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DETERMINATION OF THE STRUCTURE OF THE WALLS OF THE FRONTAL SINUS ACCORDING TO SPIRAL COMPUTED TOMOGRAPHY Alekseeva V., Gargin V. The anatomical structure of the frontal sinus is of key importance for the development of its inflammation and the development of complications with spread to neighboring organs and tissues (orbital phlegmon, brain abscesses, meningitis). The aim of our study was to compare the density and thickness of the bone tissue of the unchanged frontal sinus and in various forms of chronic inflammation. Materials and methods. We observed 121 patients with various forms of chronic frontal sinusitis: 56 with chronic hyperplastic (mucosal hyperplasia (up to 6 mm) and 33 patients with chronic purulent-polypous frontal sinusitis, manifested by a total and subtotal decrease in sinus pneumatization according to spiral computed tomography (SCT). 32 SCT samples were selected to form a comparison group without any abnormalities of the paranasal sinuses. Results. The maximum density typical for the lower wall of the frontal sinus under physiological conditions and was found to be 107.96 ± 201.64Hu, the minimum for the posterior wall in purulent-polypous frontal sinusitis was -103.74 ± 195.37Hu. The bone thickness both in the posterior region and in the region practically does not depend on the degree of the severity of pathological changes in it and is 1.0006 ± 0.538 mm, 0.91 ± 0.26 mm, 0.82 ± 0.169 mm under physiological conditions , with mucosal hyperplasia and with purulent-polypous frontal sinusitis in the posterior wall, respectively. In the region of the lower wall, 4.05 ± 2.04 mm, 2.32 ± 1.16 mm, and 4.002 ± 1.16 mm, respectively, according to the above order. Conclusion. It can be assumed that the larger the change in PNSs, the lower the bone density. This in turn affects the prediction of possible complications during surgical treatment of chronic frontal sinusitis. Key words: frontal sinus, computed tomography, bone thickness, bone density Резюме. ВИЗНАЧЕННЯ МОРФОЛОГІЧНОЇ СТРУКТУРИ СТІНОК ЛОБНОЇ ПАЗУХИ ЗА ДОПОМОГОЮ СПІРАЛЬНОЇ КОМП'ЮТЕРНОЇ ТОМОГРАФІЇ Алєксєєва B.B., Гаргін B.B. Анатомічна будова лобної пазухи має ключове значення для виникнення запальних процесів та розвитку ускладнень із поширенням на сусідні органи та тканини (формування флегмони орбіти, абсцесів мозку, менінгіту). Метою нашого дослідження було порівняння щільності та товщини кісткової тканини лобної пазухи в фізіологічних умовах та при різних формах хронічного запального процесу. Матеріали та методи. Під спостереженням було 89 пацієнтів з різними формами хронічного фронтального синуситу: 56 - з хронічним гіперпластичним фронтальним синуситом (гіперплазією слизової оболонки до 6 мм) та 33 пацієнти з хронічним гнійно-поліпозним фронтальним синуситом, що при проведенні спіральної комп’ютерної томографії (СКТ) проявлявся тотальним і субтотальним зниженням пневматизації. Контрольна група - 32 СКТ людей з фізіологічним станом навколоносових пазух. Результати. Максимальна щільність кісткової тканини була визначена в області нижньої стінки лобної пазухи та становила - 107.96 ± 201.64 Hu, мінімальна - в області задньої стінки при гнійно-поліпозному лобному синуситі - -103.74 ± 195.37 Hu. Товщина кісток практично не залежала від ступеня виразності патологічних змін у ній і становить в області задньої стінки - 1.0006 ± 0.538 мм, 0.91 ± 0.26 мм, 0.82 ± 0.169 мм у фізіологічних умовах, при гіперплазії слизової оболонки і при гнійно-поліпозному фронтальному синуситі. В області нижньої стінки 4.05 ± 2.04 мм, 2.32 ± 1,16 мм та 4.002 ± 1.16 мм відповідно. Висновки. Можна припустити, що щільність кісткової тканини залежить від ступеня виразності патологічних змін в лобній пазусі. Це в свою чергу впливає на прогнозування розвитку ускладнень. Ключові слова: лобна пазуха, спіральна комп'ютерна томографія, товщина кісток, щільність кісток. Резюме. ОПРЕДЕЛЕНИЕ МОРФОЛОГИЧЕСКОЙ СТРУКТУРЫ СТЕНОК ЛОБНОЙ ПАЗУХИ С ПОМОЩЬЮ СПИРАЛЬНОЙ КОМПЬЮТЕРНОЙ ТОМОГРАФИИ Алексеева B.B., Гаргин B.B. Анатомическое строение лобной пазухи имеет ключевое значение для возникновения воспалительных процессов и развития осложнений с распространением на соседние органы и ткани (формирование флегмоны орбиты, абсцессов мозга, менингита). Целью нашего исследования было сравнение плотности и толщины костной ткани лобной пазухи в физиологических условиях и при различных формах хронического воспалительного процесса.Материалы и методы. Под наблюдением находилось 89 пациентов с различными формами хронического фронтального синусита: 56 - с хроническим гиперпластическим фронтальным синуситом (гиперплазией слизистой оболочки до 6 мм) и 33 пациента с хроническим гнойно-полипозным фронтальным синуситом, что при проведении спиральной компьютерной томографии (СКТ) проявлялся тотальным и субтотальным снижением пневматизации. Контрольная группа - 32 СКТ людей с физиологическим состоянием околоносовых пазух.Результаты. Максимальная плотность костной ткани была определена в области нижней стенки лобной пазухи в физиологических условиях и составила - 107.96 ± 201.64 Hu, минимальная - в области задней стенки при гнойно-полипозном лобном синусите - -103.74 ± 195.37 Hu. Толщина костей практически не зависила от степени выраженности патологических изменений в ней и составляла в области задней стенки - 1.0006 ± 0.538 мм, 0.91 ± 0.26 мм, 0.82 ± 0.169 мм в физиологических условиях, при гиперплазии слизистой оболочки и при гнойно-полипозном фронтальном синусите. В области нижней стенки 4.05 ± 2.04 мм, 2.32 ± 1.16 мм и 4.002 ± 1.16 мм, соответственно. Выводы. Можно предположить, что плотность костной ткани зависит от степени выраженности патологических изменений в лобной пазухе. Это в свою очередь влияет на прогнозирование возможности развития осложнений. Ключевые слова: лобная пазуха, спиральная компьютерная томография, толщина костей, плотность костей.

Aim. To describe a case of fat obliteration using platelet-rich plasma in a patient with recurrent chronic frontal sinusitis.Materials and methods. A clinical case of a 60-year-old patient who had repeatedly performed extranasal frontotomy for recurrent chronic frontal sinusitis with a short-term effect is described. Due to the ineffectiveness of conservative and traditional surgical treatment, taking into account the characteristics of the clinical picture and the presence of a cosmetic defect in the area of projection of the right frontal sinus, as well as CT results (postoperative bone defect of the right half of the frontal bone), a right-side extranasal frontotomy was performed. The operation involved sinus obliteration with adipose tissue obtained from areas of the thigh anterior surface by lipoaspiration under low pressures with the addition of platelet-rich plasma (PRP) prepared by a single centrifugation of whole venous blood. An assessment of the patient’s condition and fat transplant was carried out on the basis of objective examination after 4 and 6 months and 1.5 year after the surgery and the results of control computed tomography (CT).Results. No complaints regarding nasal breathing from the frontal sinus were registered during control examinations. A good cosmetic result and the absence of pain during palpation in the right frontal sinus were observed. According to CT results, the density of the contents of the frontal sinus corresponded to that of adipose tissue; the volume of material did not changed.Conclusion. Frontal sinus obliteration with adipose tissue and PRP addition is a promising method for treating patients with recurrent chronic frontal sinusitis and repeatedly performed extranasal frontotomy. This method has several advantages over other methods.

Background/Objective Complicated acute rhinosinusitis in the pediatric population is an uncommon problem that may affect the orbit or brain and is life‐threatening. This condition requires surgical intervention with endoscopic sinus surgery for source control, and prior studies have demonstrated the safety of balloon sinuplasty in chronic frontal sinusitis. Methods/Results We present our approach with a balloon sinus dilation hybrid procedure to resolve four distinct types of complicated acute frontal sinusitis in pediatric patients, including intracranial manifestations, intraorbital complications, and recurrent disease. All four patients were able to be managed operatively with frontal balloon sinuplasty. Conclusions Prior efficacy has been demonstrated for chronic frontal sinusitis in the pediatric population. We demonstrate that frontal balloon sinuplasty is also feasible in the proper clinical setting for acute frontal sinusitis, even in the presence of regional complications or recurrent disease. Level of Evidence 4, We report a case series of four pediatric patients with acute frontal rhinosinusitis manifesting with extra‐sinonasal complications who underwent surgical intervention with endoscopic sinus surgery. In all four patients, we were able to successfully use balloon sinus dilation in the acute setting.

OBJECTIVE To describe the osteoplastic approach and to perform a systematic review of the indications and outcomes of the osteoplastic flap procedure for frontal sinus surgeries with or without obliteration. DATA SOURCES PubMed, Medline, Google Scholar, and Cochrane databases. REVIEW METHODS All published studies in the English language on the osteoplastic flap with or without obliteration were identified from 1905 to 2018. All studies with

Isolated frontal sinus disease is a rare and highly morbid condition. Although chronic frontal sinusitis has been described in literature, clinically it is quite uncommon in the absence of paranasal sinusitis and rhinitis. Here we examine a case of isolated chronic frontal sinusitis presenting with anosmia-a curious clinical manifestation.

Objective:This study prospectively assessed the axillary flap approach versus punch-out procedure for agger nasi cell (ANC) removal.This is akey for successful frontal sinus surgery and its implication on the patency of the frontal ostium and middle turbinate lateralization(MTL). Subjects and Methods: The study subjects consisted of 50 patients of whom 30 patients were males (80 frontal sinuses; 30 patients with bilateral disease and 20 patients with unilateral disease) with proven chronic frontal sinusitis, with pneumatized ANC according to CT findings.All patients undergone Endoscopic Sinus Surgery (ESS) with dissection of frontal recess. Group I included 40 sides that undergone removal of ANC using the axillary flap procedure (procedure 1), Group II included 40 sides that undergone removal of ANC using the punch out procedure (procedure 2). Adelaide chronic rhinosinusitis (CRS) symptom scoring questionnaires was used to all patients during their last follow-up visit 3 months after surgery. Results: ANC were the most common variation and were observed in all the patients (20 patients unilaterally and 30 patients bilaterally). MTL following ANC removal has been found in 7.5% ofGroup I and 25% in Group II patients. Association between Adelaide symptoms severity score of postoperative symptoms and MTL was significant for nasal obstruction and rhinorrhea in both procedures (1 and 2). Non visualization of the frontal ostium following ANC removal has been found in 7.5% of Group I and 15% in Group II.Comparison between both procedures on MTL and non-visualization shows that the number of patients with MTL-positive using procedure 1 was significantly less than procedure 2 while there was a non-significant difference between procedure 1 and 2 regarding non-visualization. Conclusions: The axillary flap technique is a safer procedure for resection of the ANC with perfect healing and less incidence of intraoperative and postoperative complications.However, it is a relatively difficult procedure and very time consuming while punch out procedure is a relatively easy, less time consuming procedure.

Objectives: To report one institution’s experience with 22 cases of the Riedel procedure in order to establish a profi le for those patients with chronic frontal sinusitis who develop chronic osteomyelitis.

Frontal sinus outflow tract (FSOT) injury may occur in cases of frontal sinus fractures and nasoethmoid orbital fractures. Since the FSOT is lined with mucosa that is responsible for the path from the frontal sinus to the nasal cavity, an untreated injury may lead to complications such as mucocele formation or chronic frontal sinusitis. Therefore, evaluation of FSOT is of clinical significance, with FSOT being diagnosed mostly by computed tomography or intraoperative dye. Several options are available to surgeons when treating FSOT injury, and they need to be familiar with these options to take the proper treatment measures in order to follow the treatment principle for FSOT, which is a safe sinus, and to reduce complications. This paper aimed to examine the surrounding anatomy, diagnosis, and treatment of FSOT.

Background: Previous studies of endoscopic frontal sinus surgery have been primarily retrospective and focused on symptom relief only. Objectives: To prospectively assess the impact of endoscopic frontal sinus surgery on frontal sinus ostium patency and disease-specific quality of life as measured by the Rhinosinusitis Disability Index (RSDI). Study Design: A 60-patient cohort with chronic frontal sinusitis (100 diseased frontal sinuses) was prospectively evaluated using the RSDI, computed tomography (CT) imaging, and endoscopic examination. Image-guided endoscopic frontal sinusotomy (Draf 2a) was performed in each case. Patients were assessed with RSDI and endoscopic assessment at least 6 months postoperatively. Results: At a mean follow-up of 10 months, endoscopic assessment revealed patent frontal recesses in 90 of 100 frontal sinuses (90%), with significant improvement in the total RSDI score (41.98 ± 26.48 preoperatively to 17.15 ± 15.66 postoperatively) as well as each of its physical, emotional, and functional subscales from 16.3 ± 9.03, 12.23 ± 10.55, 13.45 ± 9.59 preoperatively to 5.95 ± 5.71, 5.55 ± 5.66, 5.65 ± 5.72 postoperatively, respectively. Similar improvement was seen in patients with asthma, polyps, and those undergoing revision sinus surgeries. Conclusions: With frontal recess mucosal preservation and meticulous postoperative endoscopic surveillance, endoscopic frontal sinusotomy results in high rates of frontal sinus ostium patency with significant improvement in quality of life.

The patency of the naso-frontal duct is a key issue in the surgical management of chronic frontal sinusitis. Most of the current operative techniques only provide access to the paramedian portions of the frontal sinus. A canalization approach that allows a functional frontal sinus to be maintained while providing good access to the most lateral areas of the sinus is described herein. Two cases of severe post-traumatic frontal sinusitis, operated on successfully by canalization method based on the conservation of the frontal sinus and the maintenance of the patency of the naso-frontal duct, using both open and endonasal approaches, are reported. One patient was followed-up for 8 years and the other for 7 months. Canalization requires validation in a larger series. This approach provides an alternative to both cranialization and strictly endoscopic methods in lateralized frontal sinus retentions and allows mucocele to be avoided.

In this report, we describe an uncommon presentation of a Pott's puffy tumor, which is defined as a subperiosteal abscess related to a chronic frontal sinusitis. This condition has become rare in our part of the world because of the widespread use of antibiotics. Clinical history, investigations, and management are presented.

The Messerklinger technique is an endoscopic approach to sinus surgery designed to be minimally invasive and preserve mucosa and hence physiological function. More recently there have been advocates for more radical endoscopic approaches to the frontal sinus such as the Modified Lothrop. This review discusses different approaches to frontal sinus surgery including any advantages and disadvantages to each approach. After examining the evidence from the literature, meticulously performed endoscopic frontal sinusotomy with or without computer guidance appears to be the most effective minimally invasive procedure for treating chronic frontal sinusitis secondary to outflow tract obstruction. Properly performed, it is almost always effective in dealing with even the most diseased frontal sinus. It offers clear advantages in reducing complications and recurrence rates in frontal sinus disease, even for revision cases.

Disease within the frontal sinus is primarily treated with endoscopic techniques; however, in certain circumstances, the endoscopic approach is insufficient or impractical to treat frontal sinus disease. The osteoplastic approach to the frontal sinus remains a time-honored procedure for treating challenging frontal sinus disease that is inaccessible to endoscopic instrumentation. Disease in the frontal sinus can be subdivided based on its laterality. Elsewhere in this text, the treatment of bilateral disease is discussed. In this article, the authors describe the osteoplastic approach to the frontal sinus for unilateral disease.

Objectives/Hypothesis: The endoscopic modified Lothrop procedure (EMLP; also known as Draf III or frontal drillout) has recently gained popularity as a minimally invasive alternative to frontal sinus obliteration. This systematic analysis was designed to assess the safety and efficacy of the EMLP. Study Design: Literature review and meta-analysis. Methods: We performed a search of all English studies published from 1990 to 2008 that reported results from a minimum of five patients undergoing the EMLP. Of the 33 papers reviewed, 18 studies (evidence level II-2 or II-3) containing data from 612 patients met inclusion criteria. Results: The most common indications for EMLP were chronic frontal sinusitis (75.2%) and mucocele (21.3%). Patients had an average age of 47.9 years (range, 14-89 years) and were followed for 28.5 months postoperatively. Only 20.3% of procedures were performed without image-guidance. Stents were rarely used (6%). The rate of major and minor complications was

Background: The frontal recess is the drainage pathway that connects the frontal sinus to the anterior ethmoid sinus. Mechanical obstruction is the primary cause of chronic frontal sinusitis with or without a secondary inflammatory process. Eosinophilic inflammation is one of the underlying causes for chronic rhinosinusitis. Objectives/Hyphothesis: To evaluate long-term frontal sinus patency after endoscopic frontal sinusotomy in chronic rhinosinusitis patients and to assess the effect of eosinophilic inflammation on frontal sinus patency. Study Design: Retrospective chart review. Symptom assessment and archived endoscopic photographs were prospectively collected on patients who underwent frontal sinusotomy between 7-1-1999 and 12-31-2000. Subjective symptom improvements were evaluated using the SNOT-20 = 20-item Sino-Nasal Outcome Test. Objective findings of endoscopic frontal sinus patency were documented by archived digital photography. Results: A total of 161 patients with 294 frontal sinuses who underwent endoscopic frontal sinus surgery in the 18 months had an average follow-up of 45.9 months. The patient population was divided into two groups: 58 patients had eosinophilic CRS (ECRS), and 103 patients had CRS without eosinophils (non-ECRS). The mean follow-up for patients with ECRS is 61.6 months and 37.0 months for non-ECRS patients. The non-ECRS patients had a documented endoscopic frontal sinus patency of 90%, and the ECRS patients had an endoscopic frontal sinus patency of 85%. The overall frontal ostium patency rate for all patients was 88.0%. Conclusions: Long-term endoscopic confirmation of frontal ostium patency demonstrates that endoscopic frontal sinusotomy can yield high quality, durable results. There was no significant difference in patency results between ECRS and non-ECRS patients.

OBJECTIVES: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic technique for frontal sinus obliteration. STUDY DESIGN AND SETTING: Retrospective case-control. Thirty-five patients underwent frontal sinus obliteration using either an endoscopic (n=10) or conventional osteoplastic flap (n=25) technique from 1994 to 2004 at an academic medical center. RESULTS: Patients undergoing endoscopic obliteration had less blood loss (P = 0.006), decreased operative time (P = 0.016), and a shorter hospital stay (P = 0.003) compared to osteoplastic control subjects. All 3 surgical complications occurred in the control group. No patients required additional surgery for frontal sinusitis. CONCLUSIONS: The endoscopic approach to frontal sinus obliteration appears to reduce patient morbidity and should be considered in the surgical management of advanced frontal sinus disease. SIGNIFICANCE: This is the first report of a minimally-invasive technique for frontal sinus obliteration.

PURPOSE OF REVIEW The modified endoscopic Lothrop procedure has been used as an alternative to osteoplastic flap with obliteration in the management of chronic frontal sinusitis. More recently it has been used to rescue cases of failed osteoplastic flap. This article reviews the recent literature regarding endoscopic rescue of failed osteoplastic flap with obliteration. RECENT FINDINGS Endoscopic sinus surgery is indicated in cases of osteoplastic flap failure when there is objective evidence of mucocele formation. All patients require CT and MR imaging preoperatively. Clinical improvement can be achieved in up to 89% of patients in the first 12 to 18 months postoperatively. SUMMARY The modified endoscopic Lothrop procedure is effective in the management of failed osteoplastic flap with obliteration in the short term. Long-term evaluation of this technique is still required. Endoscopic rescue is technically challenging and requires an experienced surgeon, ideally with access to image guidance equipment.

Objective Endonasal extended frontal sinusotomy is needed in rare cases of therapy-resistant chronic frontal sinusitis. Several types of burs have been invented to ablate strong bone in the frontal sinus access but nevertheless surgical results seem to differ significantly. The benefits and shortcomings of different burs are subjected to a comparative evaluation. Study design Five cadaver specimens were duplicated by means of dental molding and casting techniques to provide identical microanatomy for comparative studies on frontal sinusotomy. Different burs (conventional straight bur, right-angled bur according to Blokmanis, and curved frontal sinus bur) were applied to create a type IIb frontal sinusotomy according to Draf in microanatomical replicas. The geometry of the frontonasal neoostium was measured and its dimensions were contrasted to the collateral damage. Bone ablation was calculated by repeated weighting and the area of damaged mucosa was quantified using a 3D analyzing system. Results A frontal sinus neoostium measuring 9 × 10 mm on average was created by type IIb frontal sinusotomy according to Draf. The complementary use of an angled bur showed some specific improvements that applied best to spacious anatomic specimens. Those specimens subjected to an extensive use of the straight drill revealed significant collateral damage forming a contrast to minor enlargement of the neoostium. The curved frontal sinus bur showed considerable technical insufficiencies. Conclusions Judicious use of the straight drill is recommended for those rare cases of therapy-resistant frontal sinusitis treated by an extended type of frontal sinusotomy. New technical refinements of the curved frontal sinus burs should be subjected to repeated evaluation.

A frontocutaneous fistula secondary to chronic frontal sinusitis can present with a fistulous opening in the forehead or in the eyelid. It may or may not be associated with Pott's puffy tumor. In this article, we present 2 cases. A case of frontocutaenous fistula with opening in the upper eyelid at the lateral portion of floor of frontal sinus and another case of chronic frontal sinusitis with sub-periosteal abscess in the forehead on the right side near the eyebrow. Relevant literature has also been reviewed.

Objective While reported results utilizing the osteoplastic flap procedure are very good, some patients fail the surgery due to recurrent or persistent frontal sinus disease. This study was performed to evaluate the utility of the endoscopic modified Lothrop sinus surgery for osteoplastic flap failure. Study design and setting A retrospective chart analysis and telephone survey of 10 patients from outside our institution for whom an osteoplastic flap with fat obliteration failed were salvaged using a computerized endoscopic modified Lothrop procedure. Results The main complaints were headache/pressure and recurrent infection. The usual pathology was chronic sinusitis and/or mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. Symptomatic clinical improvement was noted in more than 90% of patients. Conclusion Salvage endoscopic modified Lothrop sinus surgery is recommended for a limited number of traditional osteoplastic flap failures. Computerized surgical navigation may help avoid complications in situations with abnormal anatomy and previous dissection. Significance The endoscopic modified Lothrop procedure should be considered to salvage failed osteoplastic flap sinus obliteration.

Background The aim of this study was to examine the long-term outcomes of the modified endoscopic Lothrop procedure for the management of the most severe forms of recalcitrant chronic frontal sinusitis. Methods This case series evaluated 13 consecutive cases of the modified endoscopic Lothrop procedure for chronic frontal sinusitis from April 1996 to December 1999. Patent communication to the frontal sinus was evaluated by postoperative endoscopic exam. Postoperative patient symptomatology and medication requirements were assessed during clinic evaluation and by standardized telephone questionnaire. Results At a mean follow-up period of 34.5 months, a 77% patency rate was obtained, with 2 of the 13 patients requiring an osteoplastic flap with obliteration. Telephone questionnaire results indicate improved symptoms and decreased medication requirements in the majority of patients who maintained patency. Conclusions These results show that the modified endoscopic Lothrop procedure provides a good alternative to the osteoplastic flap with obliteration for patients with the most severe forms of chronic frontal sinusitis. Initially, high patency rates decline with longer-term follow-up, and severe forms of chronic rhinosinusitis continue to significantly impact patient-perceived quality of life in some patients. The modified endoscopic Lothrop procedure should be reserved for patients who have failed more conservative endoscopic approaches to the frontal recess.

Background The gold standard for surgical treatment of chronic frontal sinusitis has been the osteoplastic flap with obliteration. In an attempt to preserve the frontal sinus, we have been performing the endoscopic modified Lothrop or frontal drill-out. Methods Retrospective chart review. Results We performed the modified Lothrop on 54 patients between 1993 and 1998. The modified Lothrop was successful (no revision surgeries and only an occasional need for antibiotics) after one procedure in 68% (30/44) of patients followed up for ≥1 year. Six patients underwent successful revision, bringing the overall success rate to 82% (36/44). Eight patients (18%) eventually underwent osteoplastic flap with obliteration, three of those after attempted revision. Mean follow-up was 40 months with failures occurring a mean of 12 months after initial Lothrop. Overall complication rate was 11%. Conclusions The modified Lothrop is a technically challenging operation that provides an acceptable alternative to the osteoplastic flap with obliteration.

Despite dramatic advances in the instrumentation and diagnostic imaging available for the treatment of paranasal sinusitis, the surgical management of chronic frontal sinusitis continues to challenge otolaryngologists. The variety of surgical options that exist attests to the complexity of this dise

Objectives: The frontal sinus has the most complex and variable drainage routes of all paranasal sinus regions. The goal of this study was to identify these anatomical factors and inflammation areas relating to chronic frontal sinusitis by comparing radiological presentations in patients with and without frontal sinusitis. Methods: All adult patients with chronic rhinosinusitis who had received computed tomography (CT) scans of the nasal cavities and paranasal sinuses between October 2010 and September 2011. Logistic regression analysis was used to compare the distribution of various frontal recess cells and surrounding inflammatory conditions in patients with and without frontal sinusitis. Results: Analysis of 240 sides of CT scans was performed with 66 sides excluded. The opacification of the frontal recess and sinus lateralis demonstrated a strong association with an increased presence of frontal sinusitis by multiple logistic regression models. Conclusion: Opacification of the frontal recess and sinus lateralis was found to be associated with a significantly increased risk of frontal sinusitis and developing severe blockage of drainage pathways. It provides evidence that mucosal inflammation disease in these two areas is a very important factor leading to chronic frontal sinusitis.

The surgical management of chronic frontal sinusitis continues to evolve. There is no single surgical approach that will lead to successful resolution of disease and symptoms in all cases, and many options must be considered. These options generally attempt to restore drainage and ventilation to the sinus or to obliterate the sinus. When chronic frontal sinusitis fails to respond to maximum medical management, surgical treatment should proceed in a logical progression from simple to more radical procedures. Advanced imaging techniques can offer critical information in this area of highly variable and complex anatomy. Most endoscopic procedures directed at the frontal recess are performed in patients who have previously undergone sinus surgery. In these patients, it is not uncommon to find anatomic variants that predispose the patient to frontal sinus disease as well as scarring and osteoneogenesis. When attempts to restore drainage and ventilation fail, osteoplastic flap with obliteration remains the time-honored treatment even though it is associated with substantial surgical morbidity and renders the otolaryngologist less able to evaluate the frontal sinus endoscopically or radiographically.

Purpose A variety of inflammatory and structural conditions can cause frontal sinusitis. The present study was conducted as pilot study to determine the primary cause of frontal sinusitis at the time of endoscopic sinus surgery. Materials and methods Retrospective chart review was performed from 1997 to 2004 of patients who underwent endoscopic frontal sinus surgery at the University of Virginia. Demographic data, intraoperative frontal recess findings, and history of prior sinus procedures were collected. Results There were 102 patients, and 176 endoscopic frontal sinus surgeries were performed with mean follow-up of 29 months. The major causes for frontal sinusitis were polyp (53%), frontal recess synechia (21%), agger nasi cell (12%), and narrow osteomeatal complex (5%). Frontal recess synechia was present only in patients who had prior surgery. Conclusions Inflammatory polyps, followed by synechia, were the most common causes of chronic frontal sinusitis requiring frontal sinus surgery. Further investigation is warranted to identify the sources of frontal recess synechia and to develop preventative strategies of this iatrogenic problem.

Background Bioactive glass (BG) is a glass ceramic material. It has been used as surgical bone replacement material in ear and oral surgery, orthopedics, and dentistry. Methods Bioactive glass was used as obliteration material in a series of osteoplastic frontal sinus operations on 10 patients suffering from chronic frontal sinusitis, which other, more-conservative treatment modalities had failed to cure. Results Bioactive glass is easy to handle, and complete obliteration of all sinusal recesses and excavations is easily achieved. No adverse effects of the implant material have been seen over a mean follow-up period of 5.0 years. One patient with a local recurrent infection in the outer table of the sinus was reoperated on 5 months after primary surgery. Repeated postoperative computed tomographic scans analyzed by digital region-of-interest (ROI) selection showed no remarkable changes in the frontal sinus cavities but a slight, yearly decrease in the density of the occlusion material. Laboratory monitoring of patients and histopathologic examination of two postoperative biopsy specimens indicated that the material is well tolerated and stable. Conclusions Bioactive glass is a promising and well-tolerated bone graft suitable for osteoplastic frontal sinus operations. Total accurate obliteration of the sinus is achieved with different sizes of granules and blocks. The results of the obliteration are maintained owing to the stability of the material. © 1998 John Wiley & Sons, Inc. Head Neck 20:315–319, 1998.

Management of chronic frontal sinusitis can be challenging due to the complicated anatomic relationships in the anterior skull base. Frontal sinus surgery itself is one of the most common causes of iatrogenic or refractory frontal sinus disease requiring revision surgery. Frontal sinus disease usually results from obstruction of the frontal recess (drainage pathway) rather than an intrinsic problem with the frontal sinus itself. The often variable drainage pathway of the frontal recess resembles an hourglass with the internal frontal sinus ostium being the neck of the hourglass. A simple nasofrontal “duct” does not exist. Proper diagnostic evaluation of the frontal sinus includes a fine-cut CT scan (including coronal and sagittal views) and a well-decongested nasal endoscopy using angled nasal endoscopes. The spectrum of microorganisms typically found in chronic frontal sinusitis is different from that of acute frontal sinusitis. Medical management with a prolonged course of antibiotics, frequently coupled with systemic corticosteroids, is the first line of therapy for chronic frontal sinusitis. In the absence of impending complications, surgery of the frontal sinuses is generally reserved for patients with symptomatic disease that has failed to respond to adequate medical therapy. Endoscopic frontal sinusotomy is the current standard of care for frontal sinus surgery, supplemented by extended endoscopic techniques or external approaches as needed for complex anatomy or tumors. Meticulous postoperative care is an important element for ensuring long-term patency of the frontal sinus outflow tract following endoscopic surgery. External approaches to the frontal sinus are very rarely utilized in the primary surgical management of inflammatory frontal sinus disease. The complications associated with untreated chronic frontal sinusitis are associated with superimposed acute infections and include orbital and intracranial infections.

The surgical management of chronic frontal sinusitis has lagged behind that of other sinuses because of a relative infrequency of the disease, the difficulty in diagnosing it, the anatomical complexity of the area involved, an inadequate understanding of the airflow and mucus drainage pathways, the complexity and lack of success of surgical procedures, and the need for advanced equipment. A review of the anatomy, embryology, and physiology of the nasofrontal region is given followed by a summary of the signs, symptoms, and radiologic findings of chronic frontal disease because often the most difficult decision is knowing when to intervene surgically. Finally, there is a discussion of current techniques and recent advances using powered instrumentation in the nasofrontal area.

For chronic sinusitis surgery, the Draf III approach provides a common median drainage pathway for bilateral frontal sinuses from orbit to orbit. The Draf IIb provides unilateral drainage from orbit to septum. In several cases, inclusion of the nasal and frontal sinus septum in a Draf IIb was advantageous without extension to the opposite frontal recess. The proposed nomenclature is Draf IIc. This study was designed to (1) develop a surgical option for chronic frontal sinusitis where access to one frontal recess is limited or unnecessary and (2) minimize unnecessary surgical manipulation of uninvolved areas. Revision endoscopic frontal sinus surgery was performed on two patients with persistent frontal sinus opacification. Surgery crossed midline including one frontal recess with resection of the superior nasal septum. The surgical result was assessed on endoscopy and computed tomography (CT). The postoperative course was unremarkable with relief of frontal pressure. Postoperative CT scan showed well-aerated frontal sinuses with a widely patent common drainage pathway. Postoperative nasal endoscopy revealed normal mucosa with no exposed bone or edema. The Draf IIc extends the Draf IIb across the midline, without including the opposite frontal recess. This can be accomplished most easily using an interfrontal sinus septal cell or an eccentric interfrontal sinus septum. The Draf IIc is a surgical option in cases of chronic or recalcitrant frontal sinus diseases, including unilateral or bilateral obstruction, where access to the ipsilateral frontal recess is limited or favorable anatomy allows drainage with reduced manipulation of an uninvolved side.

Historically, chronic frontal sinusitis has been a difficult disease to treat. Attempts have been made for more than 100 years to treat it with intranasal techniques. These techniques, although successful in some patients by some surgeons, never gained widespread acceptance. External and obliterative frontal sinus operations have been the standard treatment method since the 1940s and 1950s. The functional approach to sinus disease has matured over the last 10 to 12 years. It now seems logical with our improved endoscopic visualization, instrumentation, and understanding of anatomy and physiology that we should be able to apply minimally invasive techniques to the frontal sinus. This article addresses the question of the frontal recess as opposed to a nasofrontal duct, frontal recess anatomy, and the technique of intranasal functional endoscopic frontal sinusotomy for chronic frontal sinusitis.

A wide variety of procedures, each with distinct disadvantages, have been performed to treat chronic inflammatory disease involving the frontal sinus. The advent and refining of computed tomographic imaging techniques and endoscopic instruments have resulted in surgeons being able to approach the frontal sinus endonasally, with much lower morbidity than previously. Endonasal drainage of the frontal sinus is now possible to treat chronic frontal sinusitis as an alternative to the more traditional external osteoplastic approach. In the past 7 years, 219 patients with symptomatic frontal sinus disease who were considered candidates for an external procedure, were operated on using an endoscopically guided endonasal approach. This article describes the details of surgical technique used to enlarge the opening between the floor of the frontal sinus and the nasofrontal recess. The procedure was successful in 32 of 37 patients evaluated 6 months to 4 years after the surgical operation. Surgical failure was caused by obstruction of the nasofrontal opening as a result of scar tissue formation or reformation of polyps.

Pneumatization of the agger nasi can encroach upon and narrow the nasofrontal duct (NFD) and contribute to chronic frontal sinus disease. To investigate this, we reviewed the computed tomographic (CT) scans and surgical outcomes in 26 patients with chronic frontal sinusitis. Sagittal reformatted CT images were used to define the anatomy of the NFD as well as mucosal disease in the NFD and frontal sinus. The CT findings were correlated with the outcome of frontal sinus surgery. Our findings suggest that agger nasi cell pneumatization with narrowing of the frontal sinus outflow tract is a significant etiology of persistent frontoethmoid pain and chronic frontal sinusitis. Sagittal reformatted images are capable of demonstrating agger nasi cell encroachment on the NFD, as well as NFD mucosal disease. Endoscopic frontal sinusotomy is an effective surgical treatment for chronic frontal sinusitis.

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 () and frontal sinus mucocele () 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.

The frontal cell is a rare anatomic anomaly that can become the etiology of chronic frontal sinusitis. It is an anterior ethmoid cell that can be differentiated from other ethmoid cells by serial analysis of sinus CT scans. Located cephalad to the middle meatus, it may obstruct natural mucociliary clearance by impinging on the frontal recess or the frontal sinus cavity. A classification of 4 types frontal cell (Type I-IV) is described. This anatomy is demonstrated in radiographic images of cadaver and patient sinuses. Four consecutive clinical cases of frontal cell obstruction of the frontal sinus are reviewed. In three instances, we performed a combined external and endoscopic intranasal frontal sinusotomy to effectively relieve the obstruction. We describe this technique in detail and provide a mean follow-up of 6 months for these four patients. With recognition of frontal cell obstruction of the frontal sinus, and proper treatment, the results appear to be very rewarding.

Chronic disease of the paranasal sinuses offers its greatest challenge to therapy when the frontal sinus is the site of the infection. This cavity has problems peculiar to itself which make its successful surgical treatment more difficult than the treatment of any other nasal sinus. The frontal sinus is the most poorly endowed by nature to withstand, or recover from, an infectious invasion. It is placed more deeply in dense bone, its lining membrane is thinner and more poorly nourished than that of the other sinuses and its drainage is the longest and the most devious. Being part and parcel of the ethmoid system and largely an outgrowth of those cells, its position, size and emptying mechanism are arranged to conform with the developmental vagaries of the ethmoid labyrinth. The nasal floor of the frontal sinus is mostly formed by the ethmoid bone, and therefore disease of the cells of

The author reports on a concept, developed over a 10-year experience with 1,080 patients, for treating chronic pansinus disease by an endonasal micro- and endoscopic technique, either alone or in combination with an external (osteoplastic) approach. He describes techniques and indications for simple drainage, extended drainage, or medium drainage of the frontal sinus. Patients who have already undergone several frontal sinus procedures can be treated definitively by combining a procedure using a transfrontal external approach (osteoplastic procedure) with fat obliteration of the frontal sinus, and endonasal micro-endoscopic ethmoidectomy. Because of inflammatory orbital periostitis, subperiosteal abscess, orbital phlegmon, or intracranial complications (meningitis, encephalitis), the endonasal micro-endoscopic approach was used to operate on 47 of 389 patients who underwent procedures for simple, extended, or median drainage of the frontal sinus.

ObjectiveTo determine the current indications for osteoplastic frontal sinus obliteration (OFSO) for the treatment of inflammatory frontal sinus disease.MethodsRetrospective case series from a single tertiary care facility. The medical records of 35 patients who underwent OFSO for chronic frontal sinusitis (n=26) and frontal sinus mucocele (n=9) between 1995 and 2007 were reviewed. Data regarding age, gender, date and nature of previous frontal sinus operation(s), pre-operative imaging, pre-operative diagnosis, and operative complications were culled.ResultsThere were 19 males and 16 females with an age range of 19 to 76 years. All patients had pre-operative sinus CT, while 6 patients had additional MRI. Among the 9 patients diagnosed with frontal sinus mucocele, OFSO was first-line treatment in 8 and salvage for 2 failed endoscopic masupialization procedures in 1. Among the 26 patients with chronic frontal sinusitis, OFSO was first-line in 9 and salvage for failed frontal sinus surgery in 17. The failed ...

Objectives: The purpose of this report is two-fold: 1) to determine the incidence and 2) to determine the efficacy of drillout procedures in the management of frontal sinus disease in a tertiary rhinology practice. Study Design: Retrospective data analysis. Methods: Chart review was performed for all patients undergoing frontal sinus surgery from May 1999 to April 2004. The incidence of drillout surgery was determined. Demographic data, symptomatology, type of drillout procedure, and primary pathology were determined. Postoperative outcome was assessed based on subjective symptomatology and objective endoscopic patency. Results: A total of 186 patients underwent 207 frontal sinus procedures during this time period; 25 patients (13.4%) required a total of 30 (14.5%) drillout procedures. The patient population had previously undergone an average of 3.2 procedures; four cases were primary and 26 were revision procedures. The breakdown of the procedures was as follows: Draf III, 17; Draf IIB, 7; and transseptal frontal sinusotomy, 6. The major indications included mucoceles (11 cases), chronic frontal sinusitis (6 cases), and tumors (5 cases). Postoperatively, presenting symptomatology resolved in 32%, improved in 56%, and remained unchanged in 12% of the patients. Endoscopic patency of the neo-ostium was noted in 23 cases (92%). Average follow-up was 16.3 months. Conclusions: In this series, drillout procedures were successfully used in 25 patients as an important adjunct to the standard endoscopic techniques for management of complex frontal sinus disease. Because the procedure was used only 30 times during a 5-year period, it was reserved for specific circumstances in carefully selected patients.

Background. Synthetic, osteoconductive, and anti- microbial bioactive glass (BAG) has been used in many surgical applications. Methods. BAG was used as obliteration material in a series of osteoplastic frontal sinus operations on 42 patients suffering from chronic frontal sinusitis, which could not be cured with other means of treatment. Results. Accurate obliteration of sinuses was achieved in 39 patients. Uneventful recovery and clinical outcome were seen in 92% of the patients. Histopathologic samples harvested at 1, 5, and 10 years after obliteration revealed a healing process pro- gressing from the fibrous tissue phase to bone formation with scattered fibrous tissue and bony obliteration maintaining BAG granule remnants. Fourier-transform infrared (FTIR) studies showed bone produced by BAG to be similar to natural frontal bone. Micorobiologic cultures obtained with histologic samples revealed no growth of bacteria. Conclusions. BAG appears to be a reliable frontal sinus obliteration material, providing favorable conditions for total bony sinus obliteration. V C 2006 Wiley Periodicals, Inc. Head Neck 28: 834-841, 2006

Surgical management of chronic frontal sinusitis continues to be challenging and difficult despite the widespread acceptance of functional endoscopic sinus surgery principles. External versus intranasal approaches were first introduced and debated at the end of the 19th century [21]. The intranasal techniques, although successful in a small group of patients, more often resulted in persistent chronic frontal sinusitis requiring more radical external or obliterative approaches. The first published reference to intranasal frontal sinus drainage was by Schaeffer in 1890. Several other surgeons contributed to this technique, and then in 1893 Jansen reported the need for “cleaning out” the anterior ethmoid cells to relieve frontal sinus obstruction. In 1917, Ingalls described the use of a “spring-gold tube” to stent the internal frontal sinus ostium [7]. Poor outcomes and the lack of proper instrumentation led to external and obliterative procedures becoming the standard of care in the 1930’s and 1940’s [1, 2, 14]. Advances in endoscopic techniques, knowledge of anatomy, and specialized instrumentation in the last 15 years have allowed for minimally invasive techniques to be employed as the primary treatment for chronic frontal sinusitis. This chapter will describe the frontal recess approach as the initial treatment option for medically resistant chronic frontal sinusitis.

Objectives: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic approach for frontal sinus obliteration. Methods: A retrospective case-control study was undertaken at an academic medical center. Frontal sinus obliteration was performed on 32 patients between 1994 and 2003. An endoscopic method of frontal sinus obliteration was used in patients with unilateral disease and a small frontal sinus (n = 7). Clinical outcome was compared to the control group (n = 25) that underwent conventional osteoplastic obliteration. Results: Patients undergoing endoscopic frontal sinus obliteration had less intraoperative blood loss (79 cc vs 288 cc, P = 0.009) and decreased operative time (3.0 hours vs 4.2 hours, P = 0.007) when compared with the control group. There were no intraoperative complications within the experimental cohort whereas 3 patients in the control group experienced an adverse intraoperative event. Mean hospital stay of those undergoing the endoscopic procedure was shorter compared with conventional obliteration (1.5 days vs 3.3 days, respectively, P = 0.01). None of the patients in either group required revision frontal sinus surgery for recurrent disease. Conclusions: Endoscopic frontal sinus obliteration appears to reduce morbidity in selected patients with chronic frontal sinusitis. This new minimally invasive technique should be considered in the surgical treatment of patients with advanced frontal sinus disease.

Objective:To describe a novel technique of delivering mitomycin C safely via endoscopic sinus surgery.Case report:Mitomycin C was applied in the median frontal drainage pathway of a 44-year-old woman suffering from recalcitrant chronic frontal sinusitis. The mitomycin C was soaked onto a neurosurgical patty, which was delivered through a nasopharyngeal tube trimmed to ensure delivery directly to the desired area, thus sparing adjacent mucosa.Conclusions:Mitomycin C has been suggested to have a useful role in reducing post-operative scarring after endonasal surgery. The long term safety of topical mitomycin C is not yet known, and inadvertent topical application to adjacent mucosa should be avoided. The described technique achieves this in a simple manner, and can be easily applied to other locations.

Expansile inflammatory diseases of the frontal sinuses may produce erosion of the posterior table of the frontal sinus. In these instances, the bone between sinus mucosa and intracranial dura is absent. Over the past decade, endoscopic frontal sinusotomy has emerged as the preferred technique for the treatment of refractory chronic frontal sinusitis. Endoscopic approaches also have a role in the most advanced instances of frontal sinusitis. A retrospective chart review of patients who were treated for frontal sinusitis with erosion of the frontal sinus posterior table was performed. Eight patients were identified. All patients underwent endoscopic frontal sinusotomy; some patients required multiple endoscopic procedures. Complete frontal recess dissection with identification of the frontal ostium was achieved for all involved frontal sinuses. In all cases, this postoperative result was monitored by CT scans (where indicated) and serial nasal endoscopy, which demonstrated good frontal sinus aeration and normal mucociliary clearance. Antibiotics were administered for culture-documented bacterial exacerbations, and systemic steroids were given for management of allergic fungal sinusitis and sinonasal polyposis associated with asthma. No patient underwent frontal sinus obliteration or cranialization. No suppurative intracranial complications were noted during the postoperative period. Endoscopic frontal sinusotomy can be used safely for the definitive management of frontal sinusitis associated with posterior table erosion. In fact, endoscopic techniques may represent the preferred approach for the treatment of this problem. Such an approach avoids the morbidity of more destructive alternatives (such as obliteration), and serves to create a frontal sinus with normal mucociliary clearance.

Endoscopic surgical approaches for chronic frontal sinusitis require the reestablishment of adequate frontal sinus ventilation and drainage for relief of symptoms. After the resection of anterior ethmoid mucosal disease and cellular structure, the anterior to posterior depth of the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla (frontal sinus ostium) often represents a critical margin for functional success. However, little information concerning this dimension is available. Depending on intraoperative surgical judgment of this distance, extended endoscopic surgical procedures involving additional bone resection may be indicated. These approaches may be hazardous due to the proximity of the cranial cavity and orbit. In addition, secondary stenosis can result from the subsequent inflammatory response. Improved CT imaging, high resolution sagittal reformatting, and computer workstations provide the ability to obtain direct preoperative measurements of the frontal recess. We used a paramedian sagittal section and recorded the maximal anterior to posterior depth from the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla in 20 patients, 31 sides, undergoing primary endoscopic frontoethmoidectomy. In addition, we found a positive correlation between this distance and agger nasi air cell size measured in the same 31 sides.

The surgical management of chronic frontal sinusitis remains an area of controversy. Since the introduction of endoscopic sinus surgery, many novel approaches to this difficult problem have been developed. Recently at the University of Virginia, mini-trephination of the frontal sinus has been used in combination with endoscopic frontal sinusotomy. This technique has enabled confident and precise identification of the frontal sinus ostium, culture of sinus contents, and irrigation of the frontal sinus. A retrospective review of 22 minitrephinations since November 1997 was performed. The short term results are encouraging with a frontal sinus patency rate of 90%; however, long-term follow-up is required. We conclude that the technique is reliable and reproducible.