Mucocele of the frontal sinus: An external approach with frontonasal passage reconstruction.

In 1959, a 43-year-old pregnant woman complained of persistent right frontal headaches, for which she had taken analgesics and antibiotics. On examination, the patient had no focal neurologic deficits. Anterior rhinoscopy showed that the turbinates were hypertrophied. A Caldwell' s view x-ray of the paranasal sinus showed a large soft-tissue mass in the right frontal sinus that extended to the contralateral side (figure, A). The radiologic appearance of this expansive soft-tissue density was consistent with that of a frontal sinus mucocele.

The mucocele was removed from the right frontal sinus via an external approach with a Lynch incision. Its contents were evacuated, and its sac was carefully excised. The mucosa outlining the frontal sinus was not disturbed. The right frontonasal duct was enlarged and cannulated with a stent fashioned from a #3 Jackson metal tracheotomy tube (an inner cannula shortened with a metal saw). The lower end of the stent was transnasally visualized, and its position was adjusted after the anterior end of the middle turbinate was amputated. The metal stent was placed at the right frontonasal duct intraoperatively (figure, B). The stent was removed transnasally 6 weeks later. Postoperatively, the patient was followed closely. She reported that her headaches had resolved, and she had no further sinonasal complaints.

Thirty-eight years after her surgery, the patient returned with a complaint of otalgia. Nasal endoscopy with a 4-mm, O[degrees] telescope revealed a well-healed right nasal cavity (figure, C). The reconstructed frontonasal passage was clearly patent and lined with healthy-appearing mucosa (figure, D). There was an adhesion between the right middle turbinate and the lateral nasal wall, but it did not interfere with sinonasal function. There was no visible scar from the Lynch incision, and there was no frontal numbness.

This long-term followup of 38 years illustrates the successful treatment of a frontal sinus mucocele via an external approach with a Lynch incision. In 1959, the two treatment options for frontal sinus mucocele were an external approach with frontonasal duct reconstruction and an osteoplastic procedure with sinus obliteration with fat. Today, thanks to the advent of functional sinus surgery, intranasal endoscopic removal of such a mucocele is another option. The successful treatment of frontal sinus mucocele via the transnasal endoscopic approach has been well documented. [1]

Computer assistance allows for a more precise anatomic approach to the frontal sinus. When such advanced technology is not available or when the surgeon is less experienced with endoscopic frontal sinus surgery, an external frontal sinusotomy with reconstruction of the frontonasal passage is still a safe and effective method of excising a mucocele (including its sac) of the frontal sinus, as was shown in this case. This procedure is best performed under close endoscopic observation of the frontal recess during reconstruction of the frontonasal passage. [2]

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn., the Section of Otolaryngology, Hospital of St. Raphael, New Haven, and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa); the Memorial Sloan-Kettering Cancer Center, New York City (Dr. Joe); and the Department of Otolaryngology, Columbia University School of Medicine, New York City (Dr. Smith).

References

(1.) Kuhn FA. Surgery of the frontal sinus. In: Kennedy DW, ed. Diseases of the Sinuses. London: B.C. Decker, 2000.

(2.) Bent JP III, Spears RA, Kuhn FA, Stewart SM. Combined endoscopic intranasal and external frontal sinusotomy. Am J Rhinol 1997;11:349-54.