Orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles: report of two cases

BACKGROUND

Two cases of orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles were reported to understand image findings, clinical and histopathologic features of orbitofrontal cholesterol granuloma to improve its diagnosis and treatment.

CASE PRESENTATION

Two East Asian patients aged 41 and 27 without personal or familial medical or trauma history presented with the common complaint of proptosis and inferomedial displacement of the eyeballs. The computed tomography (CT) of both cases showed an irregularly shaped, well-defined lesion in the left frontal bone associated with bony erosion. The lesions resulted in the bone absorption of frontal bone and orbital roof, which extended into the superior orbital space. Anterior orbitotomy through subbrow incision by drainage and curettage resulted in a curative outcome. The histopathological examination revealed inflammatory granulation tissues, fibrous capsule wall, cholesterol clefts with altered blood pigments, and calcifications, consistent with the diagnosis of cholesterol granuloma. No recurrence was observed for one year after surgery in one case and three years in the other.

CONCLUSIONS

When the following features are observed: orbital CT exhibits cystic lesion with irregular bone destruction in the superolateral orbit, magnetic resonance imaging (MRI) depicts lesions are hyperintense signals on T1 weighted images (T1WI), and T2 weighted images (T2WI), and the contrast-enhanced imaging reveals that the most of tumor is showed a non-significant enhancement, orbitofrontal cholesterol granuloma should be considered.

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.

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.

Image-guided endoscopic marsupialization technique for frontal sinus mucocele with orbital extension: A case report

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Navigated assisted ESS is a safe treatment for FM with orbital extension.

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A navigation support could avoid an external approach.

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The image-guided system could be useful if bony landmarks are missing.

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The image-guided system could be useful if orbital erosion is present.

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Navigated assisted ESS could completely drain lateral and multi-cystic lesions.

Introduction

Frontal sinus mucocele with intra-orbital extension represents a rare benign cyst-like lesion. Surgical management could be summarized in an open approach, an endoscopic marsupialization or a combined procedure. The present study reports a case of frontal mucocele with wide intra-orbital invasion treated with endoscopic marsupialization assisted by an image-guided navigation system.

Presentation of case

A 34-year-old African male was referred to the otolaryngology clinic for unilateral supraorbital swelling and post-nasal drip. A clinical ophthalmic assessment showed normal ocular movement, the absence of diplopia and normal visual acuity. CT scan showed a large soft tissue density lesion originating from the right frontal sinus with a supero-medial orbital erosion. The mass invaded the orbital cavity compressing and dislocating the eyeball forward and laterally. An image-guided ESS was performed according to Draft type IIa. Frontal mucocele’s inferior wall was open in order to drain muco-purulent content. No complications were detected and the patient was completely recovered with open frontal sinus drainage at 4 months follow-up visit.

Discussion

We have successfully treated a wide intra-orbital frontal mucocele with an endoscopic marsupialization thanks to image-guided navigation system support. This technology prevented an external approach with associated morbidity and longer hospitalization.

Conclusion

Navigated assisted endoscopic approach with marsupialization can be considered a safe treatment for FM with orbital extension. In particular, the image-guided system could be useful if bony landmarks are missing, if orbital erosion is present, and to completely drain lateral and multi-cystic lesions.

Frontal Mucocele Extended Orbita and Endoscopic Marsupialization Technique

Mucocele is benign, slow-growing, mucous-filled cystic lesions that arise in the paranasal sinuses. It causes progressive distension of the bony walls and induces compressive symptoms. Surgical treatment of paranasal sinus mucoceles includes endoscopic approach or external approach. The authors report a patient of frontal mucocele who presented with a history of progressive unilateral protrusion. Computed tomography scan revealed a large mucocele of the frontal sinus with orbital extension on the same side. He was successfully treated with endoscopic marsupialization without any serious complications.

Endoscopic endonasal orbital transposition to expand the frontal sinus approaches

BACKGROUND

The management of frontal sinus disease still remains a challenging issue for rhinologists. Although endoscopic frontal sinus surgery has significantly advanced over the past years, there are some conditions in which the external approaches are still necessary. Recently, the increasing experience in endoscopic sinus surgery together with important technologic advancements have allowed expansion of the indications for selected lesions localized more and more lateral into the frontal sinus.

OBJECTIVE

The aim of this study was to describe the endoscopic endonasal approach to the far lateral portion of the frontal sinus and to evaluate the outcomes of this technique.

METHODS

A retrospective evaluation was carried out with patients at a single institution, who, from 2004 to 2012, underwent an exclusive endoscopic transnasal approach to the far lateral portion of the frontal sinus at a single institution. The surgical technique included the Draf IIb procedure, a modified Lothrop procedure (Draf III), and endoscopic lateralization of the orbit, differently associated according to the needs of each case.

RESULTS

Twenty-four patients were eligible for the present study. The lesions included were mucoceles in 9 cases, fibro-osseous lesions in 10 cases, and inverted papillomas in 5 cases. The overall follow-up ranged from 12 to 120 months (mean, 40.6 months). At the time of the last follow-up, no recurrence of disease was observed in the patients treated; in one case of osteoma, a small and stable in size (1 mm) persistent lesion was observed in an asymptomatic patient. One scheduled and one accidental cerebrospinal fluid leak with immediate skull base reconstruction occurred. No intraoperative or postoperative early or late orbital complication was observed in any case.

CONCLUSION

The endoscopic endonasal orbital transposition seems to facilitate the endoscopic management of selected far-lateral frontal sinus lesions. However, it is a demanding procedure that requires experience and skill to avoid intraoperative skull base and orbital complications.

Secondary adult encephalocele with abscess formation of calcified frontal sinus mucocele

INTRODUCTION

Although encephalocele is a rare congenital abnormality, secondary encephalocele is extremely rare and can cause fatal complications. Here, we report a case of secondary encephalocele caused by frontal sinus wall defect due to chronic sinusitis, which was completely removed by cranialization with autologous bone graft. A 50-year-old man with a 10-year history of chronic sinusitis visited our hospital due to suddenly altered mentality characterized by stupor. Computerized tomography scanning and magnetic resonance imaging revealed an enlarged left frontal sinus with sinusitis. The frontal sinus cavity was calcified, and the left frontal lobe had herniated into the cavity accompanied by yellow pus. A large dural defect was also found around the frontal sinus area. After removal of the abscess and some of the frontal lobe, frontal skull base repair by cranialization was performed using autologous bone graft. Streptococcus pneumoniae was cultured from the cerebrospinal fluid (CSF), necessitating treatment with antibiotics. After the operation, the mental status of the patient improved and no CSF leakage was observed.

DISCUSSION

In addition to correct diagnosis and early treatment including antibiotics, the surgical repair of defects is needed in patients with secondary encephalocele to prevent further episodes of meningitis. Surgical correction of frontal sinus encephalocele can be achieved through bifrontal craniotomy or endoscopic transnasal repair. If a patient has CSF leakage, open craniotomy may facilitate repair of the dural defect and allow for cranialization of the sinus.

CONCLUSIONS

Removal of dysplastic herniated brain tissue and cranialization of the frontal sinus may be a good option for treating secondary encephalocele and its associated complications, including meningitis, abscess formation, and infarction of the herniated brain parenchyma.

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.

Current indications for the osteoplastic flap

INTRODUCTION AND OBJECTIVES

Endoscopic sinus surgery is the technique of choice in most of the frontal sinus diseases, both inflammatory and tumour-related. This is why the external approach using osteoplastic flap (OF) would be limited to cases with a difficult endoscopic approach. Our aim was to review the current indications of the osteoplastic flap in the treatment of frontal sinus pathology, through a retrospective study of patients undergoing this technique.

METHODS

We performed a retrospective study of 14 patients who were treated with the osteoplastic flap procedure. All the surgical indication criteria, type of sinus disease, presence or absence of prior endoscopic surgery, surgical findings, complications and recurrence were reviewed.

RESULTS

The pathologies found were 1 osteoma (7.1%), 3 inverted papilloma (21.4%) and 10 mucoceles (71.4%). Nine patients had a prior endoscopic surgery and 10 patients had an orbital dehiscence (9 mucocele, 1 papilloma). Frontal osteoma was Grade IV and the papilloma cases were Krouse Stage III. Surgical revision was required for 21.4%.

CONCLUSIONS

The main indications for an OF in patients with inflammatory disease are lateral extension and frontal recess neo-osteogenesis. In osteoma cases, it depends on the size of the tumour. In inverted papilloma cases, the indication is multifocal implantation with origin in the anterior and lateral wall. In all cases, performing the osteoplastic flap must be individualised.

Endoscopic marsupialisation of the lateral frontal sinus mucocele with orbital extension: a case report

Introduction:

Frontal sinus mucoceles are the commonest among all paranasal mucoceles. With introduction of functional endoscopic sinus surgery, surgeons prefer endoscopic management of sinus mucoceles, but lesions that appear in the lateral part of the frontal sinus can be difficult to access and often need external approaches.

Case Presentation:

We described a lateral frontal sinus mucocele with intra-orbital extension, which was successfully managed by endoscopic sinus surgery.

Conclusions:

Endoscopic sinus surgery is the treatment of choice in most frontal sinus mucoceles including lateral frontal mucoceles.

The hybrid lid crease approach to address lateral frontal sinus disease with orbital extension

OBJECTIVE

This study aimed to describe the hybrid lid crease approach in conjunction with functional endoscopic sinus surgery (FESS) for lateral frontal sinus disease with orbital extension.

STUDY DESIGN

Retrospective case review.

METHODS

Patients undergoing hybrid lid crease approach with FESS for frontal sinus disease were reviewed retrospectively. Surgical indications consisted of inverting papilloma with extension into the frontal sinus (n = 1) and frontal sinus mucocele (n = 2). Inclusion criteria included presence of disease in the lateral frontal sinus with extension into the orbital space and erosion of the superior orbital rim. Preoperative and postoperative parameters included complete ophthalmologic exam, endoscopic exam, and computed tomography scan.

RESULTS

We were able to access the frontal sinus and orbit in all 3 cases and address sinus pathology of the lateral frontal sinus and orbit using the lid crease approach with FESS. All patients had improvement in ophthalmologic symptoms and interval disease resolution and were satisfied with their postoperative lid crease incision.

CONCLUSION

The lid crease approach offers direct access to the frontal sinus with minimal dissection through a well-hidden incision. In our case series of lateral frontal sinus pathology with orbital extension, the hybrid lid crease approach with FESS allowed complete eradication of disease without recurrence.

Management of Lateral Frontal Sinus Pathology in the Endoscopic Era

OBJECTIVES

Considerable advances in endoscopic technique and experience have allowed an increasing number of patients with complex frontal sinus disease to be treated with endoscopic surgery. The objective of the current study was to evaluate management strategies and outcomes regarding treatment of lateral frontal sinus disease.

STUDY DESIGN

Prospective case series.

SETTING

Academic tertiary medical center.

SUBJECTS AND METHODS

Prospectively collected data concerning frontal sinus pathology located lateral to the plane of the lamina papyracea (lateral disease) were reviewed. Data were collected regarding demographics, etiology, surgical technique, revision rate, anatomic considerations, and clinical follow-up. Only patients with at least 24 weeks of clinical follow-up and pathology who required removal and dissection in this region were included in the study.

RESULTS

Over 5 years, 156 patients (mean age, 47.9 years; range, 14-84 years) with 183 lateral frontal sinus pathologies and an average clinical follow up of 76 weeks (range, 24-237 weeks) were evaluated. Endoscopic or open surgery was attempted in 84 patients (54%) prior to intervention at our institution. Primary pathologies included inflammatory/obstructive diseases (n = 119), skull base defects (n = 33), and tumors (n = 31). Initial interventions included endoscopic (Draf IIA, n = 76; Draf IIB, n = 52; Draf III, n = 23), extended (IIA + trephine, n = 1; III + trephine, n = 2; III + osteoplastic flap, n = 2), and open (osteoplastic flap, n = 3; Reidel, n = 1; cranialization, n = 1) procedures. Seven patients (4%) required a subsequent revision procedure.

CONCLUSION

The vast majority of lateral frontal sinus pathology was managed using endoscopic techniques with excellent outcomes and a low revision rate in the current study.

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.

Frontal sinus septations predict the presence of supraorbital ethmoid cells

OBJECTIVES/HYPOTHESIS

This study is undertaken to determine if the presence or absence of multiseptated frontal sinuses is associated with the presence or absence of supraorbital ethmoid cells (SOECs).

STUDY DESIGN

Analysis of prospectively collected data.

METHODS

Sixty consecutive patients with chronic rhinosinusitis were identified from a prospectively collected database at a tertiary-referral institution as having full-sinus computed tomography (CT) scans. Preoperative or initial CT scans of the sinuses were reviewed, specifically identifying the presence or absence of supraorbital ethmoid air cells (SOECS) and frontal sinus multiseptated sections on coronal imaging. Statistical analysis was performed using the chi-squared test to evaluate any association between the two structural entities.

RESULTS

Sixty total patients were identified, for a total of 120 sides. Of the 61 sides with frontal septations, 43 (70%) had SOECs present and 18 (30%) did not. Of the 59 sides without frontal sinus septations, 13 (22%) had SOECs present and 46 (78%) did not (chi squared = 28.3; P = 0.0000001). The difference in the presence of supraorbital ethmoid cells between whites and blacks is also statistically significant (chi squared = 4.23; P = 0.040).

CONCLUSION

The presence of frontal sinus septations appears to be significantly associated with and predictive of the presence of supraorbital ethmoid cells. Thus, identifying frontal sinus septations on sinus CT is implicated with more complex anatomy of the frontal recess.

Image-Guided Surgery Influences Perioperative Morbidity from Endoscopic Sinus Surgery

Objective

Although image-guided surgery (IGS) is considered a valuable tool, its impact on perioperative morbidity for endoscopic sinus surgery (ESS) remains unclear. The evidence from reported literature is systematically reviewed with meta-analysis.

Data Sources

MEDLINE (1946 to September 14, 2012, week 2) and EMBASE (1974 to September 14, 2012, week 37).

Review Methods

MEDLINE and EMBASE were searched using a search strategy for publications on IGS during ESS that reported original data on perioperative morbidity. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed. Both comparative cohort studies with non-IGS cases and case series were included. Primary outcome was major and total complications. Secondary outcomes were specific orbital and intracranial injury, major hemorrhage, ability to complete the operation, and revision surgery. The incidence of these events was defined as dichotomous variables and expressed as a risk ratio (RR) in a fixed-effects model.

Results

In total, 2586 articles fulfilled the search, producing 55 included studies. Fourteen were comparative cohorts of IGS and non-IGS sinus surgical patient populations used for meta-analysis. Among the cohorts, major complications were more common in the non-IGS group (RR = 0.48; 95% confidence interval [CI], 0.28-0.82; P = .007). Total complications were greater in the non-IGS group (RR = 0.66; 95% CI, 0.47-0.94; P = .02). All other outcomes did not reach significance on meta-analysis.

Conclusion

Contrary to current review articles on the topic of IGS use during ESS, there is evidence from published studies that the use of IGS for sinus surgery, within selected populations, is associated with a lower risk of major and total complications compared with non-IGS sinus surgery.

Endoscopic treatment of frontal sinus mucoceles with lateral extension

To describe a new and useful criterion to identify endoscopically approachable lateral frontal sinus mucoceles. We retrospectively reviewed all patients diagnosed with frontal mucocele with lateral extension who underwent endoscopic sinus surgery (ESS) at the Department of Otorhinolaryngology, San Raffaele Scientific Institute over a 4 year period, from January 2008 to March 2012. We analyzed patient charts, pre- and post-operative imaging, operative reports, postoperative periods, and follow-up records. Our series is composed of seven patients, four males and three females, with a mean age of 56 years. Symptoms at presentation varied depending on the extent of mucocele growth and orbital and intracranial invasion. Mucocele extension medially to a virtual sagittal plane tangential to the medial side of the ocular globe was also evaluated with computed tomography, to determine the appropriateness and feasibility of an ESS procedure. After pre-operative investigations, patients underwent marsupialization of the mucocele with ESS. Postoperative follow-up ranged from 1 to 4 years. At present, all patients remain free of disease, as documented by radiological imaging. In defining endoscopically approachable lesions, it is essential to determine their extension beyond a virtual sagittal plane tangential to the medial side of the ocular globe. The success of the endoscopic procedures described was undoubtedly linked to the localization of the mucocele medial wall. This criterion is more important than the size of the mucocele, and accurate computed tomography evaluation can identify those mucoceles approachable with ESS, even if laterally extended.

Endoscopic trans(naso)orbital management of supraorbital mucoceles with biliary T-tube stenting

The objective of this article is to describe our surgical technique for accessing orbital and supraorbital ethmoid sinus mucoceles and the novel application of a biliary T-tube to stent and redirect mucociliary flow into the frontal recess. We describe in technical terms our surgical approach and the use of an 8-Fr pediatric biliary T-tube as a paranasal sinus stent with demonstrative case reports. Four patients have been successfully managed employing the endoscopic trans(naso)orbital approach to access and marsupialize supraorbital and superiorly located orbital mucoceles without egress to the frontal recess. Patency of drainage was maintained by utilizing a flexible, pediatric, biliary T-tube that is inserted via an above (trephination) and below (endoscopic) approach in three patients, and without the need for stenting in one patient (median follow-up, 14.5 months). The presented surgical strategy is safe and effective in accessing and maintaining long-term patency of problematic supraorbital and superiorly located intraorbital mucoceles without communication to the frontal recess.

The association between supraorbital ethmoid air cells and orbital proptosis in patients with chronic rhinosinusitis

BACKGROUND

Orbital proptosis is a known possible complication in patients with chronic rhinosinusitis (CRS). This study was undertaken to determine the association of sinus anatomy and anatomic variants with the predisposition for such a complication.

METHODS

All adult patients (n = 16) with orbital proptosis were identified from a prospectively-collected database at a tertiary institution. These were compared with a series of randomly-selected patients (n = 50) diagnosed with chronic sinusitis and who had undergone sinus computed tomography. The presence or absence of supraorbital ethmoid air cells (SOECs) was noted and compared between the 2 groups. The primary sinus anatomy responsible for the proptosis was also identified. Statistical analysis was performed using the chi squared test.

RESULTS

Sixteen patients with orbital proptosis were identified, of which all but 1 had SOECs present. Causal analysis showed that in all but 1 case the SOECs were the cause of proptosis. Of the 50 patients with CRS but without proptosis, only 13 had SOECs present and 37 patients did not (chi squared = 22.8, p = 0.000002).

CONCLUSION

SOECs appear to be highly associated with and most often are responsible for orbital proptosis in patients with CRS.

Modified hemi-Lothrop procedure for supraorbital frontal sinus access: a cadaveric feasibility study

OBJECTIVE

The endoscopic modified Lothrop procedure (EMLP) is a relatively safe and efficacious advanced approach to access the frontal sinus for recalcitrant disease. There have been limited data specifically addressing those patients with advanced but unilaterally limited and supraorbitally based frontal sinus disease. In this study, the authors propose a modification of the EMLP technique, titled a modified hemi-Lothrop procedure (MHLP), which would limit the dissection of the EMLP to removal of the frontal sinus floor of the unilaterally diseased frontal sinus, thereby sparing the mucosa and natural drainage pathways of the nondiseased contralateral frontal sinus.

STUDY DESIGN AND SETTING

Cadaveric study at an academic medical center.

METHODS

A cadaveric dissection with photodocumentation was performed to demonstrate the MHLP and to quantify the accessibility of this approach to far-laterally based frontal sinus disease.

RESULTS

The MHLP dissection was shown to provide adequate access to the most distal supraorbital and laterally based aspects of the frontal sinus. Using 3 cadavers, the authors demonstrated and documented the technique of MHLP to access lateral frontal sinus disease from the contralateral nasal cavity via a superior septectomy window.

CONCLUSION

The MHLP was demonstrated to be a feasible approach and alternative to more traditional endoscopic procedures in addressing unilateral frontal sinus disease. This modification may be useful in addressing difficult to access unilateral disease that may otherwise require more extensive resection. This demonstration helps define the accessibility of the lateral frontal sinus via an MHLP and begins to provide estimates of which patients may benefit from this approach.

Indications for the osteoplastic flap in the endoscopic era

PURPOSE OF REVIEW

To review and highlight recent articles on the osteoplastic flap over the last 12 months.

RECENT FINDINGS

Although advances in endoscopic sinus surgery have permitted rhinologists to manage a wide range of frontal sinus disease, recent retrospective studies have examined specific indications for the osteoplastic flap in this endoscopic era. Whether it will be inflammatory, anatomical or sinonasal tumor considerations, the osteoplastic flap remains an important surgical technique when endoscopic approaches are limited.

SUMMARY

The osteoplastic flap will remain an important tool in the armamentarium of the endoscopic surgeon to provide comprehensive management of the frontal sinus.

The prevention and management of complications in ethmoid sinus surgery

Prevention of complications during ethmoid sinus surgery begins with sound knowledge of the relevant anatomy, preoperative planning with use of radiologic imaging, and careful, thoughtful dissection intraoperatively. Despite these measures, however, complications may occur. This article highlights potential complications and treatment techniques to salvage good outcomes following endoscopic ethmoidectomy.

[Paranasal sinuses mucoceles. Our experience in 72 patients]

INTRODUCTION

Traditional treatment for paranasal sinuses mucoceles recommended total removal through external approaches. Since the 90s, endoscopic marsupialization has been proposed as optimal surgical treatment. We present our experience in the treatment of this pathology.

MATERIAL AND METHOD

A retrospective review of 72 patients treated for paranasal sinuses mucoceles between 1980 and 2006 in our ENT department was performed. We describe clinical features, surgical approaches employed and recurrence of disease.

RESULTS

The sample was composed of 72 patients with average follow-up period of 44 months (range 13-214 months). A total of 81 mucoceles were presented, with 44% affecting the frontal sinus or frontoethmoidal cells, followed in frequency by maxillary sinus mucoceles (35%). Twenty-nine percent of the patients did not present predisposing factors; 31% of patients had a history of nasal polyposis, 35% had undergone previous sinus surgery and 14% suffered previous facial fractures; 48 mucoceles patients were treated endoscopically and 33 were treated with external or combined approaches. Recurrence was found in 7 patients, 2 in the endoscopic surgery group and 5 in the external/combined surgery group.

CONCLUSIONS

Endoscopic marsupialization is a safe approach with a low rate of recurrence. The endoscopic approach may be unsuitable for frontal lateral sinus mucoceles or those with significant bone blockage.

Combined endoscopic and minitrephination techniques in the surgical management of frontal sinus type IV cell disease

OBJECTIVE

The aim of the study was to present minimally invasive combined endoscopic and minitrephination techniques in the surgical management of frontal sinus type IV cell disease.

METHODS

Case report of a 44-year-old man with localized pain in the right forehead. Computed tomography of the sinus revealed an opacified expanding type IV cell within the right frontal sinus, draining into the frontal sinus itself. An endoscopic approach through the frontal recess was not successful in reaching this cell. A minitrephination approach was then used and an endoscope was inserted through the trephination hole. Instruments were inserted endoscopically into the right frontal sinus through the frontal recess and then using direct endoscopic visualization through the minitrephination access, the frontal cell was opened and marsupialized.

RESULTS

The patient recovered uneventfully with his localized frontal pain completely resolved 3 years after surgery.

CONCLUSION

The minitrephination approach can be used to introduce an endoscope into the frontal sinus to assist in the surgical management of remote cephalad and lateral lesions within the sinus that are otherwise difficult to reach using endoscopic techniques alone.

Indications for external frontal sinus procedures for inflammatory sinus disease

BACKGROUND

In the modern age of endoscopic sinus surgery (ESS), there is an undefined role for external approaches in the treatment of inflammatory disease. This study examines the frontal sinus surgery practices of three experienced rhinologists with a focus on those who underwent an external approach. Our goal was to characterize these patients and propose indications for the use of an external approach alone or in combination with functional ESS (FESS) for frontal sinus inflammatory disease.

METHODS

A retrospective review was performed of frontal sinus procedures performed for inflammatory disease at one institution from 2004 to 2007.

RESULTS

Seven hundred seventeen procedures were performed, 38 (5.3%) of which were external alone (14 procedures) or in combination with FESS (24 procedures). Osteoplastic flap with obliteration (12/14) made up the majority of external alone procedures and the most common indication was neo-osteogenesis of the frontal recess. Trephination was the most common external adjunct to FESS (12/24), and often was performed for type 3 frontal recess cells or in the initial management of acute frontal bone osteomyelitis (FOM). Twenty-eight of 38 (74%) patients had a history of previous surgery. Of the 10 patients with no history of previous surgery, 6 (60%) had an external adjunct for frontal recess neo-osteogenesis. There were no major complications but 9/38 (23.7%) patients required revision surgery for persistent/recurrent symptoms.

CONCLUSION

External approaches alone and in combination with FESS are predominantly secondary to neo-osteogenesis of the frontal recess. Factors associated with neo-osteogenesis include previous trauma, endoscopic surgery, and FOM. External frontal sinus surgery provides adequate management of inflammatory disease but has a high revision rate.

Computed tomographic and endoscopic analysis of supraorbital ethmoid cells

OBJECTIVES

The aim of this study is to look at the incidence of supraorbital ethmoid cells (SOEC) in normal Chinese subjects by using spiral computed tomography (CT) scanning. In addition, subjects with chronic rhinosinusitis with SOEC were reviewed for endoscopic analysis.

METHODS

A total of 202 normal Chinese subjects underwent spiral CT. Meanwhile, a retrospective review of patients who had undergone endoscopic sinus surgery over a 1-year period was conducted.

RESULTS

SOEC showed an incidence of 5.4% (22 sides), and all of them arose from the anterior ethmoid cells. On coronal CT, an SOEC might give the appearance of multiple frontal sinuses, type III frontal cells, suprabullar cells, frontal bullar cells, interfrontal septal cells, or that there was a septation present within the frontal sinus. Meanwhile, 11 chronic rhinosinusitis patients with 12 SOEC were identified.

CONCLUSION

A thorough knowledge of endoscopic anatomy and CT of the frontal recess and various fronto-ethmoid cells were required for safe dissection of the SOEC and frontal ostium.

Presentation and management of extensive fronto-orbital-ethmoid mucoceles

OBJECTIVES

The aim of the study was to report the presentation and management of extensive fronto-orbital-ethmoid (FOE) mucoceles.

METHODS

This study is a retrospective chart review of 13 consecutive patients requiring surgical intervention for extensive FOE mucoceles. Patients were treated over the period from 1999 to 2003. Variables examined include chief complaint, risk factors, location of erosion, management, and complications. Follow-up ranged from 12 to 36 months.

RESULTS

Most common chief complaint was eye proptosis, followed by forehead swelling and orbital cellulitis. Four patients had previous functional endoscopic sinus surgery (FESS) and another 4 patients had history of prior trauma and frontal sinus obliteration. Eleven patients had skull base erosion and 12 had orbital wall erosion. Four patients were managed endoscopically. Of these, 1 had previously undergone FESS, whereas the other 3 had no risk factors. All patients with prior trauma/obliteration were treated with coronal flap and frontal sinus obliteration. One patient who had undergone 2 previous FESS was successfully treated with coronal flap without obliteration. One patient treated with an osteoplastic flap had cerebrospinal fluid leak that was identified and repaired intraoperatively with a pericranial flap.

CONCLUSION

Extensive FOE mucoceles can be successfully and safely treated by endoscopic and non-endoscopic methods. The choice of surgical approach mainly depends on the anatomy of the frontal recess. Prior trauma and FESS are associated with requiring coronal flap and frontal sinus obliteration.