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ENDOSCOPIC MANAGEMENT OF FRONTAL MUCOCELE WITH ORBITAL EXTENSION INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com

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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 AIRS Con 2003 www.indiandentalacademy.com


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 AIRS Con 2003 www.indiandentalacademy.com


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 AIRS Con 2003 www.indiandentalacademy.com


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 AIRS Con 2003 www.indiandentalacademy.com


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 AIRS Con 2003 www.indiandentalacademy.com


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) AIRS Con 2003 www.indiandentalacademy.com


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 AIRS Con 2003 www.indiandentalacademy.com


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 AIRS Con 2003

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Endoscopic management of frontal mucocele/ dental implant courses by Indian dental academy