Frontal Sinus Obliteration

Abstract

Osteoplastic frontal sinusotomy with obliteration was popularized by Goodale and Montgomery in the 1950s and has been considered the gold standard procedure for the surgical management of frontal sinus disease for many years. However, with advancements in functional endoscopic sinus surgery since the mid 1980s, the role of this operation has been questioned. Goodale and Montgomery in 1958 and Hardy and Montgomery in their subsequent review article describe the results of osteoplastic frontal sinusotomy with fat obliteration in 250 patients. Abnormalities included chronic frontal rhinosinusitis, frontal sinus mucocele, frontal sinus fractures, and complicated acute frontal rhinosinusitis. Patients were evaluated clinically using plain radiography and early-generation computed tomography. In the last 20 years numerous articles have been written about the endoscopic management of frontal sinus disease. Technology and instrumentation have advanced to the point that the frontal sinus can be accessed successfully and with minimal morbidity via transnasal endoscopic approaches. The purpose of this article is to examine the role of osteoplastic frontal sinusotomy with obliteration as the treatment of frontal sinus abnormality in an age of minimally invasive functional endoscopic sinus surgery. The pros and cons of this procedure will be presented, and reasonable indications will be outlined. A comprehensive description of anatomy is beyond the scope of this article. However, a brief review of frontal sinus anatomy is useful to understand the anatomic effects of inflammatory disease processes and the importance of appropriate choice of surgical approach to the frontal sinus. Unfortunately, the term nasofrontal duct continues to appear in the literature when in fact no such duct exists anatomically. Early anatomists recognized this long before the endoscopic era. The drainage from the frontal sinus is variable and at times difficult to ascertain, even with mutliplanar imaging, but most simplistically can be thought of in terms of the “frontal sinus outflow tract” (FSOT). The FSOT resembles an hourglass on sagittal view and includes the frontal sinus infundibulum, frontal sinus ostium, and frontal recess. Each of these areas can be affected by the varied pneumatization patterns of the ethmoid sinus, and each, if compromised, can lead to obstruction of outflow from the frontal sinus and secondary inflammatory disease. For example, an osteoma in the frontal sinus infundibulum may eventually obstruct outflow from the frontal sinus. The patient may develop a mucocele, mucopyocele, acute frontal rhinosinusitis with osteomyelitis (Pott puffy tumor), or chronic frontal rhinosinusitis. A large obstructing agger nasi cell or type I/II frontal cell can lead to the same scenarios by obstructing the frontal recess. In each of these clinical situations, however, the problem is not with the frontal sinus primarily but with obstruction of drainage within the FSOT.