Giant Frontal Sinus Mucocele With Headache and Vision Changes: Case Report

ABSTRACT

Giant frontal sinus mucoceles, caused by ostial obstruction, can lead to severe complications such as headaches, vision impairment, and brain compression. Early diagnosis through imaging and prompt surgical intervention, such as craniotomy, is critical to remove mucopurulent debris and necrotic bone, preventing vision loss and intracranial complications. For giant frontal sinus mucoceles with extensive bony necrosis and intracranial extension, open craniotomy for complete debridement of mucopurulent debris and necrotic bone may be necessary over endoscopic marsupialization to prevent recurrence and intracranial complications, despite the trend toward minimally invasive surgery.

1. Introduction

A mucocele in a para‐nasal sinus is essentially a buildup of mucus and shed lining tissue inside the sinus. Over time, this causes the sinus walls to stretch and expand, leading to a cyst‐like growth that can potentially damage surrounding structures. It's a condition that can grow and affect the area over time [1]. They account for approximately 65% of all paranasal sinus mucoceles, with the frontal sinus being the most commonly affected site; their progressive growth can cause significant complications, including bone erosion, intracranial extension, and compression of adjacent structures such as the brain or optic nerves [1, 2]. Clinical presentations on the size and extent of the lesion may include forehead swelling, headache, visual disturbances, or even neurological deficits.

The diagnosis relies on imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) [1, 3]. CT scans are pivotal in assessing bone erosion and sinus anatomy, while MRI provides detailed information about soft tissue involvement. Prompt surgical intervention is the treatment of choice to prevent severe complications [4].

This report describes a rare case of a giant frontal sinus mucocele, causing cortical thinning and mild brain compression, presenting with occipital headaches, vision impairment, and forehead swelling [5]. This case underscores the importance of early diagnosis, imaging, and surgical excision to avoid complications and achieve a favorable outcome. Furthermore, it highlights the specific surgical decision‐making process that may necessitate an open craniotomy approach over endoscopic techniques for complex, infected lesions with significant bony destruction.

2. Case Presentation

Informed consent for publication of this case report was obtained from the patient. A 65‐year‐old female from Dharan presented with a history of progressive swelling on her forehead for 1 year. The patient was asymptomatic initially; however, the lump gradually increased in size over six months, accompanied by severe occipital headaches, which were exacerbated by forward bending and associated with blurred vision. There was no history of trauma, loss of consciousness, vomiting, seizures, weight loss, fever, or voice changes. On examination, her Glasgow Coma Scale (GCS) score was 15, normal pupils, vital stable (BP 120/80, HR 80, RR 22, SpO2 98%), afebrile, clear lungs, normal heart sounds, no abnormalities detected. Systemic examination revealed no significant abnormalities.

3. Differential Diagnosis, Investigations and Treatment

Radiological investigations showed a large, non‐enhancing lesion in the left frontal sinus on CT (Figure 1), consistent with a giant frontal sinus mucocele. MRI revealed a lobulated lesion with hyperintensity on T1/T2‐weighted images, indicating proteinaceous/mucoid content, mild compression of the underlying frontal lobe, and posterior displacement and compression of the left orbital roof, explaining the patient's visual disturbances, brain, and no edema.

FIGURE 1.

Axial CT scan of the head (bone window) demonstrating an expansile lesion in the left frontal sinus with significant bony erosion and intracranial extension.

Preoperative tests revealed mild tricuspid/mitral regurgitation with normal LVEF (60%–65%). Lab results showed mild anemia (Hb 11.4), normal electrolytes, renal/liver function, and controlled blood sugar. A mucocele culture detected Acinetobacter baumannii (sensitive to amikacin, cotrimoxazole, and levofloxacin). All other parameters were within safe limits for surgery. Surgical management involved craniotomy and excision of the mucocele under general anesthesia (Figure 2). Intraoperative findings included 50 mL of mucopurulent material and necrosis of the frontal bone extending into the sinus. The procedure lasted 2 h and 15 min with 450 mL of blood loss. The patient required 4500 mL of intravenous fluids and had an uneventful postoperative course.

FIGURE 2.

Intraoperative photograph showing the exposed mucocele cavity following frontal craniotomy and debridement of necrotic bone.

Postoperatively, she was managed with intravenous levofloxacin (750 mg once daily) for a total of 14 days, guided by culture sensitivity, analgesics, and fluids, spending 2 days in the ICU for observation. At discharge, the patient was hemodynamically stable, afebrile, and tolerated oral intake with no neurological deficits. She was advised to do daily wound dressing, staple removal after 10 days, and follow‐up in the neurosurgery outpatient department in 2 weeks. The complete clinical timeline has been shown in Table 1.

TABLE 1.

Clinical timeline of diagnosis and management.

Time point	Clinical event
Year‐1 to month‐6	Asymptomatic progressive forehead swelling.
Month‐6 to presentation	Swelling increased. Onset of severe occipital headaches and blurred vision.
Day 0	Hospital admission, clinical and radiological (CT/MRI) diagnosis.
Day 1	Preoperative workup and antibiotic initiation.
Day 3	Surgical intervention: Craniotomy and excision of mucocele.
Day 3–5	Postoperative ICU observation for 2 days.
Day 7	Discharge with wound care instructions.
Day 17	Scheduled staple removal.
Week 4	First outpatient follow‐up.

4. Conclusion and Results (Outcome and Follow‐Up)

The need for prompt identification and treatment of enormous giant frontal sinus mucoceles is demonstrated by this case. Even though these lesions are usually benign, if treatment is not received, they may cause serious complications, including intracranial expansion and visual disturbances. To determine the extent and character of the lesion and guide appropriate surgical planning, radiological imaging, especially CT and MRI, is essential. In this case, a successful craniotomy and total excision of the mucocele led to a positive postoperative result. This case specifically illustrates that giant mucoceles with extensive bony necrosis and infection may require an open cranial approach for definitive management. The patient's follow‐up strategy includes clinical review and nasal endoscopy at 3 months to confirm patency, with surveillance imaging reserved for symptomatic recurrence. At her 4‐week follow‐up, she remains asymptomatic with a well‐healed scar.

5. Discussion

Mucoceles are mucus‐filled sacs lined by sinus epithelium that form within an air sinus due to a blocked outlet. This obstruction can lead to sinus expansion as the trapped mucus gradually erodes the surrounding bony walls. Mucus builds up in frontal sinus mucoceles, which are uncommon, benign, slow‐growing lesions brought on by blockage of sinus drainage routes.

Large mucoceles can cause symptoms like headaches, vision problems, forehead swelling, and, in rare cases, neurological impairments, even though they are usually asymptomatic in the early stages [1, 2].

In this instance, a huge frontal sinus mucocele that had gotten worse over the course of a year was present when the patient first arrived. The magnitude and mass effect of the lesion are reflected in the accompanying symptoms, which include intense headaches and blurred vision [2]. Frontal mucoceles are diagnosed via CT (shows bony expansion) and MRI (differentiates mucus from tumors). Endoscopy assesses obstruction. Complications include orbital/intracranial spread ([6, 7]). The gold standard way to diagnose a mucocele is with a CT scan (to check bone changes) and an MRI (to evaluate soft tissue spread) [7]. On a CT scan, a frontal mucocele typically appears as an expansile lesion within the sinus, demonstrating bony thinning or erosion with smooth, well‐defined margins. The mucoid content appears as a homogeneous low‐density material [7]. On MRI, the mucocele is characteristically variable on T1 (from hypo‐ to hyperintense based on protein content) and hyperintense on T2‐weighted images, reflecting its fluid‐filled nature. Importantly, it shows no contrast enhancement, helping differentiate it from tumors or abscesses [8]. The diagnosis of this case was made by imaging techniques like CT and MRI, which showed the extent of the lesion, its proteinaceous content, and the compression of nearby brain and orbital regions. A reasonably circumscribed lesion without invasive features was suggested by the lack of edema and substantial neurological damage on imaging, as shown in image 2.

The primary treatment is surgical drainage, with endoscopic marsupialization being the preferred approach. For complex cases, osteoplastic flap surgery may be required. Antibiotics are used only if infected (pyocele). The gold standard treatment is endoscopic marsupialization (first‐line) or open approaches (for complex cases) [9]. While endoscopic marsupialization is the gold standard for most frontal sinus mucoceles, this case presented specific indications for an open craniotomy approach. The decision was based on the lesion's giant size with significant intracranial extension and mass effect, which complicates complete endoscopic visualization and access. Crucially, the intraoperative finding of extensive necrosis of the frontal bone indicated associated osteomyelitis, necessitating complete excision of devitalized bone to eliminate a nidus for recurrence—a procedure best achieved via an open approach. Furthermore, the presence of infected mucopurulent material ( Acinetobacter baumannii ) favored a definitive procedure allowing for exhaustive debridement. Surgical intervention is indicated for symptomatic mucoceles (headache, visual changes), orbital/intracranial extension, or cosmetic deformity [7]. Asymptomatic cases may be monitored if stable [6]. In our case, a craniotomy was done, and the lesion was completely removed based on the above rationale, as shown in image 1.

Frontal mucocele surgery has excellent outcomes, with low recurrence (< 5%) if proper drainage is achieved [9]. Results have been greatly enhanced by developments in imaging and surgical methods, such as minimally invasive endoscopic operations. However, open surgical techniques are frequently required for complex lesions, like the one in this patient. This case demonstrates that the choice of surgical approach must be tailored to the specific pathology.

The presence of mucopurulent debris and necrotic frontal bone after surgery emphasizes how crucial complete debridement is to avoiding recurrence. The success of careful surgical and postoperative care was demonstrated by the uneventful postoperative course. The significance of early detection and action in the treatment of sinus mucoceles is highlighted by this case. Despite being benign, consequences including intracranial expansion, infection, or irreversible vision loss can result from a delayed diagnosis. These lesions have the potential to grow over time, which could lead to compression of nearby structures and erosion of the bone sinus walls.

To keep an eye out for problems or recurrence, follow‐up care is essential. After surgery, patients require monitoring of symptoms (headaches, vision) and may undergo nasal endoscopy in 1–3 months to confirm healing. Scans (CT/MRI) are reserved for recurrent symptoms. Most patients recover completely [7]. In this case, her initial follow‐up showed normal healing—no pain, swelling, or vision issues. The surgical site was well‐healed. Long‐term management involves surveillance for recurrence, particularly in cases with significant bony involvement. This instance illustrates how important a multidisciplinary approach involving otorhinolaryngology, neurosurgery, and radiology is in achieving good results for complicated sinonasal diseases.

Author Contributions

Sujan Ghimire: conceptualization, writing – original draft, writing – review and editing. Ritika Bhatta: writing – original draft, writing – review and editing. Yagya Raj Sharma: writing – original draft, writing – review and editing. Vitasta Muskan: conceptualization, supervision, writing – original draft, writing – review and editing. Alok Dahal: conceptualization, supervision, visualization, writing – original draft, writing – review and editing.

Funding

The authors have nothing to report.

Disclosure

All the authors declare that the information provided here is accurate to the best of our knowledge.

Ethics Statement

Ethical approval was exempted by the BP Koirala Institute of Health Science for case reports.

Consent

Written informed consent was obtained from the patient for publication.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.