Modern concepts of frontal sinus surgery

Standard Endoscopic Approaches in Frontal Sinus Surgery: Technical Pearls and Approach Selection

The mainstay of frontal sinus surgery for chronic rhinosinusitis is to achieve and maintain an adequate frontal outflow tract. Using a stepwise approach and identifying critical endoscopic anatomic landmarks, to minimize complications and obtain long-term good endoscopic surgical results, should achieve this. The goal is to relieve the patient's symptoms, restore functional mucociliary flow, achieve a wide frontal sinus ostium and prevent long-term scarring and stenosis. Meticulous dissection and appropriate use of instrumentation and techniques aids in preventing unnecessary damage to normal mucosa while achieving one's goal of an adequate surgical ostium.

The nasofrontal beak: A consistent landmark for superior septectomy during Draf III drill out

INTRODUCTION

Cerebrospinal fluid (CSF) leak occurs in 1-11% of endoscopic Draf III, or endoscopic modified Lothrop, procedures. CSF leak can occur during surgery during a superior nasal septectomy. This study investigated whether the posterior edge of the nasofrontal beak (NFB) at the level of the internal frontal ostium is a safe landmark to use to avoid skull base injury when beginning the superior septectomy.

METHODS

Preoperative computed tomography maxillofacial scans were reviewed from 100 patients from the University of Pennsylvania sinus surgery data base. The narrowest anteroposterior distance between the posterior edge of the NFB and the anterior aspect of the olfactory fossa (OF) at the level of the internal frontal ostium was measured in each patient. Measurements were taken in the midline and to the left and right of midline. Six fresh cadaver heads were also dissected to evaluate these relationships.

RESULTS

On computed tomography analysis, the NFB was anterior to the OF on the left and right of the midline in 100% of the patients, with mean distances of 6.04 and 6.41 mm, respectively. The NFB was anterior to the OF in the midline in 98% of patients, with a mean distance of 9.02 mm. In all six cadavers, the posterior edge of the NFB was anterior to the OF in the midline and to the left and right of midline at the level of the internal frontal ostia.

CONCLUSIONS

During Draf III, the posterior edge of the NFB was a reliable landmark for avoiding iatrogenic CSF leak during the superior septectomy.

Indications and outcomes for Draf IIB frontal sinus surgery

BACKGROUND

Extended frontal surgery techniques are often required when maximal medical therapy and standard endoscopic surgical approaches fail in patients. Although outcomes of the Draf III (modified Lothrop) procedure have been widely reported, postoperative outcomes and indications for the Draf IIB frontal sinusotomy have been relatively underreported. We presented our institution's experience with the Draf IIB procedure.

METHODS

Patients who underwent the Draf IIB frontal sinusotomy between 2007 and 2012 were identified by retrospective chart review. Data collected included demographics, imaging, sinus patency, and Sino-nasal Outcome Test 20 scores.

RESULTS

A total of 22 Draf IIB frontal sinusotomies were performed in 18 patients. Thirteen of eighteen patients had previous frontal sinus surgery. The most common indications for the extended approach were chronic frontal sinusitis due to lateralized middle turbinate remnant (8 patients), mucocele (6), postoperative synechiae (5), and frontal sinus mass (3). Sinus ostium patency was maintained in 20 of 22 sinuses over an average follow-up period of 16.2 months. No complications were reported.

CONCLUSIONS

The Draf IIB frontal sinusotomy is a relatively safe procedure, with multiple indications. Long-term sinus ostium patency was maintained in >90% of operated sinuses, which indicated that the Draf IIB procedure may present an acceptable alternative to more aggressive extended frontal sinus approaches in selected patients.

Frontal Sinus Surgery: Its Evolution, Present Standard of Care, and Recommendations for Current Use

From a historical perspective, frontal sinus surgery has evolved from radical, highly invasive, disfiguring approaches to function-preserving, minimally invasive, and non-disfiguring intranasal procedures. Most sinus surgeons would agree that a sound surgical procedure is one that relieves patients' symptoms and provides a safe sinus in which future intracranial and orbital complications will not occur. For the future, sinus surgeons are searching for the ideal procedure, ie, one that is minimally invasive, reversible, and ensures the patient a safe frontal sinus for the long term. The ideal surgery will also leave minimal morbidity, will leave no cosmetic defect, and will allow for easy postoperative surveillance. To achieve this new standard in frontal sinus surgery, continuous refinements are required in the medical management and understanding of the disease processes that undermine long-term surgical success. Further advancements in instrumentation and visualization techniques are also necessary to enhance surgical precision, spare mucosa, and prevent the scarring and neo-osteogenesis that may cause surgical failures. Perhaps the most important development may be in the selection criteria for appropriate candidates who will benefit most from frontal sinus surgery.

Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review

BACKGROUND

Historically dacryocystorhinostomy (DCR) has been performed externally with very good outcomes. Current literature shows comparable success rates between endonasal and external approaches. A common reason for the failure of a DCR is the reclosure of the nasolacrimal stoma by granulation tissue and synechiae.

OBJECTIVE OF REVIEW

A systematic review and critical evaluation of the evidence relating to the preservation of nasal mucosal flaps in DCR surgery.

TYPE OF REVIEW AND EVALUATION METHOD

A systematic review using the consort guidance for review of randomised control trials.

SEARCH STRATEGY

A search of the following evidence-based medicine databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, Ovid, Medline, EMBASE and PubMed. The search was limited to English language articles, and the following key words were used: Endonasal, Endoscopic, Dacryocystorhinostomy, DCR, Mucosal Flaps, between years 1970 and 2015.

RESULTS

The best available evidence was level 1B, comprising two randomised control trials and three comparative studies included in the review. The main outcome measures used were lacrimal irrigation and absence of epiphora. Two of the studies demonstrated a statistically significant benefit of mucosal sparing either with nasal mucosal flaps or with lacrimal flaps. More debridement was needed, and granulation tissue was also seen in the groups without mucosal preservation. There was no difference in surgical complications between a mucosal and non-mucosal-sparing technique.

CONCLUSIONS

The overall quality of current evidence is poor, and there does however appear to be a trend towards improved outcomes and reduced granulation in groups where nasal mucosal and lacrimal flaps were preserved, but this is not clear-cut. There was no evidence of increased complication rates with mucosal-sparing techniques. We recommend that until further good quality research is available we should be performing a mucosal-sparing technique when performing DCR routinely.

Endoscopic endonasal orbital transposition to expand the frontal sinus approaches

BACKGROUND

The management of frontal sinus disease still remains a challenging issue for rhinologists. Although endoscopic frontal sinus surgery has significantly advanced over the past years, there are some conditions in which the external approaches are still necessary. Recently, the increasing experience in endoscopic sinus surgery together with important technologic advancements have allowed expansion of the indications for selected lesions localized more and more lateral into the frontal sinus.

OBJECTIVE

The aim of this study was to describe the endoscopic endonasal approach to the far lateral portion of the frontal sinus and to evaluate the outcomes of this technique.

METHODS

A retrospective evaluation was carried out with patients at a single institution, who, from 2004 to 2012, underwent an exclusive endoscopic transnasal approach to the far lateral portion of the frontal sinus at a single institution. The surgical technique included the Draf IIb procedure, a modified Lothrop procedure (Draf III), and endoscopic lateralization of the orbit, differently associated according to the needs of each case.

RESULTS

Twenty-four patients were eligible for the present study. The lesions included were mucoceles in 9 cases, fibro-osseous lesions in 10 cases, and inverted papillomas in 5 cases. The overall follow-up ranged from 12 to 120 months (mean, 40.6 months). At the time of the last follow-up, no recurrence of disease was observed in the patients treated; in one case of osteoma, a small and stable in size (1 mm) persistent lesion was observed in an asymptomatic patient. One scheduled and one accidental cerebrospinal fluid leak with immediate skull base reconstruction occurred. No intraoperative or postoperative early or late orbital complication was observed in any case.

CONCLUSION

The endoscopic endonasal orbital transposition seems to facilitate the endoscopic management of selected far-lateral frontal sinus lesions. However, it is a demanding procedure that requires experience and skill to avoid intraoperative skull base and orbital complications.

Secondary Reconstruction of Frontal Sinus Fracture

Fractures of frontal sinus account for 5%-12% of all fractures of facial skeleton. Inadequately treated frontal sinus injuries may result in malposition of sinus structures, as well as subsequent distortion of the overlying soft tissue. Such inappropriate treatment can result in aesthetic complaints (contour deformity) as well as medical complications (recurrent sinusitis, mucocele or mucopyocele, osteomyelitis of the frontal bone, meningitis, encephalitis, brain abscess or thrombosis of the cavernous sinus) with potentially fatal outcomes. Frontal contour deformity warrants surgical intervention. Although deformities should be corrected by the deficiency in tissue type, skin and soft tissue correction is considered better choice than bone surgery because of minimal invasiveness. Development of infection in the postoperative period requires all secondary operations to be delayed, pending the resolution of infectious symptoms. The anterior cranial fossa must be isolated from the nasal cavity to prevent infectious complications. Because most of the complications are related to infection, frontal sinus fractures require extensive surgical debridement and adequate restructuring of the anatomy. The authors suggest surgeons to be familiar with various methods of treatment available in the prevention and management of complications following frontal sinus fractures, which is helpful in making the proper decision for secondary frontal sinus fracture surgery.

Preventing and Managing Complications in Frontal Sinus Surgery

This review covers potential complications of frontal sinus surgical management and strategies for prevention of these complications. Accordingly, recent advances in frontal sinus surgical techniques are described, and the management of complications stemming both from these and traditional techniques are detailed.

Anatomic Considerations in Frontal Sinus Surgery

Comprehension of the complex anatomic variants comprising the frontal sinus outflow tract is essential for successful surgical intervention. Deviation from sound technique increases the potential for a variety of deleterious sequelae, including recurrent disease as well as catastrophic intracranial and orbital injury. Furthermore, incomplete removal of elements occluding the frontal recess can result in severe stenosis that can increase the difficulty of further interventions. This review covers anatomic considerations that should be kept in mind when performing frontal sinus surgery.

Endoscopic Approaches to the Frontal Sinus: Modifications of the Existing Techniques and Proposed Classification

Frontal sinus surgery has long been technically challenging in terms of access and chronic disease management. Decades of experience and advances in technology have led to the widespread use of various surgical approaches to the frontal sinus. Modifications to these existing procedures have been described to minimize unnecessarily invasive approaches. The lack of a classification that incorporates the newly described modifications prompts the proposal of a new classification. Eloy I-III incorporates all the previously described approaches as well as 3 recently published, and 1 newly described, procedures.

Usefulness of three-dimensional computed tomographic anatomy in endoscopic frontal recess surgery

PURPOSE

The endoscopic bidimensional vision offered by the endoscope during endoscopic sinus surgery involves difficulty in visualizing surgical field depth which makes it difficult to learn this surgical technique and makes it necessary for the endoscopic surgeon to mentally create a three-dimensional (3D) picture of the paranasal sinuses anatomy. In particular, frontal recess surgery requires good knowledge of its anatomic position, also since it is necessary to use angled endoscopes, which distort the view, and angular instruments which are difficult to use. Purpose of this project is to offer to the endoscopic surgeon a detailed 3D model of the nose and paranasal sinuses with particular attention to the frontal recess.

METHODS

A 3D reconstruction of the frontal recess and its related structures, starting from computer tomography scans of the human skull, was realized using a professional 3D graphics software.

RESULTS

A detailed reconstruction of the main structures which contribute to form the frontal recess was obtained. Particular attention was paid when reproducing the agger nasi cells, uncinate process, ethmoidal bulla, anterior ethmoidal cells, frontoethmoidal cells and their anatomic variants.

CONCLUSIONS

This is the first experience reported in literature regarding this new technique of iconographic didactics applied to endoscopic sinus surgery. It represents a new frontier, which surpasses and integrates the previous didactic techniques to help the surgeon to mentally create a 3D image of the paranasal sinuses.

Endoscopic Frontal Sinus Obliteration: A New Technique for the Treatment of Chronic Frontal Sinusitis

OBJECTIVES: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic technique for frontal sinus obliteration.

STUDY DESIGN AND SETTING: Retrospective case-control. Thirty-five patients underwent frontal sinus obliteration using either an endoscopic (n = 10) or conventional osteoplastic flap (n = 25) technique from 1994 to 2004 at an academic medical center.

RESULTS: Patients undergoing endoscopic obliteration had less blood loss (P = 0.006), decreased operative time (P = 0.016), and a shorter hospital stay (P = 0.003) compared to osteoplastic control subjects. All 3 surgical complications occurred in the control group. No patients required additional surgery for frontal sinusitis.

CONCLUSIONS: The endoscopic approach to frontal sinus obliteration appears to reduce patient morbidity and should be considered in the surgical management of advanced frontal sinus disease.

SIGNIFICANCE: This is the first report of a minimally-invasive technique for frontal sinus obliteration.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

First olfactory fiber as an anatomical landmark for frontal sinus surgery

OBJECTIVES/HYPOTHESIS

Access to the frontal sinuses is technically challenging owing to their anterosuperior location, diverse anatomy, close proximity to critical structures and the need to work in a relatively narrow space with angled-lens endoscopes and instruments. This study attempts to study the relationship of the first olfactory fiber with the frontal sinus posterior wall, assessing its fidelity as a surgical landmark during frontal sinus surgery.

STUDY DESIGN

Anatomic study.

METHODS

Fifteen cadaveric specimens were studied. Measurements were obtained bilaterally using the data from individual CT scans. Median A-P was defined as the anteroposterior (A-P) diameter measured just lateral to the intersinus septum, paramedian A-P was measured 5 mm lateral to the septum, and maximum A-P was defined as the maximum anteroposterior diameter on axial images. A surgical navigation device was used to calculate the distance between the first olfactory fiber and the posterior table of the frontal sinus.

RESULTS

The mean distance between the first olfactory fiber and the posterior wall of the frontal sinus was (4.03 ± 2.7) mm on the right side and (4.2 ± 2.9) mm on the left. This distance strongly correlated with the maximum A-P diameter of the sinus.

CONCLUSIONS

In a cadaveric model, the first olfactory fiber was found to be an average of 4.0 mm posterior to the frontal sinus. The significant variability of this distance should be considered when using the first olfactory fiber to establish the posterior boundary of a frontal sinusotomy. Drilling no further posterior than 7 mm rostral to the first olfactory fiber would be safe in 91% of patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:1039-1045, 2016.

A golden experience: Fifty years of experience managing the frontal sinus

OBJECTIVES/HYPOTHESIS

The frontal sinus is one of the most anatomically complex and inaccessible of the paranasal sinuses. As a result, surgeons have continually tried to improve surgical management of the frontal sinus. The senior author (c.w.g.) shares 50 years of experience managing the frontal sinus.

DATA SOURCES

PubMed literature search.

REVIEW METHODS

Review of the literature regarding landmark innovations in frontal sinus surgery.

RESULTS

Open approaches established that the frontal sinus is accessible, and in certain circumstances, such as with large osteoma or papilloma, are still required. The endoscope changed the surgical landscape and allowed for greater finesse and decreased morbidity. Sinus balloon dilation is the newest change in frontal sinus management and shows promise in properly selected cases.

CONCLUSION

Surgery of the frontal sinus continues to evolve and improve. Although there are new techniques, the older techniques are still pertinent.

A novel biodegradable frontal sinus stent (MgNd2): a long-term animal study

The frontal sinus recess consists of anatomically narrow passages that are prone to stenosis in endonasal frontal sinus surgery for chronic sinus disease. Over the past 100 years, diverse frontal sinus stents have been developed and evaluated in clinical and animal studies. However, superinfection, formation of granulations tissue, stent dislocation and late stenosis of the duct have remained challenges and subject of debate in the literature. Currently developed biodegradable materials, including rare earth-containing magnesium alloys are promising candidates for application as temporary implant materials. The Mg 2 % wt Nd alloy (MgNd2) was used to design a nasal stent that fit the porcine anatomy. In the current study, we evaluate biocompatibility, biodegradation and functionality of a frontal sinus stent in 16 minipigs over 6 months. Intraoperative endoscopy revealed free stent lumen in all cases. Blood examination and clinical examinations indicated no systematic or local inflammation signs. The histopathology and elements analysis showed a very good biocompatibility. The μ-computed tomography-based volumetric analysis showed substantial stent degradation within 6 months. Our MgNd2 based stent appears to be a promising, solid basis for the development of a frontal sinus stent for clinical use.

Outcomes of frontal mucoceles treated with conventional endoscopic sinus surgery

CONCLUSION

Conventional endoscopic sinus surgery (CESS) is useful for frontal mucoceles. A patient with short anterior-posterior distance and bone thickening may need an axillary flap, Draf type IIb, or Draf type III procedure.

OBJECTIVE

To present outcomes of frontal mucoceles treated with CESS and predict risk factors for poor outcomes to help define surgical indications.

METHODS

A consecutive clinical series was reviewed retrospectively. The authors performed CESS without agger nasi resection (Draf type IIa) for 13 frontal sinus mucoceles in 12 patients between October 2011 and July 2013. Patient age, sex, blood eosinophil count, history of operation and co-existence of acute infection were compared. For the condition of the frontal sinus, anterior-posterior distance and width of frontal recess, bone thickening of the frontal recess, bone absorption due to continuous pressure by mucocele and anatomy of the frontal recess was noted.

RESULTS

All operations were done without a navigation system. The post-operative course was uneventful in all 12 patients, and all symptoms gradually receded. Among 13 mucoceles, one frontal sinus (7.7%) closed during follow-up.

Medial and Superior Orbital Decompression: Improving Access for Endonasal Endoscopic Frontal Sinus Surgery

OBJECTIVE

Visualization by Draf I-III endoscopic access to the frontal sinus via drainage pathways is sometimes inadequate. We compare lateral frontal sinus exposures by Draf approaches versus our modification of removing the medial-superior wall of the orbit while preserving the periorbita.

METHODS

Twenty cadaveric heads dissected using Draf IIB, III, and modified Draf III with medial and superior orbital decompression (MSOD) underwent thin-cut computed tomography (CT) scanning. Under image guidance, measurements extended from the midline crista gali to the most lateral point of the frontal sinus. A case report shows the modified Draf III improved frontal sinus access.

RESULTS

Comparing Draf IIB and III with Draf III with MSOD, respectively, distances between midline and most lateral point averaged 19.1 mm, 23.7 mm, and 30.4 mm (left) and 18.7 mm, 25.1 mm, and 32.2 mm (right). Differences between Draf III with/without MSOD were 6.65 mm (left) and 7.09 mm (right); 12 heads were excluded because of under-pneumatization of the sinuses.

CONCLUSIONS

Draf III with MSOD extended surgical access to lateral regions of the frontal sinus. This extension achieved better visualization and instrumentation with minimal removal of the frontal bone's orbital segment anterior and superior to the anterior ethmoidal artery while preserving the periorbita.

Endoscopic Transseptal Approach to Frontal Sinus Disease

This paper describes an endoscopic transseptal approach to identify and access the frontal sinus and reviews the clinical cases. Between May 2004 and July 2010, endoscopic modified Lothrop procedure (EMLP) with transseptal approach was performed on sixteen patients. The indications for EMLP were complicated frontal sinusitis or cyst, revision surgery for failed frontal sinusotomy or Lynch procedure, or trauma cases. The first step of this procedure was to open a window in the bilateral anterior portion of the middle turbinates and nasal septum. The nasal septum, which could be observed through the window, should be the landmark of the midline during the surgery. A drill bur was raised up just behind the nasal bone along the midline of the nose. After the bilateral frontal sinuses and their posterior walls were confirmed, the interfrontal septum was removed superiorly. We reviewed the clinical records of patients who underwent the EMLP with transseptal approach. We have managed sixteen patients in this fashion. Neither intracranial nor orbital complications were encountered during or after surgery. Endoscopic transseptal frontal sinus surgery is simple to perform, and does not cause severe complications.

Frontal sinus fractures with suspected outflow tract obstruction: a new approach for sinus preservation

OBJECTIVE

The description of a new approach for the management of patients with frontal sinus fractures and associated obstruction of the frontal outflow tract to, restore sinus function and avoiding sinus obliteration.

SUBJECTS AND METHODS

In a prospective study, 21 patients with anterior wall frontal sinus fractures associated with potential obstruction of the frontal outflow tract, underwent rigid internal fixation and intraoperative guarded nasal endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. Patients were followed up clinically and radiologically by CT to assess the status of the frontal sinus and to detect any manifestations of frontal sinusitis or any other complications.

RESULTS

Seventeen patients completed the postoperative follow-up while four patients were excluded from the study. Postoperative follow-up ranged from 6 to 34 months with a mean of 20 months. All patients had associated craniofacial fractures. Follow-up CT scans showed complete restoration of frontal sinus ventilation and mucociliary clearance for 13 patients. Four patients showed frontal sinus mild mucosal thickening without signs of chronic sinusitis.

CONCLUSION

Patients with anterior wall frontal sinus fractures associated with frontal sinus outflow tract obstruction could be successfully managed with rigid internal fixation and intraoperative guarded endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. This type of management could increase the chance of frontal sinus preservation and decrease the need for frontal sinus obliteration for similar patients.

What is the evidence for the use of mucosal flaps in Draf III procedures?

PURPOSE OF REVIEW

Recent literature has described the use of mucosal grafts or transplants to reduce the rate of frontal ostium restenosis after the endoscopic-modified Lothrop procedure. This article presents a review of the literature on the rates of revision and restenosis related to Draf III procedures, factors implicated in the causation of restenosis and the evidence to support the role of mucosal grafts in reducing restenosis rates.

RECENT FINDINGS

Compared to historic data and to the meta-analysis data by Anderson and Sindwani, results from three case series examining the use of mucosal flaps after endoscopic-modified Lothrop procedure look extremely promising compared to a baseline average stenosis rate of 19% and revision rate of 14% quoted in the literature.

SUMMARY

Although the concept appears sound in principle and the limited series published show potential reduction in revision rates, there is inadequate evidence to state conclusively that this technique will improve the results of Draf III procedures in all surgical hands.

Endonasal modification of the frontal sinus drainage type IIb according to Draf

The description of different endonasal drainage options (type I, II and III according to Draf) and their successful use in numerous patients has reached a milestone in frontal sinus surgery. We herein describe a modification of an endonasal frontal sinus drainage type IIb with the additional removal of the lower part of the frontal sinus septum without opening the frontal recess of the other side and without resection of the nasal septum. The modified endonasal endoscopic frontal sinus drainage type IIb was performed on 9 patients at the Department of Otorhinolaryngology, University Medical Center, Homburg/Saar between 02/2011 and 6/2013 after having gained patients' consent. Follow-ups with endoscopic examination were performed after 6, 12 and 24 months (median follow-up: 14 months). Endonasal endoscopic opening of the frontal sinus was achieved in all patients. Endoscopic examination 6, 12 and 24 months after surgery revealed patent frontal sinus drainage in 8 patients. The frontal sinus drainage could not be visualized endoscopically in one patient who was free of symptoms for 24 months and where a ventilated frontal sinus was proven radiologically by computed tomography. The study demonstrates the option to additionally remove the lower part of the inter-frontal septum with a frontal sinus drainage type IIb. As the number of patients treated by this modified frontal sinus type IIb drainage is limited, further investigations are needed to define the value of a modified frontal sinus drainage type IIb.

A novel multipurpose mini-endoscope for frontal sinus endoscopy "sinus view"

Endoscopic frontal sinus surgery has been proven to enable the treatment of most frontal sinus pathologies but may be challenging for the surgeon in regard to the variable frontal sinus anatomy. Frontal sinus drainage identification and frontal sinus visualization are an essential part of successful frontal sinus surgery. We demonstrate a novel modular mini-endoscopic system for frontal sinus surgery. Fifty-two patients (37 male, 15 female) with a chronic rhino-sinusitis were enrolled. In this study, all patients were subjected to standard endonasal endoscopic sinus surgery with use of the fibre optic endoscope "Sinus View" (1.1 mm diameter, 10,000 pixels, irrigation channel and additional working channel) accessing the frontal sinus. A frontal sinus drainage type I in 38 cases, a frontal sinus drainage type IIa in 9 cases and a frontal sinus drainage type IIb in 5 cases according to Draf were performed. The modular mini-endoscopic system "Sinus view" was used to identify frontal sinus drainage in ten patients before ethmoidectomy and in the remaining patients (N = 42) after ethmoidectomy. Visualization of the frontal sinus drainage or the frontal sinus itself was easily carried out after irrigation. A clear identification of the frontal sinus by illumination was achieved in all cases. In addition the working channel of the endoscope was successfully used to perform visualized balloon dilatation at the frontal sinus drainage or for biopsy. The endonasal visualization of the frontal sinus drainage and frontal sinus itself is facilitated by also using a modular mini-endoscope with the option to use the working channel of the endoscope for biopsy or balloon dilatation.

The hybrid lid crease approach to address lateral frontal sinus disease with orbital extension

OBJECTIVE

This study aimed to describe the hybrid lid crease approach in conjunction with functional endoscopic sinus surgery (FESS) for lateral frontal sinus disease with orbital extension.

STUDY DESIGN

Retrospective case review.

METHODS

Patients undergoing hybrid lid crease approach with FESS for frontal sinus disease were reviewed retrospectively. Surgical indications consisted of inverting papilloma with extension into the frontal sinus (n = 1) and frontal sinus mucocele (n = 2). Inclusion criteria included presence of disease in the lateral frontal sinus with extension into the orbital space and erosion of the superior orbital rim. Preoperative and postoperative parameters included complete ophthalmologic exam, endoscopic exam, and computed tomography scan.

RESULTS

We were able to access the frontal sinus and orbit in all 3 cases and address sinus pathology of the lateral frontal sinus and orbit using the lid crease approach with FESS. All patients had improvement in ophthalmologic symptoms and interval disease resolution and were satisfied with their postoperative lid crease incision.

CONCLUSION

The lid crease approach offers direct access to the frontal sinus with minimal dissection through a well-hidden incision. In our case series of lateral frontal sinus pathology with orbital extension, the hybrid lid crease approach with FESS allowed complete eradication of disease without recurrence.

Management of Lateral Frontal Sinus Pathology in the Endoscopic Era

OBJECTIVES

Considerable advances in endoscopic technique and experience have allowed an increasing number of patients with complex frontal sinus disease to be treated with endoscopic surgery. The objective of the current study was to evaluate management strategies and outcomes regarding treatment of lateral frontal sinus disease.

STUDY DESIGN

Prospective case series.

SETTING

Academic tertiary medical center.

SUBJECTS AND METHODS

Prospectively collected data concerning frontal sinus pathology located lateral to the plane of the lamina papyracea (lateral disease) were reviewed. Data were collected regarding demographics, etiology, surgical technique, revision rate, anatomic considerations, and clinical follow-up. Only patients with at least 24 weeks of clinical follow-up and pathology who required removal and dissection in this region were included in the study.

RESULTS

Over 5 years, 156 patients (mean age, 47.9 years; range, 14-84 years) with 183 lateral frontal sinus pathologies and an average clinical follow up of 76 weeks (range, 24-237 weeks) were evaluated. Endoscopic or open surgery was attempted in 84 patients (54%) prior to intervention at our institution. Primary pathologies included inflammatory/obstructive diseases (n = 119), skull base defects (n = 33), and tumors (n = 31). Initial interventions included endoscopic (Draf IIA, n = 76; Draf IIB, n = 52; Draf III, n = 23), extended (IIA + trephine, n = 1; III + trephine, n = 2; III + osteoplastic flap, n = 2), and open (osteoplastic flap, n = 3; Reidel, n = 1; cranialization, n = 1) procedures. Seven patients (4%) required a subsequent revision procedure.

CONCLUSION

The vast majority of lateral frontal sinus pathology was managed using endoscopic techniques with excellent outcomes and a low revision rate in the current study.

Newly designed double-vascularized nasoseptal flap to prevent restenosis after endoscopic modified Lothrop procedure (Draf III): laboratory investigation

Despite advances in endoscopic approaches, instrumentations and imaging guidance systems, the management of frontal sinus is still challenging. Failure of the endoscopic procedure and restenosis of the newly formed ostium have been demonstrated even with large frontal sinusotomy. We describe a newly designed double nasoseptal flap to cover the bare bone after endoscopic modified Lothrop procedure (EMLP). Five fresh, double-injected cadavers were dissected through an endoscopic endonasal approach. Posteriorly based nasoseptal flap on one side and laterally based nasoseptal flap on the other side were harvested before performing wide EMLP. Feasibility of the procedure, versatility of the flap, coverage area and measurements were calculated. Harvesting the mucoperichondrial/mucoperiosteal flap over the septectomy site was straightforward step. Two different designed flaps (one on each side) are more practical to avoid torsion of the flap. The flap measures 2 × 3 cm on average that was able to cover the bare bone of the anterior and posterior wall of frontal sinus. Osteoneogenesis and progressive osteoplastic activity after EMLP plays a major role in restenosis of frontal sinus. Vascularized nasoseptal flap helps in preventing closure of the newly formed ostium. Applying these flaps over the bare bone enhances the healing process and minimizes the crust formation.

Frontal sinusitis with mixed bacterial colonies treated with the combination of endoscopic modified lothrop procedure and external approach

Isolated frontal sinusitis with mixed bacterial colonies is extremely rare and has not been described. We report a case of isolated frontal sinus forming mixed bacterial colonies that occurred in the previously exposed frontal sinus. The material in the frontal sinus was macroscopically similar to sinus fungus ball. Surgical strategy followed that for sinus fungus ball. The material could not be completely removed even with an endoscopic modified Lothrop procedure (Draf type III procedure). Additional external incision enabled complete removal of the remnant infectious substance. Histological examination detected two different types of organisms as intermingled bacterial colonies. External approaches to the frontal fungus ball have recently been replaced by the endonasal approach. Our case suggests that material trapped in a pit or small crevice in a frontal sinus may not be removed intranasally.

Cranialization of the frontal sinus for secondary mucocele prevention following open surgery for benign frontal lesions

Objective

To compare frontal sinus cranialization to obliteration for future prevention of secondary mucocele formation following open surgery for benign lesions of the frontal sinus.

Study Design

Retrospective case series.

Setting

Tertiary academic medical center.

Patients

Sixty-nine patients operated for benign frontal sinus pathology between 1994 and 2011.

Interventions

Open excision of benign frontal sinus pathology followed by either frontal obliteration (n = 41, 59%) or frontal cranialization (n = 28, 41%).

Main Outcome Measures

The prevalence of post-surgical complications and secondary mucocele formation were compiled.

Results

Pathologies included osteoma (n = 34, 49%), mucocele (n = 27, 39%), fibrous dysplasia (n = 6, 9%), and encephalocele (n = 2, 3%). Complications included skin infections (n = 6), postoperative cutaneous fistula (n = 1), telecanthus (n = 4), diplopia (n = 3), nasal deformity (n = 2) and epiphora (n = 1). None of the patients suffered from postoperative CSF leak, meningitis or pneumocephalus. Six patients, all of whom had previously undergone frontal sinus obliteration, required revision surgery due to secondary mucocele formation. Statistical analysis using non-inferiority test reveal that cranialization of the frontal sinus is non-inferior to obliteration for preventing secondary mucocele formation (P<0.0001).

Conclusion

Cranialization of the frontal sinus appears to be a good option for prevention of secondary mucocele development after open excision of benign frontal sinus lesions.

Endoscopic and combined external-transnasal endoscopic approach for the treatment of inverted papilloma: analysis of 110 cases

The aim of the study was to evaluate the effectiveness of the endoscopic approach for the management of inverted papilloma (IP) of the nose and paranasal sinuses and the possible factors associated with its recurrence. One hundred and forty-one patients affected by an IP originating at the level of the sinonasal tract were treated surgically using an endoscopic technique alone or a combined external-endoscopic approach at the ENT Department of the University of Bologna between January 1994 and December 2012. Of these patients, 110 were selected for the recurrence analysis. Univariate and multivariate analyses were performed to detect risk factors for IP recurrence. The patients had a mean follow-up of 56.7 months (24-167 months). Seven cases (6.3%) of recurrence were observed in patients treated with the endoscopic approach for the primary or recurrent tumor. Previous surgery (p = 0.005) and number of previous surgical procedures (p = 0.003) were associated with higher recurrence rate. The number of previous operations was associated to recurrence-free survival at Cox regression analysis. In our study, the endoscopic approach showed itself to be a useful tool for the radical resection of an IP. The endoscopic approach should be tailored for the different extensions of IP. Recurrent cases showed an increased risk of further recurrence. Therefore, these should be treated paying particular attention to the boundaries of the primary tumor.

The Draf III septal flap technique: a preliminary report

AIM

The most prevalent complication of Draf III surgery is recurrence of frontal recess stenosis. The aim of this study is to introduce a method to prevent closure of the recess.

TYPE OF THE STUDY AND SETTING

This is a retrospective study that was conducted in Ear, Nose and Throat Referral Center, Amir'Alam Hospital, Tehran.

METHODS AND MATERIALS

We introduced a new technique for reconstructing frontal recess mucosa and prevention of restenosis following Draf III operation; we covered the posterior wall of the common recess with a vascular mucosal flap from nasal septum.

RESULTS

During a 6-month period we used septal flaps based on anterior ethmoidal artery on four patients who had undergone endoscopic Draf III operation. During a 3-month follow-up period, frontal recess stenosis did recur in any of the patients.

CONCLUSION

Applying a precise and astute surgical method along with reconstructing common recess mucosa will improve the outcomes of endoscopic frontal sinus drill-out. We strongly recommend application of septal mucosal flap based on the anterior ethmoidal artery during Draf III operation to decrease the incidence of scar and recurrence of common frontal recess stenosis.

Expanded endoscopic endonasal approaches to skull base meningiomas

Anterior cranial base meningiomas have traditionally been addressed via frontal or frontolateral approaches. However, with the advances in endoscopic endonasal treatment of pituitary lesions, the transphenoidal approach is being expanded to address lesions of the petrous ridge, anterior clinoid, clivus, sella, parasellar region, tuberculum, planum, olfactory groove, and crista galli regions. The expanded endoscopic endonasal approach (EEEA) has the advantage of limiting brain retraction and resultant brain edema, as well as minimizing manipulation of neural structures. Herein, we describe the techniques of transclival, transphenoidal, transplanum, and transcribiform resections of anterior skull base meningiomas. Selected cases are presented.

Mini-endoscopy of the frontal sinus to guide endonasal frontal sinus surgery

Endoscopic frontal sinus surgery requires special attention to the numerous anatomical variations. Additionally, in situations of revision surgery, endonasal frontal sinus identification may be challenging. Numerous strategies have been described to access the frontal sinus in endonasal endoscopic frontal sinus surgery including an additional external approach. A pilot study is presented using a newly designed modular mini-endoscope (1.1 mm, 10.000 pixel, 2 working channels and 120° lens) to assist the frontal sinus surgery through a transcutaneous puncture of the frontal sinus. We used this mini-endoscope for primary frontal sinus surgery on 3 patients and for revision frontal sinus surgery on 4 patients. In all patients, the mini-endoscope could be placed in the frontal sinus without side effects. The visible illumination at the frontal sinus floor, caused by the mini-endoscope being in the frontal sinus, guided the surgeon endonasally directly to the frontal sinus floor. Frontal sinus drainage was achieved by the described guidance on all patients. In conclusion, mini-endoscopy of the frontal sinus might be an interesting option in endoscopic frontal sinus surgery to guide the surgeon by illumination in complex anatomical situations to the frontal sinus. This technique will contribute to further improvement in endonasal endoscopic frontal sinus surgery.

High-resolution computed tomography analysis of the frontal sinus ostium: a pilot study

PURPOSE

Identification and exposure of the frontal sinus recess (FSR) during endoscopic sinus surgery (ESS) are challenging due to the variable anatomy, the narrow opening of the frontal sinus ostium (FSO), and the proximity of vital anatomic structures. Hence, a strong understanding of frontal sinus anatomy is required to prevent intracranial entry. Consistent and easily identifiable landmarks and measurements could assist safe entry into the FSO. In this study, we determine the distances from the columella and anterior nasal spine (ANS) to the nasofrontal beak (NFB) and anterior skull base (ASB) using high-resolution computed tomography (HRCT) scans.

METHODS

A radiographic analysis was performed at a tertiary care medical center. Measurements from the ANS to the NFB and ASB, and from the columella to the NFB and ASB were made using sagittal HRCT. Thirty-two HRCT scans were analyzed by three observers, and the mean distances and standard deviations were calculated.

RESULTS

The mean distance from the ANS to the NFB was 52.3±3.4mm in men and 47.7±3.5mm in women (p<0.0001). Mean distance from the ANS to the ASB was 61.8±4.1mm in men and 56.5±4.1mm in women (p<0.0001). Mean distance from the columella to the NFB was 58.9±2.3mm in men and 53.0±3.3mm in women (p<0.0001), and from the columella to the ASB was 67.9±3.7 mm in men and 61.3±4.1mm in women (p<0.0001).

CONCLUSION

While performing FSR exposure in ESS, it is recommended to stay a distance of less than 66.9 mm in men and 60.6mm in women from the columella to minimize intracranial complications.

Current advances in sinus preservation for the management of frontal sinus fractures

PURPOSE OF REVIEW

This review summarizes the current advances in sinus preservation techniques with endoscopic sinus surgery for the well tolerated and effective management of frontal sinus fractures.

RECENT FINDINGS

Advances in computed tomography (CT) imaging can now reproduce higher quality reformatted images, creating excellent diagnostic coronal, axial, and sagittal image views that provide a better evaluation of the frontal sinus outflow tracts (FSOTs). The FSOTs are pivotal in determining which technique is used in the management of frontal sinus fractures. Several recent studies have proposed sinus preservation protocols using endoscopic management of the frontal outflow tract as a viable alternative to frontal sinus obliteration. Among those protocols, extended endoscopic sinus frontal surgery with reconstruction of the frontal outflow tracts has been demonstrated to be well tolerated and effective. It can be used in conjunction with frontal sinus trephinations as well as to treat complications.

SUMMARY

Modified treatment protocols have been developed based on thorough clinical examination and CT imaging in an attempt to provide a practical and safe protocol for the management of frontal sinus injuries. Conservative care and sinus preservation with or without endoscopic surgery can be done in selected cases with good result. The importance of preserving the frontal sinus is gaining acceptance in the evidence-based literature.

Transnasal endoscopic approach to symptomatic sinonasal osteomas

BACKGROUND

One of the most challenging benign tumors for the ear, nose, and throat (ENT) surgeon is represented by sinonasal osteomas. Surgical treatment should regard just symptomatic osteomas, because these tumors can provoke rhinosinusitis and mucoceles. Recently, new instruments have been applied in endoscopic sinus surgery (ESS). This study was designed to present our experience in the endoscopic management of osteomas of the paranasal sinuses. Clinical findings, preoperative imaging strategy, and surgical techniques are discussed.

METHODS

We retrospectively reviewed clinical records of patients who underwent ESS for sinonasal osteomas between 2003 and 2010 in our institutions.

RESULTS

We have treated with a transnasal endoscopic approach 29 patients affected by paranasal osteomas (13 men and 16 women; age range, 20-78 years; mean, 49.5 years). We found frontoethmoidal junction localization in 14 patients, frontal sinus in 6 patients, ethmoid in 6 patients, sphenoid in 1 patient, maxillary in 1 patient, and multiple osteomas in 1 patient. Initially, patients were treated by the cavitation technique with standard ESS instruments, whereas in more recent cases surgery was assisted by the use of ENT navigation system, curved drills, and ultrasound bone emulsifier. No major complications occurred. No radiological or endoscopic signs of recurrence (mean follow-up, 52 months; range, 6-89 months) have been observed.

CONCLUSION

Endoscopic removal of osteomas of the sinonasal region is feasible, taking into account the location and size of the lesion. Particular importance should be given to new instruments that have been applied in the last years in ESS.

Endoscopic treatment of adversely located osteomas of the frontal sinus

OBJECTIVES

We assess the utility and limitations of an endoscopic technique in the treatment of osteomas that are considered difficult to manage endoscopically, ie, those located superiorly or laterally in the frontal sinus, extending beyond a virtual plane through the lamina papyracea, and we describe the principles of a surgical technique that facilitates removal of such tumors.

METHODS

We performed a retrospective study on 8 patients with symptomatic frontal sinus osteomas, including tumors extending past the commonly recognized limits of endoscopic resection because of their size or site of attachment.

RESULTS

All tumors were removed by a purely transnasal endoscopic approach. No major complications were observed during or after the operation. All patients experienced improvement or total regression of their symptoms.

CONCLUSIONS

With appropriate instruments and specific endoscopic techniques, it is possible to resect osteomas that not long ago were deemed inaccessible to endoscopic surgeons. The commonly recognized limits of endoscopic treatment of such tumors may be exceeded in some cases; however, favorable anatomic conditions are decisive for a successful operation.

Role of osteoplastic frontal sinus obliteration in the era of endoscopic sinus surgery

Objective. Determining the indications for osteoplastic frontal sinus obliteration (OFSO) for the treatment of inflammatory frontal sinus disease. Study Design. Retrospective case series from a single tertiary care facility. Methods. Thirty-four patients who underwent OFSO for chronic frontal sinusitis (n = 23) and frontal sinus mucocele (n = 11) comprised our study group. Data reviewed included demographics, history of prior frontal sinus operation(s), imaging, diagnosis, and operative complications. Results. The age range was 19 to 76 years. Seventy percent of patients with chronic frontal sinusitis underwent OFSO as a salvage surgery after previous frontal sinus surgery failures, while 30% underwent OFSO as a primary surgery. For those in whom OFSO was a salvage procedure, the failed surgeries were endoscopic approaches to the frontal sinus (69%), Lynch procedure (12%), and OFSO outside this study period (19%). For patients with frontal sinus mucocele, 72% had OFSO as a first-line surgery. Within the total study population, 15% of patients presented for OFSO with history of prior obliteration, with a range of 3 to 30 years between representations. Conclusions. Osteoplastic frontal sinus obliteration remains a key surgical treatment for chronic inflammatory frontal sinus disease both as a salvage procedure and first-line surgical therapy.

Endoscopic frontal sinus drainage Draf type III with mucosal transplants

BACKGROUND

This study was designed to evaluate the extent of restenosis that occurs after an endoscopic frontal sinus drainage Draf type III (Draf III; modified Lothrop procedure) using a modified technique with reconstruction of the frontal sinus drainage pathway with mucosal transplants, in combination with occlusive postoperative care.

METHODS

Retrospective case series was performed with 24 consecutive patients undergoing Draf III drainage between 2005 and 2010 using the modified technique of covering the bare bone with mucosal transplants from the nasal septum. To ensure optimal moist wound healing, occlusion of the nose was realized by taping the nose for 2 weeks postoperatively. Frontal ostium measurements were done intraoperatively and at follow-up visits for a minimum of 12 months. Data on patient history, demographics, comorbidities, and computed tomography scans were collected.

RESULTS

Mean follow-up was 25.6 months. Eight patients were lost to follow-up. Ninety-four percent of frontal sinus neo-ostia remained open. One patient needed revision surgery using an osteoplastic flap with obliteration. The frontal neo-ostium narrowed by an average of 36.9% from 20.5 × 12.5 to 15 × 9.6 mm. On average, three visits were needed for postoperative care. The patients did not experience significant pain throughout the postoperative healing time.

CONCLUSION

The modified Lothrop procedure is a well-established technique in endoscopic sinus surgery to handle difficult frontal sinus drainage pathways or revision surgeries. The modified technique provides good results in combination with minimized postoperative care and morbidity. A comparative study would be necessary to show superiority to the standard method of Draf III.

Our experience with the surgical management of paranasal sinus osteomas

The aim of this work is to describe our experience with the management of osteomas of the fronto-ethmoidal region, and to evaluate the limits and possibilities of different approaches: endonasal endoscopic versus external surgical resection of symptomatic osteomas. A review of 26 patients with detected osteomas in tertiary health care center was accomplished. We analysed the 26 adult patients, which detected paranasal sinus (PNS) osteomas--patients who underwent paranasal sinus CT examinations almost exclusively for other reasons. We analysed the patient's symptoms, localization and size of osteomas, clinical and imaging signs, in relation to adjacent structures. Of the 26 cases, 16 located in the etmoid sinus, eight in the frontal sinus, of which two with orbital one with an ethmoid extension, and one isolated maxillary and sphenoid sinus were involved. We treated 11 patients with endoscopic (eight cases) and external surgical approaches (three cases). Besides this surgical excision; 15 cases were kept in follow up, because of asymptomatic nature of the PNS osteomas or patients lack of consent. While the extranasal approach is still a part of the treatment concept for removing osteomas; over the last years, in suitable cases, the endoscopically controlled endonasal approach has greatly gained importance due to the improved surgical equipment and experience.

Revision sinus surgery

Revision sinus surgery for inflammatory disease has been revolutionized by endoscopic sinus surgery. Clinical trials have shown statistically significant positive outcome data for patient symptoms and quality of life, as well as improvements in objective findings on postoperative nasal endoscopy and computed tomography imaging for patients undergoing revision sinus surgery. The keys to successful revision surgery are adjunctive medical management, aggressive postoperative debridement, mucosal preservation, and removal of osteitic bone. Both the physician and patient should also understand the underlying disease process and comorbid factors so that anticipated postoperative outcomes can be met with realistic expectations.

Osteoma of the skull base and sinuses

Osteomata of the frontal and ethmoid sinuses have traditionally been surgically removed via external approaches. However, endoscopic techniques have increasingly been used for the surgical management of selected cases. Advances in visualization and instrumentation, as well as the excellent access provided by the Draf type 3 procedure, expanded the reach of endoscopes. We describe current limits of endoscopic approaches in the removal of osteomata from the frontal sinus and our algorithms for their management. We believe that the vast majority of frontal sinus osteomata can be managed endoscopically, and that only significant anterior or extreme infero-lateral extension constitute major limiting factors.

Long-term results after primary frontal sinus surgery

BACKGROUND

The objectives of this study were to evaluate the long-term frontal ostium patency rate and symptom improvement in patients undergoing primary endoscopic frontal sinusotomy (Draf 2A) and to assess the impact of patient factors, disease factors, and frontal ostium size on surgical outcomes.

METHODS

Retrospective chart review was used. Endoscopic assessment of frontal ostium patency and patient-reported symptoms were prospectively collected on patients who underwent primary frontal sinusotomy between January 2003 and December 2009.

RESULTS

A total of 109 patients underwent primary endoscopic surgery on 210 frontal sinuses over the study period. The overall patency rate was 92%. Complete resolution of symptoms was noted in 85 patients (78%). Stenosis of the frontal sinus ostium correlated significantly with persistence of symptoms, infection, or polyp recurrence (p = 0.0066), and frontal ostium size (p < 0.03). No significant correlation could be found between the presence of eosinophilic mucin, asthma, polyposis, and smoking on patency or resolution of symptoms.

CONCLUSION

To our knowledge, this is the largest study of primary endoscopic frontal sinus surgery in the literature. The technical and subjective measures of success are high. Frontal ostium size correlates with risk of stenosis of the frontal sinus. Patients with a stenosed frontal ostium and residual frontal sinus disease are more likely to be symptomatic or have endoscopic evidence of polyp recurrence or endoscopic evidence of persistent infection. Asthma, eosinophilic mucin chronic rhinosinusitis (EMCRS), allergy, and smoking do not appear to affect outcomes.