Geographic and temporal trends in frontal sinus surgery

International Frontal Sinus Anatomy Classification (IFAC): evaluation of frontoethmoidal cells prevalence in a Brazilian population

OBJECTIVES

The aim of this study was to evaluate the prevalence of the frontal cell variants according to International Frontal Sinus Anatomy Classification (IFAC), in the population of a Brazilian tertiary hospital, and analyze the reliability of the classification between observers.

METHODS

A cross-sectional study in the Hospital de Clínicas of the State University of Campinas, Brazil. One hundred and three Computed Tomography's (CTs) were evaluated by radiologists and otorhinolaryngologist to estimate the prevalence of frontoethmoidal cells according to the IFAC. Intraclass Correlation Coefficient (ICC) among examinators was used to evaluate reliability of this findings.

RESULTS

103 CT scans, totaling 206 sides, were evaluated independently. The agger nasi cell was the most prevalent, present in 95.63% of cases, 37.86% of the exams contained supra agger cells, frontal supra agger cell showed prevalence 37.37%; suprabular cell was present in 77.18% of the sides. As for the frontal suprabular cell, the prevalence was 30.09%, the supraorbital ethmoid cell was present in 32.03%, and frontal septal cell had a 33.49% prevalence. The ICC among the evaluators was classified as "good reliability" or "excellent reliability" for all cells.

CONCLUSION

This study describes the frontal cell prevalence among a population in tertiary Brazilian hospital, using the IFAC. This classification had a high ICC.

LEVEL OF EVIDENCE

Level 2: Individual cross-sectional study with consistently applied reference standard and blinding.

Three-Dimensional Evaluation of the Frontal Sinus in Koreans

(1) Background: Among the four paranasal sinuses, the frontal sinus is in the frontal bone. Recent research trends have been focusing on identifying sex based on the frontal sinus. Thus, this study aimed to provide reference data for the frontal sinus in Korean adults by comparing their sizes using a 3D program. Moreover, this study examined the correlation between the size of the frontal sinus and the length of cranial bone. (2) Methods: Cone-beam computed tomography (CBCT) data were obtained from 60 (male 30, female 30) patients in their 20 s who visited the Department of Dankook University Hospital (DKUDH IRB 2020-01-007). The provided patient CBCT data were utilized to reconstruct the patients’ frontal sinuses and cranial bones in 3D using the Mimics (version 22.0, Materialise, Leuven, Belgium) 3D program. All measurements were analyzed using SPSS (ver. 23.0, IBM Corporation, Armonk, NY, USA). (3) Results: By comparing the frontal sinus size of Korean adults according to sex using a 3D program, this study revealed that males had larger frontal sinuses than females. (4) Conclusions: The findings of this study could help in preventing complications that occur in various clinical treatments and analyzing the growth of the frontal sinus in the future.

Critical Evaluation of Trends in Otolaryngology Resident Caseload by Subspecialty from 2005 to 2019

BACKGROUND

Subspecialty caseloads logged by otolaryngology residents over the last 15 years is currently unknown. This study examines the trends at the national level.

METHODS

Otolaryngology case log data was collected from the Accreditation Council for Graduate Medical Education (ACGME) from 2005 to 2019. Data were categorized according to the following surgical subspecialties: pediatrics, rhinology/skull base, head and neck, facial plastics, otology, and laryngology. Linear regression analyses were performed for each procedure within each subspecialty, total subspecialty means, and total caseload means across all years.

RESULTS

Overall surgical volume significantly increased between 2005 and 2019 (P < .0001); however, there was a significant decline in pediatrics procedures (R² = 0.80, P < .0001). Rhinology/skull base procedures increased the most drastically (R² = 0.96, P < .0001).

CONCLUSION

While total mean resident case logs have steadily increased between 2005 and 2019, pediatric cases have declined substantially due to fewer tympanostomy tube insertions and adenotonsillectomies. Rhinology/skull base procedures have increased most significantly secondary to an increase in endoscopic sinus surgeries. Despite changes in case volume amongst specialties, the annual increase in resident case load suggests that otolaryngology residents are meeting the demands of their graduate medical training.

Analysis of Sinus Balloon Catheter Dilation Providers Based on Medicare Provider Utilization and Payment Data

BACKGROUND

The use of balloon catheter dilation (BCD) to treat chronic rhinosinusitis has increased dramatically since its conception, necessitating further characterization of BCD providers and trends in its usage. Medicare data on BCD providers have made it possible to study recent demographic patterns. There has also been an increase in mid-level providers' scope of otolaryngologic practice that is not well defined.

OBJECTIVE

To better understand BCD adoption by studying volume of BCD procedures as well as training, geography, and practice socioeconomic characteristics of BCD providers for Medicare beneficiaries.

METHODS

We reviewed Medicare Provider Utilization and Payment Data Public Use Files for 2014 and 2015 for providers with claims for BCD of the sinuses. We extracted provider zip code, state, gender, and number of services per BCD code. We obtained median household income by zip code and geographic region based on US Census Bureau data. Providers were classified using an Internet search to determine practice setting and type of specialty training/certification.

RESULTS

In 2014 and 2015, 428 providers performed 42 494 BCDs billed to Medicare beneficiaries. Among BCD providers, 5.1% were female, 98.1% had Doctor of Medicine/Doctor of Osteopathic Medicine credentials, and 1.9% had nurse practitioner/physician assistant credentials. Over the 2-year period, the median number of BCDs was 63 for physicians and 37 for mid-level providers. Fellowship-trained rhinologists performed a median of 38 BCDs over 2 years. The most common subspecialty certification/training was in facial plastics and reconstructive surgery. The majority of providers (63.8%) performed 1 to 99 BCDs over the 2 years. In the South, there were 21.9 BCD procedures performed per 100 000 people compared to 7.3 in the Northeast, 9.3 in the Midwest, and 8.5 in the West.

CONCLUSION

There is a large range in total BCD procedures performed by individual providers, and this varies by certain provider characteristics. Mid-level providers have emerged as a significant population performing BCD.

National Geographical Variation in Sinus Balloon Dilation

OBJECTIVE

The primary aim of this study was to describe national variations in sinus balloon dilation (SBD), examine the relationship between endoscopic sinus surgery (ESS) and SBD prevalence patterns, and evaluate associations between reimbursement rates and regional variations in sinus surgery.

STUDY DESIGN

Retrospective observational study.

SETTING

Medicare Provider Utilization and Payment (PUP) Part B Data from January 1, 2016, to December 31, 2016.

SUBJECTS AND METHODS

Physicians in the PUP Part B Database Performing ESS or SBD in 2016. States were stratified into average- or high-volume utilizers based on the number of ESS procedures and SBD procedures per population and compared.

RESULTS

Eight states were classified as high-volume utilizers of SBD-Florida, Kansas, Louisiana, Mississippi, Nevada, New Mexico, South Dakota, and Texas. Only 3 of these states-Kansas, Mississippi, and Nevada-were classified as high-volume utilizers of ESS. Reimbursement rates were significantly higher for SBD as compared to ESS ($1538 [interquartile range (IQR), 1473-1664] vs $335 [IQR, 261-412] per procedure, P < .001). High-volume utilizer SBD states had a higher number of otolaryngologists (13.0 [IQR, 7-16] vs 6.0 [IQR, 2-3]) otolaryngologists per state (P < .001) and a trend toward an increased rate of performing ESS procedures (19 [IQR, 19-41] vs 6.0 [IQR, 2-32], P = .034) procedures per million residents) than average-volume utilizer SBD states.

CONCLUSIONS

The southern United States has a significantly higher rate of SBD procedures performed compared to the rest of the country, but these rates do not appear to be directly related to statewide variations in SBD reimbursement.

Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

Evolving Trends in Cochlear Implantation: A Critical Look at the Older Population

OBJECTIVES/HYPOTHESIS

Cochlear implantation (CI) is a well-accepted surgical option for the treatment of moderate to profound deafness. The purpose of this study was to evaluate the temporal and geographic trends of this procedure nationwide in the Medicare population in an attempt to explore the impact of evolving technologies and changes in healthcare policy.

METHODS

Medicare Part B national summary procedural datasets from 2007 to 2016 were obtained. Current Procedural Terminology codes for CI as well as auditory osseointegrated implantation were obtained. Centers for Medicare and Medicaid Services (CMS) datasets were evaluated to determine temporal trends. For geographic trends, specific carrier datasets from 2007 and 2016 were used.

RESULTS

From 2007 through 2016, the number of CI procedures increased annually from 1603 to 3600 (124.6%). Other procedures to treat hearing loss including bone-anchored implantation exhibited comparatively modest increases (23%, 90%). CI procedures increased every year in contrast to bone-anchored implants. Controlling for Medicare population, the greatest number of CI procedures performed per capita in the United States was in the West North Central, with an average 1.05 CIs per 10,000 beneficiaries.

CONCLUSION

The number of CI procedures performed in the elderly population has increased markedly over the past 10 years, far outpacing growth in other hearing surgeries. Potential reasons may relate to changes in criteria for CI candidacy over the past decade, although significant regional variability demonstrated suggests a lack of consensus. Further studies would be necessary to ascertain the true reason for geographic disparities.

Efficacy of steroid-eluting stents in management of chronic rhinosinusitis after endoscopic sinus surgery: updated meta-analysis

BACKGROUND

Recently, there has been mounting evidence suggesting the efficacy of steroid-eluting stents (SES) for management of chronic rhinosinusitis after endoscopic sinus surgery (ESS). This meta-analysis serves to evaluate the efficacy of SES in improving postoperative outcomes after ESS.

METHODS

A systematic literature search was performed of PubMed for articles published between 1985 and 2018. The outcome variables were reported at, on average, 30 days postintervention.

RESULTS

Seven of the 76 published studies, all of which were industry-sponsored, were included for a collective cohort of 444 SES and 444 control sinuses. In patients who received SES vs controls, collective odds ratios (ORs) for postoperative need for intervention, surgery, and oral steroid were 0.45 (95% confidence interval [CI], 0.33-0.62; p < 0.001), 0.30 (95% CI, 0.18-0.52; p < 0.001), and 0.58 (95% CI, 0.40-0.84; p = 0.004), respectively. In addition, collective ORs for frontal sinus ostia (FSO) patency, moderate-to-severe adhesion/scarring, and increase in polyp score were 2.53 (95% CI, 1.61-3.97; p < 0.001), 0.28 (95% CI, 0.13-0.59; p < 0.001), and 0.42 (95% CI, 0.25-0.74; p = 0.002), respectively. Collective mean differences for FSO/ethmoid inflammation and FSO diameter were -10.86 mm (p < 0.001) and +1.34 mm (p < 0.001), respectively.

CONCLUSION

Aggregate evidence suggests that SES can improve ESS outcomes by reducing rates of postoperative intervention and recurrent polyposis and inflammation, while promoting FSO patency. All included and analyzed studies were industry-sponsored and ruling-out publication bias was not possible. Future independent and nonsponsored studies to further evaluate SES's long-term efficacy are warranted.

How often is sinus surgery performed for chronic rhinosinusitis with versus without nasal polyps?

BACKGROUND

There currently are no data on the relative frequency of endoscopic sinus surgeries (ESS) performed for chronic rhinosinusitis with nasal polyposis (CRSwNP) versus chronic rhinosinusitis without nasal polyposis (CRSsNP) in the United States.

OBJECTIVES

To compare the rate of surgical interventions for CRSwNP and CRSsNP.

METHODS

Cases identified by CPT codes were extracted from the 2009-2011 State Ambulatory Surgery Databases for California, Florida, Maryland, and New York. Patient demographics, extent of surgery, mean charges, and operating room (OR) time were compared.

RESULTS

A total of 97,228 ESS cases were performed in the four states; 29.3% of surgeries were for patients with CRSwNP, 66.0% of patients with CRSsNP, and 4.8% for other indications. The proportion of ESS for CRSwNP varied across states, with California having the highest percentage (34.6%) and Maryland having the lowest (26.4%) (p < 0.0001). Patients with Medicaid (33.8%) and Medicare (32.2%) had higher rates of surgery for CRSwNP compared with patients with private insurance (29.9%) (p < 0.001). Surgeons who performed a higher volume of sinus surgery compared to lower volume surgeons performed a lower percentage of surgery for CRSwNP (24.4 versus 33.5%; p < 0.001). ESS cases for CRSwNP were more extensive (relative risk of four sinus surgeries of 1.88; p < 0.0001), used image guidance more frequently (relative risk, 1.39; p < 0.0001), and were less likely to include a balloon procedure (relative risk, 0.69; p < 0.0001). Patients with CRSwNP had longer OR times (ESS that involved all four sinuses took 14 minutes longer) (p < 0.0001), but no difference in charges compared with patients with CRSsNP who underwent a similar extent of surgery.

CONCLUSION

Almost 30% of ESS were performed for CRSwNP, and these cases were, on average, more extensive, used more OR time, and more often used image guidance than surgeries for CRSsNP. The rate of surgery performed for CRSwNP varied based on geography, payer, and surgical volume, which indicted that patient selection impacted surgical management.

Evolving patterns in the diagnosis and management of allergy-mediated disorders

BACKGROUND

This analysis explores the increasing heterogeneity of trends in allergy management under the premise that the practice of allergy has undergone significant changes in national economics, healthcare delivery, and treatment options from 2007 to 2016.

METHODS

Centers for Medicare and Medicaid Services (CMS) data were obtained for: (1) temporal trends in allergy immunotherapy injection (Current Procedural Terminology [CPT] codes 95115, 95117) and testing (CPT 95004, 95024) from 2007 to 2016; (2) geographic trends; and (3) practitioners administering immunotherapy. Although there are no sublingual immunotherapy (SLIT) CPT codes, billing for unlisted allergy/immunologic services (CPT 95199) were obtained.

RESULTS

Since 2007, there were 99.5 million allergy tests and 33.5 million immunotherapy injections billed to Medicare beneficiaries. Increases in testing have outpaced rising immunotherapy administration (49.7% vs 19.6% increase). Significant regional variation in testing rates was noted, with the greatest ratio of testing to immunotherapy in the South (0.35) and smallest ratio in the Northeast (0.18). The maximum unlisted allergy services billed was 594 (of which includes SLIT), compared to annual subcutaneous immunotherapy (SCIT) totals in the millions. The majority of immunotherapy in 2016 was administered by allergists/immunologists (51.6%) followed by otolaryngologists (31.2%), trends that have remained consistent since 2012.

CONCLUSION

Physicians have been more aggressive in the workup of allergy-mediated disorders in recent years. Although differences in allergen load exist, there is tremendous geographic variation in the ratio of testing to immunotherapy. While the role otolaryngologists play in immunotherapy remains stable, allergists manage the majority of patients, reinforcing the importance of interdisciplinary cooperation and outreach. SLIT does not appear to play a significant role in this population.

Endoscopic and external approaches for orbital decompression: an analysis of trends from a U.S. perspective

BACKGROUND

Although the endoscopic approach has been increasingly utilized for a variety of sinonasal and skull base pathologies, there has been little inquiry into its adoption in the surgical management of orbital disease. Our objective was to evaluate nationwide temporal and geographic trends in approaches for orbital decompression.

METHODS

Data available from the Centers for Medicare and Medicaid Services (CMS) were evaluated, focusing on the use of open and endoscopic approaches for orbital decompression (CPT codes 67414, 67445, 31292, and 31293) among Medicare beneficiaries over a 10-year period. Regional data were also analyzed.

RESULTS

There were 8047 orbital decompressions billed to Medicare from 2007 to 2016. The number of external and endoscopic approaches increased by 73.0% and 29.2%, respectively, while the number of Medicare beneficiaries increased by 29.1%. Endoscopic decompression represented 23.5% of Medicare-billed orbital decompressions in 2016 (221 of 939), down from 29.2% in 2007 (171 of 586). The South had the greatest proportion of decompressions utilizing an endoscopic approach (30.2%).

CONCLUSION

There has not been a clear movement toward the endoscopic approach for orbital decompression, with modest growth when compared with external approaches. Potential explanations include the specialty-exclusive nature of approaches, as well as a lack of consensus; the latter idea is further reinforced by geographic variation. High-quality prospective trials may clarify the role of endoscopic approaches in these patients.

[The differential approach to the surgical treatment of pathologies of the frontal sinus]

The surgical intervention for the management of frontal sinusitis is required in a large fraction of patients presenting with this condition. The treatment of choice for the pathology in question is endoscopic endonasal frontotomy. Whenever the endoscopic technique is impossible to employ, the surgeon has to resort to an extranasal operation on the frontal sinus. The indications for the application of such strategy include the pathological conditions complicated by the intracranial and orbital processes, the presence of large benign tumours, recurrent post-surgical purulent sinusitis and traumatic frontal sinusitis. For the preservation of the functionally competent frontal sinus during extranasal frontotomy, a frontonasal fistula with all bony walls and maximally spared mucous membrane can be created. In order to remove an osteotoma from the frontal sinus, we applied the osteoplastic approach with the formation of the osteo-periosteal flap from the frontal wall of the sinus. In those cases when it was impossible to restore the frontal sinus and there was a closed bone cavity undergoing purulent inflammation we practiced obliteration of the cavity with the use of a porous carbon implant.

Computed tomography analysis of frontal cell prevalence according to the International Frontal Sinus Anatomy Classification

BACKGROUND

The International Frontal Sinus Anatomy Classification (IFAC) is an international consensus document published in 2016 to standardize the nomenclature of cells in the region of the frontal recess and frontal sinus. The IFAC was designed to be surgically relevant and anatomically precise. The current study was undertaken to assess the prevalence of the frontal cell variants as defined by the IFAC, as well as to determine the interrater reliability of the IFAC.

METHODS

Three independent reviewers examined triplanar nondiseased maxillofacial computed tomography (CT) scans to assess the anatomy of the frontal recess according to the IFAC system. The prevalence of each cell type was assessed and interrater reliability was measured using an intraclass correlation coefficient (ICC).

RESULTS

One hundred CT scans (200 sides) were examined. Of the 200 sides, 96.5% contained an agger nasi cell (ICC, 0.82; 95% confidence interval [CI], 0.77-0.86), 30.0% contained a supra agger cell (ICC, 0.89; 95% CI, 0.86-0.92), 20.0% contained a supra agger frontal cell (ICC 0.80; 95% CI 0.74-0.84), 72.0% contained a supra bulla cell (ICC, 0.81; 95% CI, 0.76-0.85), 5.5% contained a supra bulla frontal cell (ICC, 0.71; 95% CI, 0.63-0.77), 28.5% contained a supraorbital ethmoid cell (ICC, 0.78; 95% CI, 0.72-0.83), and 30.0% contained a frontal septal cell (ICC, 0.80; 95% CI, 0.74-0.84). The ICC was good to excellent for identification of all frontal cell types.

CONCLUSIONS

This study describes the normative distribution of frontal recess cells in a nondiseased population according to IFAC and demonstrates favorable interrater reliability of the classification system.

Patient and surgeon factors explain variation in the frequency of frontal sinus surgery

OBJECTIVES/HYPOTHESIS

Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges.

RESULTS

There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both).

CONCLUSIONS

Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2008-2014, 2018.

Evolving trends in sinus surgery: What is the impact of balloon sinus dilation?

OBJECTIVES/HYPOTHESIS

Balloon dilation (BD) represents a minimally invasive alternative to endoscopic sinus surgery (ESS). Although BD was introduced in 2006, distinct Current Procedural Terminology (CPT) codes were not available until 2011, making prior analysis of population-based trends difficult. Our objectives were to evaluate these trends and compare any changes to the use of traditional ESS techniques. Geographic trends also were evaluated.

METHODS

Medicare Part B national datasets encompassing procedures from 2011 to 2015 were obtained. ESS CPT codes (frontal sinusotomy, maxillary antrostomy with/without tissue removal, sphenoidotomy) and BD codes were searched to determine temporal trends in their use. Additionally, state carriers were individually evaluated for geographic trends.

RESULTS

National use of BD increased greater than five-fold (39,193 from 7,496 among Medicare patients), whereas the use of ESS increased by only 5.9%. This increase in BD was observed across all sites, including the sphenoid (7.0x), maxillary (5.1x), and frontal (4.7x) sinuses. In the most recent year for which data was available (2015), a significantly greater portion of sinus procedures in these sites utilized BD in the South (42.1%) compared to the Northeast (30.6%), West (29.5%), and Midwest (25.3%) regions (P < 0.0001).

CONCLUSION

The performance of BD has increased markedly in recent years. Because the use of ESS codes remain stable, observed BD trends are unlikely to be due simply to greater familiarity with newer CPT coding. The reasons for the striking increase in BD popularity are speculative and beyond the scope of this analysis, but further study may be needed.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:1299-1303, 2018.

Evaluation of a steroid releasing sinus implant for the treatment of patients undergoing frontal sinus surgery for chronic rhinosinusitis

INTRODUCTION

Management of the frontal sinus places great demands on the otolaryngologist. Given that the fronto-ethmoidal region is susceptible to recurrent inflammation, scarring, and stenosis, maintaining long-term patency of the frontal sinus is a difficult challenge. Oral and topical anti-inflammatory therapy, post-operative stenting, and 'home-brew' drug elution have been used for the treatment of the frontal sinus with mixed success. Recently an implant has been approved for post-operative placement into the frontal recess. This implant provides reliable and consistent steroid drug elution to address inflammation of the frontal recess secondary to chronic sinusitis. Areas covered: This review discusses the development and application of steroid eluting implants in the postoperative care of patients with chronic frontal sinusitis. All randomized controlled trials evaluating steroid eluting implants are discussed. Relevant supporting material discussing background, economics, safety are included. Expert commentary: Steroid eluting implants fulfill a unique niche in the treatment following frontal sinus surgery. They are shown to decrease the need for post-operative interventions and improve outcomes in patients with chronic sinusitis. There is significant potential for growth in the use of steroid eluting implants.

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.

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.