Frontal sinus mucocoeles: new algorithm for surgical management

Frontal sinus mucocoeles require a structured approach to their surgical management. We share our experience of a novel method of positional classification for frontal mucocoele and corresponding surgical algorithm.

A retrospective case-note review examined all frontal sinus surgery for mucocoele, spanning three years (2008-2010). Patients had pre-operative nasendoscopy, multi-planar CT and MRI when indicated. Several important variables (position, drainage dimensions, fronto-ethmoidal cells and degree of neo-osteogenesis) were noted. A systematic algorithm was used for surgical drainage based on these characteristics. The three year outcomes using this approach are presented.

Thirty-six patients were identified with a total of 43 frontal mucocoeles. Using our classification, 30 mucocoeles were medial; seven were intermediate; six were lateral. Thirty-four patients underwent a primary endoscopic procedure; six required a combined primary osteoplastic-flap (OPF) and endoscopic approach. Six patients required revision surgery for polypoidal change or neo-ostium stenosis. All patients were eventually rendered asymptomatic.

Implementation of our positional classification and surgical algorithm was successful with a revision rate of 19%. Presence of frontal sinus wall dehiscence and extra-sinus mucocoele extension are invalid indicators for external approach. We feel our classification and treatment algorithm, with its associated indicators for surgical escalation (i.e. limited dimensions of frontal ostium, presence of Type III / IV front-ethmoidal cells etc), are applicable for future management of frontal mucocoeles.