Frontal sinus irrigation: indications, results, and complications

Development of a New Device for Postoperative Self-Irrigation of the Maxillary and Frontal Sinus

OBJECTIVES

Nasal saline irrigation is the corner stone of postoperative care after functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS). However, intrasinus penetration of the saline solution can be challenging and may require difficult head position, particularly for the frontal sinus. Our aim was to evaluate a novel device for direct intrasinus self-irrigation, usable at home for both maxillary and frontal sinus.

METHODS

Thirty devices were implemented in 23 patients: in the maxillary sinus for 18 patients and in the frontal sinus for 5 patients. The device was removed after 7 days on average (5-10 days), and nasal saline irrigation was carried on with a squeeze bottle for 6 weeks. Retrospective evaluation of the device included: device-related complication, patient satisfaction, and ostial or middle turbinate synechiae at 3 months.

RESULTS

No device-related complication (obstruction, displacement, infection, bleeding) occurred. Twenty-one (91.3%) patients were satisfied with the device. Two patients required the help of a nurse for irrigation. No ostial of middle turbinate synechiae was visualized at 3 months. This new endonasal device enables direct intrasinus self-irrigation after FESS for CRS.

CONCLUSION

This preliminary study showed that this device is safe and easy to use. However, further investigations are required to assess its potential role to reduce the risk of synechiae and revision surgery.

Mucus extravasation into the orbit during frontal sinus irrigation

During minitrephination and irrigation of the frontal sinus, mucus extravasated into the orbit through a defect in the sinus floor. The mucus incited a foreign body reaction and became encapsulated within the orbit necessitating excision via an anterior orbitotomy.

Evaluating the safety of frontal sinus trephination

OBJECTIVES/HYPOTHESIS

The depth of the frontal sinus was measured using axial computed tomography (CT) images to examine the safety of frontal sinus trephination at selected distances from the midline.

STUDY DESIGN

Review of 200 sinus CT scans.

METHODS

Two hundred sinus CT scans (400 frontal sinuses) were reviewed to measure the frontal sinus depth at 5 mm, 10 mm, and 15 mm from midline.

RESULTS

Males had a significantly deeper frontal sinus than females at all measurements points (P < .001). The measurements revealed a considerable number of small but nonhypoplastic frontal sinuses, which were shallower than the length of standard frontal trephine instruments (7 mm) and would risk penetration of the posterior table of the sinus. Of all frontal sinuses studied, 9.54% were <7 mm deep at 5 mm from the midline, 10.12% at 10 mm, and 8.96% at 15 mm from the midline. Overall, 15.3% of all frontal sinuses studied had at least one point where the measured depth was <7 mm.

CONCLUSIONS

Although the majority of patients have frontal sinuses deep enough to accommodate standard trephine instruments, surgeons should recognize that up to 15% of nonhypoplastic frontal sinuses may not be sufficiently deep at a given point to allow safe trephination without risking unintentional transgression of the posterior table. This study suggests that trephination routinely carried out at a given predetermined distance from the midline may be an unsafe practice. Careful evaluation of the imaging is essential in every case to avoid inadvertent injury and to help select the safest distance from the midline for frontal sinus trephination.

Is there a reason for performing frontal sinus trephination at 1 cm from midline? A tomographic study

The complex anatomy of the frontoethmoidal recess, as well as its anatomical relationship with the vital adjacent structures in the region explain the reason for considerable surgical care to protect these structures and minimize complications related to healing. Trephination is an accepted procedure to access the frontal sinus.

Aim

Discuss the best location for performing frontal sinus trephination.

Methods

Measuring sinus frontal depth at 3 points equidistant to the midline (crista galli) through the axial tomographic sections.

Results

We measured 138 frontal sinus (69 patients). Frontal sinus depth at 0,5 cm was statistically larger than 1 cm and 1,5 cm, as well as the 1 cm trephine point was significantly larger than 1,5 cm (12,22±4,25 vs 11,78±4,65 p<0,05; 12,22±4,25 vs 10,78±5,98 p<0,001; 11,78±4,65 vs 10,78±5,98 p<0,05). The trephine set used (maximum depth of penetration of 0,7 cm) is safe to be applied in approximately 80% of the patients.

Conclusion

Analizing the results, the trephination may be performed at variable points of the frontalsinus, but the distance of 1 cm from midline appears to be safer and shows better aestethic results.

Cirugía mínimamente invasiva para el tratamiento de la sinusitis fronto-etmoidal complicada

OBJECTIVES

Functional endoscopic sinus surgery (FESS) is nowadays the "gold standard" for frontal sinus pathologies, but management of acute situations and the aproach and/or the extent of the surgery perfomed in the frontal recess remains controversial nowadays.

MATERIAL AND METHODS

We report our experience in 4 patients with orbital celulitis due to frontal sinusitis who underwent combined external surgery (mini-trephination) and endoscopic sinus surgery.

RESULTS

All patients managed sinus patency without any complications.

CONCLUSIONS

We found this combined sinusotomy as an easy, effective and reproductible technique in order to resolve the difficult surgical management of complicated frontal sinusitis.