Frontal Sinus Surgery

Jacques Peltier, MD Faculty Advisor: Matthew Ryan, MD

Department of Otolaryngology University of Texas Medical Branch

Grand Rounds Presentation October 11, 2006

www.onlinelaege.com

Anatomy • Uncinate process

• Agger Nasi

Anatomy

• Hiatus Semilunaris

• Ethmoid infundibulum

• Frontal Sinus Drainage Pathway

• Frontal Sinus Ostium

Anatomy

Anatomy

• Cribriform Plate

• Lamina papyracea

• Fovea ethmoidalis

Anatomic Variations

Anatomy

• Anterior Terminal Recess

• Posterior Terminal Recess

Finding The Frontal Recess

Finding The Frontal Recess

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

Frontal Cells

Frontal Cells

Frontal Cells

Anatomic Variations

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.

Draf Procedures

Draf I

• Anterior ethmoid cells

• Uncinate process

• Obstructing frontal cells

Draf II

• Floor of the frontal sinus

• Lamina papyracea to Septum

• Anterior face of Frontal

Draf III

• Modified Lothrop

• Interfrontal septum

• Nasal septum

• Frontal sinus floor

Frontal Sinus Trephination

• Finding the frontal recess

• Mucoceles

• Isolated Type IV frontal cells

• With endoscopic techniques to assist with Draf II and III

Frontal Sinus Trephination

Frontal Sinus Trephination

Frontal Sinus Trephination

Frontal Sinus Trephination

Combined Approaches

Combined Approaches

Combined Approaches

Modified Lothrop

Modified Lothrop

Take down the septum first

Osteoplastic Flap Vs. Draf III

• Narrow Nasal Airway

• Small Frontal Sinus

• Deep Nasion

• Floor of sinus < 1.5 cm

• Heavy thick nasofrontal beak

• Proliferative osteitis, complicated chronic infection

• Favor Draf III for mucoceles

Osteoplastic Flap Vs. Draf III

Osteoplastic Flap

• May be modified to

fit the patient

Osteoplastic Flap

• Small bony flap

• Care to preserve

supratrochlear

bundle

Osteoplastic Flap

• 6 foot Caldwell

• Image guidance

• Wire probe

Osteoplastic Flaps

Osteoplastic Flaps

Osteoplastic Flap

Osteoplastic Flap

Osteoplastic Flap

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

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

Pearl # 2 Identify the Anterior Ethmoidal Artery

• Superior extension of anterior wall of bulla

• Nipple on the medial orbital wall

• 1-4 mm’s below skull base

• Typically posterior to supraorbital ethmoid cells

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

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

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

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 >4-5 mm

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?

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

Pearl #9 Always avoid complications in FESS. Most

operations are for benign disease

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