# Frontal Sinus Mucocele with Intraorbital Involvement:
A Case Report

Achraf Saoudi, Nihed Abdelmoula, Nawress Thabet, Nour Ben Ahmed, Yasmine Ben Arif, Abdelfateh Slama

► To cite this version:

Achraf Saoudi, Nihed Abdelmoula, Nawress Thabet, Nour Ben Ahmed, Yasmine Ben Arif, et al. Frontal Sinus Mucocele with Intraorbital Involvement: A Case Report. Asian Journal of Research in Surgery, 2025, 8 (2), pp.521-527. 10.9734/ajrs/2025/v8i2328. hal-05376628

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# Frontal Sinus Mucocele with Intraorbital Involvement: A Case Report

Achraf SAOUDI a*, Nihed ABDELMOULA a,
Nawress THABET a, Nour BEN AHMED a,
Yasmine BEN ARIF a and Abdelfateh SLAMA a

## Authors' contributions

This work was carried out in collaboration among all authors. All authors read and approved the final manuscript.

## Article Information

DOI: https://doi.org/10.9734/ajrs/2025/v8i2328

**Open Peer Review History:**

This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers, peer review comments, different versions of the manuscript, comments of the editors, etc are available here: https://pr.sdiarticle5.com/review-history/147264

## Case Report

Received: 01/09/2025

Published: 20/11/2025

## ABSTRACT

Mucoceles are unusual cystic lesions filled with mucoid secretion. They develop secondary to blockage of the sinus drainage pathways. Despite their benign nature, their progressive growth can cause bone erosion and compression of adjacent structures. The frontal sinuses represent the most frequent site of occurrence. Managing sinus mucocele consists of surgical removal and sinus drainage.

We present the case of a 38-year-old male patient who presented with a 3-cm painful swelling of the left upper eyelid, causing ptosis. Radiological assessment suspected frontal mucocele with orbital and bone involvement. The tumour was removed through a trans ciliary incision. Reconstruction of the defect was performed with fat grating and Titanium mesh.

Keywords: Mucocele; sinus; frontal; cyst; tumor; orbit.

<footnote>a Oral and Maxillofacial Department, University Hospital Sahloul, University of Sousse, Faculty of Medicine of Sousse, Sousse, Tunisia.</footnote>

<footnote>*Corresponding author: E-mail: achrafsaoudi97@gmail.com;</footnote>
# 1. INTRODUCTION

Frontal sinus mucoceles are benign, slow-growing, expansile mucus-filled cavities resulting from the obstruction of normal sinus drainage or chronic mucus overproduction (Chowdhury et al., 2025). While inherently non-neoplastic, their growth can have significant clinical consequences due to the anatomical proximity of the frontal sinus to orbital and intracranial structures. Orbital involvement may lead to periorbital swelling, ptosis, proptosis, diplopia, or, in advanced cases, a compressive optic neuropathy (Chowdhury et al., 2025; Varghese et al., 2025).

Radiological evaluation is crucial, with computed tomography (CT) providing detailed information on bony erosion and magnetic resonance imaging (MRI) delineating soft tissue involvement and potential intracranial or intraorbital extension (Tsitouridis et al., 2007; Bouatay et al., 2019). Surgical management remains the mainstay of treatment, requiring, in some cases, an interdisciplinary collaboration involving maxillofacial, otorhinolaryngological and neurosurgical expertise (Ali, 2023).

This study highlights a case of frontal sinus mucocele with orbital involvement, emphasizing the clinical presentation, imaging findings, surgical management, and reconstructive approach, offering practical guidance for the management of similar cases.

# 2. CASE STUDY

## 2.1 Case History/Examination

We report the case of a 38-year-old man with no notable medical history who presented with a painful, progressive swelling of the left upper eyelid, which had been gradually increasing in size for one year leading to ptosis and visual disturbance. (Fig. 1) The patient reported a history of untreated facial trauma sustained during early childhood. Clinical examination revealed a tender, 2-cm swelling of the left upper eyelid, fixed to the deeper tissues and the superior orbital rim. Ophthalmologic evaluation confirmed left-sided ptosis, with fundoscopic examination showing no evidence of optic disc edema or atrophy. No diplopia was noted.

## 2.2 Investigations and Treatment

An ultrasound examination was performed, showing a well-defined cystic lesion, avascular

on Doppler, in intimate contact with the superior rectus muscle, causing displacement of the globe (Fig. 2).

An MRI was performed as a complementary investigation revealed a well-circumscribed lesion measuring 22*19*28 mm, with orbital palpebral extension, associated with erosion of both the anterior and posterior walls of the frontal sinus. No abnormal meningeal or parenchymal signal abnormalities were detected (Fig. 3).

<figure><img src="image_2.png" /><figcaption>**Fig. 1. Swelling of the left upper eyelid causing ptosis**</figcaption></figure>

Computed tomography confirmed bony erosion of the frontal sinus walls (Fig. 3).

Surgical access to the mucocele was achieved through a trans ciliary incision.

Dissection was carried out to expose the frontal bone which was eroded. A small frontal bone window was created.

Mucocele was exposed. It was situated in a cavity, separated from the frontonasal duct by a membrane. The lesion was meticulously separated from the surrounding tissue (Fig. 4).

Afterwards, the anterior bone defect was reconstructed with a titanium plate (Fig. 5).

The mucocele was situated within a sinus cavity isolated from the frontonasal duct by a bony septum. Subsequently, the cavity was obliterated with fat graft, and the sinus was kept functional and included.

## 2.3 Outcome and Follow-Up

Postoperatively, the patient showed favorable healing within 2 weeks. The surgical site showed appropriate healing with mild edema which improved over time. No signs of wound infection or neurological and ophthalmological complication were noted. Histopathological examination confirmed the diagnosis of sinus mucocele. At the five-month follow-up, the patient showed no signs of recurrence.
<figure><img src="image_3.png" /><figcaption>Fig. 2. Ultrasound image: A non-vascular cystic lesion displacing the globe</figcaption></figure>

<figure><img src="image_4.png" /><figcaption>Fig. 3. A. CT Image showing bone resorption (red arrow). B. MRI Image showing a well-defined lesion with high T2 signal displacing the eyeball downward (yellow arrow)</figcaption></figure>
<figure><img src="image_5.png" /><figcaption>Fig. 4. An intra-operative view demonstrating the trans ciliary approach, which provided direct access and removal of a frontal mucocele</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>Fig. 5. An intra-operative image demonstrating the reconstruction of the frontal bone with titanium plate</figcaption></figure>

### 3. DISCUSSION

The paranasal sinuses consist of four paired air-filled cavities located within the facial bones, lined by respiratory mucosa, and directly communicating with the nasal cavity. They serve functions such as lightening the skull, humidifying air, and aiding voice resonance (Cappello et al., 2025).

Sinus mucoceles result from an obstruction of the sinus ostium. The etiology of sinus outflow obstruction may be either primary or secondary. Primary mucoceles arise from impaired mucus drainage, which can result from chronic inflammation (such as sinusitis or allergic reactions), cystic dilatation of mucous glands, neoplastic obstruction, or anatomical variations affecting the sinus ostium, while secondary occur after sinus injury (Trauma, surgery) (Varghese et al., 2025; Kim et al., 2011; Cagigal et al., 2006).

Frontal mucoceles are the most common among all paranasal sinus mucoceles,

accounting for approximately 60% of cases (Ali, 2023). This may be explained by the high susceptibility of frontal sinus to trauma and the narrowness of the frontonasal duct (Chowdhury et al., 2025).

Post-traumatic mucoceles are well-documented, comprising 9-28% of cases and may develop years after initial trauma (Vishwakarma et al., 2017; Moniakis et al., 2024).

Our patient's childhood neglected trauma aligns with this latency pattern and likely contributed to mucocele formation.

Frontal mucoceles predominantly occur in adults aged between 30 and 70 years with no statistically significant gender predilection (Aladeyelu et al., 2025).

The clinical significance of mucoceles lies not in their histological behavior, which is non-neoplastic, but in their capacity to cause substantial morbidity through local mass effect (Varghese et al., 2025).
The local mass effect causes an increase in pressure and stress-induced bony remodeling. At the same time, the chronic inflammation within the obstructed sinus leads to the release of inflammatory mediators, which stimulate osteoclastic bone resorption (Aladeyelu et al., 2025).

Clinical manifestations often depend on the extent and direction of mucocele expansion. Frontal mucoceles have a close relation to the orbit and brain. Posterior extension may result in intracranial complications such as meningitis. While inferior or medial expansion can cause orbital symptoms, including proptosis, ptosis, diplopia, oculomotricity impairment or reduced vision (Varghese et al., 2025; Suri et al., 2004).

Radiological imaging is essential in diagnosis and preoperative planning.

CT imaging is the modality of choice for initial assessment. It provides excellent delineation of bony changes (Tsitouridis et al., 2007).

MRI is complementary to CT. Mucocele usually appear as a well-defined expansive mass with variable signal in T2 and T1, depending on mucocele proportions of water, mucus and protein. MRI adds value in differentiating mucoceles from other neoplastic lesions and in evaluating soft tissue involvement and intracranial or intraorbital spread (Tsitouridis et al., 2007; Bouatay et al., 2019).

Treatment of mucoceles is surgical and the access routes are either external or endonasal. The choice between endonasal, endoscopic, and open surgical techniques for the management of frontal sinus mucoceles remains guided by the extent of disease, anatomical accessibility, and the surgeon's expertise (Courson et al., 2014).

Endonasal approach represents the modality of choice of treating an uncomplicated frontal mucocele. It is a minimally invasive technique and offers highly effective treatment with reduced postoperative morbidity and shorter hospital stay (Suri et al., 2004).

Conversely, an open approach retains an essential role in the treatment of extensive mucoceles with intraorbital or intracranial extension, where endoscopic access may be technically limited. Open approaches offer direct access for complete resection and facilitate simultaneous reconstruction of bony defects (Ali, 2023).

A combined technique (external technique and endoscopy) may be used in more advanced cases (Santos et al., 2017).

A meta-analysis conducted by Courson et al. has demonstrated that both approaches achieve comparable recurrence rates. Recurrence in the endonasal approach is likely to happen when complicated cases are attempted endoscopically (Courson et al., 2014).

In the present case, the orbital extension of the lesion and the requirement for direct surgical access guided our choice of an open transciliary approach.

By following the natural curve of the eyebrow, this technique, which follows the natural curve of the eyebrow, offers a cosmetically favorable incision while providing optimal exposure of the frontal sinus floor and anterior wall. It allows accurate excision of the mucocele, followed by sinus cavity obliteration and reconstruction of the affected structures (Aggarwal et al., 2012; Robinow et al., 2023).

Among the various techniques used for defect obliteration, synthetic materials such as hydroxyapatite cement and acellular dermal matrix may be used, but are associated with notable limitations. These alloplastic materials may increase the risk of infection, inflammatory reaction, or poor long-term integration. Moreover, techniques using bone grafts and bone flaps can be performed but are associated with donor site morbidity and prolonged surgery time (Petruzzelli and Stankiewicz, 2002).

In contrast, autologous fat grafting is a widely used technique due to its biocompatibility, reproducibility, ease of harvesting, and low complication rate (Eledeissi et al., 2018).

Titanium mesh offers multiple advantages in craniofacial reconstruction. Its excellent biocompatibility results in minimal inflammatory response, making it well-tolerated by surrounding tissues. Moreover, the mesh is highly malleable, allowing precise shaping and contouring and causes negligible artefact on both MRI and CT-Scan (Lakhani et al., 2001).

The combination of autologous fat grafting and titanium mesh is a cost-effective technique, widely accessible, that ensures rigid structural support and reinforcement and avoids donor-site morbidity, while achieving favorable long-term outcomes with low complication rates (Eledeissi et al., 2018; Lakhani et al., 2001).
Courson et al stated that major complications such as cerebrospinal fluid leak, haemorrhage and orbital injury were statistically comparable between endoscopic and open surgical techniques. However, minor complications such as supraorbital nerve injury, bad scarring, alopecia and infection are more frequent in open approach (Courson et al., 2014).

These minor complications are not life-threatening and could be, in most cases, avoided or minimized.

Nerve injury is generally temporary with spontaneous recovery. It can be mitigated with a good understanding of anatomy, gentle use of retraction, and limited use of monopolar electrocautery.

Alopecia can be avoided by aligning the incision with the hair follicles and minimising electrocautery to avoid damage to the hair follicles and blood vessels.

In our case, no complication was noted.

In summary, this case report provides a holistic view on the diagnosis and surgical management of a frontal sinus mucocele with orbital involvement, emphasizing clinical, radiological findings and surgical approach. This study describes the trans ciliary approach and the combined use of autologous fat graft and titanium mesh for reconstruction, which yielded favorable outcome. However, further studies involving larger patient cohorts are needed to validate these findings. Long-term follow-up is essential to evaluate the risk of recurrence and the durability of the reconstruction.

## 4. CONCLUSION

Frontal sinus mucoceles, while benign, can lead to significant complications due to their potential for local tissue destruction and functional impairment. In complicated cases with bone erosion and orbital involvement, an open surgical approach via a trans ciliary incision can provide excellent exposure for complete excision and reconstruction. The use of autologous fat grafting in combination with titanium mesh is a reliable solution after mucocele removal.

## CONSENT

As per international standards or university standards, patient(s) written consent has been collected and preserved by the author(s).

## ETHICAL APPROVAL

As per international standards or university standards, written ethical approval has been collected and preserved by the author(s).

## DISCLAIMER (ARTIFICIAL INTELLIGENCE)

Author(s) hereby declare that NO generative AI technologies such as Large Language Models (ChatGPT, COPILOT, etc) and text-to-image generators have been used during writing or editing of manuscripts.

## COMPETING INTERESTS

Authors have declared that they have no known competing financial interests or non-financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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