Frontal sinus mucocele with orbital complications: Management by varied surgical approaches
A 61-year-old female presented to our OPD with chief complaints of right superomedial eye swelling for last 2 years. The swelling was associated with excessive watery discharge and pain in right eye as well as pain in right frontal region. There was no history of diplopia or decreased vision from right eye. There was no history of nasal discharge or nasal obstruction. There was previous history of endoscopic marsupilization of mucocele by a private practitioner 2 months back but it recurred again. On physical examination, there was fluctuant swelling present in superomedial region above the right eye. There was mechanical ptosis due to swelling and the eyeball was pushed inferiorly and laterally. Vision was normal in right eye with full extraocular movements in all directions except in supero-medial direction. Pupillary reaction to light and accomodation were normal. Fundus examination was normal. On anterior rhinoscopy, nose was normal. On contrast-enhanced CT, there was large expansile cystic lesion was found to be present involving right frontal sinus containing hypodense contents with expansion of both anterior and posterior table of frontal sinus []. The swelling had so much eroded the anterior and posterior table of frontal sinus that frontal lobe of brain was in direct contact with the eyeball and it was compressing the eyeball and blocking the sinus ostia []. On MRI, the swelling was isointense on T1 and hyperintense on T2. The swelling was in close contact with both orbit and frontal lobes and was almost adherent to both these structures.\nThe patient was planned for surgery through the combined ENT-neurosurgical approach. A bicoronal flap incision was made and right-sided frontal craniotomy was done. The anterior and posterior wall of frontal sinus was eroded. The mucocele wall was adherent to dura and the supraorbital wall. Mucocele was dissected slowly from dura and orbit. Mucosa was carefully removed up till the frontal recess area. Complete removal of mucocele was ascertained and whole mucosa of the frontal sinus was scrapped out. Brain was seen to be prolapsing down and compressing the orbit. To prevent this, reconstruction of the posterior table of frontal sinus was necessary. A biosynthetic biopore material was placed between the prolapsing brain and the posterior table of frontal sinus []. By doing this, frontal lobe was segregated from the eyeball and hence compression of eyeball got relieved. The frontal sinus was then completely obliterated with fat and fibrin glue. The bone flap was reposited back and the incision was closed in layers. Post-operatively, there was no episode of CSF leak and wound healing was normal. Post-operative CT scan was done which showed resolution of mucocele with biopore forming the posterior table of frontal sinus []. At present, the patient is on regular follow-up for 3 months and is asymptomatic till date.