Frontal Sinus Surgery

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Frontal Sinus Surgery

• Jacques Peltier, MD
• Matthew Ryan, MD
• Department of Otolaryngology
• University of Texas Medical Branch
• Galveston, TX
• October 11, 2006

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Anatomy

• Uncinate process
• Agger Nasi

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Anatomy

• Hiatus Semilunaris
• Ethmoid infundibulum

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Anatomy

• Frontal Sinus Drainage Pathway
• Frontal Sinus Ostium

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Anatomy

• Cribriform Plate
• Lamina papyracea
• Fovea ethmoidalis

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Anatomic Variations
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Anatomy

• Anterior Terminal Recess
• Posterior Terminal Recess

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Finding The Frontal Recess
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Finding The Frontal Recess
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Frontal Cells

• Type I - Single cell above the agger nasi
• Type II - Two or more cells above the agger cell
• Type III - Single cell extending from the agger
  cell into the frontal sinus
• Type IV - Isolated cell within the frontal sinus

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Frontal Cells
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Frontal Cells
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Frontal Cells
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Anatomic Variations
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Surgical Indications

• Chronic sinusitis unresolved with maximal medical
  therapy
• Polyps and allergic fungal sinusitis
• Intracranial complications of sinusitis
• Mucoceles or mucopyoceles
• Benign neoplasms such as osteomas, inverting
  papillomas, or fibrous dysplasia.

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Draf Procedures
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Draf I

• Anterior ethmoid cells
• Uncinate process
• Obstructing frontal cells

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Draf II

• Floor of the frontal sinus
• Lamina papyracea to Septum
• Anterior face of Frontal

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Draf III

• Modified Lothrop
• Interfrontal septum
• Nasal septum
• Frontal sinus floor

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Frontal Sinus Trephination

• Finding the frontal recess
• Mucoceles
• Isolated Type IV frontal cells
• With endoscopic techniques to assist with Draf II
  and III

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Frontal Sinus Trephination
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Frontal Sinus Trephination
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Frontal Sinus Trephination
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Frontal Sinus Trephination
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Combined Approaches
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Combined Approaches
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Combined Approaches
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Modified Lothrop
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Modified Lothrop

• Take down the septum first

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Osteoplastic Flap Vs. Draf III

• Narrow Nasal Airway
• Small Frontal Sinus
• Deep Nasion
• Floor of sinus lt 1.5 cm
• Heavy thick nasofrontal beak
• Proliferative osteitis, complicated chronic
  infection
• Favor Draf III for mucoceles

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Osteoplastic Flap Vs. Draf III
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Osteoplastic Flap

• May be modified to
• fit the patient

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Osteoplastic Flap

• Small bony flap
• Care to preserve
• supratrochlear
• bundle

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Osteoplastic Flap

• 6 foot Caldwell
• Image guidance
• Wire probe

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Osteoplastic Flaps
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Osteoplastic Flaps
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Osteoplastic Flap
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Osteoplastic Flap
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Osteoplastic Flap
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Pearls to Operating in the frontal recess

• Taken from a lecture by David Kennedy MD at the
  academy meeting this year
• Pearl look for lectures at academy that will
  assist your grand rounds

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Pearl 1 Carefully Examine the Anatomy in more
than one CT plane

• Size of the frontal recess
• Size of the frontal sinus
• Bony thickening or neo-osteogenesis
• Identify the frontal sinus drainage pathway
• Note the position of the anterior ethmoidal artery

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Pearl 2 Identify the Anterior Ethmoidal Artery

• Superior extension of anterior wall of bulla
• Nipple on the medial orbital wall
• 1-4 mms below skull base
• Typically posterior to supraorbital ethmoid cells

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Pearl 3 Plan the least invasive approach
possible

• Ethmoidectomy with Middle Meatal Antrostomy
  without frontal recess surgery
• Frontal recess surgery
• Endoscopic frontal sinusotomy
• Frontal sinus trephination
• Unilateral extend frontal sinus surgery (Draf II)
• Endoscopic Modified Lothrop (Draf III)
• Osteoplastic flap with or without obliteration

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Pearl 4 Positively Identify the Skull Base
Posteriorly

• Skeletonize from posterior to anterior
• Open cells immediately posterior to the middle
  turbinate
• Identify the sinus with a seeker

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Pearl 5 Positively identify the frontal sinus
with a probe

• Need a relatively dry field
• 45 degree telescopes are helpful
• Identify medial orbital wall and stay close to it
  dissecting superiorly
• Opening to frontal sinus typically medial
• Identify opening with a probe

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Pearl 6 Preserve the Mucosa

• Consider leaving polyps if sinus is open
• Remove osteitic intersinus septae carefully
• Do not traumatize unless sinus can be opened
  widely
• Standard frontal sinusotomy
• Draf Type II
• Works well if you can
• Preserve mucosa
• Remove bony partitions
• Create an ostium gt4-5 mm

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Pearl 7 Keep the Sinus Open Postoperatively

• Remove fibrin and blood from frontal recess and
  frontal sinus
• Remove residual bone
• Antibiotics, topical steroids?
• Oral Steroids?

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Pearl 8 Avoid obliteration in tumors and
allergic fungal sinusitis

• Combine osteoplastic approach with
• Draf 3 if possible in these situations
• Avoids imaging difficulties after surgery

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Pearl 9 Always avoid complications in FESS.
Most operations are for benign disease
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Conclusion

• Very little evidence based medicine
• Do the least invasive procedures first
• Be aware of various surgical options
• Image guidance a valuable tool
• First do no harm