The document discusses surgical approaches for frontal sinus conditions. It describes the anatomy of the frontal sinus and various open and endoscopic surgical procedures for treating chronic sinusitis, trauma, tumors, and other indications. Open approaches include trephination, frontal sinusotomy, and ablation. Endoscopic approaches include DRAF types I-III. Complications and considerations for each procedure are also outlined.

1. FRONTAL SINUS
SURGERIES
Dr Tabeer Arif

2. layout
• Introduction
• Surgical anatomy
• Types
• Indications
• Contraindications
• Workup
• Procedure
• Complications
• Conclusion

3. Introduction
• Frontal sinus surgery has been performed for medically unresponsive
chronic sinusitis, congenital malformations, trauma and neoplasms
• Range from opening into the sinus to complete obliteration of the
frontal sinus

4. Surgical Anatomy
• Mucosa lined air filled space in the frontal bone
• Bilateral and usually asymmetrical
• Frontal sinus drainage pathway into infundibulum or middle meatus
• Frontal recess is bordered by the Agger nasi (the most anterior ethmoid
cell) anteriorly and the ethmoidal bulla cells posteriorly between the
middle turbinate and lamina papyracea

9. • The supraorbital and supratrochlear arteries (from ophthalmic artery)
• The superior ophthalmic vein
• The supraorbital and supratrochlear branches of the trigeminal nerve
supply innervation.

11. Frontal cells
• Type I: Single cell above agger nasi
• Type II: Multiple cells above agger nasi
• Type III: Single cell extending from agger nasi into the frontal
sinus
• Type IV: Single isolated cell in frontal sinus

12. Types
External Approach:
• Trephination
• Frontal sinusotomy
• Frontoethmoidectomy
• Ablation of Frontal sinus

13. Endoscopic Approach:
• Type I (simple drainage) DRAF I
• Type II (extended drainage) DRAF II
• Type III (endonasal median drainage, modified Lothrop) DRAF III

14. Combined approach:
• Trephination with nasoendoscopy
• Endoscopic frontal sinusotomy
• Frontal sinus rescue procedure
• Intranasal modified Lothrop procedure
• Osteoplastic + endoscopic procedure

15. Indications
Endoscopic approach:
• Chronic frontal sinusitis unresponsive to antibiotic treatment (3 weeks
atleast)
• Polyposis
• Tumors
Open approach:
• pathology situated laterally within the sinus
• very small sinuses
• Multiple failed endoscopic procedure
• Trauma

16. Workup
• Detailed history
(h/o trauma, headache, watery nasal discharge, visual problems)
• Complete ENT examination
• Nasoendoscopy
• Occipitofrontal sinus X-ray
• CT scan
• MRI

17. OPEN APPROACHES

18. Trephination
• Indicated in acute purulent frontal sinusitis
• 1-cm brow incision medial to the supraorbital nerve
• Periosteum is elevated to expose the anterior wall of the frontal sinus.
• A cutting burr is used to drill into the frontal sinus
• The lateral wall of the nasal frontal recess is remove
• Irrigation with antibiotics
• Catheter placed in frontal sinus
• Closure of incision around catheter

21. • Post-op irrigation with antibiotics and 0.05% oxymetazoline
• Repeated irrigation of the sinus results in freeflow of the irrigating
solution through the nose
• Catheter removed and the trephination allowed to close by secondary
intention.
• It can be combined with nasoendoscopy

22. Frontal Sinusotomy
• Indications:
• Failure of type III drainage
• Type III drainage not possible
• Laterally located mucopyocoele
• Major destruction of posterior wall
• Major benign tumor
• Aesthetic correction

23. • Provides wide exposure that allows complete exenteration of all the
mucosa of the frontal sinus
• At the completion of the procedure, the nasofrontal ducts are
obliterated with autologous tissue such as muscle, and the sinus is
obliterated with abdominal fat.
Template

25. • Bicoronal incision
• Gull wing incision
• Temporary tarsoraphy

27. • The frontal bone exposed down to the supraorbital rims
• Outline the configuration of the frontal sinus using a template or a
navigation device.
• Periosteum incised
• Osteotomy into frontal sinus using a drill or a saw
• Intersinus septum fractured
• Base of the bone flap is fractured
• Diseased tissue removed

33. Obliteration of Frontal Sinus
• Mocosa removed
• Obliteration of the nasofrontal duct.
• Sinus obliterated with an adipose tissue graft from abdomen.
• Bone flap is fixed in its place
• Incision closed
• Compressive dressing (48-72 hrs)
• Antiobiotics
• 2 suction Drains (24-48hrs)

35. Complications:
• Periorbital edema
• Ecchymosis
• Headache
• Mucocoele
• Persistent frontal fullness and pain
• Difficulty in diagnosis of recurrent frontal sinus disease

36. FrontoEthmoidectomy
• It establishes communication between the floor of the frontal sinus and
the anterior ethmoid cells, in effect marsupializing the most anterior of
the paranasal sinuses with the middle meatus
• in patients who are not candidates for an endoscopic procedure.

37. • Tarsoraphy
• Incision - above medial aspect of upper eyelid curving down to the level
of medial canthus.
• Periosteum elevated
• Trephination done
• Communication established between floor of frontal sinus and anterior
ethmoid air cells which are removed until free communication with the
middle meatus is obtained.

39. • Removal of diseased mucosa
• Reconstruction of nasofrontal duct with nasoseptal mucosal flap
High dgree of recurrence of frontal obstruction
Supraorbital and supratrochlear nerve damage
Occular motility disturbance – double vision

40. Frontal Sinus Ablation
• Osteomyelitis in anterior wall of frontal sinus due to acute or chronic
pyocele
• Subperiosteal abcess of forehead(pott’s puffy tumor)
• Bicoronal incision
• The frontal sinus is ablated by complete removal of the anterior wall of
the frontal sinus, with or without the supraorbital rims
• The sinus is prepared as for a fat obliteration procedure, except that
the skin of the forehead is laid down smoothly on the healthy posterior
table of the sinus.

41. • Suction drain is inserted
• Pressure dressing applied
• Reconstruction
• Wound is kept dry for 5 days
• Facial sutures – 5days
• Scalp sutures – 14 days

42. Cranialization
Indications:
• Comminuted fracture of posterior wall
• Severe post-traumatic oedema of frontal lobe
• Foreign body of frontal lobe
• Destruction of posterior sinus wall by chronic inflamation or neoplasm

43. • Bone fragments removed
• Mucosa removed
• Mobilization of dura
• Duraplasty
• Obliteration of Connection with nose
• Fat graft Contraindicated if both maxillary arteries have been destroyed

44. ENDOSCOPIC
APPROACHES

45. • GA
• Local decongestant
• Local anaesthetic with vasoconstrictor

46. Type I
• Simple Drainage
Indications:
• Failure of conservative surgery in acute rhinosinusitis
• First time sugery
• revision after incomplete ethmoidectomy
Ethmoidectomy (including cell septa in frontal recess area)
• Inferior part of killian’s infundibulum is not disturbed

50. Type II
• Extended Drainage
Indications:
• Serious complication of acute
rhinosinusitis
• Medial mucopyocoele,
• Tumor surgery
• Good quality mucosa
 Resection of floor of frontal sinus between:
• Lamina papyracea and middle turbinate type IIa
• Lamina papyracea and nasal septum type IIb
anterior to ventral margin of olfactory fossa

53. • Wide approach to ethmoid by reducing the lacrimal bone, parts of agar
nasi and parts of frontal process of maxilla until lamina papyracea is
seen
• Frontal recess identified
• Uncapping the egg – if frontal cells are present
• Type IIa widened to type IIb with a diamond burr
• Frontal sinus opening is bordered by bone on all sides and mucosa is
left on at least one part
• Rubber finger stall (for 5 days)

57. • Neostium diameter – upto 11mm in IIa
• If less than 5 mm silicone stents

58. Type III
• Endonasal Median Drainage
Indications:
• Difficult revision surgery
• Samter’s triad
• Mucoviscidosis
• Kartagener’s syndrome
II b opening is enlarged by resecting portions of superior nasal septum in
area of frontal sinus floor

59. • Neo-ostium should be 1.5 cm
Frontal T :
• Long crus – posterior border of perpendicular ethmoid lamina resection
• Short wings – posterior margins of frontal sinus floor resection
• Rubber finger stall in frontal sinus and ethmoid cavities on each side
(for 7 days)

63. Frontal Sinus Rescue
• Indication: frontal sinus obstruction by a laterally retracted middle
turbinate.
• Resection of the scar, the anterior remnant of the mucosa covered
middle turbinate becomes visible.
• Resection of medial osseous lamella and mucosa of the middle
turbinate with the mucosa covering the skull base.
• The lateral mucosal lamella is turned medially covering the skull base.
• The frontal sinus neo-ostium is epithelized.

65. Rhinofrontal sinuseptomy
• Indication: several failed previous frontal sinus surgeries
• Combined intra-extranasal approach
• Through open frontoethmoidectomy frontal pathology is resected
• Total resection of frontal intersinus septum
• Partial endonasal resection of nasal septum
• B/L subtotal resection of free dependant part of middle turbinate
• B/L endoscopic ethmoidectomy

66. • Enlargement of isthmus area between frontal sinuses and nasal cavity
• Complete epithelization of neo-communication with free mucosal grafts
and closure of the open approach
• 91% patients were free of symptoms
• CSF leak reported in 1 patient

67. • In most cases type I or II is sufficient in medically unresponsive frontal
sinusitis
• Type III procedure in samter’s triad
• Post-operative sinusitis: completion of ethmoidectomy with type II a/b
– type III – osteoplastic flap frontal sinus procedure
• Frontal sinus with AP diameter more than 0.8 mm – type III
• Frontal sinus AP diameter less than 0.8 mm – obliteration
• Medial border of lesion lateral to the line through the lamina papyracea
– endonasal approach rarely possible

68. Congenital Malformations
• Nasal fistulas and cysts are removed completely
• Small ones endoscopically and larger via an external approach
• Neurosurgical collaboration
• Meningoencephalocoeles:
• Small, hidden in nasal cavity – micro-endoscopic approach
• Large obvious ones – external approach

69. Frontal Sinus Trauma
• No Wait and see policy in severely fractured frontal sinus
Riedel’s operation: radical resection of whole anterior frontal sinus wall
including all frontal sinus mucosa
• Coronal incision
Anterior and/or posterior wall trauma with Killian’s infundibulum intact –
reconstruction of anterior and posterior sinus wall
• Fragments are put together
• Metallic plate
• Biodegradeable miniplates

70. Severely comminuted posterior wall fractures – reconstruction of
anterior wall, resection of posterior wall, removal of all frontal sinus
mucosa : Cranialization of Frontal Sinus
• dead space obliteration
Orbital roof fractures – entrapment of superior Oblique and/or rectus
muscle
• Reduction of bone fragments, repair of peri-orbita lesion
Dural defect repair
Fibrin glue

71. Osteoplasty
• Frontal sinus anterior wall osteoplasty
• In frontal pneumosinus dilatans
• Horizontal full thickness bone strips are removed

73. Tumor Resection
• Tumor not extending lateral to the line passing through lamina
papyracea – endonasal
• Origin or fixation point in lower third if posterior wall of frontal sinus –
endonasal
• Fixation at anterior wall – external
• Intra-cranial extension
• Inverted papilloma – Drilling of mucopericondrium at the area of origin
of tumor

74. Malignant tumors:
• Endonasal (tumor just reaching the frontal sinus, no major bone
destruction)
• Midfacial degloving (lower sinuses involvement)
• Subcranial resection (skull base, intradural involvement)

75. Conclusion
• Most inflammatory frontal sinus disease requiring surgery can be
operated nasoendoscopically
• Only 5% of all frontal sinus surgeries are through an open appraoch

76. Thank you.