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We read the article by Lai et al1 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 procedure2–4 involved transnasal 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 mucoceles protruding into the other sinuses or nasal cavity has been an accepted treatment for years.5–9 Frontoethmoidal mucoceles are typical of such mucoceles where the bony wall surrounding the mucocele is thin and therefore easily accessible transnasally. The endoscopic procedure creates a large area clear of cells which allows the greatest possible marsupialisation of the mucocele. No stenting is required. Har-El9 reported the largest series of 108 mucoceles 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 mucocele, which in turn minimises the chances of recurrence.