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Frontal Sinus Mucopyocele Presentingas a Subcutaneous Forehead Mass

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Ryan A. Carmichael, DDS, MD,* and David R. Kang, DDS, MDy

Mucoceles of the paranasal sinuses are benign, chronic, expanding lesions that characteristically develop

because of obstruction of the sinus ostium. The frontal sinus is the most common sinus to be affected by amucocele, which usually results from trauma or inflammatory processes. Patients with these lesions

frequently present with visual complaints of decreased visual acuity, visual field abnormalities, proptosis,

ptosis, displacement of the globe, or restricted ocular movements secondary to erosion through the thin

bone of the superior orbit and compression on the globe. Often, intracranial extension of frontal sinus mu-

coceles is also present from erosion through the posterior table of the frontal sinus. Very rarely, they will

present as a subcutaneous forehead mass or swelling. To the best of our knowledge, only 5 cases of a fron-

tal sinus mucocele presenting as a forehead subcutaneous mass has been previously reported. We report

the case of an 80-year-old woman with a history of remote forehead trauma who presented with a frontalsinus mucopyocele manifesting as a subcutaneous forehead mass eroding through the skin.

Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial

Surgeons

J Oral Maxillofac Surg 73:2155-2161, 2015

Mucoceles of the paranasal sinuses are benign,

chronic, expanding lesions, filled with sterile mucus

and epithelial cells.1 They characteristically develop

from a continuous or intermittent obstruction of the si-nus ostium, which causes dilatation of the sinus cavity

secondary to accumulation of mucoid material.2 This

subsequently causes displacement of the surrounding

structures through bony destruction of the adjacent si-

nus walls.3 The frontal sinus is the most common sinus

to be affected by a mucocele, which is generally the

result of trauma or inflammatory processes or develops

iatrogenically from previous sinus surgery.1,4,5 Patientswith these lesions frequently present with visual

complaints secondary to orbital involvement. The

visual complaints include diplopia, decreased visual

acuity, visual field abnormalities, proptosis, ptosis,

periorbital swelling, displacement of the globe and

restricted ocular movements.3,6 Often, intracranial

extension of frontal sinus mucoceles is also present

nt, Department of Oral and Maxillofacial Surgery, Texas

ersity Baylor College of Dentistry; and Division Oral and

ial Surgery, Department of Surgery, Baylor University

enter, Dallas, TX.

nt Professor, Department of Oral and Maxillofacial

exas A&M University Baylor College of Dentistry;

nt of Surgery, Texas A&M University College of

and Department of Surgery, Baylor University Medical

llas, TX.

s correspondence and reprint requests to Dr Kang: Depart-

ral and Maxillofacial Surgery, Texas A&M University Baylor

2155

from erosion through the posterior table of the

frontal sinus. This can result in complications such as

meningitis, meningoencephalitis, pneumocephalus,

brain abscess, seizures, and cerebrospinal fluid (CSF)fistulas.2,3,7 Very rarely, they will present as a

forehead mass or swelling. To the best of our

knowledge, only 5 cases of frontal sinus mucocele

presenting as a forehead subcutaneous mass or

swelling have been previously reported.2,8-11 We

present the case of an 80-year-oldwomanwith a history

of remote forehead traumawho presented with a fron-

tal sinus mucopyocele manifesting as a subcutaneousforehead mass, with erosion through the skin.

Case Report

An 80-year-old woman presented to the emergency

department (ED) for evaluation of a recent growth

along her forehead. Approximately 45 years earlier,

College of Dentistry, 3302 Gaston Avenue, Dallas, TX 75246; e-mail:

david.kang@baylorhealth.edu

Received April 9 2015

Accepted May 15 2015

Published by Elsevier Inc on behalf of the American Association of Oral andMaxil-

lofacial Surgeons

0278-2391/15/00597-2

http://dx.doi.org/10.1016/j.joms.2015.05.013

FIGURE 1. A, Computed tomography (CT) axial soft tissue window demonstrating the erosion of the mucopyocele into the soft tissue of theforehead. B, CT axial bone window demonstrating erosion of the mucopyocele through the anterior table of the frontal sinus.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutaneous Forehead Mass. J Oral Maxillofac Surg 2015.

2156 FRONTAL SINUS MUCOPYOCELE AS SUBCUTANEOUS FOREHEAD MASS

FIGURE2. A, Frontal photograph demonstrating the fluctuant presenting mass on the forehead. B, Profile photograph depicting the size of theforehead mass.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutaneous Forehead Mass. J Oral Maxillofac Surg 2015.

FIGURE 3. Ulceration and decompression of the frontal sinus mu-copyocele.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutane-ous Forehead Mass. J Oral Maxillofac Surg 2015.

CARMICHAEL AND KANG 2157

she had been struck in the face with a lamp by her ex-

husband and had experienced fractures to the face and

a significant laceration. She did not undergo any surgi-

cal intervention at that time other than closure of the

soft tissue lacerations. Recently, she had hit her fore-head on the corner of an open kitchen drawer as she

crouched down to pick up a dropped utensil. Approx-

imately 1 week later, her forehead began to swell and

she presented to the ED. Computed tomography scans

were performed and revealed obliteration of her left

frontal sinus and left ethmoid sinus, with a nickel-

size erosion of her frontal bone, and a mass extending

from the sinus into the subcutaneous tissues (Fig 1).On clinical examination, a midline forehead mass

was evident between the eyebrows and extended infe-

riorly past the nasofrontal junction and superiorly to

the middle half of the forehead. The lesion appeared

to be warm and fluctuant and was approximately

4 cm wide and extended 6.5 cm vertically, with a cen-

tral area of erythema (Fig 2). She denied experiencing

any ocular or neurologic symptoms or any notabledrainage from her nose or eyes. The remainder of

her physical examination findings was unremarkable.

From the clinical and radiologic findings, the most

likely diagnosis was a mucopyocele that had eroded

through the anterior table of the frontal sinus. We sus-

pect that her facial trauma 45 years earlier might have

compromised her nasofrontal duct, leading to the

development of a mucocele that slowly eroded andthinned the anterior table of the frontal sinus. Her

recent trauma might have fractured the paper-thin

anterior table, allowing the mucopyocele to erode

and expand through the anterior table of the frontal si-

nus into the soft tissue of the forehead.

She was then sent home in preparation for surgery;

however, within 3 days, she returned to the ED with

ulceration and drainage from the forehead (Fig 3).

The drainage was cultured, and she was given

ampicillin/sulbactam (Unasyn) and scheduled for sur-gery. A coronal flap was elevated down to the level

of the perforation of the frontal bone, and, with gentle

manipulation, the purulent drainage was identified

and the mucopyocele curetted and removed. The

specimen was then sent for culture and pathologic ex-

amination (Fig 4). The frontal sinus was then burred

down to completely remove the mucosa. The naso-

frontal duct was explored through the ethmoid sinusto establish drainage to the nose.

FIGURE 4. A, Initial view of the mucopyocele after coronal flap exposure. B, Purulent drainage from the mucopyocele. C, Mucopyoceleremoved from the frontal sinus after curettage. D, Specimen removed from the frontal sinus.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutaneous Forehead Mass. J Oral Maxillofac Surg 2015.

2158 FRONTAL SINUS MUCOPYOCELE AS SUBCUTANEOUS FOREHEAD MASS

A bilobed pericranial flap was elevated as the central

component was disrupted from the fistula tract (Fig 5).

The fistula tract through the forehead skin was then

excised in an elliptical fashion (Fig 6). The nasofrontalduct was occluded with bone chips and sealed with

Floseal (Baxter International, Deerfield, IL). The left

frontal sinus was obliterated using the contralateral

pericranial flap (Fig 7), and the bony defect was re-

paired using titanium mesh (KLS Martin, Jacksonville,

FL). The ipsilateral pericranial flap was then placed

over the mesh, and the scalp was closed in a layered

fashion with the skin closure completed in a subcutic-ular fashion (Fig 8) using a Quill Monocryl suture (Sur-

gical Specialties Corp, Vancouver, BC, Canada). One

flat channel drain was placed and was removed on

the second postoperative day.The final pathologic examination revealed findings

consistent with mucopyocele, and final cultures re-

vealed pan-susceptible Staphylococcus species andFusobacterium species. She was given a 1-week

course of amoxicillin/clavulanic acid (Augmentin),

and the remainder of her postoperative course was un-

remarkable (Fig 9).

Discussion

Paranasal mucoceles most commonly affect the

frontal sinus (60%), with most of the remainder

involving the ethmoid labyrinth and maxillary andsphenoid sinuses.4 The 2 most frequent causes of fron-

tal sinus mucoceles are trauma and inflammatory

changes.1 Obeso et al5 noted in a retrospective study

of 72 patients presenting with paranasal mucoceles

that 35% had undergone previous sinus surgery and

14% had had previous facial fractures, suggesting

that some mucoceles might be iatrogenic.

Post-traumatic mucoceles can present from

2 months to up to 50 years or longer after the originalinjury.7,12 Because of the often slow-growing nature of

frontal sinus mucoceles and the demographic data

of trauma patients, very few patients have a well-

documented history of trauma to the frontal sinus. In

a published data review and experience from their

institution, Koudstaal et al13 identified only 13 patients

with a history of trauma to the frontal sinus preceding

the development of a mucocele, a remarkably smallnumber when one considers the incidence of frontal

FIGURE 7. Right pericranial flap used to obliterate frontal sinusand the left pericranial flap which was draped over the titaniummesh before closure.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutane-ous Forehead Mass. J Oral Maxillofac Surg 2015.

FIGURE 5. Bilobed pericranial flap raised.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutane-ous Forehead Mass. J Oral Maxillofac Surg 2015.

CARMICHAEL AND KANG 2159

sinus fractures.14 Several strategies have been sug-

gested for the treatment of frontal sinus fractures,

with most treatment decisions predominantly depend-

ing on involvement of the anterior wall, posterior wall,intracranial involvement, and nasofrontal duct.14-19 A

key element to the successful treatment of patients

with frontal sinus fractures is an understanding of

frontal sinus drainage and whether the nasofrontal

duct has been injured. When the frontal sinus

FIGURE 6. Fistula tract excised in an elliptical fashion, underlyingthe frontal sinus after curettage of the sinus mucosa and peripheralostectomy.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutane-ous Forehead Mass. J Oral Maxillofac Surg 2015.

drainage is impaired and the mucus is retained, a

mucocele can develop. Therefore, it has beenrecommended that fractures of the frontal sinus that

cause obstruction of the nasofrontal ducts should be

treated by complete sinus membrane removal and

obliteration of the sinus cavity.16

Frontal sinus mucoceles can occur at any age in both

genders. However, most are seen between the fourth

and seventh decades of life.20 If themucocele becomes

acutely infected, it is termed amucopyocele. It can pre-sentwith subtle or overt signs of infection and addition-

ally carries the risk of sepsis and meningitis.13,21

Mucoceles typically expand in the direction of least

resistance; therefore, frontal sinus mucoceles tend to

erode the thinner bone of the superior orbit and

subsequently will displace the globe inferiorly, which

can result in diplopia, decreased visual acuity, visual

field abnormalities, proptosis, ptosis, periorbitalswelling, displacement of the globe, and restricted

FIGURE 8. Closure of the wound intraoperatively.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutane-ous Forehead Mass. J Oral Maxillofac Surg 2015.

FIGURE 9. View at 3 months of follow-up. The patient reported nocomplications or complaints.

Carmichael and Kang. Frontal Sinus Mucopyocele as Subcutane-ous Forehead Mass. J Oral Maxillofac Surg 2015.

2160 FRONTAL SINUS MUCOPYOCELE AS SUBCUTANEOUS FOREHEAD MASS

ocular movements.2,6 Other sequelae include

meningitis, meningoencephalitis, pneumocephalus,

brain abscess, seizures, chorioretinal folds, and

CSF fistulas.2,22

The diagnosis is determined by clinical examination,

with the aid of computed tomography (CT) and mag-

netic resonance imaging (MRI).3 CT with contrast is

the preferred method of imaging, although MRI is use-

ful in complicated cases with intracranial extension or

infection because of its superior ability to identify the

relationship of the mucocele with the brain, orbit, and

soft tissues.13 The CT findings of a mucocele willdemonstrate an expanded sinus with gradual thinning

and erosion of the bony margins of the frontal sinus,

with the posterior wall and orbit particularly prone

to erosion because of its inherent thinness.23

The anterior wall of the frontal sinus is uniformly

thicker and stronger than the posterior wall,15 which

is likely the reason that anterior table erosion is less

commonly seen.21 A rarely reported presentation offrontal sinus mucoceles is when the mucocele extends

anteriorly into the subcutaneous region and presents

as a forehead mass or forehead ulcer.2,8-11 Fernandes

and Pirgousis2 reported on a 59-year-old woman who

presented for a longstanding frontal mass that had

been present and continually enlarging for at least

10 years. She had marked extra-axial proptosis and

displacement of the orbital cavity with the resultantcomplete loss of vision and light perception in the

affected eye.2 Borkar et al10 reported on a 53-year-old

woman with a frontal mucocele with cranio-orbital

extension that presented with slowly progressive

swelling of the left forehead without any preceding

trauma or paranasal sinus surgery. Akiyama et al8 re-

ported on a 57-year-old woman also with a frontal si-

nus mucocele with cranio-orbital extension who

presented with a 3-month history of an asymptomatic

tumor of the forehead. Tan et al9 reported on a 33-year-

old woman with visual complaints of blurring of the

inferior visual field, periorbital swelling, and a painless

subcutaneous forehead mass above the affected eye.She had no history of trauma or previous surgery. CT

and MRI studies showed a mass that had also eroded

into the orbit and intracranially with a subcutaneous

forehead component.9 Altintas Kaksi et al11 reported

a case of an 80-year-old woman who had presented

with a nonhealing ulcer on her forehead and also

had no history of trauma or previous surgery. She

had no associated ocular or neurologic symptoms,and imaging demonstrated a frontal sinus mass with

a 3- to 4-mm defect on the anterior wall of the frontal

sinus and a 3-mm sinus tract opening to the skin of the

forehead.11

The treatment modalities for the prevention of mu-

cocele formation include observation, cranialization,

obliteration, and nasofrontal duct stenting. The pre-

vailing principles for these procedures involve eithermaintenance of normal sinus function by maintaining

nasofrontal duct patency or removal of all remaining

sinus mucosa and isolation of the sinus from the nasal

cavity and cranium.3 Definitive treatment of frontal si-

nus mucoceles is surgical, which varies from func-

tional endoscopic sinus surgery to craniotomy and

craniofacial exposure with or without obliteration of

the sinus.3,24 If the mucocele cannot be approachedendoscopically and thus lasting drainage function

cannot be guaranteed, an extranasal, transfacial

procedure is indicated. Important objectives of

operative therapy include reliable sanitation of the

mucocele, incorporating management of intracranial

or intraorbital complications; drainage of the

mucocele into the nose, either by preservation or

extension of the natural nasofrontal duct orcomplete removal of the mucocele and the mucosa

of the frontal sinus and reliable closure of the

nasofrontal duct; preservation or reconstruction of

the anterior wall of the frontal sinus to protect the

frontal lobe and maintain the contour of the

forehead.1 When the posterior wall of the frontal sinus

is eroded and the dura is involved, the most common

treatment modality is radical extirpation of the muco-cele, cranialization, and nasofrontal duct obliteration

through transcranial access.24 The success of oblitera-

tion depends on the careful extirpation of the mucosa,

permanent closure of the nasofrontal duct, and the

choice of appropriate obliteration material. Oblitera-

tion of the nasofrontal duct aims to prevent an

ascending frontal sinus infection and prevent the

growth of the nasal mucosa upward into the frontal

CARMICHAEL AND KANG 2161

sinus. To date, no consensus has been reached on the

ideal obliteration material.1

Because mucoceles can develop years after trauma

without any peak in incidence, it has been advocated

that patients who have sustained frontal sinus injuries

be monitored for life and that these patients should be

informed of the possibility of mucocele development

to be aware of the possible symptoms over time.13

The most sensitive follow-up modalities for early

mucocele detection are CT and MRI.3,25

In conclusion, frontal sinus mucoceles and muco-

pyoceles are infrequent occurrences and rarely pre-

sent as a subcutaneous forehead mass. The present

case demonstrates that a subcutaneous soft tissue

swelling or mass on the forehead can be the initial pre-

senting sign of a frontal sinus mucocele or mucopyo-cele, reminding us of the importance of life-long

follow-up in patients sustaining frontal sinus injuries.

References

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