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| CASE REPORT |
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| Year : 2022 | Volume
: 13
| Issue : 3 | Page : 484-487 |
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Frontal sinus stenting: A feasible option for post-traumatic recurrent giant mucocele compromising vision
Smile Kajal, Hitesh Verma
Department of Otorhinolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| Date of Submission | 12-Oct-2021 |
| Date of Acceptance | 28-Feb-2022 |
| Date of Web Publication | 10-Dec-2022 |
Correspondence Address:
Dr. Hitesh Verma
Department of Otorhinolaryngology and Head-Neck Surgery, Room No. 4075, 4th Floor, Academic Block, All India Institute of Medical Sciences (AIIMS), New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njms.njms_476_21
 Abstract | | |
Giant mucocele of frontal sinus following facial trauma is not uncommon. It can lead to the gradual erosion of anterior and posterior bony walls and may extend to the orbital and intracranial structures leading to visual compromise or intracranial complications. A 52-year-old man presented with a history of swelling above the right eye, right eye proptosis, and decreased vision. He had a history of a road traffic accident 30 years ago following which he had lost vision in his left eye and had undergone surgery twice earlier for right frontal mucocele. Computed tomography showed cranialization of the right frontal sinus and a well-defined mass lesion in the region of frontal sinus compressing on the right eye globe. Naso-orbital meningoencephalocele was considered as a differential but magnetic imaging resonance confirmed the lesion as a mucocele. As this was the second recurrence and there was an endangered vision in the only functional eye, he underwent emergency excision of mucocele and recreation of the frontal sinus outflow tract (FSOT) with silastic stenting to maintain its patency. Post-operatively, the patient's vision returned to normal at a 1-week interval. There was a reduction in swelling and proptosis in a 6-month period and the stent was removed after 1 year. Treatment of recurrent frontal sinus mucocele can be challenging. Frontal sinus stenting can be considered in such cases to maintain the patency of FSOT for a prolonged period. Regular follow-up, inspection, and cleaning of the nasal cavity and the stented area are important to prevent any stent-related complications.
Keywords: Frontal sinus, recurrent mucocele, stenting
How to cite this article:
Kajal S, Verma H. Frontal sinus stenting: A feasible option for post-traumatic recurrent giant mucocele compromising vision. Natl J Maxillofac Surg 2022;13:484-7 |
How to cite this URL:
Kajal S, Verma H. Frontal sinus stenting: A feasible option for post-traumatic recurrent giant mucocele compromising vision. Natl J Maxillofac Surg [serial online] 2022 [cited 2023 Jan 27];13:484-7. Available from: https://www.njms.in/text.asp?2022/13/3/484/363077 |
| Introduction | |  |
Mucoceles are benign mucus-containing cysts that originate from a chronic inflammatory process in a closed space due to post-traumatic or surgical scarring, secondary to a benign tumor or fibrous lesion causing an ostial obstruction. They can cause extensive damage due to the expansile nature and bony erosion of surrounding structures. The most common locations are the frontal and ethmoidal sinus.[1],[2],[3] Giant mucoceles of the frontal sinus can lead to the gradual erosion of bony walls and extend to the orbital and intracranial structures leading to visual compromise, meningitis, brain abscess, or cerebrospinal fluid (CSF) fistulas.[4] The most effective treatment is surgery with more inclination towards endoscopic sinus surgery rather than an external approach.[5] But following both endonasal and external approach surgery, up to 30% of patients suffer from post-operative re-stenosis of the frontal sinus outflow tract (FSOT) resulting in recurrent frontal sinus disease.[6] Therefore, frontal sinus stenting has been used to prevent restenosis of FSOT or recurrent frontal sinus disease.[7],[8] We present here a case of post- traumatic recurrent giant frontal mucocele compromising vision which was managed using frontal sinus stenting.
| Case Report | | |
A 52-year-old man presented to our outpatient clinic with a history of a road traffic accident 30 years ago in 1988, following which he had complete loss of vision in the left eye. He underwent a neurosurgical procedure along with surgery for his left eye. He was apparently well till 2002 when he started developing swelling over the right eye and was diagnosed having frontal mucocele on the right side for which he underwent surgery by external approach. The patient did not have medical records for these procedures. He had recurrent right frontal sinus mucocele with orbital and intracranial extension in 2004 for which he underwent re-exploration by external approach and lateral orbitotomy. He then presented to us in 2018 with a history of swelling over the right eye for the last 9 months, right eye proptosis for 2 months, and decreased vision in the right eye for 2 weeks. On local examination, it was found that there was a well-defined, soft, non-pulsatile, non-tender swelling above the supero-lateral part of the right eyeball pushing the eyeball out and down resulting in abaxial proptosis [Figure 1]. | Figure 1: Pre-operative clinical photograph of patient showing a well-defined swelling over right eye
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Computed tomography (CT) showed cranialization of the frontal sinus (post previous surgery) and a well-defined mass lesion compressing on the right eye globe [Figure 2]a. Magnetic Resonance Imaging (MRI) confirmed a well-defined T1 and T2 hyperintense extraconal mass lesion suggestive of mucocele in supero-lateral aspect of the right orbit [Figure 2]b. There was no distinct plane between the mucocele wall and the corresponding dura. Both CT and MRI showed phthisis bulbi in the left eye. | Figure 2: (a) Computed tomography showing a mass lesion compressing the right eye globe (red arrow). (b) Magnetic resonance imaging showing a T2 hyperintense lesion extending into right orbit (red arrow)
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Although the diagnosis of recurrent mucocele was quite evident clinico-radiologically, we kept a remote possibility of traumatic naso-orbital meningoencephalocele as our differential diagnosis. The patient's lesion did not show any dural pulsations and there was no history of recurrent episodes of meningitis, which is usually present in such cases.[9] Therefore, we kept recurrent frontal mucocele as our provisional diagnosis and planned the patient for excision of mucocele under emergency setting as there was an endangered vision in the only functional eye.
Intraoperatively, an extended Lynch Howarth incision was given in view of the far lateral mucocele. The mucocele wall was found to be adherent to the dura mater. Had we proceeded with the excision of mucocele at this stage, the risk of CSF leakage and brain exposure was high. Therefore, we recreated the FSOT first, and then used the silastic tube of Merocel©, which is commonly used for nasal packing, as a stent to maintain its patency. After this, the mucocele cavity was opened and a thick mucoid discharge was aspirated. The sac contents were removed completely, and the tube stent was secured with the nasal septum. The final histopathological examination of the cyst wall showed hyalinized collagen tissue focally lined by stratified squamous epithelium. The cyst contents showed necrotically and degenerated material with giant cell reaction and foamy histiocytes and cholesterol clefts suggestive of mucocele contents.
The patient's vision came back to normal at a 1-week interval. There was a progressive reduction in swelling and proptosis over a 6-months period [Figure 3]. The stent was kept in-situ for 1 year [Figure 4] and then removed. The nasal endoscopy at 1-year after stent removal showed a patent FSOT [Figure 5]. | Figure 3: Postoperative reduction in swelling and proptosis at 6 months interval
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 | Figure 4: Clinical photograph and Non contrast computed tomography showing stent in-situ (red arrow)
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 | Figure 5: The nasal endoscopy at one year follow-up post stent removal showing a patent frontal sinus outflow tract (red arrow). MT: Middle turbinate
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| Discussion | | |
Frontal mucoceles are divided into lateral, intermediate, and medial mucoceles in relation to the sagittal plane of the lamina papyracea. Medial and intermediate mucoceles can be managed with an endoscopic approach but it may not be adequate for lateral mucoceles.[10] A meta-analysis and systematic review on the management of frontal sinus mucoceles showed that results from endoscopic and open approaches were comparable, although endoscopic approaches were being increasingly preferred.[11],[12] Frontal sinus stenting is considered for recurrent lesions, extensive polyposis, FSOT stenosis by scarring or traumatic fracture, or if neo-ostium is less than 5 mm.[7],[13] In our case, there was recurrent frontal sinus mucocele impinging on the eyeball leading to decreased vision in the only functional eye. So, it was important to provide a long-term patent outflow tract by stenting to prevent recurrence and to prevent further visual loss.
Prolonged stenting ranging from 16 months to 32 months has shown that it is well tolerated but requires proper hygiene and regular endoscopic cleansing.[14],[15],[16] Prolonged stenting up to 60 months has also been reported in the literature but it is recommended to remove the stent once stable FSOT patency is achieved because serious complications like superinfection due to biofilm formation, toxic shock syndrome, skull base erosion, and CSF leakage may occur in future. Other relatively minor complications like stent dislodgement, granulation tissue formation, and minor infections can be avoided with regular inspection and cleaning of the nasal cavity and stented area.[17],[18],[19],[20] Our patient was on regular follow-up and did not encounter any complications except nasal crusting which was cleaned on every visit. Recently, drug-eluting stents have also been used in the management of severe frontal sinusitis. These may prolong the in-situ life of the stent and decrease the chances of recurrent frontal sinusitis.[21] No drug was given via stent in our case.
| Conclusion | | |
Recurrent frontal sinus mucoceles are challenging to manage. Frontal sinus stenting can be considered in such cases to maintain the patency of the frontal sinus outflow tract. Regular follow-up, inspection, and cleaning of the nasal cavity and the stented area are important to prevent any stent-related complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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