Frontal mucocele presenting as a subcutaneous tumour on the forehead

Isolated extra-sinus subcutaneous mucocele: A case report

INTRODUCTION

Paranasal sinus mucoceles are epithelialized cystic masses formed through the accumulation of sterile mucus. Mucoceles are expansile lesions, and their symptoms change according to their extension into the surrounding structures: anteriorly to the subcutaneous tissue, laterally to the orbit, or posteriorly to the cranium. Herein, we report the case of a pediatric patient with an isolated subcutaneous mucocele with no sinus connection.

PRESENTATION OF CASE

Physical examination revealed a non-tender fluctuating round mass approximately 4 cm in diameter in the right supraorbital region. Computed tomography and magnetic resonance imaging findings suggested a mucocele, and the diagnosis was confirmed via histopathological examinations postoperatively. The patient underwent a combined surgical approach that included an endoscopic transseptal approach to the frontal sinus with a right sub-brow incision and drain placement. The right frontal sinus was opened, and the mucocele was marsupialized. At the 3-month follow-up visit, the frontal sinus neo-ostium appeared patent on endoscopic examination, and the frontal sinuses were clear on imaging.

DISCUSSION

The optimal treatment for frontal mucoceles is marsupialization and adequate sinus drainage. As the patient had an isolated subcutaneous extra-sinus mucocele above the orbit, a combined approach was used to ensure thorough removal of the lesion to reduce the recurrence rate.

CONCLUSION

This report emphasizes the importance of using a combined approach for the removal of lesions and limiting the potential risk of recurrence in similar cases.

Association between the insertion type of the uncinate process and the development of Frontal Sinus Mucoceles - is there a relationship?

BACKGROUND

The frontal sinus drainage pathway is formed by either the ethmoid infundibulum or the middle meatus, which depends on the superior insertion of the uncinate process. According to Landsberg & Friedman the are 6 types of superior uncinate process insertion. The aim of this study is to find an association between the uncinate process insertion type and the development of frontal sinus mucoceles.

METHODS

Fifty sinus CT scans were analysed. Exclusion criteria were previous nasal surgeries, malignancy, polyposis and an insufficient image quality. Superior insertions of the uncinate process were analysed according to the Landsberg & Friedman classification. The results were tabulated and analysed using SPSS 25.0.

RESULTS

The analysis revealed type 1 insertion in 6% of the CT scans, type 2 in 32%, type 3 in 26%, type 4 in 0%, type 5 in 28% and type 6 in 8%. Despite 44% of the CT scans with frontal sinus mucocele showing a type 2 insertion of the uncinate process, both the Chi-Square test and the Cramer's V test showed no statistical significance (p>.05). Logistic regression also showed that uncinate process insertion type does not influence the likelihood of development of frontal sinuses mucoceles.

CONCLUSIONS

The insertion of the uncinate process does not influence the development of frontal sinus mucoceles.

Outcomes in Surgical Treatment of Mucocele in Frontal Sinus

The aim of the study was to correlate several studies dating from 1997 to 2015 to identify the most effective treatments for mucocele in the frontal sinus (with/without other paranasal sinuses), considering successful outcomes and recurrence. We aimed to conduct a literature review for articles published between 1997 and 2015. For this, we accessed articles in the SciELO database, as well as LILACS, PubMed, and Google Scholar databases. Were identified 32 work-related injuries in the paranasal sinuses; 2 of these were not related to mucoceles or mucopyocele, 4 had no relation to the frontal sinus, 9 were related to the frontal sinus and other paranasal sinuses, 4 were related to mucocele associated with other sinuses, and 13 involved only the frontal sinus. Endoscopic techniques decrease intra- and postoperative morbidity, reducing the operative time, allow a larger view of the lesion and surrounding anatomical structures, and decrease chances of recurrence. Thus, the successful outcomes have been beneficial to both the surgeon and the patient.

Frontoethmoidal Mucoceles: CT and MRI Evaluation

Paranasal sinus mucocele is an expanded, airless, mucus-filled sinus caused by obstruction of the sinus ostium. It is a benign slow growing epithelial lined lesion, bulging against adjacent anatomical structures, without infiltrating them. The purpose of our study is to describe the CT and MR findings in 19 patients (ten women, nine men, 18–72 years, mean age: 48.1) with surgically confirmed frontoethmoidal mucoceles between 1999–2005. CT scans displayed mucoceles as non enhancing soft tissue density lesions, generally isodense to the brain parenchyma, expanding the sinuses in most cases, eroding adjacent bones and extending intraorbitally or intracranially. Signal intensity in T2WI and T1WI MR images varied, but generally lesions had high signal intensity in T2WI and low to intermediate signal intensity in T1WI. Some of the lesions demonstrated regular linear peripheral enhancement after administration of contrast medium. The causes of mucoceles included mucosal thickening from chronic sinusitis, adhesions from previous operation in the nasal cavity, previous trauma, small nasal polyps and a small osteoma, while in six patients (31.5%) the cause of the mucocele remained unrecognized even after surgery. No underlying malignant tumor was found in any of the cases as the cause of obstruction. CT and MRI established the correct diagnosis in all patients. CT was more sensitive in determining bone erosions, while MRI had the advantage of multiplanar imaging and was much more sensitive for differentiating mucocele from a tumor on the basis of MR signal intensity characteristics. In conclusion, CT and MRI are the methods of choice for diagnosing mucoceles of the paranasal sinuses and are of major importance for the treatment plan. Each method seems to have its own advantages and should be used as complementary investigations of sinonasal pathology. Enhanced CT scan should only be performed in the absence or contraindication for enhanced MR imaging.

Giant frontal mucocele complicated by subdural empyema: treatment of a rare association

Giant frontal mucocele (GFM) is an extremely rare cause of frontal lobe syndrome. Subdural empyema (SDE) is an uncommon complication of paranasal sinisutis, for which craniotomy and decompressive craniotomy are the most effective surgical procedures. A 54-year-old man was brought unconscious to the emergency room where recurrent generalized seizures occurred. Heroine abuse, HCV-related hepatitis, prolonged antibiotic therapy for treatment of purulent rhinorrhea, along with recent personality changes were reported. High white blood cell count, pansinusitis, GFM, SDE and cerebritis were documented. The patient underwent bifrontal craniotomy in emergency, extensive drilling of the inner aspect of the frontal bone, surgical toilet of the enlarged frontal sinus and its "cranialization". Prevotella intermedia and Fusobacterium nucleatum were isolated and antibiotic therapy was started intravenously and then continued orally for 3 months. 2 years later the patient has recovered, though minor signs of frontal lobe syndrome persist. To the authors knowledge, this is the first case of GFM with SDE reported in the literature. Although decompressive craniectomy is advocated in extreme conditions, as in this case, "internal decompressive craniectomy", obtained with craniotomy and cranialization of the frontal sinuses, is strongly advocated in cases of SDE associated with megasinuses.

Pediatric frontal mucocele secondary to a bifid frontal sinus septum

A mucocele is a mucus-containing sac lined with epithelium that arises within a sinus when its drainage is compromised. The frontal sinus is the most common location, with frontal mucocele development occurring when the nasofrontal duct becomes obstructed because of polyps, bone tumors, prior surgery, sinusitis, trauma, or anatomic variation. We report an unusual case of a sterile pediatric frontal mucocele presenting as a slowly enlarging forehead mass due to a bifid frontal sinus septum. A 9-year-old girl presented to the craniofacial clinic for evaluation of a right frontal mass that had been slowly growing over the past year. She was otherwise healthy and had no history of previous trauma or sinus infections. Computed tomography (CT) scan results revealed a localized frontal fluid collection with protrusion and thinning of the anterior frontal bone between 2 midline bony septii. Surgical cranialization of the frontal sinus was performed. The anatomy of her lesion seen both on CT scan and intraoperatively likely explains this unusual case presentation. Instead of the usual inciting event of an intact frontal sinus drainage system becoming blocked, this patient seemed to have a primary developmental lack of any drainage system that led to her mucocele. During formation of her frontal sinus, she developed a bifid septum within the midline that excluded a portion of her frontal sinus from the lateral nasofrontal ducts. With mucus-producing epithelium trapped within these bony confines, pressure began to mount with expansion and thinning of the bone both anteriorly and posteriorly. The lack of any infectious symptoms and sterile culture results may support that this space developed primarily and was never in continuity with the external drainage system. Only 4 other patients have been reported with asymptomatic forehead swelling as the only presenting symptom, with the age ranging from 33 to 79 years. This patient represents the first clinical report of a congenital developmental mucocele.

[Giant mucoceles: neurosurgical view. Report of two cases]

Two patients harboring giant frontal mucoceles are reported. In both cases complaints of chronic headaches and progressive unilateral proptosis were preponderant. Surgical treatment included a frontal craniotomy with excision of the lesion, skull base reinforcement with pedicled galea and wide opening of the frontal sinuses. In the second case an intranasal endoscopic approach was combined with craniotomy at the same surgical operative time. Some aspects regarding etiology, association with other diseases and some surgical aspects are discussed.