Keywords: Mucocele; endoscopic sinus surgery; marsupialization

Abstract Top of page Abstract INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION CONCLUSION Bibliography Objectives/Background Traditional teaching has emphasized the need for complete removal of sinus mucoceles to achieve a cure. However, with the introduction of endoscopic sinus surgical instruments and techniques, there has been a trend toward transnasal endoscopic management of sinus mucoceles. The aim of this study is to establish the efficacy of endoscopic management of sinus mucoceles. Study Design Retrospective review. Patients and Methods Between 1988 and 2000, 103 patients with 108 paranasal sinus mucoceles were treated endoscopically. This series includes 66 frontal and frontoethmoid, 17 ethmoid, 7 sphenoethmoid, 12 sphenoid, and 6 maxillary mucoceles. Ninety patients (83.3%) had intraorbital extension and 85 of them presented with some degree of proptosis or eye displacement. Sixty patients (55.5%) had erosion of the skull base with varying degrees of intracranial extension of the mucocele. Follow- up ranged from 1 to 131/2 years with a median of 4.6 years. Intervention All patients underwent endoscopic-wide marsupialization of the mucocele cavity. Stents were used in frontal mucoceles only. Results Recurrence of a frontal mucocele was seen in 1 patient (0.9%). In 5 patients, out of 23 patients who presented with massive pansinus polyposis in addition to the mucocele, recurrent polyposis required revision surgery. However, the mucoceles did not recur in those patients. Conclusions There is increasing evidence in the literature that endoscopic management of sinus mucoceles results in long-term control with recurrence rates at or close to 0%. Rhinologic surgeons should consider the endoscopic technique as the surgical treatment of choice.

INTRODUCTION Top of page Abstract INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION CONCLUSION

Bibliography Traditional teaching in the United States has emphasized the need for complete removal of the sinus mucocele lining to achieve a cure. However, in recent years there has been a trend toward transnasal endoscopic management of paranasal sinus mucoceles. Advances in endoscopic sinus techniques and instrumentation, as well as the introduction of intraoperative imaging and navigation systems, have made the endoscopic approach increasingly popular, with almost no morbidity. 115

PATIENTS AND METHODS Top of page Abstract INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION CONCLUSION Bibliography Between 1988 and 2000, 103 patients with 108 paranasal sinus mucoceles were treated endoscopically. The author performed all procedures in 1 of 3 major academic medical centers. Patients with follow-up of less than 12 months and patients who were lost to follow-up before 3 years have passed from the time of surgery were excluded from the study. (It should be noted that only 2 patients were lost to follow-up.) Follow-up included physical examination with office endoscopy. Computed tomography scans were obtained if symptoms recurred or if office endoscopy revealed recurrent polyposis. Surgical Technique The details of the surgical technique of endoscopic marsupialization have been described previously by this and other authors. 6,7 In brief, for maxillary mucoceles, we perform either wide middle meatal antrostomy or endoscopic partial medial maxillectomy. Since 1997, we prefer endoscopic partial medial maxillectomy, which includes a wide middle meatal antrostomy, and resection of the posterior two thirds of the inferior turbinate with the adjacent lateral nasal wall. The nasolacrimal system is preserved with this technique. The mucocele cavity is irrigated but the inferior, superior, lateral, and posterior linings are not removed. For ethmoid and sphenoethmoid mucoceles, we perform a wide intranasal marsupialization with complete removal of the anterior, inferior, and medial aspects of the mucocele. The orbital, superior, and posterior linings are left undisturbed. For sphenoid mucoceles, we use one of two techniques. If there is ethmoid sinusitis, we perform complete ethmoidectomy first, and then remove the anterior and inferior aspects of the sphenoid mucocele, thus marsupializing the cavity to the ethmoid, nasal, and nasopharyngeal spaces. For isolated sphenoid mucocele with normal ethmoid cells, we approach the sphenoid sinus through the superior meatus, remove the superior turbinate, and then remove the anterior and inferior walls of the mucocele. Only limited posterior ethmoidectomy is performed in the superior meatus. Thus, the mucocele cavity is marsupialized into the nasal, nasopharyngeal, and posterior ethmoid spaces. For frontal sinus mucoceles, we perform wide frontal sinusotomy, which may include removal of anterior ethmoid cells and agger nasi cells as well as the middle turbinate. A minimum of Draf type 2 procedures is done. However, the majority of large

mucoceles were managed with a modified Lothrop procedure with wide bilateral frontal sinusotomy, which includes removal of the superior part of the nasal septum. Extreme care is taken to avoid removal of any orbital bony wall. All linings related to the brain, posterior sinus wall, and orbit are left undisturbed. For a large bilateral opening (modified Lothrop), stenting is usually not required. For a smaller unilateral marsupialization, we usually stent the cavity with a soft endotracheal tube which is sutured to the nasal septum. Irrigation and gentle suctioning may be performed through the tube. The stent is usually removed in 8 to 12 weeks. Intraoperative imaging is usually not required for maxillary, ethmoid, or sphenoethmoid mucoceles. We use an intraoperative C-arm image intensifier for frontal (especially small and/or laterally situated) and sphenoid mucoceles.

RESULTS Top of page Abstract INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION CONCLUSION Bibliography There were 54 males and 49 females in this series, ranging in age from 5 to 83 years. Three patients had 2 separate mucoceles each and 1 patient had 3 separate mucoceles. The total number of 108 mucoceles includes 66 frontal and frontoethmoid, 17 ethmoid, 7 sphenoethmoid, 12 sphenoid, and 6 maxillary mucoceles. Ninety patients (83.3%) had intraorbital extension and 85 of them presented with some degree of noticeable proptosis or eye displacement. Sixty patients (55.5%) had erosion of the skull base with varying degrees of extracranial extension of the mucocele. Thirty-one of them had major intracranial extension in which the intracranial extent was larger than the sinus component. Follow-up periods ranged from the minimum of 12 months to 131/2 years with a median of 4.6 years. Recurrence of a frontal mucocele was seen in 1 patient only (0.9%). This was a laterally situated small mucocele with a narrow frontal outflow tract sandwiched between the orbit and the skull base. Its size and configuration did not allow wide marsupialization. It was subsequently managed successfully with an open procedure and obliteration. We had one case of a major complication. During endoscopic marsupialization of a gigantic frontoethmoid mucocele, cerebrospinal fluid leak was noted intraoperatively. Interestingly, it was not coming from an area of intracranial extension of the mucocele, but from injury to a thin bony wall in the cribriform region. It was immediately repaired with a mucosal graft and a middle turbinate flap. The patient was placed on bed rest and was discharged 6 days later with no sequelae. It is now 6 years after surgery and he has no evidence of recurrent cerebrospinal fluid leak or recurrent mucocele formation. Twenty-three patients had massive pansinus infection and polyp disease in addition to the mucocele. Five of these patients required revision endoscopic sinus surgery for recurrent polyps and infections. However, the mucoceles did not recur in any of these patients.

DISCUSSION Top of page Abstract INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION CONCLUSION Bibliography Intranasal marsupialization of mucoceles was reported as early as 1921 by Horwath 16 who stated that By removing the floor of the mucocele, one practically makes the mucocele part of the roof of the nose.16(p. 745) Since then, simple drainage and marsupialization of mucoceles has been performed by some rhinologists with good longterm results. 17,18 However, traditional teaching in the United States has emphasized the need for complete removal of the mucocele lining to achieve a cure. In the frontal sinus, subsequent obliteration of the sinus cavity has also been advocated. With the introduction of endoscopic techniques and instrumentation, there has been a trend in North America toward transnasal endoscopic management of sinus mucoceles. For us to accept the endoscopic approach as a viable alternative, we must consider the epidemiologic, histologic, physiological, and clinical aspects of this treatment approach and its results. Epidemiology Our series of patients with mucoceles, which is the largest available in the English literature, adds to the increasing number of publications advocating endoscopic management of mucoceles. 115 All studies show successful results with recurrence rates at or close to 0%. However, it should be emphasized that long follow-up time is required for mucoceles. Therefore, the results of these studies, including the present one, may not be final. Histology Inherent in the concept of marsupialization of mucoceles is the ability of the sinus mucosa to return to normal or near-normal epithelium. Studies by Lund et al. 19 have shown that the mucocele lining does not lose the histologic characteristics of respiratory mucosa. In fact, in some cases, an almost normal respiratory mucosa can be seen lining the mucocele cavity. Takasaka et al., 20 in a study that included electron microscopic investigation, demonstrated that almost half of the patients with frontal and ethmoid mucoceles had evidence of a ciliated pseudostratified columnar epithelium. In a previous publication, 8 we documented that histologic studies of a frontal mucocele lining 6 months after marsupialization show areas of normal ciliated respiratory epithelium. Clinical/Morphologic Aspects An 80-year-old woman presented with a large frontal mucocele causing a significant cosmetic deformity of the forehead (Fig. 1). She underwent a modified Lothrop procedure with creation of a large communication between the mucocele cavity and the nose. A large stent was placed and removed after 8 weeks. The patient reported complete resolution of her headache, pressure, and eye complaints. However, as expected, the cosmetic deformity did not change immediately after surgery. While considering a bone-

contouring procedure through a bicoronal incision to reduce the bulging forehead, we have noticed spontaneous regression. In 6 months, the bulge was about half its original size. In 12 months, the patient had complete spontaneous resolution and a normalappearing forehead (Fig. 2). Figure Fig. 1.. A large frontal mucocele. (A) Axial computed tomography scan. (B) Coronal magnetic resonance image.

Figure Fig. 2.. (A) Preoperative photograph. (B) Six months postoperatively. (C) Twelve months postoperatively.

Physiology In a previous study, we examined the ciliary transport mechanism in a large maxillary mucocele 21/2 years after its marsupialization. 8 We have shown that despite the fact that the mucocele was treated with middle meatal antrostomy only, which is a nondependent opening, the mucocele lining had the ability to transport dye toward the ostium. Many surgeons use intraoperative computerized navigation systems for management of mucoceles. It provides them with added confidence. It is usually not required for maxillary, ethmoid, and sphenoethmoid mucoceles. For small or laterally situated frontal mucoceles, we prefer a C-arm image intensifier, which provides us with real-time information on bone removal. Like in other sinus and skull base procedures, we look forward to the incorporation of real-time, intraoperative magnetic resonance, or computed tomography scanning in the management of mucoceles.

CONCLUSION Top of page Abstract INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION CONCLUSION Bibliography There is increasing epidemiologic, clinical, histologic, and physiological evidence in the literature that endoscopic management of sinus mucoceles is successful, with low morbidity rates and with recurrence rates at or close to 0%. Rhinologic surgeons should

consider the endoscopic technique as the surgical procedure of choice for management of paranasal sinus mucoceles.

Bibliography Top of page Abstract INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION CONCLUSION Bibliography 1 Kennedy DW, Josephson JS, Zinreich SJ, et al. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 1989; 99: 885895. Direct Link: Abstract PDF(1176K) References 2 Moriyama H, Hesaka H, Tachibana T, et al. Mucoceles of ethmoid and sphenoid sinus with visual disturbances. Arch Otolaryngol Head Neck Surg 1992; 118: 142146. PubMed, ChemPort, Web of Science Times Cited: 39 3 Lund VJ. Endoscopic management of paranasal sinus mucoceles. J Laryngol Otol 1998; 112: 3640. PubMed, ChemPort, Web of Science Times Cited: 38 4 Ikeda K, Takahashi C, Oshima T, et al. Endonasal endoscopic marsupialization of paranasal sinus mucoceles. Am J Rhinol 2000; 14: 107111. CrossRef, PubMed, ChemPort, Web of Science Times Cited: 22 5 Schaefer ST, Close LG. Endoscopic management of frontal sinus disease. Laryngoscope 1990; 100: 155160. Direct Link:

Abstract PDF(561K) References 6 Har-El G, Balwally AN, Lucente FE. Sinus mucoceles: is marsupialization enough? Otolaryngol Head Neck Surg 1997; 117: 633640. CrossRef, PubMed, ChemPort, Web of Science Times Cited: 21 7 Har-El G. Transnasal endoscopic management of frontal mucoceles. Otolaryngol Clin North Am 2001; 34: 243251. CrossRef, PubMed, ChemPort, Web of Science Times Cited: 14 8 Har-El G, Dimaio T. Histologic and physiologic studies of marsupialized sinus mucoceles. J Otolaryngol 2000; 29: 195198. PubMed, ChemPort, Web of Science Times Cited: 5 9 Hoffer ME, Kennedy DW. The endoscopic management of sinus mucoceles following orbital decompression. Am J Rhinol 1994; 8: 6165. CrossRef, Web of Science Times Cited: 8 10 Beasley NJP, Jones NS. Paranasal sinus mucoceles: modern management. Am J Rhinol 1995; 9: 251256. CrossRef, Web of Science Times Cited: 10 11 Makeieff M, Gardiner Q, Mondain M, Crompette L. Maxillary sinus mucoceles10 cases8 treated endoscopically. Rhinology 1998; 36: 192195. PubMed, ChemPort 12

Busaba NY, Salman SD. Maxillary sinus mucoceles: clinical presentation and long-term results of endoscopic surgical treatment. Laryngoscope 1999; 109: 14461449. Direct Link: Abstract Full Article (HTML) PDF(482K) References 13 Hartley BEJ, Lund VJ. Endoscopic drainage of pediatric paranasal sinus mucoceles. Int J Pediatr Otorhinolaryngol 1999; 50: 109111. CrossRef, PubMed, ChemPort, Web of Science Times Cited: 11 14 Hurley DB, Javer R, Kuhn FA, Citardi MJ. The endoscopic management of chronic frontal sinusitis associated with frontal sinus posterior table erosion. Am J Rhinol 2000; 14: 113120. CrossRef, PubMed, ChemPort, Web of Science Times Cited: 6 15 Stankiewicz JA. Sphenoid sinus mucocele. Arch Otolaryngol Head Neck Surg 1989; 115: 735740. PubMed, ChemPort, Web of Science Times Cited: 28 16 Horwath WG. Mucocele and pyocele of nasal accessory sinuses. Lancet 1921; 2: 744 746. CrossRef 17 Goodyear HM. Mucocele in frontal and ethmoid sinuses. Simplified surgical treatment. Ann Otol Rhinol Laryngol 1944; 53: 242245. 18 Wolfwitz BL, Solomon A. Mucoceles of the frontal and ethmoid sinuses. J Laryngol Otol 1972; 86: 7982. PubMed 19

Lund VJ. Fronto-ethmoidal mucoceles: a histopathological analysis. J Laryngol Otol 1991; 105: 921923. CrossRef, PubMed, ChemPort, Web of Science Times Cited: 42 20 Takasaka T, Onodera A, Sato M, et al. Electron microscopic studies of the postoperative maxillary cyst. Journal of the Otolaryngological Society of Australia 1979; 4: 331334. Get PDF (321K)

Home > September 2005 - Volume 16 - Issue 5 > Giant Mucocele of the Frontal Sinus

< Previous Article | Next Article > Text sizing: A A A Journal of Craniofacial Surgery: September 2005 - Volume 16 - Issue 5 - pp 933-935 doi: 10.1097/01.scs.0000168999.20258.ca Special Section: Giant Congenital Nevus

Giant Mucocele of the Frontal Sinus

Gali, Manlio MD, DMD, PhD; Mandrioli, Stefano MD; Tieghi, Riccardo MD; Clauser, Luigi MD, DMD, PhD
Free Access Article Outline Author Information Department of Cranio Maxillo Facial Surgery, St. Anna Hospital, Ferrara, Italy. Ferrara, Italy Address correspondence to Dr. Luigi Clauser, MD Department of Cranio-Maxillo-Facial Surgery, Corso Giovecca, 203, 44100 Ferrara, Italy; E-mail: csr@unife.it.

Abstract Giant mucocele of the frontal sinus is a rare pathology of benign entity caused by retention of mucous secretions in the sinus. It may expand and erode the surrounding structures such as bones and cerebral parenchyma. The authors describe a patient with frontal giant mucocele involving the orbit, the ethmoid, and intracranial portion of the dura. The main presenting symptoms were diplopia and proptosis. A computed tomography scan and magnetic resonance imaging were performed to permit differential diagnosis from other pathologies such as ossifying fibroma, fibrous dysplasia, and other neoplasms. A single stage maxillofacial and neurosurgical approach to treatment was taken consisting in the removal of the mucocele and reconstruction of the eroded bones with cranial bone grafts. The dura was repaired with temporalis muscle fascia sealed with fibrin glue. Two years after surgery, the patient shows no recurrence and satisfactory morphologic and functional results. Mucoceles of the frontal sinus are relatively uncommon lesions of benign entity that

occur with approximately equal frequencies in adult males and females, with the highest incidence in the third and fourth decades. They are uncommon in pediatric subjects.1,2 Mucoceles are slow growing and locally aggressive lesions that occur as a result of accumulation and retention of mucous secretions in the sinus caused by the loss of draining properties of the mucous epithelium of the sinus.2-6 The fluid content progressively obliterates the sinus, and the pressure so generated leads to gradual erosion and distortion of the anterior and posterior bone walls.7-10 The lesion may extend to the orbital and intracranial structures and lead to meningitis, brain abscess, or cerebrospinal fluid (CSF) fistulas.9,11,12 Because of the proximity of mucoceles to the brain, progress in volume may cause morbidity and potential mortality.13 The etiology may be multifactorial: trauma, allergy, inflammation, anatomic abnormality, previous surgery, osteoma, fibrous dysplasia, or ossifying fibroma.2-4,9,6 The main symptoms of orbital involvement are pain, swelling, exophthalmos, diplopia, and loss of vision. Proptosis is usually the main complaint. Oculomotor nerve palsy with ptosis is rare, but it can be seen in patients with frontal mucocele.14 Diagnosis is based on a clinical investigation conducted with the aid of computed tomography (CT) scans and magnetic resonance imaging (MRI). The CT scan is the main diagnostic assessment tool used for determining regional anatomy and extent of the lesion, in particular the intracranial expansion and the scope of bone erosion.7 MRI is helpful in making a definitive diagnosis because gadolinium enhancement on MRI differentiates mucoceles from neoplasms.15 Surgery is the only effective treatment and may range from functional endoscopic sinus surgery to craniotomy and craniofacial exposure with or without obliteration of the sinus.13,16-22 Back to Top | Article Outline CASE REPORT A 72-year-old man presenting with a large right frontal lesion that caused proptosis and diplopia was referred to the Department of Cranio-Maxillo-Facial Surgery of St. Anna University Hospital. The mass had slowly grown over the course of 2 years, restraining the globe downward and causing limitations in ocular movements (Fig 1). It was not painful and CSF leak was noted. CT and MRI scan showed a lesion arising from the right frontal sinus with erosion of the anterior and posterior walls, orbital roof, and ethmoid with intracranial extension and dura involvement (Fig 2).

Fig 1 Fig 2 Image ToolsImage Tools A combined one-stage maxillofacial-neurosurgical approach was then performed. Intravenous antibiotics were administrated perioperatively and continued until the fifth postoperative day. Coronal incision with subperiosteal dissection and right fronto-orbital craniotomy was carried out. The mucocele consisted of mucopurulent fluid, and the ostium of the sinus was blocked by secretions. The anterior and posterior walls, the orbital roof, the ethmoid, and intracranial portion of the dura were eroded. The sinus mucosa was completely removed, and the sinus and nasofrontal duct were obliterated with pericranial galeal flap, fibrin glue, and temporal muscle patch. The bony repair was carried out with bone grafts harvested from calvaria. The bone grafts were fixed to the residual frontal walls by microplates. Finally, the dura was repaired with temporalis muscle fascia sealed with fibrin glue. The postoperative phase was normal, and all preoperative signs and symptoms resolved after surgery. A CT scan performed at 6 months postoperatively showed no evidence of recurrence or resorption of bone grafts. Two years after surgery, the result is satisfactory both morphologically and functionally (Fig 3).

Fig 3 Image Tools Back to Top | Article Outline DISCUSSION Frontal sinus mucoceles represent a relatively rare, slow-growing pathology, usually clinically silent, caused by the loss of drainage properties of the mucosa of the sinus. They can involve the orbit, the anterior cranial fossa, and intracranial content. Some authors23,24 describe the role of cytokines as osteolytic factors involved in the disruption of the surrounding structures.

Patients with extensive cranio-orbital mucoceles with intracranial involvement require major surgery with restoration of the normal cranio-orbital anatomy and function. The surgical procedure should be performed in one stage through a coronal subperiosteal approach with craniotomy and wide exposure of the fronto-orbito-ethmoid region. Management of the frontal sinus should be followed by cranialization and accurate removal of the mucosa, obliteration of the nasofrontal duct with vascularized pericranialgaleal flap and temporal muscle, and immediate dura repair. Reconstruction of the missing bones can be achieved by using cranial bone. Endoscopic sinus surgery should be the treatment of choice for noninvasive frontal mucocele. Back to Top | Article Outline REFERENCES 1. Iqbal J, Kanaan I, Ahmed M, al Homsi M. Neurosurgical aspects of sphenoid sinus mucocele. Br J Neurosurg 1998;12:527-530 Cited Here... | PubMed | CrossRef 2. Diaz F, Latchow R, Duvall AJ III, Quick CA, Erickson DL. Mucoceles with intracranial and extracranial extensions. Report of two cases. J Neurosurg 1978;48:284288 Cited Here... | PubMed | CrossRef 3. Lunardi P, Missori P, Di Lorenzo N, Fortuna A. Giant intracranial mucocele secondary to osteoma of the frontal sinuses: Report of two cases and review of the literature. Surg Neurol 1993;39:46-48 Cited Here... | PubMed | CrossRef 4. Nakajima Y, Yoshimine T, Ogawa M, Takanashi M, Nakamuta K, Maruno M, Hasegawa H. A giant intracranial mucocele associated with an orbitoethmoidal osteoma. Case report. J Neurosurg 2000;92:697-701 Cited Here... | PubMed | CrossRef 5. Iannetti G, Cascone P, Valentini V, Agrillo A. Paranasal sinus mucocele: diagnosis and treatment. J Craniofac Surg 1997;8:391-398 Cited Here... | View Full Text | PubMed | CrossRef 6. Doyle CS, Simeone FA. Mucocele of the sphenoid sinus with bilateral internal carotid artery occlusion. Case report. J Neurosurg 1972;36:351-354 Cited Here... | PubMed | CrossRef 7. Perugini S, Pasquini U, Menichelli F, Salvolini U, de Nicola M, Valazzi CM, Benedetti S. Mucoceles of the paransal sinuses involving the orbit. Neuroradiology 1982;23:133-139 Cited Here... | PubMed

8. Perie S, Sequert C, Cabanes J, Visot A, Krastinova D, Derome P, Chabolle F. Frontal mucoceles of orbital or cerebral extension: therapeutic strategy. Ann Otolaryngol Chir Cervicofac 1996;113:384-391 Cited Here... | PubMed 9. Delfini R, Missori P, Iannetti G, Ciappetta P, Cantore G. Mucoceles of the paranasal sinuses with intracranial and intraorbital extension: report of 28 cases. Neurosurgery 1993;32:901-906 Cited Here... | View Full Text | PubMed | CrossRef 10. Hashim AS, Asakura T, Awa H, Yamashita K, Takasaki K, Yuhi F. Giant mucocele of paranasal sinuses. Surg Neurol 1985;23:69-74 Cited Here... | PubMed | CrossRef 11. Voegels RL, Balbani AP, Santos RC, Butigan O. Frontoethmoidal extension of intracranial mucocele: A case report. Ear Nose Throat J 1998;77:117-120 Cited Here... | PubMed 12. Nakayama T. Giant pyocele in the anterior intracranial fossa-case report. Neurol Med Chir 1998;38:499-502 Cited Here... 13. Weitzel EK, Hollier LH, Calzada G, Manolidis S. Single stage management of complex fronto-orbital mucoceles. J Craniofac Surg 2002;13:739-745 Cited Here... | View Full Text | PubMed | CrossRef 14. Lin CJ, Kao CH, Kang BH, Wang HW. Frontal sinus presenting as oculomotor nerve palsy. Otolaryngol Head Neck Surg 2002;126:588-590 Cited Here... | PubMed | CrossRef 15. Lanzieri CF, Shah M, Krauss D, Lavertu P. Use of gadolinium-enhanced MR imaging for differentiating mucoceles from neoplasm in the paranasal sinuses. Radiology 1991;178:425-428 Cited Here... | PubMed 16. Chiarini L, Nocini PF, Bedogni A, Consolo A, Gianetti L, Merli GA. Intracranial spread of a giant frontal mucocele: case report. Brit J Oral Maxillofac Surg 2000;38:637640 Cited Here... 17. Kennedy DW, Senior BA. Endoscopic sinus surgery. A review. Otolaryngol Clin North Am 1997;30:313-330 Cited Here... | PubMed 18. Benninger MS, Marks S. The endoscopic management of sphenoid and ethmoidal

mucoceles with orbital and intranasal extension. Rhinology 1995;33:157-161 Cited Here... | PubMed 19. Bordley JE, Bosley WR. Mucoceles of the frontal sinus: Causes and treatment. Ann Otol Rhinol Laryngol 1973;82:696-702 Cited Here... | PubMed 20. Rinehart GC, Jackson IT, Potparic Z, Tan RG, Chambers PA. Management of locally aggressive sinus disease using craniofacial exposure and the galeal frontalis facia-muscle flap. Plast Reconstr Surg 1993;92:1219-1225 Cited Here... | PubMed 21. Costantinidis J, Steinhart H, Schwerdtfeger K, Zenk J, Iro H. Therapy of invasive mucoceles of the frontal sinus. Rhinology 2001;39:33-38 Cited Here... | PubMed 22. Stiernberg CM, Bailey BJ, Calhoun KH, Quinn FB. Management of invasive frontoethmoidal sinus mucoceles. Arch Otolaryngol Head Neck Surg 1986;112:1060-1063 Cited Here... | PubMed 23 Lund VJ, Henderson B, Song Y. Involvement of cytokines and vascular adhesion receptors in the pathology of fronto-ethmoidal mucoceles. Acta Otolaryngol Stockh 1993;113:540-546 Cited Here... 24. Sharma GD, Doershuck CF, Stern RC. Erosion of the wall of the frontal sinus caused by mucopyocele in cystic fibrosis. J Pediatr 1994;124:745-747 Cited Here... | PubMed | CrossRef Cited By: This article has been cited 3 time(s). Singapore Medical Journal Frontal mucocoele secondary to nasal polyposis: an unusual complication Chew, YK; Noorizan, Y; Khir, A; Brito-Mutunayagam, S; Prepageran, N Singapore Medical Journal, 50(): E374-E375. Archives of Neurology Diplopia due to frontal sinus mucocele Lockman, J; Login, IS Archives of Neurology, 64(): 1667-1668. Veterinary Radiology & Ultrasound Imaging Diagnosis: Intracranial Mucocele in A Dog Sessums, KB; Lane, SB

Veterinary Radiology & Ultrasound, 49(6): 564-566. 10.1111/j.1740-8261.2008.00434.x CrossRef Back to Top | Article Outline Keywords: Giant mucocele; frontal sinus; bone grafting; craniofacial surgery