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

Anatomic Relationship Between the Head of the Middle Turbinate and First Olfactory Filum: A Radiographic Assessment

BACKGROUND

The endoscopic modified Lothrop procedure (EMLP) has become a frequently utilized procedure in rhinologic surgery. One of the most serious complications of the procedure is cerebrospinal fluid leak, which may occur due to lack of recognition of the anterior skull base in the region of the first olfactory filum (FOF), or direct injury to the FOF itself.

OBJECTIVES

To evaluate the position of the head of the middle turbinate (MT) relative to the FOF, which is an important landmark in the EMLP.

METHODS

A series of previously obtained patient computed tomography scans of the sinus were reviewed. A reproducible process was implemented to obtain the measurements. First, the FOF was identified on an axial series. Using a localization feature of the radiographic software, this anteroposterior (AP) position could be visualized in a coronal plane. Subsequently, the MT was viewed in a sagittal plane, where a measurement between the head of the MT and the AP position of the FOF could be performed.

RESULTS

The AP distance between the head of the MT and the FOF was measured in 92 patients. The head of the MT was either at or anterior to the FOF in all measured subjects. The mean anterior distance of the head of the MT to FOF was 3.6 mm (±2.4 mm) on the right, and 3.8 mm (±2.2 mm) on the left. The range in AP distance was 0 to 12 mm. There was no significant difference in AP distance between the head of the MT and FOF based on gender (P = .413) or diagnosis (P = .254).

CONCLUSIONS

In our study, the head of the MT was reliably at or anterior to the FOF in all subjects, suggesting its utility as a fixed landmark in endoscopic sinus surgery, particularly in the EMLP.

LEVEL OF EVIDENCE

N/A.

Radiopathologic predictors of 1- and 2-year frontal sinusotomy outcomes in a southeast Asian chronic rhinosinusitis population

BACKGROUND

The frontal sinus and its drainage pathway are difficult spaces to navigate surgically. The complexity of the frontal recess anatomy as well as inflammatory factors may influence outcomes of endoscopic frontal sinusotomy. It is not clear which factors are more important in determining post-operative frontal ostium patency.

OBJECTIVE

The objective is to investigate whether the distribution of fronto-ethmoidal cells, frontal recess dimensions and sinonasal inflammation predict frontal ostium patency at 1- and 2-years after endoscopic frontal sinusotomy.

METHODS

A retrospective review of 94 chronic rhinosinusitis patients (185 sides) who had undergone endoscopic frontal sinusotomies between 2015 and 2019 was conducted. Computed tomography was used to evaluate the type of fronto-ethmoidal cells present and determine the dimensions of the frontal recess. The International Classification of the Radiological Complexity of frontal recess and frontal sinus was used to grade the complexity of frontal recess anatomy. Mucosal inflammation was graded according to a structured histopathology report. Frontal ostium patency at 1- and 2-years post-operatively was recorded.

RESULTS

The frontal ostium patency rates were 80.9% and 73.4% at 1- and 2-years respectively. Eosinophilic predominance (adjusted OR 3.5, 95% CI 1.6-8.0, p = 0.003) and mucosal ulceration on histology (adjusted OR 4.5, 95% CI 1.1-17.9, p = 0.033) predicted ostial stenosis at 1 year. Smoking (adjusted OR 7.6, 95% CI 2.4-24.7, p = 0.001), aspirin exacerbated respiratory disease (AERD) (adjusted OR 7.6, 95% CI 1.9-30.1, p = 0.004) and histological findings of severe inflammation (adjusted OR 8.9, 95% CI 1.9-41.2, p = 0.005) were independent predictors of ostial stenosis at 2 years. Frontal cell patterns, frontal recess dimensions and frontal recess complexity did not predict frontal ostium stenosis at both 1- and 2-years post-operatively.

CONCLUSION

Post-operative control of sinonasal inflammation is important in maintaining frontal ostium patency, regardless of frontal cell patterns or frontal recess dimensions.

[History of frontal sinus surgery and current view of the problem. Part 1]

Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.

Pott's puffy tumor: A comprehensive review of the literature

PURPOSE

Pott's puffy tumor (PPT) is a rare clinical entity characterized by osteomyelitis of the frontal bone with subperiosteal abscess collection. The frequency of reported cases of PPT in the literature has increased in recent years. Previous reviews of PPT exist primarily in the form of small, retrospective case series and anecdotal case reports. Therefore, the aim of this study is to provide the literature's largest comprehensive, up-to-date review of the essential clinical findings, diagnostic modalities, microbiologic considerations, and treatment approaches utilized in the management of PPT, both in pediatric and adult populations.

MATERIALS AND METHODS

We searched MEDLINE, PubMed, and Embase databases for English-language studies published from January 1950 through January 30, 2022. The authors reviewed all cases of PPT, focusing specifically on those describing therapeutic management of PPT. A total of 321 patients were included, consisting of 318 patients (from 216 articles) and an additional 3 adult cases from our institution.

RESULTS

PPT most often results from untreated rhinosinusitis, as well as direct head trauma, substance use, and odontogenic disease. Infections are classically polymicrobial with an anaerobe-predominant microbiome. Both CT and MRI imaging modalities are commonly obtained for presurgical assessment of sinusitis and intracranial extension. The core of treatment is an early and aggressive approach to prevent long-term complications. A significant association exists between surgical management and clinical outcomes for patients with PPT. Recent literature suggests endoscopic sinus surgery is essential for successful disease resolution.

CONCLUSIONS

PPT is an important and relatively morbid disease process that is often underrecognized and misdiagnosed at presentation due to its variable clinical presentation. Management of PPT includes both antimicrobial therapy and surgical intervention. Determination of the optimal approach depends on patient clinical features including age, history of prior endoscopic sinus surgery, and presence of intracranial involvement on presentation. An individualized, targeted, and interdisciplinary approach to the treatment of PPT is critical for successful disease resolution.

The Draf III procedure: A review of indications and techniques

The Draf Ⅲ procedure involves the creation of a common frontal sinus cavity. The most common indication for the Draf Ⅲ procedure is chronic rhinosinusitis of the frontal sinuses despite the failure of more conservative interventions such as bilateral Draf Ⅱa procedures. Primary Draf Ⅲ may be indicated in patients with a high risk of failures such as those with severe polyposis and those with a frontal sinus opening less than 4 mm on computed tomography imaging. Other indications for the Draf Ⅲ include access for tumor removal and repair of traumatic fractures of the frontal sinus. The “inside‐out” Draf Ⅲ procedure is the standard approach when the frontal recess anterior–posterior diameter is wide enough for instrument access, usually larger than 4–5 mm. The “outside‐in” Draf Ⅲ procedure can be done when the frontal recess is too narrow to safely accommodate instruments. Regular follow‐up with debridement should be done to prevent neo‐ostium stenosis.

The prognostic variables affecting the frontal sinusotomy patency outcome and how to manage: A prospective study

OBJECTIVES

The study aimed to assess the factors affecting the frontal sinus patency after endoscopic frontal sinusotomy.

DESIGN

A prospective cohort study.

SETTING

Tertiary centre hospital.

MAIN OUTCOME MEASURES

Fifty patients with refractory chronic frontal sinusitis (83 operated frontal sinuses) had frontal sinusotomy and followed up for six months. Multiple operative factors were included the type of the procedure, intraoperative sinus findings, degree of mucosal preservation and middle turbinate stability. Other factors were also assessed, including smoking, the presence of allergic rhinitis, asthma, gastroesophageal reflux and other associated medical comorbidities.

RESULTS

The sinus patency success rate was 75.9%. There was a significant difference regarding the intraoperative anteroposterior sinus ostium diameter (5.36 ± 1.45 mm vs 8.88 ± 2.38 mm, P-value: .001* in the failed group and the success group, respectively). There was a significant association between the patency outcome and the presence of associated medical comorbidities (P-value: .001*), the presence of allergic rhinitis (P-value: .001*), the degree of sinus mucosal preservation (P-value: .012*) and the degree of middle turbinate stability (P-value: .001*). The multivariate analysis showed that the intraoperative anteroposterior diameter of the sinus ostium, middle turbinate stability and presence of allergic rhinitis were significant predictors (P-value: .012*, .042* and .013*, respectively).

CONCLUSION

Sinuses with anteroposterior ostium diameters less than 5.36 mm are more susceptible to restenosis. The flail middle turbinate increases the risk of postoperative middle meatus synechia and frontal sinus patency failure. The presence of allergic rhinitis has a negative impact on the patency outcome.

Endoscopic management of frontal sinus CSF leaks

Introduction

Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition.

Objective

To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach.

Methods

A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined.

Results

Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 − 41 months).

Conclusion

Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Quality of Life Outcomes in Frontal Sinus Surgery

Introduction: Although significant experience has been gained in the technical nuances of endoscopic sinus surgery procedures, the patient-reported outcomes of frontal endoscopic sinus surgery procedures are still poorly understood. In this study we used the validated patient outcome measure Sino Nasal Outcome Test-22 (SNOT-22) to assess the preoperative and postoperative quality of life in patients undergoing extended endoscopic frontal sinus surgery (Draf type 2 and Draf type 3 procedures). Methods: Out of a total of 680 patients undergoing endoscopic sinus and skull base surgery and 186 patients undergoing frontal sinus surgery, 99 chronic rhinosinusitis patients with (CRSwNP) or without (CRSnNP) nasal polyps undergoing Draf 2 or Draf 3 were assessed. Results: The mean preoperative SNOT-22 was 45.6 points for patients undergoing Draf 2 and 59 for patients undergoing Draf 3, while the mean radiological Lund–Mackay Score was 14.3 and 14.5, respectively. Mean SNOT 22 improvement was 22.9 points for Draf 2 and 37 points for Draf 3 respectively and remained significant in all time intervals, including at 4 years after surgery. With the exception of loss of smell/taste, all symptoms improved by a far bigger extent in Draf 3 group, despite the considerably worse starting point. Effect size (Cohen / Standard Deviations) of Draf 3 was greatest in the following symptoms: “being frustrated/restless/irritable” (1.63), “nasal blockage” (1.43), “reduced concentration” (1.35), “fatigue” (1.29) “runny nose” (1.26) and “need to blow nose” (1.17). Frontal sinus (neo) ostium was patent (fully or partly) at last follow up in 98% of Draf 2 patients and in 88% of patients following Draf 3. Patients with non-patent frontal (neo-) ostium however had a mean postoperative SNOT 22 score of 43 compared to 20 of those with patent frontal sinus (neo-) ostium, although the difference was not statistically significant. Conclusion: Patients undergoing Draf 3 have a greater burden of disease, including both nasal and emotional/general symptoms compared to Draf 2 patients; surgery results in improvement in both groups, although Draf 3 patients have the greatest benefit, especially in emotional / general symptons. In this way both groups achieve similar postoperative quality of life, despite the different starting points.

Draf IIB with superior septectomy: finding the "middle ground"

BACKGROUND

Previous studies have demonstrated a high failure rate of endoscopic sinus surgery (ESS) with Draf IIa in patients with diffuse polyposis, asthma, and aspirin-exacerbated respiratory disease. A high percentage of these patients progress to endoscopic modified Lothrop procedure (EMLP). We describe a modification of the Draf IIb with a superior septectomy (IIb+SS), which may provide similar therapeutic benefit as demonstrated by the distribution of sinus irrigations in the sinus cavity with ESS with IIb+SS vs ESS with EMLP.

METHODS

ESS with IIb+SS was performed on 6 cadaver heads. Fluorescein-dyed irrigations were performed on each head and penetration was recorded using video endoscopy. EMLP was subsequently performed on each head with repeat dye-irrigation and video endoscopy. The videos were reviewed by 4 blinded fellowship-trained rhinologists, and irrigant penetration of the maxillary, ethmoid, frontal, sphenoid sinuses, and olfactory cleft was graded 0 to 3 (3 implying complete staining).

RESULTS

The mean scores when comparing IIb+SS to EMLP were as follows: overall 1.99 vs 1.97 (p = 0.816), maxillary sinus 2.67 vs 2.38 (p = 0.128), ethmoid sinus 1.88 vs 1.98 (p = 0.536), sphenoid sinus 2.58 vs 2.50 (p = 0.467), frontal sinus 1.13 vs 1.38 (p = 0.073), and olfactory cleft 1.71 vs 1.63 (p = 0.529). There was no significant difference between subsites. Interrater reliability was good (Cronbach's alpha = 0.781).

CONCLUSION

Performing ESS with IIb+SS provides similar irrigation delivery benefits to ESS with EMLP, without the need for altering natural sinus outflow and creating circumferential scarring. Further studies evaluating its use in patients that are high risk for revision surgery are needed.

First results of frontal sinus obliteration with a synthetic, resorbable and osteoconductive bone graft of ß-tricalcium phosphate

BACKGROUND

Despite advances in endoscopic sinus surgery, frontal sinus obliteration is still indicated in some cases. Current options for obliteration include autologous and synthetic materials. The use of ß-tricalcium phosphate as a resorbable bone graft substitute is a good alternative for frontal sinus obliteration. This study aimed to report our experience with this material.

METHODS

A retrospective chart review of patients who underwent frontal sinus obliteration at our clinic between 2008 and 2013 was performed. Demographic data, indications, previous surgery, and immediate and late complications were examined. Information on persisting symptoms and patient outcomes was collected using a telephone questionnaire in February 2016.

RESULTS

None of the patients underwent further surgery for frontal sinus disease. All of them reported a good cosmetic result and symptom improvement.

CONCLUSION

ß-tricalcium phosphate is a good, safe and cost-effective material for frontal sinus obliteration.

Outcomes After Frontal Sinus Surgery: An Evidence-Based Review

Endoscopic sinus surgery is an effective intervention at improving quality of life for patients with medically refractory chronic rhinosinusitis. The evidence supporting frontal sinusotomy is limited to single institution case series. However, the data for Draf IIa frontal sinusotomy do demonstrate that most patients experience lasting frontal sinus patency on postoperative endoscopic examination and improvements in quality of life. Salvage endoscopic frontal sinus surgery via a Draf III shows high rates of neo-ostium patency and subjective improvements in symptoms at a 2-year time point in case series.

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.

Changing trends in sinus and septal surgery, 2007 to 2009

BACKGROUND

Sinus surgery remains one of the most commonly performed procedures in the United States, with more than 600,000 patients undergoing sinus operations each year. Advances in our understanding of chronic rhinosinusitis (CRS), as well as the technology used to treat it, has resulted in significant changes in surgical management. The aim of this study was to identify recent changes in the performance and coding of certain endoscopic sinus surgical procedures (ESS) in the hope of generating further discussion and research in this area.

METHODS

The MarketScan Research Database was used to query health insurance claims for all rhinological procedures performed between 2007 and 2009. Current Procedural Terminology (CPT) codes for sinonasal procedures that are endorsed by the American Medical Association were analyzed and compared to general otolaryngological procedures in an attempt to identify trends in the performance and coding of certain ESS procedures.

RESULTS

Compared to general otolaryngological procedures such as adenotonsillectomy, there was a statistically significant increase in the use of CPT codes for all ESS procedures between 2007 and 2009. The most marked interval changes were seen in the use of the CPT codes for procedures previously considered more complex, namely frontal sinusotomy (75%), sphenoidotomy (33%), and maxillary antrostomy with tissue removal (31%).

CONCLUSION

The performance of certain ESS procedures previously considered more complex due to anatomy, access, and proximity to vital structures has increased dramatically in the past few years, whereas increases in basic procedures have mirrored anticipated changes similar to those seen in general otolaryngological procedures.

An evidence-based review of endoscopic frontal sinus surgery

BACKGROUND

Endoscopic approaches to treat frontal sinus disease gained in popularity over the past 20 years with a plethora of published studies that emphasize the high success rate of such surgeries. This study was designed to determine the levels of clinical evidence in the otolaryngology literature that address the efficacy of endoscopic approaches in the management of frontal sinus disease including frontal sinusitis.

METHODS

Twenty-three publications that reported the surgical outcomes of endoscopic approaches to treat frontal sinus disease were reviewed. Data were collected regarding the study design, operative technique, number of patients, duration of follow-up, diagnostic method, surgical success rate, and method(s) used to assess surgical outcome.

RESULTS

The study designs were a retrospective case series without control (16 articles), prospective case series without control (3 articles), and retrospective case series with internal control (4 articles). Eighty-three percent of the published articles provide an evidence level of IV, while the remaining 17% provide an evidence level of III. The surgical technique was described as frontal sinusotomy (n = 4), frontal sinusotomy or frontal sinus drillout (n = 1), frontal sinus drillout alone (n = 1), endoscopic modified Lothrop procedure (n = 9), Draf types I, II, or III (n = 6); trans-septal frontal sinusotomy (n = 1); and frontal sinus rescue procedure (n = 1). The mean number of subjects was 44, and the average follow-up period was 23.6 months. Surgical success rate ranged from 50 to 100%.

CONCLUSION

Despite the number of reports in the literature that address the surgical outcome of endoscopic approaches for treatment of frontal sinus disease, the majority of these studies have a small population size, short follow-up period, and provide a low clinical evidence level.

Indications for external frontal sinus procedures for inflammatory sinus disease

BACKGROUND

In the modern age of endoscopic sinus surgery (ESS), there is an undefined role for external approaches in the treatment of inflammatory disease. This study examines the frontal sinus surgery practices of three experienced rhinologists with a focus on those who underwent an external approach. Our goal was to characterize these patients and propose indications for the use of an external approach alone or in combination with functional ESS (FESS) for frontal sinus inflammatory disease.

METHODS

A retrospective review was performed of frontal sinus procedures performed for inflammatory disease at one institution from 2004 to 2007.

RESULTS

Seven hundred seventeen procedures were performed, 38 (5.3%) of which were external alone (14 procedures) or in combination with FESS (24 procedures). Osteoplastic flap with obliteration (12/14) made up the majority of external alone procedures and the most common indication was neo-osteogenesis of the frontal recess. Trephination was the most common external adjunct to FESS (12/24), and often was performed for type 3 frontal recess cells or in the initial management of acute frontal bone osteomyelitis (FOM). Twenty-eight of 38 (74%) patients had a history of previous surgery. Of the 10 patients with no history of previous surgery, 6 (60%) had an external adjunct for frontal recess neo-osteogenesis. There were no major complications but 9/38 (23.7%) patients required revision surgery for persistent/recurrent symptoms.

CONCLUSION

External approaches alone and in combination with FESS are predominantly secondary to neo-osteogenesis of the frontal recess. Factors associated with neo-osteogenesis include previous trauma, endoscopic surgery, and FOM. External frontal sinus surgery provides adequate management of inflammatory disease but has a high revision rate.

Open surgery versus endoscopic surgery in benign neoplasm involving the frontal sinus

The frontal sinus, because of its proper anatomic features, has a particular relation with nasal cavities. Indeed, its anatomic opening (ostium) is strictly related to a complex ethmoidal structure prechamber mainly composed of the frontal recess.This constitutional feature makes the endoscopic approach more complex in comparison with other major sinuses treatment.In the following work, we present a systematization of surgical approach in relation to different pathologies, analyzing differences and results throughout the comparison of 2 groups: one treated with the endoscopic approach, and the other with open surgery.From these observations, we can assess that surgical approach choice must consider several parameters such as neoplasm localization, extension, dimension, and frontal recess anatomic features.