Dear Editor

We read the article “Transcaruncular approach for the management of frontoethmoidal mucocoeles” by Lai et al. [1] with interest.

The authors report a modification of the non-obliterative external procedure that was first described by Lynch in 1921.[2] The Lynch-Howarth procedure [2-4] involved trans-nasal stenting to prevent medial-ward collapse of the orbit obstructing drainage from the frontal sinus into the nose. Although the transcaruncular procedure uses a different external approach, it nevertheless often involves removal of part of the lamina papyracea for access to the sinuses. Hence, as with the Lynch approach, prolapse of orbital contents into the defect may occur, increasing the risk of re-stenosis. In addition, the cells in the frontal recess are not formally cleared and thus drainage into the nasal cavity is not assured. Stenting of sinus openings results in a significant fibrotic reaction in a proportion of patients, and closure of such a previously stented opening is likely. Furthermore, the follow-up period in this study is too short to confirm the success or failure of this technique as recurrence often takes years to manifest.[4]

Endoscopic management of mucocoeles protruding into the other sinuses or nasal cavity has been an accepted treatment for years.[5-9] Frontoethmoidal mucocoeles are typical of such mucocoeles where the bony wall surrounding the mucocoele is thin and therefore easily accessible trans-nasally. The endoscopic procedure creates a large area clear of cells which allows the greatest possible marsupialization of the mucocoele. No stenting is required. Har et al.[9] reported the largest series of 108 mucocoeles with a median follow-up of 4.[7] years with a recurrence rate of only 0.9%. Therefore, we would recommend an endoscopic approach for frontoethmoidal mucoceles as the integrity of the lamina papyracea is maintained and the largest possible opening is created into the mucocoele, which in turn minimizes the chances of recurrence.

References

(1) Lai PC, Liao SL, Jou JR et al. Transcaruncular approach for the management of frontoethmoid mucoceles. Br J Ophthalmol 2003;87:699-703.

(2) Lynch RC. The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope 1921;31:1-5.

(3) Surgical procedures on the paranasal sinuses: the frontal sinus. In The paranasal sinuses: surgery and technique, 2nd edition, Ritter FN (Ed). St. Louis: Mosby, 1978: 136-45.

(4) Neel HB, McDonald TJ, Facer GW. Modified Lynch procedure for chronic frontal sinus diseases: rationale, technique, and long-term results. Laryngoscope 1987;97:1274-79.

(5) Kennedy DW, Josephson JS, Zinreich SJ et al. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 1989;99:885-95.

(6) Schaefer SD, Close LG. Endoscopic management of frontal sinus disease. Laryngoscope 1990;100:155-60.

(7) Har-EL G, Balwally AN, Lucente FE. Sinus mucoceles: is marsupialization enough? Otolaryngol Head Neck Surg 1997;117:633-40.

(8) Lund VJ. Endoscopic management of paranasal sinus mucocoeles. J Laryngol Otol 1998;112: 36-40.

(9) Har-EL G. Endoscopic management of 108 sinus mucoceles. Laryngoscope 2001;111:2131-34.