of frontoethmoidal mucocele with intracranial extension
Dr. T. Balasubramanian M.S. D.L.O.
68 year old female patient reported to ENT out patient
1. C/O swelling left side of forehead - 2 years
2. Headache on and off - 2 years
3. Swelling over left eye - 1 1/2 years
Pic showing a patient with frontal mucocele with proptosis
The preoperative picture shows the patient having
swelling over her left forehead with the left eye pushed downwards and
Vision normal in both eyes
CT scan of the patient clearly showed the swelling
over left frontal sinus with erosion of the outer and inner
tables. The mass is also seen to extend into the frontal lobe of
CT scan of the patient
The clinical diagnosis was frontal mucocele with
This patient underwent endoscopic decompression of the
mucocele through the nasal cavity.
The major advantages of endoscopic approach are
1. The procedure has minimal risk
2. There is no scar
3. Intranasal drainage path can be created
4. Minimal complications
Using a 4mm 0° nasal endoscope the surgery was
performed. The complete surgery was performed under general
anesthesia. On deroofing the agger nasi cell the contents of the
mucocele started to extrude. The frontal sinus ostium was
widened. When the scope was introduced through the widened
frontal ostium the posterior table of the frontal sinus was found to be
eroded. The frontal lobe of the brain was clearly visible.
The brain can be identified by its characteristic pulsations coinciding
with the patient's respiration.
Large agger nasi cell shown
Incision being made in the agger nasi area
Contents of mucocele seen extruding
Endoscopic view of brain tissue
Post op picture of the patient
A mucocele is an epithelium
lined mucous containing sac. It usually develops when the sinus
ostium gets obstructed by chronic sinusitis, polyps or tumors.
These mucoceles are known to erode the bone and may involve the brain
and orbit. It may also present as a forehead mass with proptosis
as in this patient.
of Frontal mucocele:
mucoceles have been classified into 5 types depending on its extent.
I: In this type the mucocele is limited to the frontal sinus only with
or without orbital extension.
II: Here the mucocele is found involving the frontal and ethmoidal
sinuses with or without orbital extension.
IIIa: In this type the mucocele erodes the posterior wall of the
frontal sinus with minimal or no intracranial involvement.
IIIb: In this type the mucocele erodes the posterior wall with major
intra cranial extension.
IV: In this type the mucocele erodes the anterior wall of the frontal
Va: In this type there is erosion of both anterior and posterior walls
of frontal sinus without or minimal intracranial extension.
Vb: In this type there is erosion of both anterior and posterior walls
of frontal sinus with a major intracranial extension.
Among mucoceles affecting the
various paranasal sinuses frontal mucoceles are the most common
(65%). Before the advent of CT scan x-ray paranasal sinuses
was the only diagnostic tool available. X-ray would usually
reveal the loss of normal haustrations found in the frontal
sinus. Infact it was even considered pathognomonic.