Voluminous frontoethmoidal mucocele with epidural involvement. Surgical treatment by coronal approach

The case is described of mucocele of the right frontoethmoidal sinus with bilateral maxillary sinusitis and a large polyp in the right nasal cavity. The mucocele had determined erosion of the anterior and posterior walls of the frontal sinus and superomedial wall of the orbit. The patient was operated upon by a surgical team comprising ENT and maxillofacial specialists. Right maxillary sinusotomy (Caldwell-Luc procedure) was performed, and an osteoplastic flap was prepared, repositioned in the canine fossa and fixed with a titanium plate. Debris was removed from the left osteomeatal complex during endoscopy. To reach the mucocele, an external surgical approach was used, through a bitemporal coronal cutaneous incision, according to Unterberger. This approach was used in order to gain better access to the area of the lesion and in order to make reconstruction easier, with a view to achieving good functional results without untoward scarring. The scalp was detached down to the root of the nose to allow optimal visualisation of the anterior area of erosion determined by the mucocele, and, after excision and removal of the latter from the bony walls, of the posterior bony breach and underlying dura mater. Another bony breach involved the medial and superior walls of the orbit. The nasofrontal canal was obliterated with bone fragments and Tissucol; the posterior breach, with Surgical and Tissucol. The orbit wall was repaired with high-density porous polyethylene sheeting; the frontal sinus was filled with fat. The anterior wall of the frontal sinus was repaired with two split of calvarial bone grafts harvested from the parietal bone and fixed with a titanium microplate. The morphological outcome of reconstruction was satisfactory, with no recurrences, as confirmed at post-operative follow-up, including computed tomography scan, at 5 months. Ocular motility and patency of the tear drainage system were also normal. No diplopia, or inflammation occurred.