FRONTAL SINUS SURGERY
Babak SaediAssociate Professor of Department
of OtolaryngologyTehran University of Medical
Sciences
http://www.dr.babaksaedi.com/DesktopDefault.aspx?tabindex=14&tabid=115&lang=fa-IR
Anatomy
Uncinate process Agger Nasi
http://www.dr.babaksaedi.com/DesktopDefault.aspx?tabindex=14&tabid=115&lang=fa-IR
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
http://www.dr.babaksaedi.com/DesktopDefault.aspx?tabindex=14&tabid=115&lang=fa-IR
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