frontal sinus surgery - onlinelaege.com · surgical indications •chronic sinusitis unresolved...
TRANSCRIPT
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Frontal Sinus Surgery
Jacques Peltier, MD Faculty Advisor: Matthew Ryan, MD
Department of Otolaryngology University of Texas Medical Branch
Grand Rounds Presentation October 11, 2006
www.onlinelaege.com
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Anatomy • Uncinate process
• Agger Nasi
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Anatomy
• Hiatus Semilunaris
• Ethmoid infundibulum
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• Frontal Sinus Drainage Pathway
• Frontal Sinus Ostium
Anatomy
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Anatomy
• Cribriform Plate
• Lamina papyracea
• Fovea ethmoidalis
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Anatomic Variations
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Anatomy
• Anterior Terminal Recess
• Posterior Terminal Recess
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Finding The Frontal Recess
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Finding The Frontal Recess
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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
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Frontal Cells
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Frontal Cells
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Frontal Cells
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Anatomic Variations
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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.
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Draf Procedures
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Draf I
• Anterior ethmoid cells
• Uncinate process
• Obstructing frontal cells
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Draf II
• Floor of the frontal sinus
• Lamina papyracea to Septum
• Anterior face of Frontal
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Draf III
• Modified Lothrop
• Interfrontal septum
• Nasal septum
• Frontal sinus floor
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Frontal Sinus Trephination
• Finding the frontal recess
• Mucoceles
• Isolated Type IV frontal cells
• With endoscopic techniques to assist with Draf II and III
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Frontal Sinus Trephination
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Frontal Sinus Trephination
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Frontal Sinus Trephination
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Frontal Sinus Trephination
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Combined Approaches
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Combined Approaches
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Combined Approaches
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Modified Lothrop
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Modified Lothrop
Take down the septum first
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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
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Osteoplastic Flap Vs. Draf III
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Osteoplastic Flap
• May be modified to
fit the patient
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Osteoplastic Flap
• Small bony flap
• Care to preserve
supratrochlear
bundle
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Osteoplastic Flap
• 6 foot Caldwell
• Image guidance
• Wire probe
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Osteoplastic Flaps
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Osteoplastic Flaps
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Osteoplastic Flap
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Osteoplastic Flap
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Osteoplastic Flap
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Pearls to Operating in the frontal recess
• Taken from a lecture by David Kennedy MD at the academy meeting this year
• Pearl – look for lectures at academy that will assist your grand rounds
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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
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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
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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
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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
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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
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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
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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?
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Pearl #8 Avoid obliteration in tumors and allergic fungal sinusitis
• Combine osteoplastic approach with
Draf 3 if possible in these situations
• Avoids imaging difficulties after surgery
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Pearl #9 Always avoid complications in FESS. Most
operations are for benign disease
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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