Frontal sinus procedures

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FRONTAL SINUS PROCEDURES

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Frontal sinus procedures

  1. 1. FRONTAL SINUS PROCEDURES DR. AJAY MANICKAM MS ENT PGT RG KAR MEDICAL COLLEGE
  2. 2. Comprehensive Anatomy O Varies remarkably in size, degree of septation, drainage configuration O Drainage is downwards – acute sinusitis heals fast, chronic is less frequent O Width and course of fronto nasal recess depends on size & number of ant etmoidal cells
  3. 3. The Frontal sinus O Upper dome attachment of Uncinate process within frontal recess described by Stammberger as Egg shell in an inverted cup O Hour Glass Configuration – Frontal infundibulum, Frontal ostium, Frontal Recess
  4. 4. Endoscopic view O The upper border of attachment of uncinate process is removed O Bulla removed systematically
  5. 5. Frontal Cells O Anterior ethmoidal air cell can migrate to frontal recess area – Frontal Cells O Type 1 – single above agger nasi cell O Type 2 – multiple cell above agger nasi O Type 3 – a cell into frontal sinus O Type 4 – isolated loner cell within frontal sinus
  6. 6. Type 1 and Type 2 cell
  7. 7. Type 3 and Type 4 cell
  8. 8. Clinical Diagnosis O History O Clinical Examination 1. Inspection 2. Palpation 3. Percussion 4. Ant Rhinoscopy & Endoscopy O Imaging O Plain X ray O CT & MRI O Scintigraphy
  9. 9. Pathology O Fronto Basal malformations O Trauma of the Frontal sinus O Inflamatory diseases O Frontal Pneumosinus dilatans O Tumours
  10. 10. Frontobasal malformations O Classification O Site of herniation O Contents of the sac
  11. 11. Frontobasal malformations OFronto basal occult or manifest? OCT & MRI ESSENTIAL OWhole skull base – Multi locular defects
  12. 12. Operative principle O Nasal fistulas and cyst – short ones endoscopically, larger via external approach O Meningo and encephalocele endonasal approach O Very large meningo encephalocele preferably external via coronal approach
  13. 13. Trauma of Frontal sinus O CT imaging & MRI O Comminuted fracture post wall – dural lacerations – has to be ruled out O Principles O No wait & see O PNS is not sterile – ascending intracranial O Earlier Riedel’s operation
  14. 14. 3 Individual situations O Fracture of anterior and/or posterior wall but intact KILLIAN’S infundibulum O Severely comminuted fracture O Fractures of the orbital roof
  15. 15. Dural Lesion O Underlay technique between brain & dura O Underlay technique between dura & bone O Onlay technique onto the posterior wall of the frontal sinus
  16. 16. Inflammatory Diseases O Frontal sinus trephenation and endoscopy O External fronto ethmoidectomy O Endonasal surgery of the frontal sinus O Rhinofrontal sinuseptomy O Osteoplastic bone flap procedure O Cranialization of the frontal sinus
  17. 17. Frontal sinus trephanation
  18. 18. External frontoethmoidectomy
  19. 19. Endonasal surgery O Type 1 – simple drainage O Type 2 – extended drainage O Type 3 – endonasal median drainage
  20. 20. Type 1 OSimple drainage established by ethmoidectomy. Inferior part is untouched. OMinor pathology
  21. 21. Type 2 O Resecting floor of frontal sinus between lamina papyracea and the middle turbinate (2a) or the nasal septum (2b)
  22. 22. Type 3 O 2b is enlarged by resecting nasal septum. The diameter is about 1.5 cm. O Starting on oneside crossing midline contralateral lamina papyracea is reached.
  23. 23. Rhinofrontal sinuseptotomy O External approach jansen-ritter approach O Resection of frontal sinus pathology O Total resection of frontal intersinus septum O Partial endonasal rection of the nasal septum O Bilateral endoscopic ethmoidectomy O Complete epithelization with free mucosal grafts.
  24. 24. Osteoplastic bone flap procedure
  25. 25. Cranialization of the frontal sinus O Initial part similar to osteoplastic frontal sinus procedure O After careful mobilization of the dura eventual duraplasty, post wall of frontal sinus completely removed. O Dead space between ant wall and dura obliterated abdominal fat.
  26. 26. Frontal pneumosinus dilatans O Pneumatization varies between individuals O Pneumatization may extend beyond the confines of the frontal bone. O May be associated with arachnoid cysts, meningioma, fibrous dysplasia O Cranio cerebral hemiatrophy (Dyke –Davidoff-Masson syndrome)
  27. 27. Tumours O Endonasal O Midfacial degloving O Subcranial O Lateral rhinotomy justified only if orbital exenteration is necessary
  28. 28. Benign frontal sinus neoplasm O Not extending more laterally than a vertical plane through the lamina – endonasal O Point of origin posterior lower third – endonasal & if there is fixation at ant wall of frontal sinus contraindicated O Intracranial extension – degree & experience of surgeon
  29. 29. Endoscopic surgery of Osteoma
  30. 30. Open approach
  31. 31. Fibrous dysplasia O Tumour like lesion – self limiting – non encapsulated O 3 types O Monostotic O Polyostotic O mcCune Albright syndrome
  32. 32. Communited fracture
  33. 33. Conclusion O Bony borders outlet intact and preserving mucosa as much as possible offer less morbidity. O If endo nasal procedure is not leading to success then osteoplastic frontal sinus operation results in 90% solution.
  34. 34. Thank you

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