FRONTAL SINUS SURGERY

Babak SaediAssociate Professor of Department

of OtolaryngologyTehran University of Medical

Sciences

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Anatomy

Uncinate process Agger Nasi

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Anatomy

Cribriform Plate Lamina papyracea Fovea ethmoidalis

FRONTAL SINUS MUCOCILIARY FLOW & CLEARANCE

Anatomic Variations

UNCINATE PROCESS

Wormald PJ 2008

Anatomy

A common reason for ESS failure is inadequate removal of cells

obstructing the outflow of the frontal sinus

Single Agger Nasi Cell Without Frontal Cells

Wormald PJ 2008

Single Agger Nasi Cell Without Frontal Cells

Wormald PJ 2008

Single Agger Nasi Cell Without Frontal Cells

Wormald PJ 2008

Transition From Frontal Sinus To Frontal Recess

Wormald PJ 2008

Frontal Cells

Kuhn FA 1994

Frontal Cells

Type I - Single cell above the agger nasi Type II - Two or more cells above the

agger cell Type III - Single cell extending from the

agger cell into the frontal sinus Type IV - Isolated cell within the frontal

sinus

Surgical Indications

Chronic sinusitis unresolved with maximal medical therapy;

Polyps and allergic fungal sinusitis Intracranial complications of sinusitis Mucoceles or mucopyoceles Benign neoplasms such as osteomas,

inverting papillomas, or fibrous dysplasia.

Finding The Frontal Recess

Finding The Frontal Recess

Endoscopic Frontal Sinusotomy

Understand the patient’s frontal recess anatomy

Ascertain the anatomical reason for frontal recess/frontal sinus obstruction

Determine the best surgical approach to the problem

Endoscopic Frontal SinusotomyPrinciples

Dissection should be performed from posterior to anterior and from medial to lateral

Preserve all frontal recess mucus membrane

The frontal ostium can be stented or left alone!!!!

Kuhn FA 2006

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Draf Procedures

Draf I

Anterior ethmoid cells Uncinate process Obstructing frontal cells

Draf II

Floor of the frontal sinus Lamina papyracea to Septum Anterior face of Frontal

Draf III

Modified Lothrop Interfrontal septum Nasal septum Frontal sinus floor

Surgical Outcomes Following the EndoscopicModified Lothrop Procedure

Conclusion: EMLP is a safe and effective surgical alternative to OPF for patients with recalcitrant frontal

sinus disease. Major complications are rare. A large percentage of patients may require revision surgery

Laryngoscope, 117:765–769, 2007

Frontal Sinus Trephination

Finding the frontal recess Mucoceles Isolated Type IV frontal cells With endoscopic techniques to assist

with Draf II and III

Combined Approaches

Endoscopic Frontal Sinoplasty

The least invasive procedure

It can be used as a stand-alone procedure or with ethmoidectomy

It pushes the medial agger nasi cell wall laterally and the ethmoid bulla lamella posteriorly

K

Kuhn FA 2006

Modified Lothrop

Frontal Recess & Frontal Beak

Wormald PJ 2008

Osteoplastic Flap Vs. Draf III

Narrow Nasal Airway Small Frontal Sinus Deep Nasion Floor of sinus < 1.5 cm Heavy thick nasofrontal beak Proliferative osteitis, complicated chronic

infection Favor Draf III for mucoceles

Osteoplastic Flap Vs. Draf III

The frontal osteoplastic flap: does it still havea place in rhinological surgery

The frontal osteoplastic flap still has a role in frontal sinus surgery.

The Journal of Laryngology & Otology (2011), 125, 162–168.

Osteoplastic Flap

May be modified to

fit the patient

Osteoplastic Flap Approach Osteoplastic and

endoscopic (above and below approach)

Frontal sinus obliteration

Wynn R, et al 2007

Riedel's Procedure

Osteomyelitis of the anterior wall of the frontal sinus

Failure of frontal sinus obliteration Some tumors of the frontal sinus

Pearl #1 Carefully Examine the Anatomy in more than one CT plane

Size of the frontal recess Size of the frontal sinus Bony thickening or neo-osteogenesis Identify the frontal sinus drainage

pathway Note the position of the anterior

ethmoidal artery

Pearl # 2 Identify the Anterior Ethmoidal Artery

Superior extension of anterior wall of bulla

Nipple on the medial orbital wall 1-4 mm’s below skull base Typically posterior to supraorbital

ethmoid cells

Pearl #3: Plan the least invasive approach possible

Ethmoidectomy with Middle Meatal Antrostomy without frontal recess surgery

Frontal recess surgery Endoscopic frontal sinusotomy Frontal sinus trephination Unilateral extend frontal sinus surgery

(Draf II) Endoscopic Modified Lothrop (Draf III) Osteoplastic flap with or without obliteration

Pearl #4 Positively Identify the Skull Base Posteriorly

Skeletonize from posterior to anterior Open cells immediately posterior to the

middle turbinate Identify the sinus with a seeker

Pearl #5 Positively identify the frontal sinus with a probe

Need a relatively dry field 45 degree telescopes are helpful Identify medial orbital wall and stay

close to it dissecting superiorly Opening to frontal sinus typically medial Identify opening with a probe

Pearl # 6 Preserve the Mucosa

Consider leaving polyps if sinus is open Remove osteitic intersinus septae carefully Do not traumatize unless sinus can be

opened widely Standard frontal sinusotomy

Draf Type II Works well if you can:

○ Preserve mucosa○ Remove bony partitions○ Create an ostium >4-5 mm

Pearl #7 Keep the Sinus Open Postoperatively

Remove fibrin and blood from frontal recess and frontal sinus

Remove residual bone Antibiotics, topical steroids? Oral Steroids?

Conclusion

Very little evidence based medicine Do the least invasive procedures first Be aware of various surgical options Image guidance a valuable tool First do no harm