Three-Stage Orbitocranial Reconstruction After Drainage of a Giant Frontoethmoidal Mucocele With Secondary Cholesterol Granuloma Reaction and Complete Orbital Roof Erosion: A Case Report

Orbital cholesterol granuloma and frontoethmoidal mucocele are benign expansile lesions usually managed by drainage and curettage through small bony defects.When erosion involves the entire orbital roof, reconstruction becomes the main determinant of functional and esthetic outcome.A 63-year-old woman without chronic comorbidities presented with a two-year history of headache, right periorbital swelling, and language impairment that progressed to severe proptosis and complete right-eye blindness.Imaging showed a cystic lesion with maximum diameters of 82.1 × 75.8 × 74.6 mm and orbital, maxillary, and intracranial extension into the anterior and middle fossae.A three-stage procedure was performed with sequential participation of ophthalmology, neurosurgery, and maxillofacial surgery.The capsule was incidentally opened during the orbital approach, draining 130 mL of mucinous material; the resulting decompression allowed the planned orbital exenteration to be abandoned.A three-piece frontoorbitozygomatic craniotomy, partial capsulectomy, cranialization of the frontal sinus, titanium mesh reconstruction of the orbital roof and anterior fossa floor, and a three-layer dural repair with a pedicled pericranial flap were performed.Histopathology showed a cyst wall of dense fibrous connective tissue lined by ciliated columnar epithelium with extensive squamous metaplasia, together with an acute inflammatory infiltrate and, within the underlying stroma, a foreign-body type giant cell reaction with cholesterol clefts and foamy histiocytes.The epithelial lining identifies the lesion as a frontoethmoidal mucocele and the granulomatous component as a secondary cholesterol granuloma reaction.The postoperative course was complicated by hemodynamic instability requiring neurocritical care and by a surgical site infection, which resolved with targeted antimicrobial therapy and without removal of the reconstructive hardware.Over 23 months of follow-up, mutism resolved completely -attributed by psychiatry to major depression -the Glasgow Coma Scale score was 15, and right-eye vision recovered from total blindness to counting fingers, with preserved orbital symmetry and contour.The three-stage sequence with layered reconstruction preserved the globe, sealed the communication between the orbit, maxillary sinus, and cranial fossa, and achieved an acceptable esthetic result.Flexibility of the intraoperative plan and coordinated multidisciplinary management were decisive.The main transferable lesson is that, in benign expansile lesions of the orbit, the absence of light perception and of a direct pupillary light reflex does not by itself establish that the globe is beyond recovery nor justify exenteration: decompression deserves to be attempted before an irreversible ablative decision is taken.