Frontoethmoidal mucocele presenting with ocular manifestations

Mucocele of the paranasal sinuses is a slowly expanding benign lesion developing when there is impeded physiological drainage of the mucous produced by the epithelial lining of the paranasal sinuses, at the sinus ostium, which is an opening that connects the sinus to the nasal cavity. Aetiologies of ostial occlusion include infection, allergy, trauma, previous surgery, benign neoplasm (osteoma or fibrous dysplasia), and malignant or metastatic tumours. Mucoceles commonly develop in the frontal sinus (70-80 per cent), followed by the ethmoid (25 per cent), frontoethmoidal (10-14 per cent), and maxillary (three per cent or less) sinuses. The most common manifestations in these cases are ocular oedema, proptosis (22-83 per cent), and diplopia (28 per cent). Due to these ocular signs and symptoms, the optometrist may be first in line managing paranasal sinus disease patients, reducing the risk of permanent damage. A case report and review of frontoethmoidal mucocele will be discussed in this report, to include the role of the optometrist in its management and treatment.

Considerations in the management of giant frontal mucoceles with significant intracranial extension: A systematic review

BACKGROUND

Giant frontal mucoceles, characterized by significant intracranial and/or intraorbital extension, can present with significant neurologic symptoms. Although typical mucoceles are managed endoscopically, giant mucoceles are often treated with an open or combined approach due to various concerns, including frontal lobe displacement, size, and rapid decompression of the intracranial component. The impact of significant intracranial extension on outcomes is not well described.

OBJECTIVE

This review studied key neurologic considerations in the management of giant frontal sinus mucoceles and analyzed outcomes of different management strategies.

METHODS

Systematic literature review by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Thirty-two articles, which represented 85 cases, met inclusion criteria. Neurologic symptoms on presentation ranged from headache (24.7%) and vision loss (12.9%) to extremity weakness (1.2%), frontal lobe syndrome (2.4%), and seizures (4.7%). Twenty-eight patients were treated endoscopically (34.1%), and 54 (65.9%) were treated with an external approach. Twenty-five of the open procedures included a craniotomy. Indications for the open approach included subdural empyema, enucleation, or large anterior table defects. Perioperative antibiotics were not consistently used. No perioperative seizures were reported with any approach. There were six cerebrospinal fluid leaks, all in the patients who underwent open procedures. The overall recurrence rate was 3.5%, with no recurrences reported in patients treated with an open approach. Follow-up ranged from 1 week to 8 years.

CONCLUSIONS

Giant frontal mucoceles often present with various neurologic symptoms. Both open and endoscopic techniques offer excellent results. Endoscopic management is effective and preferred, except in special circumstances. An interdisciplinary team approach should be used to optimize surgical planning.

A giant frontoethmoid mucocele with intracranial extension

Mucoceles are mucus-containing cysts lined by epithelium. Although benign, they may show expansive growth and remain undiagnosed until symptoms due to compression of surrounding structures arise. We report a rare case of frontoethmoid mucocele with intracranial extension in an 80-year-old woman with complaints of headache, right diplopia and proptosis. A right frontoorbital craniotomy was performed, and a mucocele in the frontal sinus extending into the frontal lobe and orbit was totally removed. The patient was successfully treated without any complication. The two-year follow-up results were satisfactory. Magnetic resonance imaging excluded any recurrence of the mucocele. Combined intranasal and transcranial approach is necessary to treat giant frontoetmoid mucoceles with intracranial extension.

Complete loss of vision caused by a giant mucocele of the frontal sinus

The authors report the case of a 75-year-old man presenting with an exceptionally large giant posttraumatic mucocele of the frontal sinus years after a gunshot blast to the head. The lesion had grown so extensively that the right eye had shrunk and calcified, resulting in total monocular blindness, a complication that has been reported only once. To the best of our knowledge, it is the first time that a giant mucocele of such a large size is reported. We describe how the patient underwent surgical removal of this massive lesion, cranial base reconstruction, and a cosmetic oculoplastic procedure. The etiology, clinical presentation, and possible complications are reviewed, as well as the importance of a regular clinical follow-up and early surgical cure. Although the diagnosis and management of mucoceles are nowadays considered quite standard, the exceptional size of the lesion illustrated here emphasizes the destructive potential of such seemingly indolent lesions. Despite the benign histology of mucoceles, one should never underestimate their morbid potential or be lulled in delaying surgical cure. Large mucoceles should be removed as quickly as possible to prevent such unacceptable complications as permanent visual loss.

Frontoethmoidal mucocele with orbital and intracranial extension

We report a case of a giant frontoethmoidal mucocele extending to the orbit and anterior cranial fossa. Clinically, the patient had an insidious onset of clinical presentation with no intracranial symptoms. We present its CT, MRI and histpathological features with a brief review of literature. Various surgical approaches are also discussed.

Transblepharoplasty approach to sequestered disease of the lateral frontal sinus with ophthalmologic manifestations

BACKGROUND

Sequestered disease within the lateral extent of the frontal sinus that has eroded into the orbit through the frontal sinus floor may be difficult to address with standard ESS techniques. We describe an approach to this problem using a transblepharoplasty incision concealed in the upper eyelid crease.

METHODS

Five consecutive patients with lateral frontal sinus disease involving the orbit were treated with combined ESS/transblepharoplasty approach. This used an upper lid incision and elevation of a myocutaneous flap. The preexisting dehiscence in the sinus floor was exposed, permitting extraction of fungal debris and marsupialization of the mucocele. Frontal sinusotomy was performed via combined above/below technique

RESULTS

The study group included 5 patients with mean age of 50 years. Two patients had post-traumatic mucopyocele, two had allergic fungal sinusitis, and one exhibited both entities. All patients had signs of ophthalmopathy: proptosis with increased IOP (5/5), gaze restriction (5/5), and decrease in visual acuity (2/5). Ophthalmologic symptoms improved postoperatively in 5/5, but 2 patients eventually required revision endoscopic surgery. No complications occurred, and incision healing was excellent in all patients.

CONCLUSION

In patients with sequestered disease of the lateral frontal sinus and ophthalmologic manifestations, the transblepharoplasty approach in combination with ESS affords excellent access while preserving cosmesis.

[Giant mucocele of all paranasal sinuses with massive bilateral globe displacement]

Although of benign nature and slowly progressive, paranasal sinus mucoceles may, depending on their localization, cause a multitude of ophthalmological symptoms due to compression and displacement of adjacent tissue. Here we report the unusual case of a patient suffering from a progressively growing giant mucocele that developed years after ENT surgery and that was neglected for almost 2 decades despite massive symptoms. This case report demonstrates the importance of including mucoceles of the paranasal sinuses into the differential diagnosis of unilateral or bilateral proptosis.