Management and Surveillance of Frontal Sinus Violation following Craniotomy

Abstract

Objectives In the setting of craniotomy, complications after traversing the frontal sinus can lead to mucocele formation and frontal sinusitis. We review the etiology of frontal sinus violation, timeline to mucocele development, intraoperative management of the violated sinus, and treatment of frontal mucoceles. Design Case series in conjunction with a literature review. Participants A total of 35 patients were included in this meta-analysis. Nine of these patients were treated at a tertiary academic medical center between 2005 and 2014. The remaining patients were identified through a literature review for which 2,763 articles were identified, of which 4 articles met inclusion criteria. Main Outcomes Measures Etiology of frontal violation, timeline to mucocele development, and method of management. Results The overall interval from initial frontal sinus violation until mucocele identification was 14.5 years, with a range of 3 months to 36 years. The most common cause of mucocele formation was obstruction of the frontal recess with incomplete removal of the frontal sinus mucosa. The majority of patients were successfully managed with an endoscopic endonasal approach. Conclusions Violation of the frontal sinus during craniotomy can result in mucocele formation as an early or late sequela. Image guidance may help avoid unnecessary frontal sinus violation. Mucoceles may develop decades after the initial frontal sinus violation, and long-term follow-up with imaging is recommended. While the endoscopic endonasal approach is usually the preferred method to treat these lesions, it may be necessary to perform obliteration or cranialization in unique situations.

Orbitozygomatic Craniotomy via an Eyebrow Incision: Management of the Opened Frontal Sinus

“…Farag et al includes nine patients with mucoceles after craniotomy from 2005 to 2014 at one large academic center and an additional 26 identified from four other articles. 10 They report an average time interval of 14.5 years from the violation of the frontal sinus during craniotomy to the diagnosis of a secondary mucocele, with a range of 3 months to 36 years. 10 Meetze et al also reports a similar timeline for the development of mucocele after frontal craniotomy in six patients, with an average of 14.8 years and a range of 1 to 39 years.…”

“…10 They report an average time interval of 14.5 years from the violation of the frontal sinus during craniotomy to the diagnosis of a secondary mucocele, with a range of 3 months to 36 years. 10 Meetze et al also reports a similar timeline for the development of mucocele after frontal craniotomy in six patients, with an average of 14.8 years and a range of 1 to 39 years. 11 Headache was the most common chief complaint for patients with secondary mucoceles and most were able to be treated with an endoscopic endonasal approach.…”

“…2,6,[8][9][10] There are reports of abscess, cellulitis, meningitis, mucoceles, and osteomyelitis that have occurred secondary to mismanagement of an opened frontal sinus. [8][9][10][11] One recent large retrospective series has shown that frontal sinus breach is an independent risk factor for surgical site infection during frontotemporal craniotomies. 9 This risk may not be as profound in subfrontal keyhole approaches through an eyebrow incision.…”

“…Frontal sinus mucocele is a long-term complication of entry into the frontal sinus. [10][11][12] There are few papers looking at the rate of secondary mucocele after surgery based on rarity and long follow-up needed. Horowitz et al looked at the rate of secondary mucocele formation for open surgeries of benign frontal sinus pathology and compared frontal sinus obliteration to frontal sinus cranialization.…”

“…10,11 Frontal recess obstruction was identified as the most common cause of secondary mucoceles. 10 It is important to maintain patency of the frontal recess during repair to lower the risk of long-term mucocele. Follow-up with an otolaryngologist is also recommended.…”