open and endoscopic approaches

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.