The five year experience with endoscopic trans-septal frontal sinusotomy

A novel three-dimensional-printed paranasal sinus-skull base anatomical model

PURPOSE

A novel precision three-dimensional (3D)-printed paranasal sinus-skull base anatomical model was generated with a commercial grade desktop 3D printer. A specific page-turning pattern was employed in this model, to display the internal spatial structure of the paranasal sinus.

METHODS

The CT image data of paranasal sinus were imported into the Mimics software to construct a 3D digital paranasal sinus-skull base model. Then, the model was sliced in the coronal position and loaded into the 3D printer to print each slice of the paranasal sinus-skull base model at a ratio of 1:1 in size. Based on CT image data, nine senior doctors assessed the simulation and accuracy of the anatomical structure features of the paranasal sinus-skull base, and the advantages and educational value of the 3D printing model using a seven-point Likert scale.

RESULTS

A life-like 3D paranasal sinus-skull base structural model was successfully printed, with its internal spatial details clearly displayed. Nine senior doctors all thought that the profile of the printed anatomical structure was similar to that displayed by CT scan; however, the model provided more 3D spatial visual information. In addition, the model was considered to be of great value in the anatomy teaching and complicated surgery of the paranasal sinus-skull base, which had a material cost of only 3 dollars.

CONCLUSIONS

The 3D printed paranasal sinus-skull base model has 3D visual functions, which provides a novel tool for anatomical studies on paranasal sinus, resident training, pre-surgical education and surgical planning.

Staged Endoscopic and Combined Open/Endoscopic Approach in the Management of Inverted Papilloma of the Frontal Sinus

Background

The endoscopic management of inverted papilloma has gained increasing popularity over the last 10 years. Although early concerns over an increased risk of recurrence seem to have been allayed, the appropriate management of lesions involving the frontal sinus and frontal recess still has to be determined.

Methods

We performed a retrospective review of the results of all patients with inverted papilloma from 2000 to 2004.

Results

A total of 18 patients were treated between October 2000 and January 2004. Six patients had frontal sinus involvement at the time of initial evaluation. One of these patients had isolated frontal sinus involvement. These patients were managed with either initial endoscopic resection with determination for the need for an additional procedure at the time of endoscopic resection (n = 5) or open/endoscopic approach for isolated frontal sinus involvement (n = 1). Of the five patients who had their disease managed endoscopically, three patients were determined at the initial procedure to need an osteoplastic flap and, subsequently, were managed successfully with a combined approach. One other patient was initially successfully managed endoscopically but ultimately required an osteoplastic flap for definitive management. The fifth patient was managed entirely endoscopically with multiple procedures. All patients treated with this protocol remain disease free with an average follow-up of 13.3 months.

Conclusion

The limitations of endoscopic resection of inverted papilloma of the frontal recess can be managed with staged procedures. Initial endoscopic resection of ethmoid/maxillary disease with subsequent open treatment of the frontal sinus has been successful in our experience.

Endoscopic Management of Failed Frontal Sinus Obliteration

Background

Frontal sinus obliteration (FSO) traditionally has represented the final stage in the algorithm for difficult to manage frontal sinus disease. In addition, FSO has been used in selected cases of frontal sinus trauma. However, this procedure has been associated with failure in 5–10% of cases. Advances in surgical instrumentation and image-guided surgical navigation have permitted endoscopic management of these failures.

Methods

Eleven patients presenting with failure of a previously performed FSO were managed endoscopically with the assistance of image-guided surgical navigation.

Results

Initial frontal sinus pathology included chronic inflammatory disease in six patients and frontal sinus trauma in two patients. Two patients underwent obliteration after neurosurgical frontal craniotomy and one patient underwent obliteration after curettage of a frontal sinus ossifying fibroma. Frontal sinuses were obliterated with fat in eight cases, bone chips in two cases, and bone cement in one case. The mean time interval to FSO failure was 11.1 years (range, 4 months–35 years). The etiology of failure included mucocele in eight patients, chronic frontal sinusitis in two patients, and Pott's puffy tumor in one patient. All 11 patients were managed endoscopically, of which 3 patients underwent a trans-septal frontal sinusotomy. Two patients required revision endoscopic surgery, but all were patent at last follow-up (mean, 14.8 months).

Conclusion

Endoscopic management of failed FSO may be performed safely. These approaches are viable alternatives to open revision procedures in the management of failed FSO. (American Journal of Rhinology 18, 279–284, 2004)

Revision Functional Endoscopic Sinus Surgery

Refractory chronic rhinosinusitis can be challenging to treat. Initial treatment focuses on medical and nonsurgical treatments. If these treatments fail, revision endoscopic sinus surgery is an option. A plan for revision surgery must address anatomic factors contributing to recurrence. Preoperative imaging and sinonasal endoscopy are systematically reviewed; areas of disease and "danger" zones are identified. Traditional anatomic landmarks are often obscured or absent; thus, a set of consistent landmarks (unchanged despite prior surgery) are used to navigate the revision endoscopic sinus surgery. Wide sinusotomies permit visualization and access to disease intraoperatively. Large sinus openings also facilitate post-operative debridements in clinic, endoscopic disease monitoring, and topical sinus therapy.

Frontal Sinus Surgery: Its Evolution, Present Standard of Care, and Recommendations for Current Use

From a historical perspective, frontal sinus surgery has evolved from radical, highly invasive, disfiguring approaches to function-preserving, minimally invasive, and non-disfiguring intranasal procedures. Most sinus surgeons would agree that a sound surgical procedure is one that relieves patients' symptoms and provides a safe sinus in which future intracranial and orbital complications will not occur. For the future, sinus surgeons are searching for the ideal procedure, ie, one that is minimally invasive, reversible, and ensures the patient a safe frontal sinus for the long term. The ideal surgery will also leave minimal morbidity, will leave no cosmetic defect, and will allow for easy postoperative surveillance. To achieve this new standard in frontal sinus surgery, continuous refinements are required in the medical management and understanding of the disease processes that undermine long-term surgical success. Further advancements in instrumentation and visualization techniques are also necessary to enhance surgical precision, spare mucosa, and prevent the scarring and neo-osteogenesis that may cause surgical failures. Perhaps the most important development may be in the selection criteria for appropriate candidates who will benefit most from frontal sinus surgery.

Extended draf IIb procedures in the treatment of frontal sinus pathology

Objectives

Draf IIb approach provides wide, unilateral access to the frontal sinus. This approach can be extended without destruction of the contralateral frontal sinus drainage pathway, performed during Draf III (modified Lothrop) procedure. There is limited data in the literature regarding the use of modified Draf IIb procedures.

Methods

Patients treated with extended Draf IIb procedures in a single center were retrospectively assessed.

Results

Ten patients were identified, including 2 cases of osteoma, 1 inverted papilloma, 1 carcinoma, 5 mucoceles, and 1 chronic rhinosinusitis patient. Six patients had undergone prior surgery, including external procedures in 3 cases. Modifications of Draf IIb were classified as the following: removal of the anterosuperior nasal septum adjacent to the nasal beak, removal of the intersinus septum, and a combination of the above-mentioned methods (upper nasal septum and intersinus septum removal). There were 3 patients operated on with type 1 modification, one patient with type 2 modification, and 6 patients with type 3 modification. There were no perioperative complications.

Conclusion

In selected cases, extended Draf IIb procedures are safe and effective in the treatment of frontal sinus disease.

The Draf III Mucosal Grafting Technique

Objective. The Draf III procedure is an advanced surgical option for frontal sinus disease refractory to endoscopic frontal sinusotomy and is used to expose the anterior limit of resection of the skull base during endoscopic management of anterior skull base tumors. Our objective was to evaluate outcomes of a strategy using mucosal grafts to decrease postoperative closure.

Study Design. Prospective cohort.

Setting. Tertiary care facility.

Subjects and Methods. Patients requiring a Draf III procedure were prospectively enrolled in the study. Demographics, reason for the procedure, percentage graft viability, and complications were recorded. The primary outcome measure was anterior-posterior (AP) diameter at 3 months.

Results. Mucosal grafting was performed during 29 Draf III procedures from 2008 to 2011. Twenty-seven patients (average age, 58 years) were available for measurement at 3 months (average postoperative follow-up, 15.4 months; range, 3–30 months). Reasons for the procedure included tumor (n = 14), chronic rhinosinusitis (CRS) with frontal ostium stenosis (n = 12), and trauma (n = 1). Average intraoperative AP diameter was 11.7 mm. All patients met the definition of success (<50% reduction in diameter), maintaining a patent combined frontal sinus ostium for the duration of follow-up (average diameter 10.8 mm at 3 months). Nine patients with CRS and frontal ostium stenosis had openings similar to the entire cohort (>1-year follow-up; average, 19.3 months) with significant symptom reduction (SNOT-22 preop 62.3 ± 20.8 vs 3 months 27.8 ± 14.8 and 1 year 21.4 ± 13.6; P < .0001).

Conclusion. Cicatricial stenosis and osteoneogenesis are common following the Draf III procedure. This study indicates that the use of mucosal grafts may assist with postoperative stenosis and should be considered a routine strategy for preventing closure.

State of the art in craniomaxillofacial trauma: frontal sinus

PURPOSE OF REVIEW

Many of the successes and controversies in endoscopic management of craniofacial trauma are exemplified in the management of frontal sinus trauma.

RECENT FINDINGS

The effort to reduce surgical morbidity and to optimize reconstruction of craniomaxillofacial injuries has resulted in the development of less invasive surgical approaches and in the use of computer image guidance in surgical planning and execution. Minimally invasive management of frontal sinus inflammatory disease has gained wide acceptance. The technology and techniques applied to surgery of the floor of the frontal sinus is now being applied to the management of frontal sinus trauma. A paradigm shift in the treatment of frontal sinus trauma may be underway.

SUMMARY

An increasing scope of less severe injuries is being managed expectantly with endoscopic frontal sinus surgery available for salvage. There may be an overall decrease in the most severe frontal sinus injuries owing to enforcement of seatbelt and airbag usage. And the most severe injuries are often best managed through cranialization with anterior skull base reconstruction. Thus, the role for frontal sinus obliteration purely to obviate fractures of the frontal sinus outflow tract may be vanishing.

An integrated approach to frontal sinus surgery

This article the most useful procedures into into a comprehensive integrated approach to frontal sinus surgery. It begins with the least invasive and progresses to the most invasive procedure in a step-by-step fashion, which can be applied as needed. The selection of procedure is governed the patient's disease anatomy,and the surgeons skill. The least invasive procedure that can be used should be attempted first, and then, if more is needed, other procedures can be added, either at the same sitting or in subsequent revisions.

Revision endoscopic frontal sinus surgery

PURPOSE OF REVIEW

Recurrent or persistent frontal sinus disease after endoscopic sinus surgery poses formidable challenges owing to the frontal sinus outflow tract's complex variable anatomy, close proximity to vital structures, and predilection for scarring and stenosis. Frontal sinus obliteration used to be the preferred technique of most sinus surgeons for addressing difficult frontal sinus disease; however, several effective endoscopic techniques exist as excellent alternative procedures for addressing this difficult clinical problem.

RECENT FINDINGS

Several endoscopic techniques have been described for addressing these problems including endoscopic frontal sinusotomy, the frontal sinus rescue procedure, endoscopic transseptal frontal sinusotomy, and the modified Lothrop procedure. Advances in treating recurrent frontal sinus disease have included recent articles reviewing the long-term outcomes of some of these techniques, the prevalence of frontal sinus cells, the optimization of medical management, and the spectrum of postoperative debridement regimens.

SUMMARY

When used in the appropriate setting, these less invasive revision endoscopic techniques provide excellent results with low morbidity and several advantages. This article reviews recent developments in the treatment of recurrent or persistent frontal sinus disease including incorporation of these techniques.

Use of the 70-degree diamond burr in the management of complicated frontal sinus disease

OBJECTIVES/HYPOTHESIS

Management of frontal sinus disease may require drill-out of bone in the frontal recess for access, ventilation, and drainage of the sinus cavity; removal of osteitic foci; or resection of neoplastic tissue. Technological advances, particularly burrs with angles of 70 degrees and stereotactic navigational imaging, offer new opportunities to provide access and minimize trauma. The preliminary study evaluates the safety and efficacy of such minimally invasive approaches.

STUDY DESIGN

Retrospective review.

METHODS

The authors describe the use of a 70-degree diamond burr in a series of 10 patients with complicated frontal sinus disease who underwent endoscopic frontal sinusotomy under stereotactic imaging guidance.

RESULTS

The diagnoses consisted of frontal sinus mucocele (n = 4), chronic frontal sinusitis (n = 1), Pott's puffy tumor after frontoethmoid fracture (n = 1), and recurrent inverting papilloma (n = 4). Partial septectomy was required in 6 of 10 patients. No complications were attributable to the drill-out procedure, despite a pre-existing frontoethmoid bony dehiscence in 6 of 10 patients. One patient had a CSF leak during removal of tumor from the skull base. One patient required revision frontal sinusotomy 10 months after the initial procedure, and another required further surgery for residual inverting papilloma on the medial orbital wall. All frontal sinusotomies were patent at last follow-up (mean period, 9.3 mo).

CONCLUSION

Extended endoscopic frontal sinusotomy may be necessary in the management of complicated frontal sinus inflammatory disease and inverting papilloma. The 70-degree diamond burr is a safe and effective tool for access to the frontal recess. Complication rates appear to be similar to those for other extended frontal sinusotomy approaches.

Sinusitis: postoperative changes and surgical complications

Functional endoscopic sinus surgery (FESS) is the standard of care for the surgical management of sinonasal inflammatory disease. This group of procedures focuses on the sinus outflow tract, and is designed to improve sinus function by restoring sinonasal physiology. Use of the monocular endoscope is associated with a range of unique surgical complications that often require cross-sectional imaging. Many patients considering sinus surgery today have had surgical procedures in the past that were directed at removing diseased mucosa, rather than improving sinus drainage, and have a different appearance on CT. This report addresses the spectrum of surgical changes found on postoperative imaging of the paranasal sinuses, and the surgical complications that may occur during endoscopic sinus surgery.