Modern concepts of frontal sinus surgery

CT analysis of frontal recess air cell and fluid dynamics simulation of frontal sinus in people with different frontal sinus development after Draf1-3 surgery

OBJECTIVE

To explore the effects of Draf1-3 on frontal sinus airflow and frontal sinus irrigation in people with different frontal sinus development METHODS: The development of the frontal sinus and the distribution of the frontal recess cells were evaluated by CT scan in 150 adults (300 sides). The airflow changes into the frontal sinus and frontal recess after Draf were analyzed by Fluent software under a steady state and quiet inspiratory state. Nasal irrigation after Draf in adults with well-developed frontal sinus was simulated using 120 mL saline at a rate of 12 mL/s in a position at 45° to observe the changes in transient flow distribution.

RESULTS

The moderately developed type of the frontal sinus was the most common. The airflow patterns in the frontal sinus and frontal recess in the moderate development group were laminar, while several large vortexes were formed between the frontal sinus and frontal recess in the well-development group. The Draf exerted more significant effects on the patterns, pressure, and velocity of the airflow in the frontal sinus and frontal recess in the well development group than in the moderate development group. The volume fraction of saline in the frontal sinus increased significantly from Draf1 to Draf3, and the time required for a complete infiltration of saline in the frontal sinus mucosa was significantly reduced.

CONCLUSIONS

Draf1-3 has different effects on the airflow field of the frontal sinus with different developmental types; and Draf1-3 can significantly improve the postoperative flushing of the frontal sinus.

IL-13 and IL-13-induced periostin levels are specifically decreased in patients following endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Type 2 (T2) inflammation plays a pathogenic role in chronic rhinosinusitis (CRS). The effects of endoscopic sinus surgery (ESS) on T2 inflammation are unknown.

OBJECTIVE

The aim of this study was to compare T2 inflammatory biomarkers from middle meatal (MM) mucus for distinguishing patients with CRS from CRS-free patients, identifying major phenotypes (CRS without nasal polyps [CRSsNP] and CRS with nasal polyps [CRSwNP]), assessing endotypic change, and establishing cross-sectional and longitudinal outcomes in patients undergoing ESS.

METHODS

MM mucus samples were collected from patients with CRSsNP and patients with CRSwNP before and 6 to 12 months after ESS and compared with samples from CRS-free control patients. T2 biomarkers were evaluated both continuously and using threshold-based definitions of T2 endotype to identify relationships with patient-reported (based on the 22-Item Sinonasal Outcomes Test and Chronic Rhinosinusitis Patient-Reported Outcomes Measure) and clinician-reported (radiographic and endoscopic) severity. Linear mixed models were developed to analyze clinical variables associated with T2 biomarker levels.

RESULTS

A total of 154 patients with CRS (89 with CRSsNP and 65 with CRSwNP) were enrolled, with a mean interval of 9 months between ESS and follow-up. An analysis of pre-ESS MM mucus samples revealed elevated levels of T2 mediators in patients with CRSwNP versus in patients with CRSsNP and CRS-free controls. Temporally stable correlations between levels of IL-13 and IL-5, levels of periostin and complement 5a, and levels of eosinophil cationic protein (ECP) and eotaxin-3 were observed. On this basis and on the basis of pathologic significance, levels of IL-13, periostin and ECP were further analyzed. After ESS, levels of IL-13 and periostin decreased significantly, whereas ECP levels remained unchanged. Across pre- and post-ESS evaluation, the T2 endotype was associated with radiographic severity but did not predict outcomes. CRSwNP status and African American race were associated with higher levels of IL-13 and periostin, whereas ECP level was higher in patients undergoing extensive surgery.

CONCLUSION

ESS decreased levels of IL-13 and periostin in the middle meatus. T2 inflammation after ESS was correlated with patient- and clinician-reported severity across phenotypes. Pre-ESS T2 inflammation did not predict post-ESS outcomes.

Comprehensive access strategies to the frontal sinus

PURPOSE OF REVIEW

Despite the impressive evolutions in endoscopic endonasal approaches and instrumentations, the frontal sinus remains a challenging area. Different surgical options have been described over the years, but the main criticism lies in choosing the most suitable approach for a given case, based on the anatomy of each patient and the disease to treat. The purpose of this study is to provide a comprehensive review of surgical access strategies currently available to address the frontal sinus, including both endonasal and traditional external procedures, analysing indications, contraindications, complications and outcomes.

RECENT FINDINGS

Frontal sinus surgery includes minimally invasive endonasal approaches (balloon dilatation, Draf type I); extended endonasal approaches (Draf type IIA-IIB-IIC, Draf type III and their modifications via orbital transposition and contralateral pyriform aperture resection); external procedures (superior eyelid incision, frontal osteoplastic flap, Riedel procedure, Riedel-Mosher operation); and combined approaches.

SUMMARY

Recent advances in endoscopic endonasal techniques have deeply reshaped the surgical options to manage frontal sinus diseases, in an attempt to minimize the invasiveness of the procedures and maximize their outcomes. Traditional external procedures should be used in selected cases nonamenable for endonasal surgery. The appropriate selection of cases appears to be of paramount importance to obtain successful outcomes.

[History of frontal sinus surgery and current view of the problem. Part 1]

Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.

Surgical Instructions in Revision Endoscopic Sinus Surgery: Pearls and Pitfalls

Functional endoscopic sinus surgery (FESS) has become one of the most common surgical techniques performed by otolaryngologists with significant data demonstrating its efficacy in managing patients with chronic rhinosinusitis (CRS). However, despite this initial success, patients may continue to present with recurrent symptoms and approximately 10-15% of them will require revision surgery. Failure of FESS may have many different causes which include inappropriate patient selection and preparation, comorbidities like cystic fibrosis and Samter's triad, insufficient surgical skills or anatomical variations that have not been addressed adequately. Two inverse European techniques were introduced in the 1980s. The one promoted by Messer-klinger, who practiced the anterior-to-posterior approach, another one, developed by Wigand who performed posterior-to-anterior dissection, opens the sphenoid ostium or removes the anterior wall of the sphenoid sinus and ends with a total ethmoidectomy. Hereby in RESS we start dissection in posterior-to-anterior fashion by following a structured approach in the identification of the fixed landmarks to allow quick and easy orientation to the skull base and medial orbital wall to avoid the complications.

The Merit of Image Guidance in Endoscopic Frontal Sinus Surgery

The introduction of image guidance navigation system in endoscopic sinus surgeries has been highly advocated in the recent past era. Ever since its introduction in the 1980s and 1990s in Germany it has been asserted that the image-guided navigation enhances surgical outcomes and diminished perioperative morbidities. The objective of this study is to reflect the experience of our institute with the image guidance navigation system in the frontal sinus endoscopic surgeries, specifically due to its constricted anatomy and proximity to vital structures. Retrospective chart review was performed for all image guided endoscopic frontal sinus procedures Performed at a tertiary referral center of King Fahad Specialist Hospital Dammam during the period from 2010 to 2019. A total of 450 endoscopic sinus and skull base procedures were performed using different image guidance systems. Out of the 450 cases, 231 cases were indicated for frontal sinus involvement. The fundamentals of anatomical knowledge are essential for the success of any surgery including image-guided surgeries. Utilization of image-guidance in endoscopic frontal surgeries assists in portraying the way to targeted frontal disease. It aids in localizing vital structures in distorted anatomy thus avoiding undesirable complications.

Long-term persistent discomfort due to a giant frontoethmoidal osteoma despite complete surgical removal - A case report

Introduction

Giant frontoethmoidal osteomas are rare, slow-growing, benign osseous tumours, frequently causing severe life impairing symptoms due to their proximity to noble structures. Initially, osteomas are often diagnosed on radiographs by chance. Their aetiology can be considered ambiguous. They may either be treated by active observation, medical therapy, radio and thermal therapy, or surgery.

Case presentation

We report the case of a 56-year-old female patient with a giant osteoma spreading from the nasal cavity to the entire frontoethmoidal sinus, leading to headaches, respiratory problems, and nausea for several years. For a period of 20 years, a watch and wait approach was applied. Finally, the osteoma was removed using a combined open and endoscopic approach. One year after the operation, a secondary mucocele developed, accompanying headaches and facial pressure due to its continuous expansion. Despite numerous consultations, she refused surgical intervention until today.

Discussion

Early detection and removal of frontoethmoidal osteomas improves the prognosis for a favourable treatment outcome. The smaller the osteoma, the easier it can be removed endoscopically. The decision to perform surgery was made when the condition drastically affected the patient's quality of life. To date, there is still no strong consent regarding the best surgical approach and the best time to do it.

Conclusion

The combination of open and endoscopic surgery remains a safe and straightforward procedure for the removal of giant frontoethmoidal osteomas. Early detection and intervention are crucial for a predictable minimally invasive treatment with a favourable outcome for the patient.

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Early removal of frontoethmoidal osteomas improves the prognosis for a favourable minimally invasive treatment outcome.

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The smaller the osteoma, the easier it can be removed exclusively by endoscopy.

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The combination of open and endoscopic surgery remains a safe and uncomplicated procedure for the removal of giant frontoethmoidal osteomas.

Trans-Nasion-Complex Approach for Endoscopic Modified Lothrop Procedure: Conception, Anatomy, and Technique

Background

The endoscopic modified Lothrop procedure (EMLP) is an important procedure used to address frontal and anterior skull-base lesions. Two techniques were established, namely, the inside-out approach and the outside-in approach. The former technique take the frontal recess and the first olfactory filament (FOF) as key landmarks while the latter use the FOF as posterior boundary. In some cases, however, these two landmarks are not available. Therefore, we supplement the outside-in approach and named it trans-nasion-complex approach (TNCA) for EMLP that can be performed without locating these two landmarks.

Methods

Two dry human skulls were used to observe the bony nasion complex. Then, five colored silicon-injected human head specimens were dissected via TNCA for EMLP. Finally, the outcomes of patients who underwent TNCA were reviewed.

Results

The nasion complex is an osseous complex that consists of the nasion and its adjacent structures, including the bilateral root of nasal bones, nasal process of frontal bones, anterior portion of the perpendicular plate of the ethmoid bone that connects with the inferior aspect of the nasal bones, and portions of the bilateral frontal process of the maxillary bones. Surgical landmarks for TNCA include the anterior superior portion of the nasal septum, anterior margin and axilla of the middle turbinate, frontal process of the maxilla bone, nasal process of the frontal bone and upper part of the nasal bone. These structures form a “mushroom sign” during cadaveric dissection and surgery. Twenty-one patients underwent TNCA, of whom 9 had tumors and 12 had chronic rhinosinusitis with nasal polyps (CRSwNP). None of them had major complications.

Conclusion

TNCA is expected to be a safe, and direct route for EMLP. Adequate understanding of the nasion complex and “mushroom sign” will be helpful to complete TNCA.

Value of a lateral inferior pedicle flap in Draf IIb for recurrent frontal sinus diseases: a prospective study

Purpose

The Draf IIb procedure allows the widest unilateral access to the frontal sinus in a minimally invasive fashion, with efficiency and safety comparable to the Draf III. However, this technique is still associated with a high postoperative stenosis rate. The exposure of drilled bone induces osteitis predisposing to scarring and neo-osteogenesis causing ostium restenosis. We developed a novel lateral inferior pedicle flap (LIPF) to cover the exposed bone and prevent restenosis during Draf IIb. We aimed to describe our technique.

Methods

Adult patients requiring a Draf IIb for unilateral recurrent frontal sinus disease were prospectively enrolled. A LIPF technique was systematically performed. Demographics and complications were recorded. The primary outcome measure was neo-ostium patency at 12 months. In patients with chronic rhinosinusitis (CRS), the clinical control rate was evaluated at 12 months.

Results

59 patients underwent the Draf IIb with LIPF technique from 2013 to 2021. 49 patients (20 women/29 men, median age of 48.0 years) completed at least 12 months of follow-up (median 41.0 months, range 12–100 months). Indications included recalcitrant CRS (n = 32), inverted papilloma (n = 9) and frontal mucocele (n = 8). Overall, the neo-ostium remained patent at 12 months in all patients, and the clinical control rate of 32 patients with recalcitrant CRS at 12 months was 100%. No main complications were recorded.

Conclusion

The LIPF technique was associated with a high rate of success for a Draf IIb.

Rare Presentations of Frontal Sinus Fungus Ball: A Systematic Review

Introduction The sinus fungus ball is an agglomeration of debris and hyphae, mainly caused by Aspergillus fumigatus, within the paranasal sinus, commonly affecting a single sinus, and it only rarely affects the frontal sinus.

Objective To identify the state of the art of fungus ball in paranasal sinuses, especially related to the epidemiology of the disease in the frontal sinus. Additionally, this article reports a rare case of fungus ball in the frontal sinus in an adult male, and discusses the variables of this condition related to the patient.

Data Synthesis All of the 8 cases of fungus ball in the frontal sinus reported in this study affected male patients: 40% had unilateral disease, and 60%, bilateral disease, contrary to the incidence data of fungus ball in the other paranasal sinuses, which reports unilateral prevalence. However, in the present study, this index changes, with 50% of unilateral and 50% of bilateral incidence regarding frontal sinus involvement. The average age of the patients was 65.36 years (range: 60-74 years). The etiologic agent was Aspergillus spp., and the endonasal endoscopic therapeutic approach corresponded to 80% of cases, while frontal osteoplasty accounted for 20% of cases, reaffirming the prevalence data from other studies.

Conclusion Despite being a low-incidence entity, frontal sinus fungus ball should be considered in patients with pain in the frontal region refractory to the usual clinical treatments.

Imaging After Sinonasal Surgery

Posttreatment imaging evaluation of sinuses encompasses a wide gamut of procedures, ranging from endoscopic procedures for sinonasal inflammatory diseases to markedly radical surgeries for malignant neoplasms (with or without reconstructions), as well as providing access for surgeries involving the anterior and central skull base. Advances in both techniques and devices have expanded the use of endoscopic approaches in managing both benign and malignant lesions, in addition to being the primary surgical method for treating all medically refractive sinonasal inflammatory disorders. Familiarity with the complex anatomy in the sinonasal region and knowledge of the various procedures is indispensable in interpreting these imaging studies.

Frontal Sinus Fractures: A Contemporary Approach in the Endoscopic Era

Although frontal sinus fractures are relatively uncommon, the potential for long-term morbidity is significant. Management strategies remain controversial due to a lack of strong clinical evidence. Despite a paucity of strong literature, a logical treatment algorithm is presented based on the structural integrity of three anatomic parameters: anterior table, frontal sinus outflow tract, and the posterior table/dura. The literature supports a paradigm shift from open surgical management to a more conservative treatment algorithm emphasizing observation and minimally invasive endoscopic techniques. Long-term follow-up for complex frontal sinus injuries is critical.

Management of paranasal sinus osteomas: A comprehensive narrative review of the literature and an up-to-date grading system

BACKGROUND

Surgical excision represents the unequivocal treatment modality for symptomatic paranasal sinus osteomas. However, the optimal surgical approach and the extent of the surgery, as well as the management stance in the case of an asymptomatic tumor, remain controversial.

METHODS

The MeSH terms 'Osteoma', 'Nasal Cavity', and 'Paranasal Sinuses' were used to retrieve articles concerning the management of paranasal sinus osteomas that were published in the last 30 years, the vast majority of which comprised case reports of one or two cases. Original articles or large series of more than six cases were prioritized.

RESULTS

Our review summarizes previous findings and opinions relevant to the management of symptomatic and asymptomatic paranasal sinus osteomas. The recent shifts in trends of their management are thoroughly discussed. Currently, an extension of the lesion through the anterior frontal sinus wall; an erosion of the posterior wall of the frontal sinus; a far-anterior intraorbital extension; an attachment to the orbital roof beyond the midorbital point; and some patient-specific adverse anatomic variations that may restrict access, are considered strong contraindications to a purely endoscopic approach. On the grounds of this thorough review, a new grading system for frontal and frontoethmoidal osteomas is proposed to allow better conformity to recent advancements and current clinical, research, and educational needs.

CONCLUSION

Over the past 30 years, endoscopic techniques have emerged as the new standard of care for favorably located paranasal sinus osteomas. Nonetheless, open approaches remain indispensable for the management of the more perplexing cases of frontal sinus osteomas.

Safety and Efficacy of the Draf IIb Procedure: A Systematic Review

OBJECTIVES

To systematically review the literature to evaluate the indications, safety, and efficacy of the Draf IIb procedure and to evaluate the added advantages of technical factors such as stents and flaps.

DATA SOURCES

Articles published until July 2019 on Medline and Cochrane databases.

REVIEW METHODS

After a systematic review based on the 2018 PRISMA guidelines was conducted, 26 of 1533 articles were included and reviewed for indications of Draf IIb; surgical technique; use of flaps, stents, grafts, or mitomycin; complications during and after surgery; and success or recurrence rate.

RESULTS

The main indication for Draf IIb was chronic frontal rhinosinusitis (61.82%). The postoperative patency rate was 87.85%. When flaps/grafts were applied, the rate was 93.5%, but their added value was not statistically significant. Stents could be an alternative for revision surgery. Treating frontal pathologies other than chronic rhinosinusitis was also satisfying. Safety was comparable to Draf III: no perioperative complications were reported, only a few postoperative ones (eyelid ecchymosis and periorbital cellulitis in 0.2% of the cases, hyposmia in 1.55%).

CONCLUSION

When properly indicated, Draf IIb frontal drilling is a safe and highly effective surgical technique for frontal pathology treatment, with efficiency and safety comparable to the Draf III, making it a valid option when a bilateral approach is not needed. More studies are required to confirm the added values of flaps, grafts, and stents.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Clinical predictors of revision surgery for chronic rhinosinusitis with nasal polyposis within 5-year follow-up

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) remains a difficult-to-cure disease. The aim of this study was to determine the potential long-term predictors of revision sinus surgery for CRSwNP.

METHODS

Prospectively gathered patients with bilateral CRSwNP who received primary endoscopic sinus surgery were enrolled. Clinical variables, including the preoperative Lund-Mackay score (LMS), were collected to clarify possible risk factors for revision surgery within a 5-year follow-up. The symptomatic burden was measured using a 10-cm visual analog scale (VAS) before and 1 year after surgery. Further survival analysis was performed to present the revision-free survival in Kaplan-Meier plotting.

RESULTS

Eighty four qualified patients were identified and all of them experienced significant improvement in VAS after primary surgery. The 5-year revision rate was 19.05%, and the mean time of revision surgery was 25.31 ± 17.11 months postoperatively. Nasal allergy (OR = 9.287; p = 0.011) and LMS (OR = 1.29; p = 0.06) were found to be the independent risk factors for revision surgery. The discriminatory power of LMS for revision surgery was acceptable (AUC = 0.79) with the best cutoff point located at LMS > 13.5. Patients with both nasal allergy and LMS≧14 had only half of revision-free survival in comparison to overall survival (38.1% vs. 80.95%, p < 0.001).

CONCLUSIONS

In patients with CRSwNP who have concurrent nasal allergy and higher preoperative LMS may indicate an advanced disease status and eventually be in a high risk of revision surgery after a long-term follow-up. An outcome-based staging system will be helpful in the future to improve the prognosis for CRSwNP.

Gigantic paranasal sinuses osteomas: clinical features, management considerations, and long-term outcomes

PURPOSE

Paranasal sinus osteomas are slow-growing, benign bony tumours that when larger than 30 mm, they are termed 'gigantic'. Special considerations apply for tumours of this calibre, and their rarity renders their management fairly controversial. This study seeks to contribute to an increased understanding concerning their management by presenting a 12-year experience from a single institution.

METHODS

Retrospective review of files of patients treated for a gigantic paranasal sinus osteoma from January 2008 to December 2019. Additionally, all patients were prospectively reexamined in early 2020 for late complications or clinical recurrence.

RESULTS

Ten patients were included, with a mean age of 53.8 years (range: 23-77 years). The leading presenting findings were proptosis (80%) and diplopia (70%). Transient visual impairment was remarkably frequent (30%). Five patients were managed with an open approach, two with an endoscopic, and three with a combined technique. The most common adverse characteristics that dictated the use of an open approach, alone or in combination with an endoscopic approach, were the involvement of the anterior wall of the frontal sinus (40%), erosion of its posterior wall (30%), and a far-anterior intraorbital extension (30%). No major postoperative complications were observed, and also no recurrences.

CONCLUSION

Our study illustrates that these tumours may require a different management attitude. Despite substantial advances in the endoscopic management of benign sinonasal tumours, managing these massive tumours solely endoscopically could, in many cases, be inefficacious or impossible. Open approaches remain valuable, representing a safe and straightforward method for adequate exposure.

Use of the medial canthal point (MCP) as a reliable anatomical landmark to the frontal sinus

OBJECTIVES

Frontal sinus surgery is considered one of the more challenging aspects of Functional Endoscopic Sinus Surgery, due to the complex variations in normal sinus anatomy but also increased morbidity due to the close proximity of critical structures such as the anterior cranial fossa and orbits. We aim to investigate the medial canthal point (MCP) as an anatomical landmark for safe frontal sinus access.

METHODS

The MCP intranasally is identified during surgery with non-tooth forceps, with one limb just anterior to the medial canthus and the other intranasally in the same coronal plane along the skull base. This point was identified on 100 paranasal sinus computed tomography (CT) scan reconstructions. The distance between the anterior cranial fossa and MCP was measured on imaging-medial canthal point distance (MCPD). The maximal anterior-posterior (AP) distance was measured on all scans.

RESULTS

The average MCPD for males was 13.0 mm (8.7-20.4 mm) and for females 12.0 mm (6.8-22.8 mm). Mean AP distance for males was 12.0 mm (4.5-20.2 mm) and for females 10.4 mm (3.8-15.9 mm). Mean distance for all 100 patients was 12.6 mm (range 7.5-22.8 mm). In all cases, the MCP was anterior to the cranial fossa. Mixed effects modelling analysis showed a significant correlation between the MCPD and AP distance (P = .006).

CONCLUSION

The MCP is a consistent anatomical landmark that can serve as an adjunct to safe frontal sinus access alongside the first olfactory fiber and CT navigation systems. However, patient selection continues to be very important, with larger well pneumatized frontal sinuses being ideal to tackle earlier in a surgeon's career.

LEVEL OF EVIDENCE

NA.

Zero-Degree Endoscopic Visualization of the Frontal Sinus Predicts Improved Topical Irrigation Delivery

OBJECTIVE

Management of chronic frontal rhinosinusitis is challenging with high rates of treatment failure, exacerbated by limitations of topical irrigation delivery. We hypothesize that intraoperative zero-degree visualization of the frontal sinus predicts improved postoperative irrigation penetration. Extending a Draf IIa frontal sinusotomy with a limited resection of the middle turbinate axilla-agger nasi complex can allow zero-degree endoscopic visualization of the frontal sinus. This study investigates the change in frontal sinus irrigation delivery after standard Draf IIa frontal sinusotomy versus further resection to achieve zero-degree visualization.

STUDY DESIGN

This is a prospective cohort study conducted in a surgical skills laboratory.

METHODS

The extent of irrigant penetration into the frontal sinuses was evaluated in 10 cadaveric frontal sinuses following Draf IIa sinusotomy using a standardized trephine visualization model. Irrigant penetration was assessed by three blinded reviewers using the following scale: 0 = irrigation restricted to nasal cavity; 1 = irrigation reaches frontal recess; 2 = irrigation reaches frontal sinus proper; 3 = irrigation fills entire frontal sinus. These results were compared to irrigation after achieving zero-degree endoscopic visualization by performing limited resection of the middle turbinate axilla-agger nasi complex.

RESULTS

Irrigant penetration following standard Draf IIa frontal sinusotomy improved after the axilla-agger nasi complex was resected to achieve zero-degree endoscopic visualization (median score 2 [interquartile range: 1-2] vs. 3 [interquartile range: 2-3], P < .01).

CONCLUSION

This study demonstrates improved penetration of frontal sinus irrigation following limited resection of the middle turbinate axilla-agger nasi complex to achieve zero-degree endoscopic visualization of the frontal sinus as compared to standard Draf IIa frontal sinusotomy.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:250-254, 2021.

Early experience with feasibility of balloon sinus dilation in complicated pediatric acute frontal rhinosinusitis

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.

Impact of Draf III, Draf IIb, and Draf IIa frontal sinus surgery on nasal irrigation distribution

BACKGROUND

Delivery of topical pharmacotherapy to the paranasal sinuses remains integral to the management of chronic rhinosinusitis. The frontal sinus remains a difficult access site for irrigations, often limited by its position relative to the nostril and ethmoid sinus. In view of the previous demonstration of improved frontal sinus irrigation with Draf III vs Draf IIa, in this work we sought to evaluate topical access of Draf IIb relative to Draf IIa and Draf III modification of the frontal sinus outflow tract.

METHODS

Unfixed human cadaver heads were dissected using Draf IIa, Draf IIb, and Draf III frontal sinusotomies. Draf IIa, Draf IIb, and Draf III frontal sinusotomies were performed in progressive sequence on each cadaver head. Nasal irrigation fluid access to the frontal sinus was tested after each successive frontal sinus intervention. Irrigations were performed using Frankfort horizontal and vertex positioning. Blinded reviewers were then asked to evaluate nasal irrigation access based on an ordinal scale.

RESULTS

Eight cadaveric specimens (age, 78 ± 12.3 years; 62.5% female) were assessed. The greatest distribution scores were recorded by Draf III, then IIb, and then IIa (90.7% vs 81.3% vs 50.1%; p < 0.001). Similarly, the rate of lavage was greatest with Draf III (50% vs 12.5% vs 12.5%). Vertex positioning and increasing volume trended toward improved distribution but did not reach statistical significance.

CONCLUSION

Adequate delivery of topical therapy to the paranasal sinuses by nasal irrigation remains critical in the postoperative state. Although increasing the dimensions of the frontal recess improves nasal irrigation delivery, the Draf III procedure provides the optimal delivery of pharmacotherapy in those with frontal sinus disease.

Sinus irrigation penetration after balloon sinuplasty vs functional endoscopic sinus surgery in a cadaveric model

BACKGROUND

Nasal irrigation is a cornerstone of treatment for chronic rhinosinusitis. The purpose of this study was to quantify irrigation penetration to the sinuses following balloon sinuplasty and functional endoscopic sinus surgery (FESS).

METHODS

Balloon sinuplasty followed by FESS was performed on 4 cadaver heads. Using a high-volume, high-flow bottle, each head was irrigated with fluorescein-dyed water prior to and following each procedure, and recorded by rigid endoscopy through trephinations. Three blinded, fellowship-trained rhinologists reviewed videos and scored the extent of staining (using an accepted scale of 0 to 3) for each site.

RESULTS

The mean score prior to any procedure was maxillary sinus 1.67, frontal sinus 1.29, and nasal cavity 1.71. After balloon sinuplasty the mean was maxillary 2.25, frontal 2.04, and nasal cavity 2.17. After FESS the mean was maxillary 2.75, frontal 2.08, and nasal cavity 2.63. There was a statistically significant increase for both maxillary (p = 0.005) and frontal sinuses (p = 0.006) following balloon sinuplasty. There was a statistically significant increase following FESS compared to balloon for the maxillary sinus (p = 0.003), but not the frontal sinus (p = 0.96). Interrater reliability was good, with Cronbach's alpha of 0.85.

CONCLUSION

Irrigation improved in all sinuses following balloon sinuplasty and FESS. There was further improvement to the maxillary sinus after FESS; however, there was no difference in irrigation to the frontal sinuses following FESS compared to balloon sinuplasty. Extended frontal sinus approaches such as the Modified Lothrop procedure should be considered if more extensive access for irrigation is required.

Complications Are Rare From Middle Turbinate Resection: A Prospective Case Series

Background

When chronic rhinosinusitis with nasal polyps (CRSwNP) fails to respond to medical therapy, endoscopic sinus surgery (ESS) plays an integral role in management. Some studies have shown that middle turbinate resection (MTR) during ESS leads to decreased polyp recurrence and revision ESS rates. Other studies suggest MTR can lead to complications.

Objective

The purpose of this study was to assess the safety of MTR during ESS for CRSwNP by determining the incidences of intraoperative cerebrospinal fluid (CSF) leak, postoperative epistaxis requiring operative intervention, and postoperative complete frontal stenosis.

Methods

A multiinstitutional, prospective case series of 91 adult CRSwNP patients was conducted. Patients with medically refractory CRSwNP underwent primary or revision ESS plus MTR by 3 surgeons. Two of the surgeons performed partial MTRs, and one of the surgeons performed complete MTRs. Patients were evaluated for the following complications: intraoperative CSF leak during MTR, postoperative epistaxis requiring operative intervention, and postoperative complete frontal ostial stenosis. Secondary outcomes included changes from preoperative to postoperative 22-item Sinonasal Outcome Test (SNOT-22) scores and revision ESS rates.

Results

Unilateral or bilateral complete ESSs with MTRs were performed on 91 CRSwNP patients. In total, 173 MTRs were performed. Two surgeons performed 97 partial MTRs on 49 patients, and the third surgeon performed 76 complete MTRs on 42 patients. One CSF leak occurred during partial MTR (1/173, 0.57%). No patients suffered postoperative epistaxis requiring operative intervention, and no patients developed complete frontal stenosis. From preoperatively to postoperatively, mean SNOT-22 scores decreased from 53.7 to 13.1 ( P = .001). No revision ESS was needed during the follow-up period. Mean follow-up time was 7.5 ± 5.4 months.

Conclusions

Partial and complete MTR during ESS for CRSwNP in this cohort resulted in very low, acceptable intraoperative and short-term postoperative complication rates and no detriment to SNOT-22 scores.

Trans-Frontal Five-Fluorouracil (TraFFF): a novel technique for the application of adjuvant topical chemotherapeutic agents in sinonasal adenocarcinoma

Sinonasal adenocarcinoma has traditionally been treated with surgery (craniofacial or endoscopic) and adjuvant radiotherapy. Two large series have demonstrated favourable 5-year survival using surgery with adjuvant topical chemotherapy applied repeatedly over several weeks. The authors describe a novel, transnasal application of topical 5-fluorouracil. However, complete coverage of the frontal region of the anterior skull base can be difficult to achieve with a purely transnasal approach in an outpatient setting. We present a novel adjunct method of delivering chemotherapeutic agents into this key area used in a 37-year-old man with T2N0M0 ethmoid adenocarcinoma. The procedure was well tolerated in an outpatient setting and remains disease free at 3 years postoperatively. We suggest that frontal trephination is a useful adjunct to aid accurate placement of adjuvant topical chemotherapeutic agents in the treatment of sinonasal adenocarcinoma.

Bilateral Transorbital and Transnasal Endoscopic Resection of a Frontal Sinus Osteoblastoma and Orbital Mucocele: A Case Report and Review of the Literature

OBJECTIVE

Describe a novel treatment approach to a rare bony neoplasm in the frontal sinus.

STUDY DESIGN

Case report.

METHODS

Retrospective chart review of an osteoblastoma of the frontal sinuses complicated by a right orbital mucocle. Demographic, endoscopic, radiographic, pathologic, and surgical data were collected for synthesis and review. MEDLINE, Embase, and Cochrane databases were searched from 1977 to 2017 to review publications of surgical management of frontal sinus neoplasms.

RESULTS

A single female patient with a large frontal sinus osteoblastoma was successfully treated with a bilateral transorbital and transnasal approach. The right orbital mucocele was marsupialized into the frontal sinus. Gross total resection of the tumor was achieved, with complete resolution of the presurgical morbidity. The surgery was tolerated well without iatrogenic injury or sequela.

CONCLUSION

Frontal sinus osteoblastoma is a rare condition. Complete surgical excision is considered curative. Various endoscopic and open approaches have been described. Here we show the feasibility and efficacy of a multiportal strategy in the successful management of a large frontal sinus osteoblastoma complicated by a right orbital mucocele.

Computed tomography analysis of intranasal distance of frontal and sphenoid sinus ostiums in children

PURPOSE

Pediatric population may be more prone to complications in comparison to adults because of the variability of developmental changes of paranasal sinuses and skull base. Knowledge of standard columellar distances regarding age in addition to anatomical landmarks is an important guide during functional endoscopic sinus surgery. We aimed to identify standard distances from columella and anterior nasal spine to the anterior and posterior border of frontal and sphenoid sinus ostiums and provide an objective reference graph in regard to age in children.

METHODS

Subjects who are older than 1 year and younger than 18 years who had undergone a head-and-neck, maxillofacial or temporal bone region high resolution computed tomography scan during the last 3 years were obtained from radiological database. The distances from columella and anterior nasal spine to the anterior and posterior border of frontal and sphenoid sinus ostiums were measured and nasofrontal and nasosphenoid angles were calculated.

RESULTS

A total number of 119 children (73 boys, 46 girls) were reviewed. The average age was 7.7 ± 5.0 years. All subjects had normal sinonasal anatomy. We found statistically significantly positive correlation between age and all distances (p < 0.001). Although all measured distances of boys were greater than girls, this difference did not reach statistical significance. Additionally, nasosphenoidal angles were significantly obtuse in boys (p < 0.05).

CONCLUSIONS

Our columellar distance graphic can provide further improvement of surgeon confidence while performing endoscopic sinus surgery or skull base surgery.

Combined Lid Crease and Endoscopic Approach to Lateral Frontal Sinus Disease With Orbital Extension

INTRODUCTION

Functional endoscopic sinus surgery for frontal sinus disease has obviated the need for external approaches. Special circumstances such as acute infection with orbital involvement or significant lateral sinus disease frequently require adjunct access. We describe the clinical outcomes of a combined upper eyelid crease and endoscopic approach for lateral frontal sinus disease with orbital extension.

METHODS

A retrospective case series of 7 patients who underwent a combined lid crease approach for frontal sinus disease with orbital extension between April 2012 and October 2016 was performed. All patients had the presence of lateral frontal sinus disease as well as orbital extension as seen on a preoperative computed tomography (CT) scan. Patient demographics, indications for surgery, and perioperative findings were examined.

RESULTS

Six of the 7 patients were male. Mean age was 61 years, and the indication for surgery was primarily drainage of mucopyocele and inverting papilloma (IP) in 1 patient. The frontal sinus and orbit were successfully accessed, and the respective pathology was addressed in both locations. No intraoperative or postoperative complications were encountered. There was no postoperative or cosmetic complications.

CONCLUSION

The combined lid crease and endoscopic approach is a safe and effective technique for accessing the lateral frontal sinus and orbit.

Algorithm for Management of the Refractive Aerosinusitis Patient

Introduction

For some career military aviators, their ability to continue on flight status is limited by the pressure and pain of aerosinusitis, which is present only while in the flying environment. Failure to treat their disease process can mean the end of their flying careers and the loss of valuable assets trained with taxpayer dollars. Because some medications commonly used in treatment of sinus diseases are not allowed in aviation, this presents a unique problem for their medical management. Surgical treatment must be aimed at treating to symptom relief and not solely disease mitigation. One alternative is operating "beyond the scope of disease" present during a one-atmosphere clinic visit.

Materials and Methods

A case series of nine career aviators with aerosinusitis treated at one academic military Otolaryngology department in a tertiary care facility. Results from a treatment algorithm that balances symptomatology and staged surgical intervention are reviewed. The primary endpoint was return to flight duty.

Results

For patients treated according to this algorithm, the mean time to return to flight duty was 3.8 mo, requiring an average of 1.2 surgeries. To date, 100% of career aviators have returned to flight duty using this method.

Conclusion

Refractory aerosinusitis represents a potentially career-ending medical condition for the aviator and lost training costs to the taxpayers. Using the treatment algorithm presented, 100% of aviators were able to return to flight duty; a savings of millions of dollars for taxpayers. Future work will focus on modifications to the surgical techniques to reduce the extent of surgery while maintaining satisfactory results. Additional study should be undertaken to assess generalizability of these results in the broader aviation community.

Draf III frontal sinus surgery: "How I do it"

BACKGROUND

The Draf III approach to the frontal sinus can be used during revision endoscopic sinus surgery for chronic rhinosinusitis and to provide access for tumor resection, mucoceles, and repair of cerebrospinal fluid leaks.

OBJECTIVE

To describe a simple and safe way to perform a Draf III approach by using the "outside-in" approach.

METHODS

By using a 0° endoscope and a single 15°, 5-mm, coarse diamond burr, the main steps of the procedure are the following: (1) elevation of the mucosal flaps and creation of the septal window, (2) drilling out the frontal beak, (3) creation of neo-ostium and removal of the interfrontal septum, (4) joining the neo-ostium with the frontal recesses, (5) smoothing off the cavity and lowering of the "frontal T," and (6) use of mucosal flaps and grafts to cover exposed bone.

CONCLUSION

This approach is a quick and easy way to perform a Draf III, and reduces operative time and minimizes complications.

Outcomes of the Modified Endoscopic Lothrop Procedure

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.

The Endoscopic Modified Lothrop: Long-Term Follow-Up on 44 Patients

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.

Outcomes of Frontal Mucocele Marsupialization: Endonasal and External Approaches

Background

Frontal sinus mucoceles are known to undergo repeated recurrences, and the management of this disease constitutes a challenge regarding the ideal treatment. The aim of this study was to evaluate the postoperative results of the endoscopic ventilation approach in the treatment of frontal mucoceles.

Methods

We retrospectively reviewed the charts of 24 subjects with mucocele who underwent endoscopic marsupialization. The preoperative characteristics of the frontal sinus on computed tomography scans were compared with the postoperative results.

Results

Postoperative endoscopic examination revealed in 15 nasal sides wide patency of the frontal outflow tract. The ostium was patent but had become slightly narrowed in nine nasal sides. Restenosis of the ostium was found in six cases.

Conclusion

A membranous type of obstruction in the region of the frontal outflow tract was related to a better outcome.

Utility of Sagittal Reformatted Computerized Tomographic Images in the Evaluation of the Frontal Sinus Outflow Tract

Background

Anatomic and mucosal obstruction of the frontal sinus outflow tract (FSOT) can result in frontal sinusitis often associated with frontal headache. Thorough evaluation of symptomatic patients requires axial and coronal computerized tomographic (CT) scans of the paranasal sinuses (PNS). With the advent of multichannel multidetector CT scanning, the availability of high-quality sagittal images has become increasingly widespread. However, the utility of these images in the assessment of FSOT patency has not yet been established.

Methods

A retrospective review of coronal and sagittal images from 25 PNS CT scans (50 sides) were randomized, blinded, and independently evaluated by two neuroradiologists. FSOT obstruction by agger nasi cells, the ethmoid bulla, and mucosal disease was assessed. A degree of confidence was rendered for each of these findings. The results were then compared against a consensus diagnosis, which was rendered based upon simultaneous reading of the coronal and sagittal images. Generalized estimating equations were used to assess the difference between sagittal and coronal images in terms of reader confidence and diagnostic concordance with the consensus.

Results

Review of sagittal images had a higher degree of concordance with the consensus than did coronal images, and was highest for mucosal disease. Both readers were more confident in rendering a diagnosis based upon the sagittal images.

Conclusion

Sagittal reformatted CT images of the PNS are helpful in the radiologic evaluation of the FSOT. Experienced neuroradiologists had a higher degree of confidence in the diagnosis of the obstruction of the FSOT using sagittal reformatted images.

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)

Image-Guided Osteoplastic Frontal Sinusotomy

Background

A 6-ft Caldwell radiograph template and transillumination, typically, are used to elucidate the frontal sinus outline for osteoplastic frontal sinusotomy (OFS). These techniques can be fraught with imprecision. The consequences of imprecise OFS may result in significant complications. Computer-aided surgery may offer a safe and accurate alternative to these techniques in selected cases. Several disadvantages were noted with early computer-aided assistance. Current infrared and electromagnetic systems have eliminated many of these disadvantages. We describe our technique and experience with an infrared image-guidance system (The LandmarX Evolution; Medtronic Xomed, Jacksonville, FL) to create a precise OFS that maximizes exposure while minimizing morbidity.

Methods

We describe the use of an infrared image guidance system, the LandmarX Evolution for OFS in three cases.

Results

The LandmarX Evolution allowed for accurate placement of the OFS in each of the three cases and successful treatment of two symptomatic frontal sinus osteomas and a recurrent inverted papilloma. No complications were encountered.

Conclusion

Image-guided OFS results in a confident and accurate entry into the frontal sinus. Image-guided OFS creation should be considered for select cases (i.e., complete opacification and altered anatomy) where performing an OFS by standard techniques may increase the complication rate. More experience with the technique and increased accessibility to image-guided equipment must be made possible before establishing this technique as a standard.

Lacrimal sac exposure and a superior lateral anterior pedicle flap to improve outcomes of Draf type II and III procedures

BACKGROUND

Although the efficacy of Draf type II and III procedures for frontal sinus diseases is well recognized, a certain amount of postoperative stenosis of the frontal neo-ostium occurs. Exposed bone induces inflammation and leads to osteoneogenesis. To prevent stenosis, we developed a surgical technique designed to minimize bone exposure while maximizing the frontal neo-ostium area created with Draf type II and III procedures. We fully exposed the lacrimal sac and used a superior lateral anterior pedicle flap to cover the exposed bone during the Draf procedure. We aimed to describe our technique.

METHODS

We reviewed 19 patients who underwent a Draf type II or III procedure with our technique. Endoscopic views from the follow-ups and complications were evaluated.

RESULTS

Overall, the neo-ostium remained patent in all patients. No complications, such as synechiae or orbital injury, were seen in any of the patients.

CONCLUSION

Draf type II and III procedures with lacrimal sac exposure and a superior lateral anterior pedicle flap are convenient and seem to be effective. However, further studies with larger numbers of patients are needed to verify our technique.

Development of a novel T-tube frontal sinus irrigation catheter

BACKGROUND

The problem of postoperative management after frontal sinus surgery remains a challenge. The bilateral opening created in the Draf III procedure does not fit any currently available stent, and patients find rinsing the frontal sinus difficult, which thus decreases compliance. The objective of this study was to demonstrate the successful use of a novel frontal sinus catheter fashioned from a biliary T tube by addressing these issues in patients with complicated sinus disease.

METHODS

This was a review of 30 patients who underwent a Draf III procedure between January and October 2014, and who had a T-tube stent inserted at the end of the procedure. Patient charts were analyzed for complications such as bleeding, infection, and restenosis as well as indications of ease of rinsing ability after surgery.

RESULTS

From the chart data, there was only one intraoperative bleed and only one postoperative bleed that required packing. Four patients had infections that required antibiotics after surgery. At the time of data collection, only one patient had signs of restenosis as judged by the operating surgeon. Patients reported an ease of rinsing ability with the T-tube stent.

CONCLUSIONS

The novel biliary T-tube stent use presented in this article is a promising future direction for postoperative care after extended frontal sinus surgery.

The clinical behavior of sinonasal inverted papilloma with cellular dysplasia: case series and review of the literature

The prognosis and recurrence rate of inverted papilloma (IP) with concomitant cellular dysplasia are not well-delineated. Demographic, clinical and imaging data of all patients who were surgically treated for sinonasal inverted papilloma (SNIP) in our center between 1996 and 2013 were reviewed. Data regarding the coexistence of dysplastic changes or malignancy within the resected tissues were also retrieved. After the exclusion of malignant cases and patients who were lost for follow-up, 92 patients were included in the study. Five patients had coexisting cellular dysplasia (4.7%), four of them had severe dysplasia and one had mild-to-moderate dysplasia. All four cases with severe dysplasia recurred, three were primarily treated endoscopically and one by external approach. Only the case with mild to moderate dysplasia which had been treated by subcranial approach did not recur. Patients with dysplasia had significantly higher recurrence rate than patients without dysplasia (80 vs. 14%, p = 0.019). This significant relation between histology and recurrence remained even after adjustment to tumor extent. The adjusted odd ratio of dysplasia (dysplasia vs. no dysplasia) is 9.7, p = 0.043. SNIP with dysplasia should be treated aggressively and followed closely. The histopathologic investigation of SNIP specimens should always note the presence of dysplasia and its severity. Further investigation on the clinical behavior of SNIP with dysplasia is needed. Multicenter studies are warranted due to the rarity of dysplastic SNIP.

Utility of intraoperative flexible endoscopy in frontal sinus surgery

Background:

Surgical management of the frontal sinus can be challenging. Extensive frontal sinus pneumatization may form a far lateral or supraorbital recess that can be difficult to reach by conventional endoscopic surgical techniques, requiring extended approaches such as the Draf III (or endoscopic modified Lothrop) procedure. Rigid endoscopes may not allow visualization of these lateral limits to ensure full evacuation of the disease process.

Methods:

Here we describe the utility of intraoperative flexible endoscopy in two patients with far lateral frontal sinus disease.

Results:

In both cases, flexible endoscopy allowed confirmation of complete evacuation of pathologic material, thereby obviating more extensive surgical dissection.

Conclusion:

In cases where visualization of the far lateral frontal sinus is inadequate with rigid endoscopes, flexible endoscopy can be used to determine the need for more extensive dissection.

Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma

OBJECTIVES

Sinonasal inverting papilloma (IP) is a benign but locally aggressive mucosal neoplasm with a high recurrence rate. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitofrontal approach for managing extensive IP.

STUDY DESIGN

Case series.

METHODS

Four patients seen between 2012 and 2016 with biopsy-proven IP with lateral frontal sinus extension underwent a combined endonasal and transpalpebral approach for tumor resection. Patient demographic data, preoperative characteristics, imaging, and follow-up data were compiled through retrospective chart review. Patients were selected for this approach when the tumor extended to the posterior frontal sinus wall, lateral frontal sinus recess, and orbit. Tumors were first approached endonasally until the frontal recess was reached. A Draf IIB or Draf III procedure was then performed to gain better exposure. Orbitofrontal exposure was achieved through an upper eyelid incision. Miniorbitofrontal craniotomy window was designed based on tumor location. Resection of the frontal and orbital extension was enhanced by endoscopic-assisted dissection through the orbitofrontal window.

RESULTS

The transpalpebral approach provided access to all walls of the ipsilateral frontal sinus, the intersinus septum, and the medial aspect of the contralateral sinus. Complete tumor resection was achieved in all patients. There were no orbital complications, no visible eyelid asymmetry or scarring, and all patients had preserved forehead sensation. There were no recurrences on follow-up.

CONCLUSION

Combining a transpalpebral orbitofrontal craniotomy with the endonasal approach allows complete resection of invasive IP with extension into the frontal sinus. This is achieved with great cosmetic results.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:3-9, 2018.

Computed Tomographic Analysis: The Effects of Frontal Recess Morphology and the Presence of Anatomical Variations on Frontal Sinus Pneumatization

The aim of this study is to describe the morphology of frontal recess area with its anatomical variations and to reveal if frontal recess morphology and the anatomical variations related to that region have effects on the pneumatization of the frontal sinuses. The frontal sinus and recess morphometry of 136 sides of 68 dry skulls were evaluated on multislice high-resolution computed tomography. The relationships between frontal sinus and frontal recess measurements were analyzed by correlation and linear regression analysis. The variables between the groups of anatomical variations were analyzed by Mann-Whitney U test and χ test or Fisher exact test. A positive relationship between the sagittal length of spina nasalis interna and morphometric measurements of frontal sinus was revealed (P <0.05). Agger nasi cells were present in 64.2% of sides, supraorbital ethmoid cells (SOECs) in 19.6%, type 3 frontal cells (FCs) in 18.9%, suprabullar cells in 24.3%, and frontal bulla was noted in 5.4%. Intersinus septal cells were observed in 16.2% of the skulls. There were statistically different increases in the measurements of frontal sinus morphometry in the presences of SOECs and type 3 FCs (P <0.05). The diameter of frontal sinus ostium was decreased in the presences of AN, SOEC, type 3 FC, and supraorbital ethmoid cell statistically (P = 0.049, P = 0.029, P = 0.043, P <0.001 respectively). In conclusion, frontal sinus pneumatization was affected by the spina nasalis interna and the presence of anatomical variations related to frontal recess or ostium region instead of the morphology of that area.

First results of frontal sinus obliteration with a synthetic, resorbable and osteoconductive bone graft of ß-tricalcium phosphate

BACKGROUND

Despite advances in endoscopic sinus surgery, frontal sinus obliteration is still indicated in some cases. Current options for obliteration include autologous and synthetic materials. The use of ß-tricalcium phosphate as a resorbable bone graft substitute is a good alternative for frontal sinus obliteration. This study aimed to report our experience with this material.

METHODS

A retrospective chart review of patients who underwent frontal sinus obliteration at our clinic between 2008 and 2013 was performed. Demographic data, indications, previous surgery, and immediate and late complications were examined. Information on persisting symptoms and patient outcomes was collected using a telephone questionnaire in February 2016.

RESULTS

None of the patients underwent further surgery for frontal sinus disease. All of them reported a good cosmetic result and symptom improvement.

CONCLUSION

ß-tricalcium phosphate is a good, safe and cost-effective material for frontal sinus obliteration.

The efficacy of extended Draf IIb procedure by partial nasal septectomy: long-term follow up

Draf IIb procedure is mostly used in a very narrow frontal recess and in a revision frontal sinus surgery. In most cases, the contralateral sinus is not involved. In order to avoid Draf III procedure's reported disadvantages we have commenced the use of the extended Draf IIb procedures in our center. Patients treated with extended Draf IIb procedure at our center between the years 1997 and 2012 were retrospectively evaluated. This procedure includes further widening of the frontal ostium and recces by excising the adjacent most superior nasal septum. Included in our study were patients who have failed previous Draf IIb procedure or had a small and narrow frontal sinus. Collected data included demographics, prior sinus pathology, previous surgical treatment, surgical complications and further treatment if required. All were evaluated by the SNOT-22 questioner pre and post-operatively and all were endoscopically evaluated during the follow up period. 15 patients and 18 frontal sinuses were included in our study, eight males and seven females with a mean age of 50.3 years. The mean pre-operative SNOT-22 fell from 46 to 24 and all patients improved clinically. No surgical complications were reported except for one case of postoperative maxillary sinusitis. Only one patient required further surgical intervention. In most cases the patients had a patent frontal sinus ostium after a follow up of 3-8 years. Extended Draf IIb procedure is less traumatic, safe and effective in the treatment of persistent frontal sinus disease, without surgically involving the healthy contralateral frontal sinus, and may obviate the need for Draf III procedure.

Management of Frontal Sinus Tumors

The most common primary tumors of the frontal sinus are osteomas and inverted papillomas, although a variety of other tumors involving this space have been reported. With the advent of new surgical techniques and instrumentation, an endoscopic approach to this region has become feasible. The preoperative assessment and decision making must take into account the complexity of frontal sinus anatomy, tumor type, tumor location, and associated attachments. These procedures allow adequate visualization, tumor removal, and postoperative monitoring, and preserve fairly normal sinus function. Open techniques may also be required and should be in the surgeon's armamentarium.

Standard Endoscopic Approaches in Frontal Sinus Surgery: Technical Pearls and Approach Selection

The mainstay of frontal sinus surgery for chronic rhinosinusitis is to achieve and maintain an adequate frontal outflow tract. Using a stepwise approach and identifying critical endoscopic anatomic landmarks, to minimize complications and obtain long-term good endoscopic surgical results, should achieve this. The goal is to relieve the patient's symptoms, restore functional mucociliary flow, achieve a wide frontal sinus ostium and prevent long-term scarring and stenosis. Meticulous dissection and appropriate use of instrumentation and techniques aids in preventing unnecessary damage to normal mucosa while achieving one's goal of an adequate surgical ostium.