Surgical management of frontal sinusitis:

Operative findings in the frontal recess at time of revision surgery

OBJECTIVE

Endoscopic sinus surgery is the gold standard for the treatment of medically refractory chronic rhinosinusitis. There is, however, a population of patients for whom persistent disease is a problem. Of all the sinuses, the frontal sinus is the most likely to have recurrent obstruction. We evaluated the findings causing frontal recess obstruction at the time of revision surgery.

STUDY DESIGN AND SETTING

A retrospective review was performed in a tertiary care academic otolaryngology department.

RESULTS

Findings obstructing the frontal recess at the time of revision sinus surgery were reviewed. Two hundred eighty-nine frontal sinuses were included. Seven findings were identified: mucosal disease (67%), retained ethmoid cells (53%), lateralized middle turbinates (30%), retained agger nasi cells (13%), scar (12%), retained frontal cells (8%), and neoosteogenesis (7%). Most frontal recesses had multiple etiologies for failure listed above, with an average of 1.6.

CONCLUSIONS

Multiple findings can be identified that contribute to frontal recess obstruction requiring revision sinus surgery. A comprehensive approach to address all factors is necessary to prevent surgical failure among patients presenting for endoscopic frontal sinus surgery.

[Endonasal frontal sinus surgery. Part 2: Frontal sinus drainage type III (median drainage), tips and tricks, postoperative care]

In Part 2 of our concept of frontal sinus surgery, we explain type III drainage (median drainage or modified Lothrop procedure) and technical details including the application of nasal packing, mitomycin C, mucosal transplants, and silicone foils or stents. Special aspects of postoperative care are highlighted. Specific instrumentation and endoscopic equipment are highly recommended.

Endoscopic management of the frontal recess in frontal sinus fractures: a shift in the paradigm?

OBJECTIVES

To evaluate alternative management strategies for anterior table frontal sinus fractures involving the frontal sinus outflow tract.

STUDY DESIGN

A prospective cohort of patients with anterior table frontal sinus fracture with frontal outflow tract involvement documented by computed tomography (CT) scan was examined between 1999 and 2001.

METHODS

A select group of patients with anterior table frontal sinus fracture involving the frontal outflow tract was treated with open reduction of bony fracture without osteoplastic obliteration of the frontal sinus. Serial CT scans were obtained starting at 8 weeks after injury. Patients with persistent frontal sinus obstruction after medical treatment underwent an extended endoscopic frontal sinusotomy or a modified endoscopic Lothrop procedure.

RESULTS

Fourteen patients sustained frontal sinus fractures and were treated during the study period. Seven patients were included in the modified treatment algorithm, with a mean follow-up of 18 months. All patients had concurrent facial fractures: superior orbital rim (n = 5), naso-orbital-ethmoid complex (n = 2), mandible (n = 2), and midface (n = 2). All 7 patients underwent open repair of the facial fractures. Postoperatively, 5 patients had spontaneous frontal sinus ventilation. Two patients, both of whom had naso-orbito-ethmoid fractures, had persistent frontal sinus obstruction clinically and radiographically. These patients were successfully managed with an endoscopic frontal sinus procedure.

CONCLUSIONS

A select group of patients with frontal sinus and outflow tract fracture may be managed with open repair of the anterior table fracture without obliteration. In these cases, suspected frontal outflow tract obstruction can be managed expectantly. Failed frontal sinus ventilation may require endoscopic frontal sinus surgery to reestablish mucociliary clearance.