Endoscopic Frontal Sinus Surgery Research Articles

Local flap reconstruction techniques after frontal sinus drainage typeII andIII according to Draf

Extended endonasal endoscopic frontal sinus surgery is characterized by bone resection beyond the lamellae of the frontal sinus and is currently classified according to Draf as typeIIa, typeIIb, modified typeIII (also referred to as typeIIc), and typeIII. This approach is indicated when the surgical goal cannot be achieved through complete removal of the anterior ethmoidal cells. Numerous studies indicate restenosis rates ranging from 7to 36%, despite creation of maximal openings. Exposed bone, which tends to epithelize slowly with significant crusting and the risk of uncontrolled wound healing depending on the local environment and other factors, is considered acontributing factor. Covering the exposed bone with mucosa can significantly reduce the risk of restenosis. Avariety of flap techniques for frontal sinus drainage in DrafIII procedures are presented, including some variants that were part of presentations at the 2023 Congress of the European Rhinologic Society in Sofia, Bulgaria. These include combinations of free mucosal grafts, pedicled mucosal flaps, and hybrids combining both techniques. Additionally, the results of current studies are presented. The results and achieved opening areas in contemporary DrafIII surgeries are significantly improved and larger compared to the early stages of these procedures. Amultitude of published studies consistently demonstrate that outcomes are markedly improved with mucosal coverage. Depending on the prevailing anatomy, mucosal conditions, and the extent of the surgical intervention, the most suitable technique should be selected. Therefore, proficiency in various methods is crucial. The use of aflap technique (free, pedicled, or combinations thereof) should be defined as the standard when performing extended frontal sinus surgery (Draf IIb, IIc, III, or endonasal frontal sinus surgery [EFSS] 4-6).

Non-Hodkin's lymphoma of the frontal sinus

Primary frontal sinus Non-Hodgkin's lymphoma (NHL) is an extremely rare condition with 20 cases published in the existing literature to date. We describe a 64-year-old patient who presented with right orbital pain, severe headache and diplopia. He was initially diagnosed with acute exacerbation of chronic rhinosinusitis and responded well to antibiotic treatment, but his symptoms returned. The diagnosis of frontal sinus NHL was made only after functional endoscopic frontal sinus surgery was performed in general anaesthesia. A tumor mass, which was filling the entire right frontal sinus, was completely removed and sent to histopathological examination. The patient was finally diagnosed with diffuse large B-cell lymphoma of the frontal sinus and referred to the haematology department for tumor staging and chemotherapy. This case emphasizes the importance of early clinical suspicion and diagnosis, which leads to early treatment and better prognosis.

Anatomic misconceptions regarding the agger nasi cell: A preliminary analysis utilizing endoscopic anatomic dissection and three-dimensional computed tomography.

The agger nasi cell is a key anatomic landmark in endoscopic frontal sinus surgery. However, discord amongst authors regarding anatomic definition and prevalence raises questions of its suitability as a surgical landmark. The purpose of this investigation is to evaluate the agger nasi cell using radiographic imaging correlated with endoscopic anatomic dissection to consider the cell's role as a surgical landmark and to explore if three-dimensional computed tomography (3D-CT) technology can provide enhanced insight into this anatomy. CT scans of 11 cadaveric sinonasal complexes were studied using triplanar CT or 3D-CT scanning with stereoscopic 3D imaging. Endoscopic dissections were performed and video recorded. Attention was given to identify agger nasi pneumatization and its origin. Pneumatization of the agger nasi region was noted in 4/11 cases (36.4%) (in two cases the pneumatization arose from the frontal recess, in two from a true agger nasi cell). The agger nasi region appeared as solid unpneumatized bone in 4/11 cases (36.4%). In 3/11 cases (27.3%) limited pneumatization was noted, bordering on but not pneumatizing the agger nasi proper. It may be confusing for otolaryngologic surgeons in training to rely on the "agger nasi cell" as a surgical landmark due to misconceptions regarding the anatomy, prevalence and anatomic definitions. Using standard CT scans to teach anatomy may have shortcomings as compared to the gold standard of surgical dissection. However, new 3D-CT holds promise to more accurately reflect small microanatomic features and provide an improved road map of a patient's anatomy in surgery.

The Frontal Sinus Drainage in Relation to Frontal Sinus Surgery.

In order to perform a successful endoscopic frontal sinus surgery, prevent complications, and lower the recurrence risk, it is essential to understand the anatomy of the frontal sinus (FS) and frontal recess cells with many variations in frontal sinus drainage (FSD). Preoperative assessment of the FSD in three levels in order to find prognostic factors in the decision process regarding the kind and the extent of surgery when required. Three FSD levels were assessed by computed tomography in two dimensions; antero-posteriorly and laterally in 100 consecutive patients with chronic sinusitis symptoms. The first level represents the proper drainage of FS. The second level is the drainage of FS without the effect of the frontoethmoidal cells. The third level is the maximum drainage that can be achieved in a single FS. The relation of FSD levels to FS and frontoethmoidal cells pathology were assisted. Within 100 patients (200 sides, 186 FSs), for the proper FSD, antero-posterior (AP) length was 5.94 ± 3.42mm in opaque FS and 5.32 ± 2.87mm in clear FS and its lateral length was 3.04 ± 1.6mm in opaque FS and 2.30 ± 1.25mm in clear FS. For the functional FSD, AP length was 8.97 ± 2.7mm in opaque FS and 8.05 ± 2.7mm in clear FS and its lateral length was 7.51 ± 1.69mm in opaque FS and 7.58 ± 1.75mm in clear FS. In the anatomical FSD, AP length was 11.25 ± 3.07mm in opaque FS and 10.01 ± 2.87mm in clear FS and its lateral length was 11.1 ± 2.6mm in opaque FS and 10.95 ± 1.7mm in clear FS. This study offers essential data for preoperative assessment in order to improve surgeons' awareness of the frontoethmoidal region for optimal safe EFSS with lower incidence of complications and recurrences.

Quality of life and olfactory outcomes following frontal sinus drill-out procedures

ObjectiveExtensive endoscopic frontal sinus surgery requires drilling of the bone close to the olfactory epithelium and exposing the first olfactory fiber. This study assesses long-term quality of life (QoL) and olfactory outcomes following endoscopic endonasal frontal sinus drill-out procedures. MethodsAll patients who underwent endoscopic endonasal frontal sinus surgery (Draf IIa or Draf III) for chronic rhinosinusitis (CRS) without nasal polyp in 2017 at a single tertiary center were included in the study. Pre- and postoperative scores of SNOT-22, odor identification, discrimination, and threshold were noted. ResultsOf the 31 patients included in this study, Draf IIa and Draf III were performed in 12 (38.7 %) and 19 (61.3 %) patients, respectively. A general assessment of QoL changes was carried out by evaluating pre- and postoperative SNOT-22 scores. A statistically significant difference was found between pre- and postoperative SNOT scores (p < 0.001): SNOT scores decreased by 9.13 units postoperatively. Comparing differences in SNOT-22 and olfactory test scores between Draf IIa and Draf III patients, we did not detect any statistically significant difference between the two procedures (p > 0.05). Draf IIa and Draf III did not display a statistically significant difference in SNOT-22 scores (p = 0.484) and did not have a significant effect on differences in pre- and postoperative identification (p = 0.675), discrimination (p = 0.535), and threshold (p = 0.141) scores. ConclusionsOur study demonstrated that extensive drill-out procedures have not a negative effect on olfactory functions, including threshold scores, in the long term. Patients who underwent frontal sinus procedures for persistent CRS have a better QoL postoperatively. However, more prospective double-blind studies are needed to support our results.

Study of Nasofrontal Beak Identification as a Useful Landmark in Endoscopic Frontal Sinus Surgery

Study of Nasofrontal Beak Identification as a Useful Landmark in Endoscopic Frontal Sinus Surgery

Extended endoscopic frontal nasal sinus surgery in management of chronic and recurrent frontal sinus diseases

BackgroundThe anatomical variation of the frontal sinus and its intimate relation to the skull base and orbit makes its surgery demanding. The extended endoscopic frontal sinus surgery allows wide better drainage and preventing the recurrence of the disease. Fourteen patients underwent EEFSS from May 2017 to May 2019. These patients are nine patients presented by chronic recurrent frontal sinusitis, three patients presented by chronic recurrent fronto ethmoidal mucocele and two patients with chronic recurrent external frontal fistula. Draff III done for ten patients of them and Draff IIB done for four patients of them. This study is designed for evaluating the efficacy of the extended endoscopic frontal sinus surgery (E E F S S) in management of chronic and recurrent frontal sinus diseases.ResultsThe neo opening of the restored frontal sinus was remained opened with Draff III with high success rate; two patients from four patients with Draff IIb were with closed nasofrontal duct. The main follow-up was 12 months; the patients were followed up post-operatively for many office visits without any other manifestations.ConclusionThe chronic recurrent frontal sinus diseases can be treated successfully with extended endoscopic frontal sinus surgery (E E F S S). The extended endoscopic frontal sinus surgery (Draff III) provides good results with low morbidity and less post-operative care.

Revision endoscopic frontal sinus surgery for refractory chronic rhinosinusitis via modified agger nasi approach.

ObjectiveTo examine the clinical effects of revision endoscopic frontal sinus surgery (RESS) through modified agger nasi (MAN)–middle turbinate resection on refractory chronic rhinosinusitis (CRS).MethodsWe reviewed 156 patients who were treated for refractory CRS from February 2012 to August 2014. These patients had been diagnosed with refractory CRS by computed tomography and endoscopy and had received several surgical and medical treatments in the past, but their condition had not been cured. They were divided into the observation group (RESS through MAN–middle turbinate resection, n = 78) and the control group (endoscopic sinus surgery, n = 78). Complete or partial control of the patient’s symptoms and signs suggested that the treatment was effective, and no improvement in the symptoms and signs indicated that the treatment was ineffective.ResultsThe 6-month treatment efficacy rate was significantly higher in the observation group (91.03%) than in the control group (71.79%). The observation group had a significantly lower complication rate (7.69%) and recurrence rate (3.85%) than the control group (17.95% and 12.82%, respectively).ConclusionRESS through MAN–middle turbinate resection together with adequate perioperative preparation has a significant effect on the outcome of refractory CRS and is worthy of clinical promotion.

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.

The Clinical Applications of Image Guidance in Revision Endoscopic Frontal Sinus Surgery

The Clinical Applications of Image Guidance in Revision Endoscopic Frontal Sinus Surgery

Quality of Life Outcomes in Frontal Sinus Surgery.

Introduction: Although significant experience has been gained in the technical nuances of endoscopic sinus surgery procedures, the patient-reported outcomes of frontal endoscopic sinus surgery procedures are still poorly understood. In this study we used the validated patient outcome measure Sino Nasal Outcome Test-22 (SNOT-22) to assess the preoperative and postoperative quality of life in patients undergoing extended endoscopic frontal sinus surgery (Draf type 2 and Draf type 3 procedures). Methods: Out of a total of 680 patients undergoing endoscopic sinus and skull base surgery and 186 patients undergoing frontal sinus surgery, 99 chronic rhinosinusitis patients with (CRSwNP) or without (CRSnNP) nasal polyps undergoing Draf 2 or Draf 3 were assessed. Results: The mean preoperative SNOT-22 was 45.6 points for patients undergoing Draf 2 and 59 for patients undergoing Draf 3, while the mean radiological Lund–Mackay Score was 14.3 and 14.5, respectively. Mean SNOT 22 improvement was 22.9 points for Draf 2 and 37 points for Draf 3 respectively and remained significant in all time intervals, including at 4 years after surgery. With the exception of loss of smell/taste, all symptoms improved by a far bigger extent in Draf 3 group, despite the considerably worse starting point. Effect size (Cohen / Standard Deviations) of Draf 3 was greatest in the following symptoms: “being frustrated/restless/irritable” (1.63), “nasal blockage” (1.43), “reduced concentration” (1.35), “fatigue” (1.29) “runny nose” (1.26) and “need to blow nose” (1.17). Frontal sinus (neo) ostium was patent (fully or partly) at last follow up in 98% of Draf 2 patients and in 88% of patients following Draf 3. Patients with non-patent frontal (neo-) ostium however had a mean postoperative SNOT 22 score of 43 compared to 20 of those with patent frontal sinus (neo-) ostium, although the difference was not statistically significant. Conclusion: Patients undergoing Draf 3 have a greater burden of disease, including both nasal and emotional/general symptoms compared to Draf 2 patients; surgery results in improvement in both groups, although Draf 3 patients have the greatest benefit, especially in emotional / general symptons. In this way both groups achieve similar postoperative quality of life, despite the different starting points.

Outcome of Endoscopic Frontal Sinus Surgery for Chronic Rhinosinusitis with and without Polyps

Outcome of Endoscopic Frontal Sinus Surgery for Chronic Rhinosinusitis with and without Polyps

Evaluación radio-anatómica del receso del seno frontal en población colombiana

Objetivos: La cirugía endoscópica del seno frontal es quizá uno de los procedimientos más complejos en el manejo endoscópico de los senos paranasales debido a su localización anatómica y a las múltiples variantes anatómicas que pueden encontrarse durante su disección. Es indispensable conocer al detalle la anatomía de esta región en nuestra población para la planeación quirúrgica de los pacientes. Actualmente en nuestro país se desconoce la frecuencia de estas variaciones. El objetivo del proyecto es evaluar la frecuencia de las variables anatómicas del seno frontal y realizar un estudio radio-anatómico en una muestra de pacientes en Colombia.&#x0D; Diseño del estudio: Observacional, descriptivo de tipo transversal.&#x0D; Métodos: Muestra aleatorizada de 406 tomografías computarizadas de senos paranasales que incluyeron 812 senos frontales recolectados durante el año 2018&#x0D; Resultados: La celdilla suprabular fue la más comúnmente reportada con una frecuencia de 59.61%. La segunda celdilla fue la supra agger nasi con una frecuencia de 57.88%, seguido de la celdilla supra agger frontal (25.12%), celdilla suprabular frontal (22.17%), celdillas supraorbitarias (34.98%) y las celdilla frontal intersinusal (24,14%). La arteria etmoidal anterior se reportó colgante en un 31.28% y el diámetro AP más frecuente fue entre 5 -10 milímetros.&#x0D; Conclusiones: Para realizar una sinusotomía frontal endoscópica de forma adecuada es necesario conocer al detalle la anatomía del receso del seno frontal. Las diferentes variantes radio-anatómicas son muy frecuentes en el grupo poblacional estudiado. Creemos que este trabajo permitirá a los cirujanos un mejor entendimiento de esta región de difícil acceso quirúrgico en nuestra población.

Frontal Ostium Grade (FOG): A New Computer Tomography Grading System for Endoscopic Frontal Sinus Surgery.

The location and size of the frontal sinus ostium are critical in determining surgical difficulty. The more anterior the ostium, the more difficult is the surgical access. We propose a novel computed tomography (CT) grading specific to the anatomical position of the frontal ostium. Observational study followed by a prospective part. Tertiary rhinology practice. On a specified sagittal CT cut, a vertical line was drawn through the posterior edge of the frontal process of the maxilla (frontal buttress/beak) along its vertical axis (reference [R-] line). A second (S-) line was placed at the point of upturn of the skull base. Based on if the S-line was posterior or anterior to the R-line, the frontal ostium was graded positive and more easily accessible or negative and thereby more challenging, respectively. If both lines overlapped, then a neutral (0) grading existed. A total of 297 CTs (594 ostia) were analyzed. In total, 394 (65%) ostia were grade positive, 52 (8.75%) were grade negative, and 103 (17.3%) were grade neutral. Ninety frontal sinusotomies were then performed using this grading system: 48 were positive, 21 negative, and 21 neutral. The average time to complete a frontal sinusotomy was 9.96 minutes for grade positive compared to 11.4 minutes for neutral and 16.05 minutes for grade negative (P < .005). This novel anatomical CT grading system is designed to be useful in planning and predicting the level of difficulty in endoscopic frontal sinus surgery.

Comparative analysis of the outcome of external and endoscopic frontal sinus surgery in children

Background: Both open and functional endoscopic sinus surgery (FESS) are performed in the case of pediatric frontal rhinosinusitis. However, data from comparative analysis of these surgery types are insufficient.Objective: Prospective randomized trial for comparison of open and endoscopic surgery outcome in pediatric chronic rhinosinusitis.Material and methods: The cohort included 30 pediatric patients (7–17 years) with open frontal sinus surgery and 34 patients who underwent FESS using DrafIIa. Lund‐Kennedy and Lund-Mackay scores, as well as Sino-Nasal Outcome Test-20 (SNOT-20)questionnaire was used for pre- and postoperative assessment.Results: Open surgery and FESS resulted in a significant improvement in total Lund‐Kennedy, Lund-Mackay, and SNOT-20 scores, being more profound in FESS group. Using FESS significantly reduced surgery duration by 15% as compared to open surgery. In addition, open surgery was associated with a higher rate of scar formation, reduced local sensitivity, as well as local soreness, lacrimation, and psychological discomfort. In regression models FESS was negatively associated with postoperative total Lund‐Kennedy, Lund-Mackay, and SNOT-20 scores.Conclusion and significance: Generally, FESS resulted in better surgery outcome as compared to open surgery, although both approaches resulted in a significant improvement in chronic rhinosinusitis.

Role of bi-portal endoscopic approach to frontal sinus in managing frontal sinus diseases

Background In spite of recent evolution of endoscopic frontal sinus surgery, some cases are still challenging due to the difficulty to reach the lateral frontal sinus even with Draf type III. This study aims to highlight the bi-portal approach to the frontal sinus disease. Materials and methods This study is a prospective study that was conducted on four patients with mean age of 56 years. Two cases were presented with allergic fungal sinusitis, one case showed an inverted papilloma and a single case of granulomatous fungal sinusitis. All patients underwent bi-portal surgery which entailed endoscopic frontal sinus surgery either Draf IIb or III plus as an external approach through the upper eyelid. Results Complete removal of the disease with no major postoperative complications, with no detection of recurrence during the 12–30-month-follow-up period. Conclusion Bi-portal frontal sinus approach is an easy noninjurious technique with very little cosmetic drawbacks allowing rhinologists to access the whole aspects of the frontal sinus, especially the lateral part.

An introduction to the international frontal sinus anatomy classification and classification of the extent of endoscopic frontal sinus surgery

额隐窝及额窦区域的解剖较为复杂，近15年来，对额筛气房和内镜额窦手术分类的研究有力地推动了内镜额窦外科技术的进步。为了更全面反映额筛气房的解剖，促进内镜额窦外科的学术交流和教学，2016年，Wormald等18位专家撰写了《国际额窦解剖分类和内镜额窦手术分类》专家共识，进一步规范了额窦区域的解剖名词和手术分类。本文概括介绍了该共识，并简要回顾了额筛气房和额窦手术分级研究进展，以期促进中国学者对新的额筛气房和内镜额窦手术分级的了解。.

A Radiological Study Assessing the Prevalence of Frontal Recess Cells and the Most Common Frontal Sinus Drainage Pathways.

To date, there are numerous studies documenting the prevalence of frontal recess cells, but only 1 study using the newly developed International Frontal Sinus Anatomical Classification (IFAC) system. The identification of the frontal cells and their influence on the frontal drainage pathway plays an important role in endoscopic frontal sinus surgery. The aim of this study is to document the radiological prevalence of various types of frontal cells, as classified by IFAC and the most common frontal sinus drainage pathways based on its anatomic relationships with these cells. Using a novel preoperative virtual planning software (Scopis Building Blocks), consecutive computerized tomography scans of the sinuses of patients were analyzed for the prevalence of frontal cells, as classified by the by IFAC, and the frontal sinus drainage pathways at the Ear Nose Throat Hospital of Ho Chi Minh City, Vietnam. In this study, 208 computed tomography scans of consecutively selected frontal sinuses of 114 patients were included for analysis. The agger nasi cell was present in 95.7% of reviewed scans. The frontal cells prevalence was as follows: supra agger cell (SAC): 16.3%, supra agger frontal cell (SAFC): 13%, supra bulla cell (SBC): 46.2%, supra bulla frontal cell (SBFC): 4.3%, supra orbital ethmoid cell: 17.3%, and frontal septal cell: 10.6%. The most common frontal sinus pathway type in relation to frontal cells was medial to SAC (70.6%), medial to SAFC (81.5%), anterior to SBC (88.5%), and anterior to SBFC (100%). In cases that had 2 frontal cells group, the drainage pathway was medial to SAC/SAFC and anterior to SBC/SBFC in most cases. This study documents the prevalence of frontal cells (classified by IFAC) using a novel preoperative virtual planning software in the Vietnamese population. It demonstrates predominantly medial anteromedial frontal drainage pathways as related to these frontal cells.

Results from a Cross-Sectional Survey of Endoscopic Frontal and Maxillary Sinus Surgery

Results from a Cross-Sectional Survey of Endoscopic Frontal and Maxillary Sinus Surgery

The Relationship Between the Width of the Frontal Recess and the Frontal Recess Cells in Japanese Patients.

Objective:The agger nasi cell (ANC) is an easily identifiable landmark when approaching the frontal sinus. The success of endoscopic frontal sinus surgery may be influenced by the width of the frontal recess (FR). The aim of this study is to examine the relationship between the FR width and the ANC size in Japanese patients. In addition, the effect of various frontal recess cells (FRCs) on the development of frontal sinusitis has been examined.Materials and methods:Multiplanar computed tomography (CT) scans of the nasal cavities and paranasal sinuses in 95 patients (190 sides) before endoscopic sinus surgery were reviewed. The presence of FRCs, the thickness of the frontal beak (FB), the ANC size, and the anterior-to-posterior (A-P) length of the frontal isthmus (FI) and FR were evaluated in patients with and without frontal sinusitis.Results:The prevalence of the ANC, frontal cell types 1, 2, 3, and 4, frontal bullar cell (FBC), suprabullar cell, supraorbital ethmoid cell, and interfrontal sinus septal cell was 85.3%, 11.6%, 0%, 7.9%, 0%, 25.3%, 45.8%, 16.8%, and 15.3%, respectively. The ANC volume showed a significant positive correlation with the A-P length of the FI and FR. The incidence of frontal sinusitis in the patients with FBCs was significantly higher than that without FBCs.Conclusion:A large ANC offers a greater potential to facilitating the approach to the frontal sinus because of the extensiveness of the FR in Japanese patients. The presence of FBCs may be related to a higher incidence of frontal sinusitis.