Single stage management of complex fronto-orbital mucoceles

Mucoceles arising in the frontal and/or ethmoid sinuses are clinically silent and often involve both the orbit and the anterior cranial fossa extensively. Five patients with advanced mucoceles of the frontal sinus involving the orbitocranial skeleton (OCM), as a result of recurrent sinusitis or trauma, were identified during a 36-month period in a major academic US institution. The range of pathology encountered involved brain herniations, CSF leaks, and extensive orbital involvement. These patients required major reconstructive efforts to restore proper orbital skeletal anatomy and function with the use of multiple calvarial bone grafts. The secondary effects of the pathologic process, such as orbital dystopia, ocular dysfunction, and CSF leak among others, resolved in all patients without further problems. Follow-up by repeat computed tomography and examination scan ranged from 6 weeks to 29 months. Adequate reconstruction of extensive OCMs involves four principles: 1) cranialization of the frontal sinus for adequate intracranial and orbital roof access; 2) complete removal of all mucosal elements from the frontal sinus, orbit, and dura; 3) precise restoration of orbital volume with calvarial bone grafts; and 4) reattachment of the medial canthal ligament to the bone grafts to avoid orbital dystopia. The results of the surgery are gratifying, but long-term follow-up is essential due to the risk of recurrence.