlusion of the sphenoid sinus outflow might have played a role in this complication. The patient was treated via a combined surgical and medical approach that entailed a bur-hole craniotomy and endoscopic debridement followed by administration of an intravenous antibiotic. The patient recovered without long-term deficit. When closing a defect of the posterior ethmoid and sphenoid skull base, especially with a pedicled graft, care must be taken to reduce the potential for retention of secretions and blood because this may lead to an intracranial complication.

Outcomes in Surgical Treatment of Mucocele in Frontal Sinus

The aim of the study was to correlate several studies dating from 1997 to 2015 to identify the most effective treatments for mucocele in the frontal sinus (with/without other paranasal sinuses), considering successful outcomes and recurrence. We aimed to conduct a literature review for articles published between 1997 and 2015. For this, we accessed articles in the SciELO database, as well as LILACS, PubMed, and Google Scholar databases. Were identified 32 work-related injuries in the paranasal sinuses; 2 of these were not related to mucoceles or mucopyocele, 4 had no relation to the frontal sinus, 9 were related to the frontal sinus and other paranasal sinuses, 4 were related to mucocele associated with other sinuses, and 13 involved only the frontal sinus. Endoscopic techniques decrease intra- and postoperative morbidity, reducing the operative time, allow a larger view of the lesion and surrounding anatomical structures, and decrease chances of recurrence. Thus, the successful outcomes have been beneficial to both the surgeon and the patient.

Management of the Lateral Frontal Sinus Lesion and the Supraorbital Cell Mucocele

Background

Masses that radiographically appear in the lateral aspect of the frontal sinus can be difficult to access and often are approached through external approaches. Supraorbital ethmoid cells pneumatize the orbital plate of the ethmoid bone to lie posterior and lateral to the frontal sinus. Opacification of a supraorbital cell may radiographically give the appearance of a laterally based frontal sinus lesion. Often, these represent mucoceles, in which their drainage can be achieved through endoscopic techniques and without the need for an external approach.

Methods

Retrospective review of patients treated for lateral frontal sinus lesions at a tertiary sinus center was performed. Radiology, endoscopic findings, operative reports, and patient symptoms were reviewed.

Results

Ten patients were identified with lateral frontal sinus lesions based on radiography of the paranasal sinuses and nasal endoscopy. All patients were determined to be supraorbital mucoceles. These patients underwent surgical drainage using computer-aided endoscopic techniques. Initially, endoscopic drainage of the mucocele was successful in all patients. One patient was lost to follow-up after 3 months and one patient underwent a revision endoscopic surgery with trephination 5 months after the initial drainage. The remaining eight patients remain free of disease by nasal endoscopy and postoperative computed tomography scans (median follow-up of 25 months; range, 8–38 months).

Conclusion

Knowledge of the anatomy of the ethmoid complex and presence of various cells within the frontal recess such as supraorbital cells are important in the management of the laterally based frontal sinus lesion. Often, these lesions may represent supraorbital cell mucoceles amenable to endoscopic drainage. Given the nature of mucoceles, long-term follow-up is needed before endoscopic drainage of these lesions can be validated. However, preliminary data suggest that an endoscopic approach provides for adequate drainage and helps avoid external approaches.

Concurrent middle and inferior meatus antrostomy for the treatment of maxillary mucoceles

Background and aims

This study describes the technique of simultaneous middle and inferior antrostomy and outlines its usefulness in the management of maxillary mucoceles.

Methods

This is a retrospective review of 12 consecutive patients with isolated maxillary mucocele operated on by means of middle and inferior antrostomy technique. We describe the clinical picture, details of the surgical technique and outcomes.

Results

There were 7 males and 5 females with ages ranging from 20 years to 65 years (mean 42 years). One patient had past trauma to the face and one had a long history of chronic sinusitis. Eight patients had undergone multiple previous sinus operative procedures including Caldwell-Luc approach. All patients underwent middle and inferior antrostomy without complications. Follow-up was between 12 months and 60 months (mean 36 months) with no recurrences to date.

Conclusion

In conclusion the results of our small series support the worth of using middle and inferior antrostomy when dealing with maxillary mucoceles.

Endoscopic Treatment of Sphenoid Sinus Mucocele: Case Report and Surgical Considerations

Introduction

The paranasal sinuses mucoceles are benign expansive cystic lesions that occur rarely in the sphenoid sinus and contain mucous material enclosed by cylindrical pseudostratified epithelium.

Objective

To report one case of sphenoid sinus mucocele that occurred with headache and was submitted to surgical treatment through endonasal endoscopy approach.

Case Report

59-year-old male patient with history of increasing frontoorbital, bilateral, fluctuating headache and exophthalmos. There was no other associated clinical abnormality. Computed Tomography (CT) and Magnetic Resonance Image (MRI) scans confirmed an expansive mass of sphenoid sinus, suggesting mucocele. The patient was submitted to endonasal endoscopic surgery with posterior ethmoidotomy, large sphenoidotomy, and marsupialization of the lesion.

Conclusion

Mucoceles of the sphenoid sinus are a very rare condition with variable clinical and radiological presentation. Surgical treatment is absolutely indicated and early treatment avoids visual damage that can be permanent. Endonasal endoscopic approach with drainage and marsupialization of sphenoid sinus, using a transnasal corridor, is a safe and effective treatment modality.

Maxillary sinus mucocele: predisposing factors, clinical presentations, and treatment

PURPOSE

Maxillary sinus mucocele (MSM) is uncommon lesion and has many presenting features. The aim of this study was to detect the possible predisposing factors, clinical characteristics, and to assess the efficacy of trans-nasal endoscopic treatment of this lesion.

METHODS

This retrospective multicenter study was conducted on 36 patients with MSM, the diagnosis of the disease was based on computed tomographic criteria. The patients' history, presenting features, and surgical management were reviewed. All patients were followed up postoperatively for at least 3 years.

RESULTS

Chronic sinusitis, previous surgery, allergic rhinitis, and nasal trauma may be implicated as predisposing factors for the disease. However, in some patients (56%) the cause may remain uncertain. MSM may present with unilateral cheek pain, heaviness, swelling, numbness, hemifacial pain, nasal obstruction, nasal discharge, and/or proptosis. All patients were treated with trans-nasal endoscopic marsupialization through the middle meatus, patients with large MSM showed bulged medial maxillary wall, and they needed to empty the fluid through inferior antrostomy to facilitate introduction of the instruments to the middle meatus. All patients reported resolution of their symptoms, and none required revision surgery through the follow-up period.

CONCLUSIONS

MSM has several predisposing factors such as chronic sinusitis, previous surgery, allergic rhinitis and nasal trauma. However, some patients have no identifiable cause. The disease can present with a variety of symptoms which are usually related to their expansion and subsequent pressure on the surrounding structures. Trans-nasal endoscopic approach is an effective and safe method for treatment of the lesion.

Maxillary Sinus Mucocele as a Late Complication in Zygomatic-Orbital Complex Fracture

This article presents an unusual case of maxillary sinus mucocele as a late complication of zygomatic-orbital complex fracture, 23 years after the initial treatment. The patient was referring diplopia and decreased visual acuity with signs of dystopia, proptosis, and epiphora. Computed tomographic scan revealed an expansive lesion in the maxillary sinus with surrounding bone erosion and displacement of the eyeball. Treatment option was excisional biopsy and orbital floor reconstruction with titanium mesh restoring the appropriate orbital position. We propose that in the case of postoperative ophthalmological sequelae of facial fractures involving paranasal sinuses, mucocele should be considered in the differential diagnosis.

Frontoethmoidal Mucoceles: CT and MRI Evaluation

Paranasal sinus mucocele is an expanded, airless, mucus-filled sinus caused by obstruction of the sinus ostium. It is a benign slow growing epithelial lined lesion, bulging against adjacent anatomical structures, without infiltrating them. The purpose of our study is to describe the CT and MR findings in 19 patients (ten women, nine men, 18–72 years, mean age: 48.1) with surgically confirmed frontoethmoidal mucoceles between 1999–2005. CT scans displayed mucoceles as non enhancing soft tissue density lesions, generally isodense to the brain parenchyma, expanding the sinuses in most cases, eroding adjacent bones and extending intraorbitally or intracranially. Signal intensity in T2WI and T1WI MR images varied, but generally lesions had high signal intensity in T2WI and low to intermediate signal intensity in T1WI. Some of the lesions demonstrated regular linear peripheral enhancement after administration of contrast medium. The causes of mucoceles included mucosal thickening from chronic sinusitis, adhesions from previous operation in the nasal cavity, previous trauma, small nasal polyps and a small osteoma, while in six patients (31.5%) the cause of the mucocele remained unrecognized even after surgery. No underlying malignant tumor was found in any of the cases as the cause of obstruction. CT and MRI established the correct diagnosis in all patients. CT was more sensitive in determining bone erosions, while MRI had the advantage of multiplanar imaging and was much more sensitive for differentiating mucocele from a tumor on the basis of MR signal intensity characteristics. In conclusion, CT and MRI are the methods of choice for diagnosing mucoceles of the paranasal sinuses and are of major importance for the treatment plan. Each method seems to have its own advantages and should be used as complementary investigations of sinonasal pathology. Enhanced CT scan should only be performed in the absence or contraindication for enhanced MR imaging.

Frontal Sinus Surgery: The State of the Art

Aim:

Review and describe the essential components of modern frontal sinus surgery.

Background

Frontal sinus surgery has evolved considerably over the last century, and advances in imaging, optics, and instrumentation have contributed to contemporary treatment paradigms. Outcomes assessment has had an important role in identifying indications for surgery and future areas of research.

Review results

Numerous advancements are part of modern frontal sinus surgery and the treatment of frontal sinusitis. Anatomic studies have revealed variations that are associated with disease and pose challenges for surgery. Open approaches remain relevant in situations of difficult disease or as part of combined approaches. Endoscopic surgery, however, is central to contemporary surgical management of frontal sinus disease. Evolving instrumentation and the development of new implantable devices are increasingly relevant in the endoscopic era. Outcomes research has refined indications for surgery and identifies areas for ongoing research.

Conclusion

State-of-the-art frontal sinus surgery is the product of significant evolution and advancement. Modern surgery is reflective of improved optics and new instrumentation, and the central role of endoscopic approaches in treating frontal sinus disease. Outcomes research has been essential for developing an evidenced-based approach to frontal sinus surgery.

Clinical significance

A review of the essential components of state-of-the-art frontal sinus surgery for the practicing otolaryngologist.

How to cite this article

Marino MJ, McCoul ED. Frontal Sinus Surgery: The State of the Art. Int J Head Neck Surg 2016;7(1): 5-12.

Frontoethmoidal mucocele following pediatric craniofacial surgery

BACKGROUND

Mucoceles occur as a result of accumulation and retention of mucous secretions in a paranasal sinus and are uncommon in the pediatric age group. Persistent or intermittent closure of its ostium through a variety of causes, including previous surgery, is implicated in etiology. The authors report 2 cases of frontoethmoidal mucocele that followed box osteotomies for the treatment of orbital dystopia, with medical literature review and discussion of possible causal factors and events.

METHODS

Case histories and radiological imaging are presented on 2 patients presenting with frontoethmoidal mucoceles following craniofacial surgery. Both had transcranial craniofacial techniques where all orbital walls and globe are moved en bloc as a "box."

RESULTS

Patient 1, a 12-year-old male patient with Crouzon syndrome, developed mucoceles within 18 months of monobloc distraction surgery and box osteotomies. This was successfully marsupialized with a combined external and endoscopic surgical approach. The second patient, a 15-year-old boy with previously corrected right-sided facial cleft, developed mucocele 9 years following box osteotomies; this was successfully managed by endoscopic drainage. Of 3 other patients having similar box osteotomies in our unit, no other mucoceles were noted as complications.

CONCLUSIONS

Mucoceles are a rare complication of craniofacial surgery, and literature review confirms a paucity of reports. Only 1 case has previously been alluded to of mucocele complicating box osteotomy for orbital dystopia. Our 2 cases illustrate and highlight a successful management approach in a multidisciplinary craniofacial unit.

Complicated giant mucoceles of the frontal sinus: approach to endoscopic marsupialization technique

A number of external and radical procedures have been the only surgical approaches for the treatment of frontal sinus mucoceles. However, these procedures have major complications including high surgical morbidity, esthetic concerns of postoperative scar formation, and difficulty in radiologic diagnosis of recurrence after obliteration. In this clinical report, we demonstrated an endoscopic marsupialization technique that could easily be applied to a very large mucocele that has extended to the intracranial region, without any serious complications.

Complicated fronto-orbital mucopyocele presenting with proptosis: a case report

Mucoceles are cystic lesions of the paranasal sinuses which develop as a result of accumulation of mucous secretion due to obstruction of the ostium of the sinuses. Despite their benign behavior, they may enlarge progressively and project into adjacent structures by destructing the bony walls of the sinuses. Frontal mucoceles may get infected and extend towards orbital cavity and compress the orbit by eroding the bony walls of the orbital cavity. Endoscopic and external approaches are performed in the surgical treatment. We report a case of complicated fronto-orbital mucopyocele which eroded the orbital roof and extended into the orbital cavity and discuss the surgical treatment strategy under the light of the current literature.

Bardet-Biedl syndrome and a large concha bullosa pyocele

Bardet-Biedl syndrome is a rare disease involving rode cone dystrophy, polydactyly, obesity, learning disabilities, hypogonadism and renal anomalies, symptoms caused by immotile cilia dysfunction. We report the first case of this syndrome in a teenager with an endonasal mass secondary to pyocele of a concha bullosa. The patient was treated successfully with endoscopic sinus surgery. Nasal obstruction secondary to a middle turbinate pyocele in Bardet-Biedl syndrome has not been described before. The pediatrician and the rhinologist should take this entity into consideration when investigating patients with Bardet-Biedl syndrome and sinonasal symptoms.

[Clinical analysis and surgical results of 58 paranasal sinus mucoceles]

INTRODUCTION

Mucoceles are slow-growing, benign lesions found in the paranasal sinuses that are locally destructive, causing bony resorption an displacement of adjacent structures. We present our experience in the surgical treatment of these lesions.

METHODS

This was a retrospective review of 58 paranasal sinus mucoceles in 54 patients between 1989 and 2012. We describe patient age and sex, mucocele location, clinical features, surgical approaches employed, recurrence and complications.

RESULTS

The mean age of patients in this series was 59 years; there were 31 males (57%) and 23 females (43%). Thirty-two cases (55%) were located in the frontal or ethmoid-frontal system, 8 (14%) in the ethmoid sinus, 14 (24%) in the maxillary sinus and 4 (7%) in sphenoid sinus. Predisposing factors were present in 55% of the patients and 45% cases were primary. Endoscopic treatment was given to 71% of mucocele patients, while 29% were treated with external or combined approaches. Recurrence appeared in 4 patients (7%), 2 in the endoscopic surgery group and 2 in the external surgery group.

CONCLUSIONS

The procedure of choice for management of paranasal sinus mucoceles is endoscopic drainage. It is a safe approach that gives good results.

Managing the frontal sinus in the endoscopic age: has the endoscope changed the algorithm?

Management of fractures involving the frontal sinus seems to be more complex than merely obtaining an ideal reduction of the bony injuries. Multiple articles on the management of these fractures suggest that a great deal of controversy persists despite many years of surgical experience. The question posed in this article is whether or not the advent of endoscopic approaches has changed or should change the approaches/algorithms used in the management of these challenging fractures. It is the conclusion of these authors that endoscopic techniques can indeed allow us to change the algorithm for management of frontal sinus trauma. New algorithms are proposed that should provide guidance to craniomaxillofacial surgeons treating these injuries in the endoscopic age.

Endoscopic partial medial maxillectomy with mucosal flap for maxillary sinus mucoceles

PURPOSE

To describe a technique of endoscopic medial maxillectomy with mucosal flap for postoperative maxillary sinus mucoceles and to present a case series of subjects who underwent this procedure.

MATERIALS AND METHODS

This case series includes four subjects with postoperative maxillary sinus mucoceles who underwent resection via endoscopic partial medial maxillectomy with a mucosal flap. We will discuss the clinical presentation, imaging characteristics, operative details, and outcomes.

RESULTS

Four subjects are included in this study. The average age at the time of medial maxillectomy was 52 years (range 35-65 years). Three subjects (75%) were female. One subject (25%) had bilateral postoperative maxillary sinus mucoceles. Two subjects (50%) had unilateral right sided mucoceles, and the remaining subject had a unilateral left sided mucocele. All subjects had a history of multiple sinus procedures for chronic sinusitis including Caldwell-Luc procedures ipsilateral to the postoperative mucocele. All subjects underwent endoscopic medial maxillectomy without complication and were symptom free at the last follow up appointment, average 24 months (range 3-71 months) after medial maxillectomy.

CONCLUSIONS

For postoperative maxillary sinus mucoceles in locations that are difficult to access via the middle meatus antrostomy, we recommend endoscopic medial maxillectomy with mucosal flap. Our preliminary experience with four subjects demonstrates complete resolution of symptoms after this procedure.

Intracranial mucocele formation in the context of longstanding chronic rhinosinusitis: A clinicopathologic series and literature review

Chronic rhinosinusitis (CRS) can lead to serious long-term adverse sequelae, particularly if left untreated. The aim of this study was to describe a series of intracranial mucoceles (ICMs) that arose in the context of longstanding CRS combined with a review of the pertinent literature. A retrospective chart review was performed on all patients who developed ICMs in association with CRS between 2003 and 2012. The clinical presentation, radiographic features, surgical approach, intraoperative findings, and patient outcome were examined in the context of a literature review. Sixty-five cases of mucoceles were identified in patients with a history of CRS, of which seven (10.8%) were intracranial. Five patients were men and two were women with a mean age of 42.1 years. Headache, facial pressure, retro-orbital pain, and visual disturbances were the most common presenting symptoms. Five of the seven had previously undergone sinonasal surgery. Imaging studies showed ICMs involving the anterior cranial fossa, two of which were bilateral. Latency between onset of CRS and ICM detection ranged from 3 to 19 years (mean, 9.4 years). All patients underwent endoscopic transnasal drainage with three also requiring a concurrent, open neurosurgical procedure to access the intracranial component. There were no postoperative complications, and no recurrences were observed after a mean follow-up of 2.7 years. ICMs presenting as delayed complications of CRS are uncommon and constitute a surgical challenge. Open, external skull base approaches used in conjunction with transnasal endoscopic drainage procedures may be necessary to achieve successful management of this rare condition.

Giant mucocele originating from the middle concha in a 5-year-old child: a case report

INTRODUCTION

Mucoceles are mucus-filled, epithelial-lined sacs that slowly develop in the paranasal sinuses when sinus or concha bullosa drainage is obstructed by inflammatory processes, trauma, or prior surgery. They are extremely rare in children. Symptoms usually arise from the nasal obstruction or compression of neighboring structures.

CASE PRESENTATION

This case report describes a 5-year-old Turkish boy with a 3-year history of nasal obstruction. A computed tomography scan showed a well-defined soft tissue density lesion, seemingly originating in the region of the middle concha and was suggestive of a middle concha mucocele. The mass was removed by endoscopic sinus surgery.

CONCLUSIONS

In the case of a child presenting with nasal obstruction, mucocele should be remembered in the differential diagnosis of intranasal tumors. Computed tomography and magnetic resonance imaging are helpful in making the diagnosis and endoscopic nasal surgery has proven successful in the treatment.

Contemporary management of frontal sinus mucoceles: a meta-analysis

OBJECTIVES/HYPOTHESIS

To analyze trends in the surgical management of frontal and fronto-ethmoid mucoceles through meta-analysis.

STUDY DESIGN

Meta-analysis and case series.

METHODS

A systematic literature review on surgical management of frontal and fronto-ethmoid mucoceles was conducted. Studies were divided into historical (1975-2001) and contemporary (2002-2012) groups. A meta-analysis of these studies was performed. The historical and contemporary cohorts were compared (surgical approach, recurrence, and complications). To study evolution in surgical management, a senior surgeon's experience over 28 years was analyzed separately.

RESULTS

Thirty-one studies were included for meta-analysis. The historical cohort included 425 mucoceles from 11 studies. The contemporary cohort included 542 mucoceles from 20 studies. More endoscopic techniques were used in the contemporary versus historical cohort (53.9% vs. 24.7%; P = <0.001). In the authors' series, a higher percentage was treated endoscopically (82.8% of 122 mucoceles). Recurrence (P = 0.20) and major complication (P = 0.23) rates were similar between cohorts. Minor complication rates were superior for endoscopic techniques in both cohorts (P = 0.02 historical; P = <0.001 contemporary). In the historical cohort, higher recurrence was noted in the external group (P = 0.03).

CONCLUSIONS

Results from endoscopic and open approaches are comparable. Although endoscopic techniques are being increasingly adopted, comparison with our series shows that more cases could potentially be treated endoscopically. Frequent use of open approaches may reflect efficacy, or perhaps lack of expertise and equipment required for endoscopic management. Most contemporary authors favor endoscopic management, limiting open approaches for specific indications (unfavorable anatomy, lateral disease, and scarring).

LEVEL OF EVIDENCE

N/A.