Reconstruction for a mucocele of an old frontal sinus...
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84 Introduction n the treatment of a mucocele that developed after an old frontal bone fracture, surgically established drainage of the frontal sinus and aesthetic reconstruction are essential. Reconstruction surgery is generally performed by using autologous tissues with abundant blood flow that provides resistance to infection. 1-3 We treated a mucocele that occurred 23 years after the treatment of a frontal bone fracture, in other words, drainage from the frontal sinus was first established and then reconstruction of the deformity of the forehead by the combination of a free dermal fat graft devoid of blood flow and artificial bone was performed. In the present study, we report that we were able to obtain satisfactory results both functionally and aesthetically. Case study A 57-year-old man, who visited the hospital with a common cold, was found to have a cutaneous fistula in Case Report Kitasato Med J 2011;41:84-89 Received 2 November 2010, accepted 5 November 2010 Correspondence to: Yuta Niimi, Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan E-mail: [email protected] Reconstruction for a mucocele of an old frontal sinus fracture Yuta Niimi, 1,2 Mitsuru Nemoto, 2 Yasuyuki Oyatsu, 1 Takeshi Nakamura, 1 Eiju Uchinuma 2 1 Department of Plastic and Reconstructive Surgery, Saku Central Hospital, Nagano 2 Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine We performed reconstruction surgery of an old frontal bone fracture complicated with a mucocele for a 57-year-old man. The crucial issues in the treatment of a mucocele that develop after an old frontal bone fracture are the proper treatment of frontal sinus, closure of the patency between the frontal sinus and cranial cavity, and reconstruction of the facial structure. In the initial surgery, the mucocele was cured by removing resin implanted in the frontal sinus and opening the nasofrontal duct and the ethmoid sinus. In the second surgery, the patency between frontal sinus and cranial cavity was closed by using a free dermal fat graft obtained from the abdominal region, because tissues around the forehead could not be used due to the effect of trauma. The thinned skin was reinforced in thickness with the free dermal fat graft. The normal part of the scalp was expanded with a tissue expander to have no skin defect in the third surgery. Also in the third surgery, for the reconstruction of the facial structure, artificial bone was used, because autologous bone was difficult to use due to the large defect and deformity of the frontal bone caused by the traumatic injury. For the reconstruction with combined use of a free dermal fat graft and artificial bone, multiple surgical steps were required. An excellent reconstruction procedure was achieved because of little sacrifice from the donor, indicating minimal invasiveness, as well as from the aesthetic point of view. Key words: old frontal sinus fracture, mucocele, reconstruction his forehead. The patient had undergone surgery to implant resin in the frontal sinus because of a frontal bone fracture sustained in a traffic accident 23 years earlier. The patient's skull in the area of the forehead was depressed and a serous exudate was observed, but there was no redness or swelling (Figure 1). The blood test results revealed no particular findings other than a white blood cell count of 9,200/ μ l. A bacterial culture test of the exudate was negative. In the x-ray examination, a defect in the frontal bone and reduced transparency in the right maxillary sinus were observed (Figure 2). Computed tomography (CT and 3D image) revealed swelling of the frontal sinus mucosa and a large defect in the frontal bone (Figure 3, 4). In the magnetic resonance image (MRI), although no fluid accumulation was detected in the frontal sinus, an image that was supposed to be suggestive of granulation tissue was found in the ethmoid sinus (Figure 5). Since we suspected an infection caused by the resin implanted in the frontal sinus, we decided to remove the resin. At the initial surgery, the resin implanted in the frontal sinus was removed with a I
Transcript of Reconstruction for a mucocele of an old frontal sinus...
84
Introduction
n the treatment of a mucocele that developed after anold frontal bone fracture, surgically established
drainage of the frontal sinus and aesthetic reconstructionare essential. Reconstruction surgery is generallyperformed by using autologous tissues with abundantblood flow that provides resistance to infection.1-3 Wetreated a mucocele that occurred 23 years after thetreatment of a frontal bone fracture, in other words,drainage from the frontal sinus was first established andthen reconstruction of the deformity of the forehead bythe combination of a free dermal fat graft devoid of bloodflow and artificial bone was performed. In the presentstudy, we report that we were able to obtain satisfactoryresults both functionally and aesthetically.
Case study
A 57-year-old man, who visited the hospital with acommon cold, was found to have a cutaneous fistula in
Case Report Kitasato Med J 2011;41:84-89
Received 2 November 2010, accepted 5 November 2010Correspondence to: Yuta Niimi, Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, JapanE-mail: [email protected]
Reconstruction for a mucocele of an old frontal sinus fracture
Yuta Niimi,1,2 Mitsuru Nemoto,2 Yasuyuki Oyatsu,1 Takeshi Nakamura,1 Eiju Uchinuma2
1 Department of Plastic and Reconstructive Surgery, Saku Central Hospital, Nagano2 Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine
We performed reconstruction surgery of an old frontal bone fracture complicated with a mucocele fora 57-year-old man. The crucial issues in the treatment of a mucocele that develop after an old frontalbone fracture are the proper treatment of frontal sinus, closure of the patency between the frontal sinusand cranial cavity, and reconstruction of the facial structure.
In the initial surgery, the mucocele was cured by removing resin implanted in the frontal sinus andopening the nasofrontal duct and the ethmoid sinus. In the second surgery, the patency betweenfrontal sinus and cranial cavity was closed by using a free dermal fat graft obtained from the abdominalregion, because tissues around the forehead could not be used due to the effect of trauma. The thinnedskin was reinforced in thickness with the free dermal fat graft. The normal part of the scalp wasexpanded with a tissue expander to have no skin defect in the third surgery. Also in the third surgery,for the reconstruction of the facial structure, artificial bone was used, because autologous bone wasdifficult to use due to the large defect and deformity of the frontal bone caused by the traumatic injury.For the reconstruction with combined use of a free dermal fat graft and artificial bone, multiple surgicalsteps were required. An excellent reconstruction procedure was achieved because of little sacrificefrom the donor, indicating minimal invasiveness, as well as from the aesthetic point of view.
Key words: old frontal sinus fracture, mucocele, reconstruction
his forehead. The patient had undergone surgery toimplant resin in the frontal sinus because of a frontalbone fracture sustained in a traffic accident 23 yearsearlier. The patient's skull in the area of the forehead wasdepressed and a serous exudate was observed, but therewas no redness or swelling (Figure 1). The blood testresults revealed no particular findings other than a whiteblood cell count of 9,200/μl. A bacterial culture test ofthe exudate was negative. In the x-ray examination, adefect in the frontal bone and reduced transparency inthe right maxillary sinus were observed (Figure 2).Computed tomography (CT and 3D image) revealedswelling of the frontal sinus mucosa and a large defect inthe frontal bone (Figure 3, 4). In the magnetic resonanceimage (MRI), although no fluid accumulation wasdetected in the frontal sinus, an image that was supposedto be suggestive of granulation tissue was found in theethmoid sinus (Figure 5). Since we suspected an infectioncaused by the resin implanted in the frontal sinus, wedecided to remove the resin. At the initial surgery, theresin implanted in the frontal sinus was removed with a
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Figure 1. Appearance at the initialpresentation
A large mucocele in the frontal region isseen.
Figure 2. X-ray image
A defect in the frontal bone and reducedtransparency at the right maxillary sinus isseen.
Figure 3. CT image
In the horizontal image, swelling of themaxil lary s inus mucosa and f luidaccumulation is seen.
Figure 4
In a 3D image, the whole frontal bone isseen as defective.
Figure 5. MRI image
Conspicuous hypertrophy in a part of themucosa in the ethmoid sinus was detected.
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Figure 6. Appearances at the initial surgery
A. Frontal sinus implanted with resin B. Frontal sinus after the resin was removed C. The removed resin
Figure 7. Appearances after the initial surgery
A. Front view B. Side view
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Figure 8. Appearances at the second surgery
A. Obtained dermal fat B. Dermal fat implanted between the frontalsinus and the dura matter
Figure 9. Appearances at the third surgery
A. Scalp has been preoperatively expandedwith a tissue expander.
B. The frontal bone is seen as it wasreconstructed with hydroxyapatite.
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coronal incision approach, and drainage tubes to thenasofrontal duct and the ethmoid sinus were emplaced(Figure 6A-C). The prominently depressed deformity ofthe forehead bone was reconstructed after the mucocelewas improved (Figure 7A, B). As the cause of thedeformity might be due to the thinned forehead skin andthe defect of the frontal bone, reconstruction of skin softtissues and hard tissues was performed in 2 surgical steps.In the second surgery performed 5 months after the initialsurgery, a free dermal fat graft obtained from theabdominal region was used to close the patency betweenthe frontal sinus and the dura matter and, at the sametime, to reinforce the thickness of the thinned forehead
skin (Figure 8A, B). Then, at the next hard tissuereconstruction, a tissue expander was inserted in theparietal region so as not to produce a skin defect. In thethird surgery performed 5 months after the second surgery,the frontal bone was reconstructed with a piece ofhydroxyapatite shaped with the aid of 3D (three-dimensional) CT to fit into the defective region, and thenthe surface of the hydroxyapatite was covered with scalppreoperatively expanded by a tissue expander (Figure9A, B). The mucocele has not recurred during these past5 years since the surgery. Furthermore, the aestheticresult of the surgery was excellent (Figure 10A-D).
Figure 10. Findings at 5 years after the surgery
C. X-ray, front view D. X-ray, side view
A. Front view B. Side view
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Discussion
There are two types of procedures in the treatment offrontal sinus repair in cases of frontal bone fracture: oneis the obliterating procedure4-6 in which after removingmucosa in the frontal sinus, implantation is made withautologous tissue or artificial material, and the other isan open procedure7,8 in which the frontal sinus cavity isconserved and the nasofrontal duct is kept open. Thepresent case is an example that had a mucocelecomplication after treatment for the frontal bone fractureby the obliterating procedure with resin implantation. Inthe obliterating procedure, even if the mucosa in thefrontal sinus was completely removed, mucosa wouldlater be regenerated. It has been reported that implantedautologous tissue or artificial material can causeinfection.9,10 In the present case, the onset of sinusitisinduced by a common cold might have triggered aprominent foreign body reaction, in which the mucosaregenerated in the frontal sinus manifested as aninteraction with the resin as a foreign body, resulting inthe formation of a mucocele.
Crucial issues in the treatment of frontal sinusitiscomplicated with a frontal bone fracture might be theproper treatment of frontal sinus inflammation, closurebetween the frontal sinus and the cranial cavity, and thereconstruction of the facial structure. In the treatmentfor the present case, the mucocele was improved byremoving the implanted resin in the frontal sinus andopening the nasofrontal duct and the ethmoid sinus. Forthe closure between the frontal sinus and the cranialcavity, autologous tissues with abundant blood flow suchas a skin flap, a periosteum flap, or a muscle flap playefficient roles for grafting.1-3 However in the presentcase, as the tissues around the forehead could not be useddue to the damage caused by trauma, a free dermal fatgraft harvested from the patient's own abdominal region(i.e., autologous tissue graft) was used for the closurebetween the frontal sinus and the cranial cavity. Althougha free dermal fat graft has advantages of being easy toadjust the size and thickness of tissues, it has a risk ofinfection during the time period until the graft has settled.In the present case, the graft was performed after aninterval of 5 months from the initial surgery, during whichperiod the mucocele was almost cured. For thereconstruction of facial structure, reconstruction of bothcutaneous soft tissues and hard tissues is required. In thepresent case, thinned skin was reinforced in thicknesswith a free dermal fat graft, and concurrently normalscalp was expanded with a tissue expander, ensuring nodefect of skin at the final surgery. If the defect in the
frontal bone is small, the graft of the cranial bone with avascular pedicle is possible. However in the presentcase, since the reconstruction with autologous boneseemed difficult, judging from the size and shape of thedefect in the frontal bone, artificial bone was used. Nofrontal sinusitis was a prerequisite for the reconstructionwith combined use of a free dermal fat graft and artificialbone. Although this reconstruction procedure requiredmultiple steps of surgery, it had the merits of beingminimally invasive with a relatively small sacrifice tothe donors and provided good aesthetic results.
In conclusion, in the treatment of a mucocele involvingan old frontal bone fracture, reconstruction with thecombined use of a free dermal fat graft devoid of bloodflow and artificial bone was possible, if the closure of thepatency between the frontal sinus and the cranial cavitywas confirmed after sufficient drainage from the frontalsinus. In old frontal bone fractures, the reconstructionprocedure should be determined on a case-by-case basisby evaluating the status of the injury to the frontal sinuswith image analysis and by careful intraoperativeobservations.
References
1. Kashiwa K, Nara T, Minato S, et al. Median foreheadflap for an old frontal sinus fracture: a case report.Jpn J Plast Surg 1989; 32: 653-60.
2. Onishi K, Nakajima T, Nakanishi Y, et al. Treatmentof frontal sinus fractures. Jpn J Plast Surg 1990; 33:1225-34.
3. Iida N, Nishimaki K, Noto H, et al. A case of frontalbone defect complicated with a fistula of the ethmoidsinus. Keisei Geka 2000; 43: 1025-31.
4. Barton RT. The use of synthetic implant material inosteoplastic frontal sinusotomy. Laryngoscope 1980;90: 47-52.
5. Bosley WR. Osteoplastic obliteration of the frontalsinus. A review of 100 patients. Laryngoscope 1972;82: 1463-76.
6. Wolfe SA, Johnson P. Frontal sinus injuries: primarycare and management of late complications. PlastReconstr Surg 1988; 82: 781-91.
7. Lindorf HH. A contribution on revisional anddrainage of the frontal sinus by osteoplastic operation.J Maxillofac Surg 1986; 14: 34-9.
8. Luce EA. Frontal sinus fractures: guidelines tomanagement. Plast Reconstr Surg 1987; 80: 500-10.
9. Schenck NL. Frontal sinus disease. III. Experimentaland clinical factors in failure of the frontal osteoplasticoperation. Laryngoscope 1975; 85: 76-92.
10. Donald PJ. The tenacity of the frontal sinus mucosa.Otolaryngol Head Neck Surg 1979; 87: 557-66.
Reconstruction for a mucocele of an old frontal sinus fracture
