The “frontal peak” sign: a potential new indication of open approach in frontal sinus mucoceles with posterior table erosion. A retrospective chart review of thirty-seven patients

To date, most frontal mucoceles are treated endoscopically, provided that there is no major neo-osteogenesis and that the frontal sinus floor is wide enough to provide an adequate working space: the presence of a sinus wall dehiscence is not considered as a contraindication to an endoscopic approach.

We report on a series of 37 patients presenting with frontal sinus mucoceles with posterior table erosion. Thirty-three (89.2%) had minimal erosion and/or a limited protrusion of the mucocele within the anterior cranial fossa on CT-scan, and were successfully operated on through an endoscopic approach.

Four patients (10.8%) displayed a distinct aspect of "frontal peak" on CT-scan, namely an acute angle between the edge of the bony erosion and the dura.

The first 2 patients were operated on through an endoscopic approach and presented with a delayed cerebrospinal fluid leak requiring a duraplasty through an open approach: in both cases, a laceration of the dura against the sharp bony edge of the erosion was found intra-operatively. The 2 other patients were primarily operated on through an open approach to drill out this frontal peak and prevent any dural trauma.

Based on this observation, we suggest that an open approach should be considered in cases of frontal mucoceles with erosion of the posterior table with the "frontal peak" sign.

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