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Frontal Mucocoeles: The Frontal Pick

Objective: Treatment of frontal mucocoeles through an endoscopic approach is a cornerstone of minimally invasive surgery. However lysis of the posterior wall of the frontal sinus may provide significant morbidity. The focus of this study is to propose an algorithm to select mucocele drainage versus sinus obliteration. Method: Retrospective review based on 37 cases of frontal mucocoeles with erosion of the posterior wall treated from 2000 to 2009. Results: While most of the cases with extensive posterior wall lysis have been successfully addressed through minimal invasive treatment, two patients presented with a “frontal pick” (ie, localized posterior wall deformity). The first patient underwent intractable CSF rhinorrhea 3 months after endoscopic marsupialization of the cyst. A “frontal pick” could be visualized, which had torn open the dura due to the relief of mucocele counterpressure. A subfrontal approach allowed obliteration of the sinus and performance of a duraplasty. The second patient was identified and successfully approached subfrontally, which allowed dissection of the frontal pick. Conclusion: When posterior wall of the frontal sinus results in a sharp-angled deformity of the posterior wall, then endoscopic marsupialization may result in CSF rhinorrhea due to tearing of the dura after relieving the counter pressure exerted by the mucocele. A sinus obliteration should then be performed.