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DOI: 10.1055/s-0040-1702600
Management of Frontal Mucocele after Pericranial Flap Reconstruction of Anterior Skull Base Resection Defect
Publication History
Publication Date:
05 February 2020 (online)
Introduction: Over the past two decades, techniques for endoscopic resection of ventral skull base lesions and reconstruction of resulting skull base defects has progressed significantly. The benefits of the endoscopic endonasal approach (EEA) include decreased postoperative morbidity with hastened recovery, the absence of an external incision, and improved intraoperative visualization—all without compromising oncologic resection in appropriately selected patients. While literature supports this approach as safe and effective, recognized complications include cerebrospinal fluid leak, meningoencephalocele, delayed healing and skull base crusting, donor site morbidity, and mucocele formation. Mucocele, in particular, is a rare complication, with published rates well below 5%. We describe a case of frontal mucocele formation after skull base resection and vascularized reconstruction, and a novel approach to its management.
Case Presentation: A 31-year-old male presented with a 1-month history of progressive left forehead swelling and pain, with related complaints of numbness radiating to the occiput. His past surgical history was notable for Hyams grade 3 right olfactory neuroblastoma, treated 3 years previously with endoscopic resection followed by pericranial flap reconstruction and adjuvant radiation. Interval imaging following treatment had revealed bilateral opacification of the frontal sinuses without associated findings, and no evidence of recurrence. Magnetic resonance imaging revealed bilateral frontal opacification, with expansion of the left frontal sinus associated with disruption of the anterior table, consistent with mucocele. Computed tomography revealed a heterogeneous collection spanning both frontal sinuses with a bony defect of the left anterior table. The patient underwent endoscopic drainage and marsupialization of the frontal mucocele under general anesthesia. Nasal endoscopy revealed extensive postoperative changes and scarring with an intact vascularized skull base reconstruction. Stereotactic image guidance was utilized to identify the left bony frontal outflow tract, and a blunt-tipped angled suction was gently advanced into the mucocele cavity. Moderate mucopurulent drainage was suctioned and irrigated. The neofrontal drainage pathway was widened anteriorly with through-cutting hand instruments and a curved microdebrider, taking care not to violate the posterior table or skull base reconstruction. The left frontal sinus was then brought into continuity with an intersinus septal cell, likely communicating with the right frontal sinus. A steroid-eluting bio-absorbable stent was then placed into the neo-frontal ostium to prevent scarring and maintain patency. The stent was removed at the first nasal debridement, and the frontal sinus drainage pathway remained patent at follow-up 4 weeks after surgery.
Discussion: Mucoceles are rare complications following vascularized reconstruction of skull base defects. We present a case of frontal mucocele following endoscopic resection of esthesioneuroblastoma and pericranial flap reconstruction, managed by endoscopic drainage and marsupialization with placement of a steroid-eluting bioabsorbable stent.