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Endoscopic management of frontal mucocele

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Endoscopic management of frontal mucocele Powered By Docstoc
					 ENDOSCOPIC MANAGEMENT
OF FRONTAL MUCOCELE WITH
    ORBITAL EXTENSION
          Dr. C. Anjaneyulu
               Asst. Professor
       Dept. of Otorhinolaryngology
 All India Institute of Medical Sciences
 AIRS Con 2003   New Delhi
                Introduction

 Frontal mucocele is an epithelium lined
 mucus containing sac that fills the
 frontal sinus.




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                 Pathogenesis


- obstruction of the frontonasal duct



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Predisposing factors
  Anatomical abnormality
  Infection
  Surgery
  Trauma
  Allergy
  Nasal polyposis
  Tumors
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Complaints :
Commonly present with opthalmic
complaints than nasal
   Proptosis
   Displacement of eye ball
   Lid swelling




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 Extend in to surrounding structures by
 expansion and destruction of bone with
 pressure effect and production of
 cytokines (IL-1), prostaglandins (PGE2)
 and collagenase.




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                Radiology


 X-Ray
 CT Scan-Accurately determine the
 regional anatomy and extent of lesion
 MRI-Soft tissue differentiation


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Case Report


  69 year old Female patient
  Complaints –
   – Protrusion of right eye ball from 1 month
     Slowly increasing
   – Swelling above the medial half of right eye
     lid

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Past history
 – Hypertension for 10 years.Blood
   pressure under control with anti
   hypertensives

 – H/O of pacemaker insertion for right
   bundle branch block with syncope in
   1996.

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   Examination :
Soft, compressible, nonpulsatile mass in medial half of right
supraorbital region
Mechanical ptosis of right upper eye lid


Protrusion of right eye ball forward, laterally and inferiorly


Eye ball movements-normal


Vision-normal


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           CT Scan of Para Nasal Sinus




  Showing large
expansile soft tissue
mass in frontal sinus
with extension into
orbit.



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                   Surgery
Endoscopic endonatsal Surgery Under
General Anaesthesia
Uncinectomy Done.
Mucosa Covered Mass at frontal recess area opened with
blacksley’s straight forceps
Mucoid material sucked out
Frontal sinusotomy opening enlarged upto around 2 cm
frontal mucocele lining was edematous mucosa,no polyps
mucocele irrigated with saline.
No bleeding
Proptosis was reduced on table intraoperatively
Anterior nasal packing was done

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Postoperative course - Uneventful

Medical treatment
 Antibiotics for 10 days
  Antiallergics for 10 days
  Decongestant nasal drops for 5 days
  Analgesics for 3 days
  Steroiods nasal spray for 14 days
   – After 24 hours - pack removal done
   – At 7 days – crust removal done
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    Histopathology Report


 Mucocele lined by respiratory
 epithelium with underlying chronic
 inflamation.




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       At 6 months follow up
 Asymptomatic
 No Proptosis
 Nasal Endoscopy - Patent frontal
 Sinusotomy opening




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     At 6 months follow up

CTScan –
Mucosa lined, well
 aerated frontal sinus
 with patent frontal
 recess area.
Orbital roof defect was
 lined by normal
 mucosa with out
 orbital extension

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                  DISCUSSION
Traditional teaching:-
 Complete removal of mucocele Lining And
 Obliteration of sinus cavity

Disadvantages:-
 Greater Surgical Morbidity
 External Scar
 Difficulty In Diagnosis of Recurrence on post
 operative imaging
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    Concept of Marsupialization
 Ablity of inflammed sinus mucosa return to
 normal.

Histopathological Studies
 Mucoceles are lined by respiratory mucosa with
 underlined inflammation (Lund etal 1991)
 After Marsupialization - mucocele cavity is lined
 by ciliated normal respiratory epithelium with
 active transport mechanism ( Har-El G etal 2000)
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Conventional Intrnasal Marsupialization

    First report - Howarth 1921
    Later-wolfowitz and solomon 1972
  Disadvantages :
    Frontal Sinus out flow tract is narrow
    and less accessible


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Nasal Endoscopic Sinus
                 Surgery
  Nasal Endoscopes – Provide excellent
  visualization of deep and angled
  spaces in paranasal sinus region




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  Endoscopic Marsupialization of
        Frontal Mucocele
Advantages :
– Low Morbidity
– Recurrence rate close to 0%
– Can perform under local anaesthesia on
  outpatient basis
– Accurate Follow up after surgery
Limitation :
– If Mucocele is situated in the lateral aspect of
  the frontal sinus
– Frontal sinus ostium is surrounded by thick
  bone 2003
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                     Conclusion
Endoscopic marsupialization is the treatment of
 choice for frontal mucoceles
 Minimal Invasive Procedure
 Out-patient basis
 Direct Visualization of Frontal Recess area and Frontal
 Sinus
 Histopatholoigical Studies showed evidence of return of
 inflammed sinus mucosa to normal with active transport
 mechanism
 Radiological studies showed evidence of normal well
 aerated frontal sinus after marsupialization
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