Management of Frontoethmoidal Cells in Frontal Recess Surgery

Abstract

Frontal recess surgery is the most demanding and technically challenging part of endoscopic sinus surgery. The complexity of the anatomy and proximity with the skull base, the orbit, and the anterior ethmoidal artery often make the endoscopic approach to the frontal sinus drainage pathway difficult and increase the possibility of complications. The basic key structures to the frontal recess are the agger nasi cell and the superior fusion of the uncinate process. Above the agger nasi, the four categories of frontoethmoidal cells contribute to the complexity of the anterior wall of the frontal recess, and the bulla ethmoidalis, the suprabullar cells, and frontal bulla cells may also narrow the frontal sinus outflow. The supraorbital cells are often associated with low position of the anterior ethmoidal artery. Finally, the intersinus septal cells displace the frontal sinus drainage pathway posterolaterally, draining anteriorly into one or both middle meatuses. Clear understanding of the three-dimensional anatomy of the area is of upmost importance for a successful surgical approach. Thorough preoperative study of the CT scan with graphical reconstruction, as described in the literature, is the best way to achieve this. The concept will be presented with examples of various pathologies and anatomical configurations. The aid of frontal mini trephination and the use of image guidance will be outlined. Finally, the balloon dilatation of the frontal drainage pathway will be discussed, with reference to possible indications and contraindications.