Laterally positioned mucocele of the frontal sinus. (Rhinoscopic Clinic).

A 47-year-old white man sought treatment for a right frontal headache of approximately 1 year's duration. The patient also noticed that the position of his right eye had changed so that he appeared to be looking down on that side. He had no fever or chills. His medical history was noncontributory, and he had neither undergone surgery nor experienced trauma in the maxillofacial area.

Physical examination confirmed the downward displacement of his right eye. His visual acuity was intact, and no diplopia was elicited. Sensation was intact along all areas of the trigeminal nerve. Intranasal examination demonstrated a septal deviation to the right. Radiographic examination, including a Caldwell view of the frontal sinus, revealed the presence of a cystic mass in the middle to lateral portion of the sinus, which appeared to be consistent with a mucocele (figure, A). An x-ray template was made to outline the frontal sinus and the cyst (figure, A).

The patient was taken to the operating room for removal of the mass. A horizontal incision was made along the superior aspect of his right eyebrow. A mini-osteoplastic inferiorly based flap was then made with a Stryker saw to allow access to the frontal sinus and exposure of the lesion (figure, B). The size of the bony incision was determined by the template markings. The mass was carefully removed in its entirety. Closure was performed with a reapproximation of the bony flap, periosteum, and skin. On gross inspection, the mass was soft, encapsulated, and approximately 3 x 2 x 2cm in size (figure, C). Its contents were brownish, tenacious, and gelatinous. The mass had indented, but not eroded, the floor of the sinus. The remainder of the sinus mucosa was normal and was saved intact.

Of all the paranasal sinuses, the frontal sinus is the most common site of mucoceles. They occur with approximately equal frequency in males and females. The most common symptoms are proptosis and headache. The headache can be located in the frontal, periorbital, facial, retro-orbital, and nasal areas.

Traditional teaching in the United States has emphasized that the lining of a sinus mucocele must be completely removed in order to achieve a cure.' Historically, surgical treatments involved an external approach, osteoplastic procedures, and sinus obliteration. However, these procedures caused relatively high morbidity and significant cosmetic deformity, and they made the sinus difficult to radiograph after obliteration. Recently, mucocele drainage by endoscopic techniques has been advocated in the belief that preservation of the frontal sinus mucosa and maintenance of the nasofrontal recess and internal frontal ostium produce better overall outcomes. (2) Endoscopic approaches have greatly reduced morbidity and have produced excellent functional results. However, because of its narrow outflow tract and anterosuperior location, the frontal sinus is the most challenging of the four paranasal sinuses to treat endoscopically. As a result, some surgeons are hesitant to use endoscopic approaches to laterally based mucoceles. (2)

The case described here took place in 1959, before endoscopic surgery became available. The frontal cyst was based laterally, and its contents were thick and tenacious. (3) The cyst did not protrude into the frontal recess. The mini-osteoplastic frontal sinusotomy provided direct access and wide exposure to the lesion. Even today, in the endoscopic surgery era, we believe that an endoscopic approach would be technically difficult and unsafe in such a case.

Postoperatively, the patient did experience some numbness over his frontal area, but it improved over time. He was followed closely, and after 3 years, he had a good cosmetic result and exhibited no evidence of recurrence (figure, D).

The mini-osteoplastic frontal sinusotomy with excision of a cyst and sinus mucosal preservation is a useful procedure for a laterally positioned mucocele of the frontal sinus.

References

(1.) Har-El G. Transnasal endoscopic management of frontal mucoceles. Otolaryngol Clin North Am 2001;34:243-51.

(2.) Kuhn FA, Javer AR. Primary endoscopic management of the frontal sinus. Otolaryngol Clin North Am 2001;34:59-75.

(3.) Batsakis JG. Tumors of the Head and Neck. Clinical and Pathological Considerations. 2nd ed. Baltimore: Williams and Wilkins, 1979.

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven (Dr. Yanagisawa), the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa and Dr. Scher), and the Section of Otolaryngology, Hospital of St. Raphael, New Haven (Dr. Yanagisawa).