- Email: [email protected]
or orbital erosion: Is the endoscopic approach sufficient?
Otolaryngology–Head and Neck Surgery (2008) 139, 570-574
ORIGINAL RESEARCH—SINONASAL DISORDERS
Paranasal sinus mucoceles with skull-base and/or orbital erosion: Is the endoscopic approach sufficient? Nathan B. Sautter, MD, Martin J. Citardi, MD, Julian Perry, MD, and Pete S. Batra, MD, Portland, OR; Houston, TX; and Cleveland, OH OBJECTIVE: The objective of this study was to review the management of paranasal sinus mucoceles with skull-base and/or orbital erosion in the endoscopic era. STUDY DESIGN: A retrospective data analysis. METHODS: A chart review was performed on 57 patients treated from January 2001 to March 2007. RESULTS: The average age at the time of presentation was 50.6 years with a 1:1 male: female ratio. The most common site was the frontal sinus (54.4%), followed by frontoethmoid (29.8%) and sphenoid (8.8%). Areas of erosion included skull base (40.4%), orbit (50.9%), and both orbit and skull base (8.8%). Endoscopic drainage using image guidance was used in all 57 patients without complications. Fifty-six cases (98.2%) had a functionally patent mucocele opening with a median follow-up of 15 months. CONCLUSIONS: The endoscopic approach can be safely used for the management of mucoceles with skull-base and/or orbital erosion. Open adjunct approaches can be avoided in most cases. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
with frontal sinus obliteration (FSO) being recommended for frontal sinus mucoceles.4 In 1989, Kennedy et al5 described successful endoscopic marsupialization of paranasal sinus mucoceles with a mean follow-up of 17.4 months. Other studies have attested to the efficacy of the endoscopic approach.1,6-8 Despite these data, a recent study by Bockmuhl et al9 reported that only 69.3 percent of 290 mucoceles were managed endoscopically, with 18.6 percent being managed via OPF. Herndon et al10 performed FSO in 9 of 13 (69%) patients with extensive fronto-orbital-ethmoid mucoceles. The purpose of this study was to evaluate the management of 57 paranasal sinus mucoceles with skull-base and/or orbital erosion; specifically, the report aimed to assess the utility of the purely endoscopic approach for successful treatment of this entity.
MATERIALS AND METHODS
P
aranasal sinus mucoceles are benign expansile lesions with potential for adjacent bony remodeling and resorption.1,2 Mucoceles with orbital and/or skull-base erosion pose a unique surgical challenge given the proximity to critical structures. Untreated mucoceles may result in serious orbital and intracranial complications, including gaze restriction, proptosis, visual loss, cerebrospinal fluid (CSF) leak, and secondary mass effect on the brain. Infection may result in suppurative complications, with risk of orbital cellulitis, meningitis, and brain abscess. Timely surgical intervention has been advocated for the optimal management of this entity. Although successful marsupialization of paranasal sinus mucoceles was described as early as 1921 by Howarth,3 the literature has engendered considerable controversy on the best surgical approach to these lesions. Traditional teaching has advocated complete removal of the mucocele cavity lining via an external approach, with osteoplastic flap (OPF)
The study was a retrospective analysis of all adult patients presenting to the Cleveland Clinic Head and Neck Institute between January 2001 and March 2007 with a diagnosis of paranasal sinus mucoceles with skull-base and/or orbital erosion as documented by radiographic criteria (CT scan and/or MRI). The study was approved by the Cleveland Clinic Institutional Review Board. A total of 58 patients met the aforementioned criteria. One patient with multiple comorbidities refused surgery and was excluded from the analysis. The remaining 57 patients formed the basis of this report. Patient charts were reviewed for age, sex, presenting symptoms, duration of symptoms, comorbidities, and previous sinonasal procedures. The primary site of origin of the mucocele was determined. The management strategy, associated complications, and clinical outcome as defined by subjective symptom improvement and objective endoscopic patency of mucocele opening were ascertained at the time of last follow-up. Pre- and
Received April 12, 2008; revised June 24, 2008; accepted July 1, 2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2008.07.004
Sautter et al
Paranasal sinus mucoceles with skull-base . . .
Table 1 Associated comorbities Comorbidity Chronic rhinosinusitis Trauma Sinonasal polyposis Cystic fibrosis Wegener’s granulomatosis Osteoma
No. of patients (%) 21 10 8 2 1 1
(37) (18) (14) (4) (2) (2)
postoperative ophthalmologic records were reviewed to assess for objective change in the ocular findings.
RESULTS Fifty-seven patients were included in this analysis. The mean patient age was 50.6 years with a male:female ratio of 1:1. The mean symptom duration at the time of initial presentation to our institution was 21.9 months. Headache was the most common presenting symptom in 18 patients (31.6%), followed by proptosis and/or periorbital swelling in 16 patients (28.1%), visual changes in 11 patients (19.3%), nasal obstruction in 5 patients (8.8%), and CSF rhinorrhea in 2 patients (3.5%). Five patients (8.8%) had incidental detection of mucocele via imaging studies for other indications and were asymptomatic at presentation. Twenty-two patients (38.6%) had a history of previous sinonasal surgery. Eleven patients had undergone previous
571
FSO. Four patients underwent prior craniotomies for intracranial pathology and subsequently developed frontal sinus mucoceles. Associated comorbidities are listed in Table 1. The most common site of involvement was the frontal sinus in 33 cases (Fig 1A and B) (54.4%), followed by the frontoethmoid region in 17 cases (29.8%), sphenoid sinus in 5 cases (8.8%), ethmoid sinus in 3 cases (Fig 2A-C) (5.3%), and maxillary sinus in 1 case (1.8%). Mucoceles were unilateral in 51 patients (89.5%) and bilateral in 6 patients (10.5%). Data on sites of erosion of adjacent skull base and/or orbit are reported in Table 2. Endoscopic drainage using image guidance was successfully used in all 57 patients without any peri- or postoperative complications. Two patients (3.5%) required drillout procedures, including endoscopic trans-septal frontal sinusotomy (1) and endoscopic modified Lothrop (EML) (1). Adjunct open approaches were used in four cases (7.0%), including endoscopic frontal trephination (3) and OPF without obliteration (1). Skull-base reconstruction was not required in mucoceles with skull-base erosion; no cerebrospinal fluid (CSF) leaks occurred in these patients during the study period. Two patients had active CSF leaks at initial presentation. A 58-year-old woman had a right frontal sinus mucocele from a previous neurosurgical procedure and a concomitant right sphenoid spontaneous CSF leak that were managed successfully endoscopically. A 71-year-old woman presented with a history of iatrogenic sphenoid CSF leak with two outside attempts at repair. Patient underwent endoscopic repair of the leak and had drainage of an adjacent sphenoid mucocele likely resulting from previous surgical manipulations.
Figure 1 A 78-year-old man presented with acute onset left frontal headaches. (A) An axial CT scan shows left frontal mucocele with complete erosion of the posterior table of the frontal sinus. (B) Endoscopic view shows functionally patent frontal opening after endoscopic drainage at 6 months.
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Otolaryngology–Head and Neck Surgery, Vol 139, No 4, October 2008
Figure 2 A 70-year-old woman with previous endoscopic sinus surgery presented with a 2-month history of decreasing left visual acuity. (A) A coronal CT scan shows left sphenoethmoid cell mucocele with bony erosion over the optic nerve. (B) T1-weighted MRI with gadolinium enhancement shows central hypodensity with peripheral enhancement suggestive of mucocele formation. (C) An endoscopic view of healed left sphenoethmoid cell with mucosal covering over the optic nerve.
Seventeen (29.8%) patients required revision endoscopic procedures. The indications for revision surgery included restenosis (9), recurrent sinonasal polyposis (6), osteoma resection (1), and retained lateral frontal compartment mucocele (1). The recurrences were detected based on the combination of symptom relapse and serial endoscopic surveillance. Subjective symptom relief for primary presenting symptomatology was achieved in all 57 cases. Pre- and postoperative ophthalmologic records were available in 18 patients. Orbital swelling and/or proptosis was present in 12
cases (21.1%), diplopia and/or gaze restriction was present in 3 cases (5.3%), and elevated intraocular pressures were present in 3 patients (5.3%). All orbital findings resolved or improved after surgery. Functional patency of the mucocele opening as documented by office endoscopy was evident in 56 cases (98.2%) at a median follow-up of 15 months (60, 0.5). One patient with a sphenoid mucocele with skull-base erosion in the setting of Wegener’s granulomatosis developed complete stenosis of the mucocele opening. Repeat MRI did not show signal changes suggestive of mucocele reformation;
Sautter et al
Paranasal sinus mucoceles with skull-base . . .
Table 2 Patterns of skull-base and orbital erosion Site of erosion Orbit Superior orbit Medial orbit Optic nerve Skull base Posterior table FS Sphenoid roof Anterior table FS Orbit and skull base Total
No. of patients (%)
No. of patients (%) 29 (51)
18 (32) 10 (18) 1 (2) 23 (40) 24 (42) 4 (7) 1 (2) 5 (9) 57 (100)
she has been observed by serial clinical examinations without any sequelae.
DISCUSSION The evolution of the endoscopic techniques has resulted in a shift of the surgical paradigm for the management of mucoceles. In 1989, Kennedy et al5 described the successful utility of the endoscopic approach in 15 of 18 patients (83.3%) with a mean follow-up of 17.4 months. Subsequent series have also successfully reported on endoscopic marsupialization of mucoceles.1,6-8 Har-El6 reported on the endoscopic management of 108 mucoceles in 103 patients; a recurrence rate of 0.9 percent was reported with a median follow-up of 4.6 years. Khong et al8 reported on 24 mucoceles in 15 patients with orbital extension by radiographic criteria. Endoscopic marsupialization was achieved in all patients with revision endoscopic surgery being required in four patients (27%) for frontal stenosis and mucocele reformation. The data in the current series are commensurate with these previous studies. Mucoceles with skull-base and/or orbital erosion were successfully managed via the endoscopic approach without untoward complications. A recurrence rate of 1.8 percent was noted, with all 57 patients having subjective improvement of the primary presenting symptomatology. Revision endoscopic procedures were required in 17 patients (29.8%) in this series. This is similar to the 27 percent and 25 percent revision rates reported by Khong et al2 and Hurley et al,8 respectively. Nine of these patients required revision endoscopic procedures for restenosis to maintain a safe patent mucocele cavity. Eight of these nine patients (89%) had undergone previous surgery, including FSO (four), craniofacial resection (two), and endoscopic sinus surgery (two). Thus, patients with previous sinus surgery, especially open frontal and skull-base procedures, may be at greater risk of restenosis from previous iatrogenic trauma. Six patients required additional surgery for the
573
recurrence of sinonasal polyposis, despite aggressive medical therapy with culture-directed antibiotics, systemic and topical steroids, and antileukotriene modifiers in the postoperative period. Mucocele reaccumulation was not noted at the time of revision surgery in this subset. Continued, ongoing medical therapy is an absolute requisite in these patients to prevent mucocele reformation. Despite the success of the endoscopic approach, OPF for frontal sinus mucoceles has been reported in two recent series. Bockmuhl et al9 managed 290 mucoceles in 255 patients; OPF with or without concomitant endoscopic approach was used in 68 cases. Herndon et al10 used the OPF with FSO in 9 of 13 (69%) patients with extensive fronto-orbital-ethmoid mucoceles; the endoscopic approach was only used in 4 patients. The utility of the OPF in this setting should not be taken lightly, and the significant morbidity of OPF must be considered in the decision-making process. In a report of 250 cases, Hardy and Montgomery11 reported a 19 percent complication rate, including 13 abdominal wound infections and 7 CSF leaks. The inability to completely remove mucosa from the adjacent dura or orbital periosteum makes FSO even more problematic and should be viewed as a relative contraindication to the management of mucoceles with orbital or skull-base erosion. Adjunct open approaches were required in four patients in this series. Combined endoscopic frontal sinusotomy and endoscopic frontal trephination were required in three cases. The “above and below” approach served to provide an additional porthole to remove frontal sinus partitions that could not be addressed with conventional frontal instrumentation. One patient with previous FSO with multiple frontal loculations required repeat OPF for exploration of the frontal sinus. Successful obliteration reversal was achieved with a 50-month follow-up. Endoscopic drillout procedures were required in two cases in this series. In both patients, significant osteoneogenesis precluded standard endoscopic frontal sinusotomy. Khong et al7 reported on the efficacy of endoscopic sinus surgery for paranasal sinus mucoceles; 21 of 28 patients (75%) required endoscopic modified Lothrop. The two main indications for drillout procedures in their study were significant bony separation between the mucocele and the adjacent sinus and loss of lateral support of the frontal sinus with risk of medial wall collapse of the orbital contents obstructing drainage.7 Drillout procedures result in significant mucosal trauma and lead to prolonged healing and slow return of mucociliary clearance. They should be used as a last resort, being reserved for patients with significant newbone formation.12 Several important advantages are afforded by the endoscopic approach. Facial incisions are avoided resulting in superior cosmesis. Overall complications and associated morbidity are reduced compared with the documented rates of OPF and other open approaches. Lund and Milroy13 have shown that the mucocele remnant retains respiratory epithelium with normal mucociliary clearance after marsupialization; thus, normal sinonasal physiologic function is preserved.
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Otolaryngology–Head and Neck Surgery, Vol 139, No 4, October 2008
This surgical strategy also facilitates postoperative endoscopic and radiographic surveillance. Indeed, serial endoscopy at regular intervals should be considered mandatory in these patients in the postoperative period. All cases of mucocele restenosis in this series were detected on routine endoscopic examination, allowing for elective, timely surgical intervention without untoward complications. The advent of balloon catheter dilatation of the paranasal sinus ostia may further enhance management of these patients.14 Balloon catheters without fluoroscopy may be used in the office setting for dilatation of the stenotic mucocele outflow tract with topical anesthesia.15 This strategy could avoid additional trips to the operating room for repeat surgery.
CONCLUSION Endoscopic marsupialization of paranasal sinus mucoceles is a safe and viable surgical strategy for lesions with skullbase and/or orbital erosion. This was accomplished in 57 cases with minimal morbidity and low recurrence rate. Adjunctive open approaches, like endoscopic frontal trephination and OPF, may be sparingly required in patients with multiseptate mucoceles or those involving the far lateral aspect of the frontal sinus. Regardless of the surgical approach, close follow-up with office endoscopy and radiographic imaging, when clinically indicated, is an absolute requisite.
AUTHOR INFORMATION From the Oregon Sinus Center, Oregon Health and Sciences University, Portland, OR (Dr Sautter); Department of Otorhinolaryngology–Head and Neck Surgery, University of Texas Medical School at Houston, Houston, TX (Dr Citardi); Division of Oculoplastics, Cole Eye Institute, Cleveland, OH (Dr Perry); and Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH (Dr Batra). Corresponding authors: Pete S. Batra, MD, Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A71, Cleveland, OH 44195. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Nathan B. Sautter, writer, study designer; Martin J. Citardi, design, writing, revision, consultant; Julian Perry, revision, consultant; Pete S. Batra, design, writing, revision, consultant.
FINANCIAL DISCLOSURES Pete S. Batra, GlaxoSmithKline: Speaker’s Bureau, Xoran Technologies: Research grant; Martin J. Citardi, GE Healthcare Navigation & Visualization: consultant, Medtronic ENT: consultant, Naryx: consultant, Quest Medical: consultant, Arthrocare: research grant.
REFERENCES 1. Serrano E, Klossek JM, Percodani J, et al. Surgical management of paranasal sinus mucoceles: a long-term study of 60 cases. Otolaryngol Head Neck Surg 2004;131:133– 40. 2. Hurley DB, Javer AR, Kuhn FA, et al. The endoscopic management of chronic frontal sinusitis associated with frontal sinus posterior table erosion. Am J Rhinol 2000;14:113–20. 3. Howarth WG. Mucocele and pyocele of the nasal accessory sinuses. Lancet 1921;2:744 – 6. 4. Goodale RL, Montgomery WW. Experiences with the osteoplastic anterior wall approach to the frontal sinus. Arch Otolaryngol 1958;68: 271– 83. 5. Kennedy DW, Josephson JS, Zinreich SJ, et al. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 1989;99: 885–95. 6. Har-El G. Endoscopic management of 108 sinus mucoceles. Laryngoscope 2001;111:2131– 4. 7. Khong JJ, Malhotra R, Selva D, et al. Efficacy of endoscopic sinus surgery for paranasal sinus mucocele including modified endoscopic Lothrop procedure for frontal sinus mucocele. J Laryngol Otol 2004; 118:353– 6. 8. Khong JJ, Malhotra R, Wormald PJ, et al. Endoscopic sinus surgery for paranasal sinus mucocele with orbital involvement. Eye 2004;18: 877– 81. 9. Bockmuhl U, Kratzsch B, Benda K. Surgery for paranasal sinus mucoceles: efficacy of endonasal micro-endoscopic management and long-term results of 185 patients. Rhinology 2006;44:62–7. 10. Herndon M, McMains KC, Kountakis SE. Presentation and management of extensive front-orbital-ethmoid mucoceles. Am J Otolarygol 2007;28:145–7. 11. Hardy JM, Montgomery WW. Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol 1976;85: 523–32. 12. Batra PS, Cannady SB, Lanza DC. Surgical outcomes of drillout procedures for complex frontal sinus pathology. Laryngoscope 2007; 117:927–31. 13. Lund VJ, Milroy CM. Fronto-ethmoidal mucoceles: a histopathological analysis. J Laryngol Otol 1991;105:921–3. 14. Citardi MJ, Kanowitz SJ. A cadaveric model for balloon-assisted endoscopic paranasal sinus dissection without fluoroscopy. Am J Rhinol 2007;21:579 – 83. 15. Luong A, Batra PS, Fakhri S, Citardi MJ. Balloon catheter dilatation for frontal sinus ostium stenosis in the office setting. ARS spring meeting COSM. Orlando, FL. May 1–2, 2008. Am J Rhinol (in press).
ORIGINAL RESEARCH—SINONASAL DISORDERS
Paranasal sinus mucoceles with skull-base and/or orbital erosion: Is the endoscopic approach sufficient? Nathan B. Sautter, MD, Martin J. Citardi, MD, Julian Perry, MD, and Pete S. Batra, MD, Portland, OR; Houston, TX; and Cleveland, OH OBJECTIVE: The objective of this study was to review the management of paranasal sinus mucoceles with skull-base and/or orbital erosion in the endoscopic era. STUDY DESIGN: A retrospective data analysis. METHODS: A chart review was performed on 57 patients treated from January 2001 to March 2007. RESULTS: The average age at the time of presentation was 50.6 years with a 1:1 male: female ratio. The most common site was the frontal sinus (54.4%), followed by frontoethmoid (29.8%) and sphenoid (8.8%). Areas of erosion included skull base (40.4%), orbit (50.9%), and both orbit and skull base (8.8%). Endoscopic drainage using image guidance was used in all 57 patients without complications. Fifty-six cases (98.2%) had a functionally patent mucocele opening with a median follow-up of 15 months. CONCLUSIONS: The endoscopic approach can be safely used for the management of mucoceles with skull-base and/or orbital erosion. Open adjunct approaches can be avoided in most cases. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
with frontal sinus obliteration (FSO) being recommended for frontal sinus mucoceles.4 In 1989, Kennedy et al5 described successful endoscopic marsupialization of paranasal sinus mucoceles with a mean follow-up of 17.4 months. Other studies have attested to the efficacy of the endoscopic approach.1,6-8 Despite these data, a recent study by Bockmuhl et al9 reported that only 69.3 percent of 290 mucoceles were managed endoscopically, with 18.6 percent being managed via OPF. Herndon et al10 performed FSO in 9 of 13 (69%) patients with extensive fronto-orbital-ethmoid mucoceles. The purpose of this study was to evaluate the management of 57 paranasal sinus mucoceles with skull-base and/or orbital erosion; specifically, the report aimed to assess the utility of the purely endoscopic approach for successful treatment of this entity.
MATERIALS AND METHODS
P
aranasal sinus mucoceles are benign expansile lesions with potential for adjacent bony remodeling and resorption.1,2 Mucoceles with orbital and/or skull-base erosion pose a unique surgical challenge given the proximity to critical structures. Untreated mucoceles may result in serious orbital and intracranial complications, including gaze restriction, proptosis, visual loss, cerebrospinal fluid (CSF) leak, and secondary mass effect on the brain. Infection may result in suppurative complications, with risk of orbital cellulitis, meningitis, and brain abscess. Timely surgical intervention has been advocated for the optimal management of this entity. Although successful marsupialization of paranasal sinus mucoceles was described as early as 1921 by Howarth,3 the literature has engendered considerable controversy on the best surgical approach to these lesions. Traditional teaching has advocated complete removal of the mucocele cavity lining via an external approach, with osteoplastic flap (OPF)
The study was a retrospective analysis of all adult patients presenting to the Cleveland Clinic Head and Neck Institute between January 2001 and March 2007 with a diagnosis of paranasal sinus mucoceles with skull-base and/or orbital erosion as documented by radiographic criteria (CT scan and/or MRI). The study was approved by the Cleveland Clinic Institutional Review Board. A total of 58 patients met the aforementioned criteria. One patient with multiple comorbidities refused surgery and was excluded from the analysis. The remaining 57 patients formed the basis of this report. Patient charts were reviewed for age, sex, presenting symptoms, duration of symptoms, comorbidities, and previous sinonasal procedures. The primary site of origin of the mucocele was determined. The management strategy, associated complications, and clinical outcome as defined by subjective symptom improvement and objective endoscopic patency of mucocele opening were ascertained at the time of last follow-up. Pre- and
Received April 12, 2008; revised June 24, 2008; accepted July 1, 2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2008.07.004
Sautter et al
Paranasal sinus mucoceles with skull-base . . .
Table 1 Associated comorbities Comorbidity Chronic rhinosinusitis Trauma Sinonasal polyposis Cystic fibrosis Wegener’s granulomatosis Osteoma
No. of patients (%) 21 10 8 2 1 1
(37) (18) (14) (4) (2) (2)
postoperative ophthalmologic records were reviewed to assess for objective change in the ocular findings.
RESULTS Fifty-seven patients were included in this analysis. The mean patient age was 50.6 years with a male:female ratio of 1:1. The mean symptom duration at the time of initial presentation to our institution was 21.9 months. Headache was the most common presenting symptom in 18 patients (31.6%), followed by proptosis and/or periorbital swelling in 16 patients (28.1%), visual changes in 11 patients (19.3%), nasal obstruction in 5 patients (8.8%), and CSF rhinorrhea in 2 patients (3.5%). Five patients (8.8%) had incidental detection of mucocele via imaging studies for other indications and were asymptomatic at presentation. Twenty-two patients (38.6%) had a history of previous sinonasal surgery. Eleven patients had undergone previous
571
FSO. Four patients underwent prior craniotomies for intracranial pathology and subsequently developed frontal sinus mucoceles. Associated comorbidities are listed in Table 1. The most common site of involvement was the frontal sinus in 33 cases (Fig 1A and B) (54.4%), followed by the frontoethmoid region in 17 cases (29.8%), sphenoid sinus in 5 cases (8.8%), ethmoid sinus in 3 cases (Fig 2A-C) (5.3%), and maxillary sinus in 1 case (1.8%). Mucoceles were unilateral in 51 patients (89.5%) and bilateral in 6 patients (10.5%). Data on sites of erosion of adjacent skull base and/or orbit are reported in Table 2. Endoscopic drainage using image guidance was successfully used in all 57 patients without any peri- or postoperative complications. Two patients (3.5%) required drillout procedures, including endoscopic trans-septal frontal sinusotomy (1) and endoscopic modified Lothrop (EML) (1). Adjunct open approaches were used in four cases (7.0%), including endoscopic frontal trephination (3) and OPF without obliteration (1). Skull-base reconstruction was not required in mucoceles with skull-base erosion; no cerebrospinal fluid (CSF) leaks occurred in these patients during the study period. Two patients had active CSF leaks at initial presentation. A 58-year-old woman had a right frontal sinus mucocele from a previous neurosurgical procedure and a concomitant right sphenoid spontaneous CSF leak that were managed successfully endoscopically. A 71-year-old woman presented with a history of iatrogenic sphenoid CSF leak with two outside attempts at repair. Patient underwent endoscopic repair of the leak and had drainage of an adjacent sphenoid mucocele likely resulting from previous surgical manipulations.
Figure 1 A 78-year-old man presented with acute onset left frontal headaches. (A) An axial CT scan shows left frontal mucocele with complete erosion of the posterior table of the frontal sinus. (B) Endoscopic view shows functionally patent frontal opening after endoscopic drainage at 6 months.
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Otolaryngology–Head and Neck Surgery, Vol 139, No 4, October 2008
Figure 2 A 70-year-old woman with previous endoscopic sinus surgery presented with a 2-month history of decreasing left visual acuity. (A) A coronal CT scan shows left sphenoethmoid cell mucocele with bony erosion over the optic nerve. (B) T1-weighted MRI with gadolinium enhancement shows central hypodensity with peripheral enhancement suggestive of mucocele formation. (C) An endoscopic view of healed left sphenoethmoid cell with mucosal covering over the optic nerve.
Seventeen (29.8%) patients required revision endoscopic procedures. The indications for revision surgery included restenosis (9), recurrent sinonasal polyposis (6), osteoma resection (1), and retained lateral frontal compartment mucocele (1). The recurrences were detected based on the combination of symptom relapse and serial endoscopic surveillance. Subjective symptom relief for primary presenting symptomatology was achieved in all 57 cases. Pre- and postoperative ophthalmologic records were available in 18 patients. Orbital swelling and/or proptosis was present in 12
cases (21.1%), diplopia and/or gaze restriction was present in 3 cases (5.3%), and elevated intraocular pressures were present in 3 patients (5.3%). All orbital findings resolved or improved after surgery. Functional patency of the mucocele opening as documented by office endoscopy was evident in 56 cases (98.2%) at a median follow-up of 15 months (60, 0.5). One patient with a sphenoid mucocele with skull-base erosion in the setting of Wegener’s granulomatosis developed complete stenosis of the mucocele opening. Repeat MRI did not show signal changes suggestive of mucocele reformation;
Sautter et al
Paranasal sinus mucoceles with skull-base . . .
Table 2 Patterns of skull-base and orbital erosion Site of erosion Orbit Superior orbit Medial orbit Optic nerve Skull base Posterior table FS Sphenoid roof Anterior table FS Orbit and skull base Total
No. of patients (%)
No. of patients (%) 29 (51)
18 (32) 10 (18) 1 (2) 23 (40) 24 (42) 4 (7) 1 (2) 5 (9) 57 (100)
she has been observed by serial clinical examinations without any sequelae.
DISCUSSION The evolution of the endoscopic techniques has resulted in a shift of the surgical paradigm for the management of mucoceles. In 1989, Kennedy et al5 described the successful utility of the endoscopic approach in 15 of 18 patients (83.3%) with a mean follow-up of 17.4 months. Subsequent series have also successfully reported on endoscopic marsupialization of mucoceles.1,6-8 Har-El6 reported on the endoscopic management of 108 mucoceles in 103 patients; a recurrence rate of 0.9 percent was reported with a median follow-up of 4.6 years. Khong et al8 reported on 24 mucoceles in 15 patients with orbital extension by radiographic criteria. Endoscopic marsupialization was achieved in all patients with revision endoscopic surgery being required in four patients (27%) for frontal stenosis and mucocele reformation. The data in the current series are commensurate with these previous studies. Mucoceles with skull-base and/or orbital erosion were successfully managed via the endoscopic approach without untoward complications. A recurrence rate of 1.8 percent was noted, with all 57 patients having subjective improvement of the primary presenting symptomatology. Revision endoscopic procedures were required in 17 patients (29.8%) in this series. This is similar to the 27 percent and 25 percent revision rates reported by Khong et al2 and Hurley et al,8 respectively. Nine of these patients required revision endoscopic procedures for restenosis to maintain a safe patent mucocele cavity. Eight of these nine patients (89%) had undergone previous surgery, including FSO (four), craniofacial resection (two), and endoscopic sinus surgery (two). Thus, patients with previous sinus surgery, especially open frontal and skull-base procedures, may be at greater risk of restenosis from previous iatrogenic trauma. Six patients required additional surgery for the
573
recurrence of sinonasal polyposis, despite aggressive medical therapy with culture-directed antibiotics, systemic and topical steroids, and antileukotriene modifiers in the postoperative period. Mucocele reaccumulation was not noted at the time of revision surgery in this subset. Continued, ongoing medical therapy is an absolute requisite in these patients to prevent mucocele reformation. Despite the success of the endoscopic approach, OPF for frontal sinus mucoceles has been reported in two recent series. Bockmuhl et al9 managed 290 mucoceles in 255 patients; OPF with or without concomitant endoscopic approach was used in 68 cases. Herndon et al10 used the OPF with FSO in 9 of 13 (69%) patients with extensive fronto-orbital-ethmoid mucoceles; the endoscopic approach was only used in 4 patients. The utility of the OPF in this setting should not be taken lightly, and the significant morbidity of OPF must be considered in the decision-making process. In a report of 250 cases, Hardy and Montgomery11 reported a 19 percent complication rate, including 13 abdominal wound infections and 7 CSF leaks. The inability to completely remove mucosa from the adjacent dura or orbital periosteum makes FSO even more problematic and should be viewed as a relative contraindication to the management of mucoceles with orbital or skull-base erosion. Adjunct open approaches were required in four patients in this series. Combined endoscopic frontal sinusotomy and endoscopic frontal trephination were required in three cases. The “above and below” approach served to provide an additional porthole to remove frontal sinus partitions that could not be addressed with conventional frontal instrumentation. One patient with previous FSO with multiple frontal loculations required repeat OPF for exploration of the frontal sinus. Successful obliteration reversal was achieved with a 50-month follow-up. Endoscopic drillout procedures were required in two cases in this series. In both patients, significant osteoneogenesis precluded standard endoscopic frontal sinusotomy. Khong et al7 reported on the efficacy of endoscopic sinus surgery for paranasal sinus mucoceles; 21 of 28 patients (75%) required endoscopic modified Lothrop. The two main indications for drillout procedures in their study were significant bony separation between the mucocele and the adjacent sinus and loss of lateral support of the frontal sinus with risk of medial wall collapse of the orbital contents obstructing drainage.7 Drillout procedures result in significant mucosal trauma and lead to prolonged healing and slow return of mucociliary clearance. They should be used as a last resort, being reserved for patients with significant newbone formation.12 Several important advantages are afforded by the endoscopic approach. Facial incisions are avoided resulting in superior cosmesis. Overall complications and associated morbidity are reduced compared with the documented rates of OPF and other open approaches. Lund and Milroy13 have shown that the mucocele remnant retains respiratory epithelium with normal mucociliary clearance after marsupialization; thus, normal sinonasal physiologic function is preserved.
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Otolaryngology–Head and Neck Surgery, Vol 139, No 4, October 2008
This surgical strategy also facilitates postoperative endoscopic and radiographic surveillance. Indeed, serial endoscopy at regular intervals should be considered mandatory in these patients in the postoperative period. All cases of mucocele restenosis in this series were detected on routine endoscopic examination, allowing for elective, timely surgical intervention without untoward complications. The advent of balloon catheter dilatation of the paranasal sinus ostia may further enhance management of these patients.14 Balloon catheters without fluoroscopy may be used in the office setting for dilatation of the stenotic mucocele outflow tract with topical anesthesia.15 This strategy could avoid additional trips to the operating room for repeat surgery.
CONCLUSION Endoscopic marsupialization of paranasal sinus mucoceles is a safe and viable surgical strategy for lesions with skullbase and/or orbital erosion. This was accomplished in 57 cases with minimal morbidity and low recurrence rate. Adjunctive open approaches, like endoscopic frontal trephination and OPF, may be sparingly required in patients with multiseptate mucoceles or those involving the far lateral aspect of the frontal sinus. Regardless of the surgical approach, close follow-up with office endoscopy and radiographic imaging, when clinically indicated, is an absolute requisite.
AUTHOR INFORMATION From the Oregon Sinus Center, Oregon Health and Sciences University, Portland, OR (Dr Sautter); Department of Otorhinolaryngology–Head and Neck Surgery, University of Texas Medical School at Houston, Houston, TX (Dr Citardi); Division of Oculoplastics, Cole Eye Institute, Cleveland, OH (Dr Perry); and Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH (Dr Batra). Corresponding authors: Pete S. Batra, MD, Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A71, Cleveland, OH 44195. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Nathan B. Sautter, writer, study designer; Martin J. Citardi, design, writing, revision, consultant; Julian Perry, revision, consultant; Pete S. Batra, design, writing, revision, consultant.
FINANCIAL DISCLOSURES Pete S. Batra, GlaxoSmithKline: Speaker’s Bureau, Xoran Technologies: Research grant; Martin J. Citardi, GE Healthcare Navigation & Visualization: consultant, Medtronic ENT: consultant, Naryx: consultant, Quest Medical: consultant, Arthrocare: research grant.
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