Abstract
Frontal sinus has complex anatomy and is the most difficult sinus to dissect under the nasal endoscope. In case of difficult accessibility through the frontal recess, we can make a detour to more invasive and external procedures to treat chronic or intractable frontal sinus diseases. However, these approaches usually need advanced surgical skills and sometimes can result in minor and/or major complications. Therefore, we developed a new surgical technique to treat frontal mucocele in a patient with severe new bone formation at the frontal recess and presented our experiences with literature review.
1
Introduction
Two factors are generally considered important in the decision of how to treat frontal mucoceles: the patency of the ipsilateral frontal sinus outflow tract and the accessibility of the mucocele via endoscope. When these 2 factors do not allow for either a frontal sinusotomy or an above and below approach, it is usually advisable to use a more invasive or external approach, such as an endoscopic modified Lothrop procedure (EMLP) or osteoplastic flap surgery with or without obliteration. However, when the contralateral frontal recess is patent, the frontal mucocele can be drained through the intersinus septum. The following case report illustrates a novel technique to the treatment of a frontal mucocele in a patient with obstructed frontal recess due to severe new bone formation and an old blowout fracture.
2
Case report
A 67-year-old man presented to our clinic with left orbital pain and frontal headache. About 4 years ago, he was diagnosed with chronic rhinosinusitis with nasal polyposis and underwent endoscopic sinus surgery at a tertiary care center. However, he did not perceive any symptomatic improvement after surgery and postoperative medical treatment. Other rhinologic symptoms such as rhinorrhea and nasal obstruction were minimal. On ophthalmic examination, there were no abnormal findings in visual acuity and eyeball movements.
Nasal endoscopic examination detected synechia formation between the middle turbinate and lateral nasal wall without polyposis. Computed tomography (CT) showed a left frontal mucocele, severe new bone formation at the frontal recess, and an old blowout fracture with orbital herniation into the ethmoid cavity ( Fig. 1 ). On the right side, the frontal sinus was well aerated, and the previously dissected frontal recess seemed to be patent.
Endoscopic sinus surgery was undertaken under general anesthesia. First, the middle meatus and frontal recess were dissected on both sides, but we could not dissect the left frontal recess because of severe new bone formation. Synechia between the middle turbinate and lateral nasal wall was removed, and frontal recess was successfully dissected on the right side. After that, we made a trephination into the anterior wall of the left frontal sinus in the inferior-medial brow region, and serous discharge was expelled out. Endoscopic findings through the trephination showed minimal mucosal disease of the frontal sinus and obstruction of the frontal ostium; therefore, we made another trephination in the right frontal sinus, and performed a frontal septotomy by using a curved curette and curved debrider. During the frontal septotomy, an endoscope was introduced into the right trephination, and surgical instruments were introduced into the left trephination. To achieve more reliable patency of the perforation made at the intersinus septum, we applied a mitomycin C (1 mL, 0.6 mg)–soaked cotton ball for 5 minutes.
Most of the headache and left orbital pain resolved by the first postoperative day, and then he was discharged. By 5 months postoperatively, CT showed well-aerated frontal sinuses and a patent frontal septotomy ( Fig. 2 ). At the 1-year follow-up examination, there was no evidence of recurrence of frontal mucocele, and he did not feel any headaches or orbital pain.
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