Endoscopic management of sinus disease with frontal lobe displacement

Advanced inflammatory disease of the paranasal sinuses may result in erosion of the skull base with frontal lobe impingement. We present a series illustrating minimally invasive management of this process.

We review 15 consecutive cases of advanced sinus inflammatory disease with frontal lobe displacement. Clinical presentation, diagnostic evaluation, and treatment modalities are described.

Patients ranged in age from 19 to 83 years, and 13/15 were men. Presenting symptoms in all patients included progressive headache (15/15), frontal pressure (15/15), orbital involvement and visual symptoms (6/15), and new-onset seizure (1/15). Implicated diagnoses included mucocele (7/15), classic allergic fungal sinusitis (3/15), and both (5/15). Initially, 14 patients were treated endoscopically, with image-guided navigation in 12 patients. Four patients underwent trephination for combined above/below marsupialization, and three patients also underwent orbital decompression. Two patients failed initial endoscopic management. One of these was salvaged endoscopically and the other required cranialization. Another patient was managed via cranialization in the primary setting. In all cases, mucosa was observed directly against dura. No cerebrospinal fluid leaks were encountered. One patient expired 1 month postoperatively secondary to congestive heart failure. Mean follow-up in the remaining 14 patients was 13.6 months. Follow-up imaging revealed reexpansion of the frontal lobe into the decompressed space.

Advanced sinus inflammatory disease associated with frontal lobe compression may have indolent presentation but significant morbidity. Minimally invasive techniques averted the need for craniotomy in 13/15 patients in this series.