Frontal sinus surgery: Endoscopic technique

Abstract

Endoscopic frontal sinus surgery, once the frontier in the evolution of endoscopic sinus surgery, is considered difficult, risky to the patient, and likely to result in a high failure rate. We clarify the surgical anatomy for frontal sinus surgery that, based on a review of our data, provides safe and predictable access to the frontal sinus. The key to safe and successful surgery of the frontal sinus is identification of the natural sinus outflow tract with preservation of at least part of the natural ostium. This is the same principle that is essential for effective surgery of the maxillary and sphenoid sinuses. We studied 200 consecutive patients with respect to indications, endoscopic and radiographic findings, results, and complications. The study will describe the technique in detail, including the following points: (1) computed tomography identification of the superior attachment of the uncinate process; (2) complete removal of the uncinate process, including its superior attachments, by using the microdebrider; (3) removal of the agger nasi and frontal cells, if present; (4) identification and preservation of the natural outflow tract; and (5) verification of an open frontal sinus by transillumination or image-guided system. Postoperative assessment of patients' symptoms and the confirmation of a patent frontal sinus by office endoscopy and transillumination indicated a 90% patency for short-term follow-up (average 12.2 months). There were no major complications. Postoperative complications included frontal recess stenosis, polypoid mucosa occluding the frontal recess, and middle turbinate lateralization. All of these situations may lead to recurrence of infection and symptoms. In-depth understanding of anatomical variations of the uncinate process and precise surgical removal of its superior attachments provide surgical access to the frontal sinus that is based on the natural ostia and is therefore more likely to remain patent.