anatomy of frontal sinus & recess

Anatomy of the Frontal Sinus

and Frontal Recess

Frontal Sinus Instructional Course

Christopher T. Melroy, MD

Frederick A. Kuhn, MD, FARS, FACS

Frontal Sinus Anatomy

The Frontal Recess is the most

common single site of recurrent or

persistent disease after intranasal

ethmoidectomy.

Kuhn FA & Kennedy DW, Analysis of Causes of Recurrent /

Persistent Disease Following Intranasal Ethmoidectomy, 8th

ISIAN, Baltimore Md., June 1989.

Internal frontal ostium

Frontal recess

Frontal sinus

Internal infundibulum

Frontal Sinus Drainage Pathway

• Narrowing of the frontal

sinus before it drains

into the internal frontal

ostium

Frontal Infundibulum

CM

FS

infu

n

Frontal Infundibulum

Imagine yourself up in a frontal

sinus…

floating down, over, and around

the tops of a complicated group

anterior ethmoid cells…

And finally entering the nose in

the middle meatus, behind the

uncinate

THIS IS THE FRONTAL RECESS !!

Frontal Recess

Frontal Recess

Frontal Recess

Agger nasi cell

Frontal Recess:

• Term first used by Killian in 1898

• Used by J. Parsons Schaeffer 1916, 1920

• Used extensively by Dr. Van Alyea –

1934, 1939, 1941 and 1946

•Van Alyea, D.E., Archives of Otolaryng., 29:881-901, 1939.

Frontal Sinus Anatomy

Frontal Sinus Anatomy(Embryology)

Frontal Sinus Anatomy (Embryology)

Schaeffer and Kasper - 4 frontal pits

• 1st pit - Agger Nasi cell

• 2nd pit - Frontal Sinus

• 3rd pit - Supraorbital ethmoid cell

• 4th pit - other anterior ethmoid cells

Schaeffer, JP, Amer J Anatomy, 20:125-145, 1916.

Kasper, KA, Archeves of Otolaryn, 23:322-343, 1936.

Frontal Sinus Embryology(the frontal pits/furrows)

Develop from the lateral

nasal wall

1st – Agger Nasi cell

2nd – Frontal Sinus

3rd – Supraorbital Ethmoid

Cell•Develops behind the FS and

extends over the orbit

Frontal Sinus Anatomy

Frontal Sinus Anatomy

Frontal Sinus Anatomy

Frontal Recess Cells:

•Agger Nasi cell

•Frontal cells

•Supraorbital ethmoid cell

•Frontal Bulla cell

•Suprabullar cell

Agger Nasi Cell

Agger Nasi Cell, M.T. basal lamella Bulla Lamella M.T. basal

lamella

ANC MT basal lam. MT basal lam.Bulla lam.

Frontal Sinus Anatomy

Opaque Frontal Recess … Obstructed by ANC

Frontal Cells

Current Definition

• Impinges on frontal recess or frontal

sinus

• Communicates with frontal recess

• distinct from agger nasi, supraorbital

ethmoid, suprabullar & frontal bullar

• 4 variations, types I-IV

Frontal Cell Types

Type I - Single cell, above Agger Nasi cell

Type II - Tier of cells may invade frontal s.

Type III - Single massive cell, invades

frontal sinus, attached to ant. table

Type IV - Single isolated cell in frontal sinus

no obvious connection to frontal

recess, not attached to ant. or

posterior table

Frontal Cells

Type I Frontal cell Type II frontal cell

**

Type II Frontal Cells

*

*

A

N

C

Type III Frontal Cell

Type III Frontal Cells

III

skull base

Type III Frontal Cell- fixing the bad result -

Type IV Frontal Cell

Type IV frontal cell Type IV frontal cell?

no.

Supraorbital Ethmoid Cell

• From 3rd frontal furrow

• Posterior and lateral to

frontal sinus

• Pneumatizes into the

frontal bone over the

orbit and behind the FS

• May extend lateral to FS

• Partition separates this

from FS

*

Supraorbital Ethmoid Cell

CM SOE

The FS is anterior and medial to the SOE

Supraorbital Ethmoid Cell

Supraorbital ethmoid Pneumatizes over

orbit, behind FS

The FS is anterior and medial to the SOE

Supraorbital Ethmoid Cell

The FS is anterior and medial to the SOE

Frontal Sinus Anatomy

Frontal Sinus Anatomy

Pre-op Post-op

Frontal Sinus Anatomy (R)

Pre-op Post-op

SOE was mistaken for FS

FS is closed

FS is anterior and medial

to SOE

Frontal Bulla Cell

Frontal Bulla Cell vs. Suprabullar Cell

Frontal Bulla Cell

* *

Suprabullar Cell

Frontal ostium

Supraorbital

ethmoid cell

Suprabullar Cell

Suprabullar Cell

IFSSC

•Pneumatization of the septum

between the frontal sinuses

•May involve a pneumatized crista galli

•May drain high into FS or low into

frontal recess

Interfrontal Sinus Septal Cell

Interfrontal Sinus Septal CellC

M IF

SS

C

Frontal Sinus Anatomy

Must be mastered before

performing frontal sinus

surgery.

Balloon Dilation

of the Frontal Sinus

Outflow Tract

Frontal Sinus Instructional Course

Christopher T. Melroy, MD

Frederick A. Kuhn, MD, FARS, FACS

Disclosure: I have received honoraria for physician training and speaking engagements from Acclarent, Inc.

• Rationale

– Most minimally-invasive way to

open a frontal sinus drainage

pathway

• Concept

– Cell walls in the frontal recess are

fractured to widen the frontal

sinus drainage pathway

Balloon Frontal Sinusotomy

Balloon Frontal Sinusotomy- technique -

CM

bra

tch

Balloon Frontal Sinusotomy- technique -

CM

bra

tch

Balloon Frontal Sinusotomy- technique -

CM

bra

tch

Balloon Frontal Sinusotomy- technique -

Balloon Frontal Sinusotomy- technique -

CM

bra

tch

• Extensive polyposis

• Known skull base trauma or defect

Balloon Frontal Sinusotomy- contraindications -

Applications / Indications:

– Primary surgery

– Revision surgery

– Management of postop ostial stenosis

• Including use in the office

– Finding the frontal sinus

– Moving cell walls within the frontal sinus

Balloon Frontal Sinusotomy

Management of postop ostial stenosis

• Including use in the office

CM

FS

sca

r

Balloon Frontal Sinusotomy- uses -

Moving cell walls within the frontal sinus

Without trephination Without osteoplastic flap

Balloon Frontal Sinusotomy- uses -

Complications (FDA database)

• Orbital injury n=2

• Passing guidewire through lamina

• No sequelae

• CSF leak n=1

• One reported case: standard instrumentation

was also used. Frontal surgery-> leak at sph.

COMPLICATION RATE – 0.010% of pts (1/10,000)

= 0.0035% of sinuses

Balloon Frontal Sinusotomy- complications -