Endoscopic Frontal Sinusotomy Research Articles

Dynamic radiologic changes in repeated barotraumatic frontal sinusitis: A CARE case report

IntroductionFlight staff are at particular risk of iterative sinus barotrauma. We here report a case of barotraumatic atelectasic frontal sinusitis with dynamic radiologic change in frontal sinus volume. Case reportA 46-year-old air pilot was referred for right frontal pain occurring at each landing. Two sinus CT scans were taken: one after a period of intense flying and the other after a month without flying. In the right frontal sinus, a type-3 Kuhn cell changed in volume from 6×11×12mm to 13×18×19mm. The alteration involved a modification in the medial wall, which was demineralized and changed position within the frontal sinus. Removal during endoscopic frontal sinusotomy allowed complete resolution of pain. DiscussionThis article reports radiologic change in a frontal sinus wall in a setting of repeated barotraumatic frontal sinusitis with a dynamic atelectasic component. In iterative barotrauma, we advocate imaging at different time points. When the ostial obstruction is identified, functional aeration surgery can be applied.

Radiopathologic predictors of 1- and 2-year frontal sinusotomy outcomes in a southeast Asian chronic rhinosinusitis population.

The frontal sinus and its drainage pathway are difficult spaces to navigate surgically. The complexity of the frontal recess anatomy as well as inflammatory factors may influence outcomes of endoscopic frontal sinusotomy. It is not clear which factors are more important in determining post-operative frontal ostium patency. The objective is to investigate whether the distribution of fronto-ethmoidal cells, frontal recess dimensions and sinonasal inflammation predict frontal ostium patency at 1- and 2-years after endoscopic frontal sinusotomy. A retrospective review of 94 chronic rhinosinusitis patients (185 sides) who had undergone endoscopic frontal sinusotomies between 2015 and 2019 was conducted. Computed tomography was used to evaluate the type of fronto-ethmoidal cells present and determine the dimensions of the frontal recess. The International Classification of the Radiological Complexity of frontal recess and frontal sinus was used to grade the complexity of frontal recess anatomy. Mucosal inflammation was graded according to a structured histopathology report. Frontal ostium patency at 1- and 2-years post-operatively was recorded. The frontal ostium patency rates were 80.9% and 73.4% at 1- and 2-years respectively. Eosinophilic predominance (adjusted OR 3.5, 95% CI 1.6-8.0, p = 0.003) and mucosal ulceration on histology (adjusted OR 4.5, 95% CI 1.1-17.9, p = 0.033) predicted ostial stenosis at 1year. Smoking (adjusted OR 7.6, 95% CI 2.4-24.7, p = 0.001), aspirin exacerbated respiratory disease (AERD) (adjusted OR 7.6, 95% CI 1.9-30.1, p = 0.004) and histological findings of severe inflammation (adjusted OR 8.9, 95% CI 1.9-41.2, p = 0.005) were independent predictors of ostial stenosis at 2years. Frontal cell patterns, frontal recess dimensions and frontal recess complexity did not predict frontal ostium stenosis at both 1- and 2-years post-operatively. Post-operative control of sinonasal inflammation is important in maintaining frontal ostium patency, regardless of frontal cell patterns or frontal recess dimensions.

Computed Tomography Analysis of the Anterosuperior Portion of the Bulla Lamella in Chinese Subjects and Its Surgical Significance in Endoscopic Frontal Sinusotomy

Introduction: The anterosuperior portion of the bulla lamella can extend into the frontal sinus and form the supra bulla frontal cell (SBFC) and supraorbital ethmoid cell (SOEC). This can affect the frontal drainage pathway and make surgery more challenging. Objectives: The aim of the study was to compare the anatomical characteristics of SBFC and SOEC in Chinese chronic rhinosinusitis (CRS) patients and explore the relationship between the cells and frontal sinusitis (FS). The surgical skills in dealing with these cells were also studied. Methods: We prospectively identified SBFC and SOEC in 114 patients with CRS by computed tomography (CT). The sides of the patients were divided into groups A (with FS) and B (without FS). CT scans were analyzed to distinguish the SBFC, SOEC, and the drainage pathway. Statistical analysis was conducted to determine whether the cells were associated with the occurrence of FS. Results: The prevalence of frontal cells was as follows: SBFC: 9.65%, SOEC: 21.93%. There was an association between the presence of SBFC and FS (p < 0.05). The anterior drainage pathway was present in patients with SBFC and SOEC, anterolateral pathway in those with SBFC/SOEC coexisting with the frontal septal cell, and anteromedial pathway in those with SBFC/SOEC coexisting with the supra agger frontal cell. Conclusions: There was an association between the presence of SBFC and the occurrence of FS. Extension of the anterosuperior portion of the bulla lamella into the frontal sinus obstructed the drainage pathway posteriorly. Understanding the anatomy may help surgeons thoroughly dissect the bulla lamella.

Comparison between the endoscopic scores of bolgerization versus partial resection of the middle turbinate for management of the postoperative lateralization in the early follow-up period after endoscopic frontal sinusotomy: A randomized controlled study

BackgroundFrontal sinusotomy is a challenging procedure that needs meticulous handling due to its unique anatomical position. Postoperative middle turbinate lateralization is critical comorbidity for the success rate, and many techniques are adopted to prevent it. The study aimed to compare the effect of middle turbinate bolgerization and partial resection on the postoperative endoscopic scores and assess their impact on the middle meatus and the frontal recess outcome. Patient and methodsThis prospective study was conducted on forty-one patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis. Nasal cavities were randomized so that partial middle turbinate resection technique was done alternately with bolgerization approach in every patient. Each participant acted as their control. Both sides were compared using Lund Kennedy Endoscopic Score (LKES) and Perioperative Sinus Endoscopy Score (POSE) at the baseline, 1st, 3rd, and 12th-month intervals postoperatively. Also, middle turbinate status was assessed at the end of the 12th-month interval using POSE score. ResultsThe total frontal sinus patency rate was 82.9% (63/76 operated sinus). Baseline scores, LKES (3.79 ± 0.777 vs 4.05 ± 0.769, p = 0.142, for the side of resection and the side for bolgerization respectively) and POSE (1.79 ± 0.413 vs 1.82 ± 0.393, p = 0.777, for the side of resection and the side for bolgerization respectively). Regarding LKES, the differences between both operated sides were fluctuating with p values: 0.001*, 0.171, and 0.044* for the 1st, 3rd, and 12th months follow-up intervals, respectively. Regarding the POSE score of the frontal sinus, the difference between both groups was steadily increasing with p values: 0.318, 0.119, and 0.017* for the 1st, 3rd, and 12th months follow-up intervals. The middle turbinate's POSE score at the 12th month was significantly higher in the side allocated for bolgerization (p-value = 0.008*). ConclusionPartial middle turbinate resection showed favorable endoscopic outcomes than bolgerization at the 12th month follow up period in patients undergoing primary ESS for chronic frontal sinusitis.

The preoperative radiological findings associated with failure of frontal sinusotomy: A prospective study.

The study aimed to assess the association between the preoperative CT findings and the patency outcome of the frontal sinus after endoscopic frontal sinusotomy in the early follow-up period. A prospective cohort study. Tertiary hospital centre. The study measures the association between the frontal sinusotomy outcome and the standard preoperative radiological scores, including Harvard, Kennedy and Lund-Mackay. It also measures the impact of the degree of sinus mucosal thickness on the outcome. Furthermore, it measures the effect of the anteroposterior lengths of both the frontal sinus ostium and the frontal recess on postoperative frontal sinus patency. Harvard, Kennedy and modified Lund-Mackay scores showed no evidence of association with the frontal sinusotomy patency outcome (P-values .397, .487 and .501), respectively. Still, the Lund-Mackay score showed a negative correlation with symptom improvement. Sinuses with a high-grade mucosal thickness on CT scan were associated with high failure rates (P-value: .009*). The anteroposterior length of the frontal sinus ostium significantly affects the outcome (P-value: .001*). In contrast, there was no association between the anteroposterior length of the frontal recess and the outcome (P-value: .965). The Harvard, Kennedy and Lund-Mackay scores could not predict the frontal sinusotomy patency outcome. Failed cases were associated with advanced degrees of mucosal pathology in the preoperative CT scan. Sinuses ostia with anteroposterior diameters less than 5.36mm showed more susceptibility for sinus restenosis postoperatively. The variability of the anteroposterior length of the frontal recess did not affect the surgical outcome.

Endoscopic Frontal Sinusotomy with Osteoma Removal

Endoscopic Frontal Sinusotomy with Osteoma Removal

Frontal Sinus Drainage in Acute Pediatric Sinusitis With Intracranial Complications.

The indication for frontal sinus drainage is uncertain when managing pediatric acute sinusitis with intracranial complications. The primary objective was to determine if addressing the frontal sinus reduced need for subsequent surgical procedures in children presenting with acute sinusitis complicated by intracranial abscess. A case series with chart review was performed at a tertiary children's hospital between 2007 and 2019. Children under 18 years of age requiring surgery for complicated acute sinusitis that included the frontal sinus with noncontiguous intracranial abscess were included. Outcomes were compared among children for whom the frontal sinus was drained endoscopically, opened intracranially, or left undrained. Thirty-five children with a mean age of 11.1 years (95% CI: 9.9-12.3) met inclusion. Most presented with epidural abscess (37%). Hospitalizations lasted 12.9 days (95% CI: 10.2-15.5), 46% required a second surgery, 11% required three or more surgeries, and 31% were readmitted within 60 days. Initial surgery for 29% included endoscopic frontal sinusotomy, 34% had a frontal sinus cranialization and 37% did not have any initial drainage of the frontal sinus. Groups were similar with respect to demographics, severity of infection, need for repeat surgery, length of stay, and readmissions (p > .05). Further, persistence of cranial neuropathies, seizures, or major neurological sequelae after discharge were no different among groups (p > .05). Drainage of the frontal sinus, when technically feasible, was not associated with reduced surgical procedures or increased complications and there is unclear benefit on measured clinical outcomes.

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.

Validation of a rhinologic virtual surgical simulator for performing a Draf 3 endoscopic frontal sinusotomy.

We recently introduced a patient-specific rhinologic virtual surgical environment (VSE) that has shown potential for surgical rehearsal of various skull base lesions. Our aim in this study was to validate the usefulness of the rhinology VSE in performing the Draf 3 procedure. An outside-in Draf 3 procedure was performed on 4 cadaver heads. Computed tomography (CT) scans were obtained before and after cadaver dissection (CD). Pre-dissection CT scans were used to construct a cadaver-specific VSE. A virtual Draf 3 dissection (VD) was performed using the same technique. Validation was conducted by comparing the final common frontal outflow tract. A subjective comparison of the post-dissection endoscopic findings (CD vs VD) and an objective measurement using the post-dissection CT scan for the CD and the reconstructed CT scan obtained from the data after the VD was performed. Subjective overall resemblance of the 2 dissections (CD vs VD) assessed by the 4-point Likert scale (0-3) was 2.5 (median interquartile range [IQR], 0.25) for the 4 cadavers. The median difference for the anteroposterior dimension of the frontal neo-ostium (CD vs VD) assessed in the midsagittal view was 0.11 mm, whereas the median difference for the lateral dimension assessed in the coronal view was 2.71 mm. Thus, no statistical difference was observed. VD showed nearly matching results with the actual cadaver dissection. With further validation, our rhinologic VSE may be used for presurgical planning and rehearsal before the actual Draf 3 procedure is performed in the operating room.

The Horizon Sign and Frontal Bar: Two Topographic Landmarks to Confirm Endoscopic Frontal Sinusotomy.

Confirming a thorough dissection of the frontal sinus during endoscopic sinus surgery can be challenging, and some surgeons would benefit from reliable topographic landmark identification to ensure completion of this sinus dissection. We defined (1) the "horizon sign" as the curvilinear shadow of the posterior table cast superiorly upon the anterior table of the frontal sinus at the acute angle of their meeting point and (2) the "frontal bar" as a sagittal septation at the union of the anterior/posterior tables. A cadaveric study, followed by an intraoperative consecutive case series, was performed to evaluate these 2 landmarks as indicators of complete dissection. The horizon sign was extremely reliable, identified in 100% of cadaveric frontal sinuses and intraoperative frontal sinuses. The frontal bar was present in only 67% of frontal sinuses by computed tomography. In live patients, the sensitivity and specificity of the frontal bar were 62% and 95%, respectively.

Value of double pedicled mucoperiosteal flaps for the prevention of restenosis in Draf IIb frontal sinusotomy

IntroductionThe extent of bone exposure is one of the major factors contributing to failure of endoscopic frontal sinusotomy procedures. Double flaps providing cover of exposed bone have already been described for Draf III procedures in a cadavre study using posterior and lateral pedicled nasoseptal flaps. As these flaps overlap on the septal side, they cannot be raised from the same nasal cavity in a Draf IIb procedure. We describe a new technique using 2 local mucoperiosteal flaps raised from the same side to entirely cover the bone margins exposed by Draf IIb frontal sinusotomy. Surgical techniqueA left Draf IIb procedure was performed to drain a frontal mucocele. A posterior septoturbinal flap (PSTF) was raised to cover the posterior sinusotomy margin. A lateral pedicle nasoseptal flap (LNSF) was raised on the same side to cover the anterior margin. With a follow-up of 6 months, the Draf IIb cavity was fully patent and the flaps were well integrated. ConclusionPSTF and LNSF flaps can be raised on the same side to cover the posterior and anterior margins of the Draf IIb frontal sinusotomy, respectively.

The value of frontal sinusotomy for chronic rhinosinusitis with nasal polyps-A cost utility analysis.

The number of surgical procedures performed for frontal sinusitis and the associated costs have increased dramatically over the past decade. The purpose of this study was to evaluate the cost-effectiveness of endoscopic frontal sinusotomy (EFS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). Cohort-style Markov decision-tree economic model with a 36-year time horizon. Matched cohorts of CRSwNP patients who underwent endoscopic sinus surgery (ESS) with (n = 139) and without (n = 49) EFS were compared to each other and to patients (n = 139) from the Medical Expenditures Survey Panel database who underwent medical management for chronic rhinosinusitis. Multi-year health utility values were calculated from responses to the EuroQol 5-Dimension instrument. The primary outcome measure was the incremental cost-effectiveness ratio (ICER). Decision analysis showed that ESS without EFS proved more cost-effective than ESS with EFS or medical management. ESS without EFS compared to medical management yielded an ICER of $9,004/quality-adjusted life year (QALY). ESS with EFS compared to ESS without EFS yielded an ICER of $62,310/QALY. At a willingness-to-pay (WTP) threshold of $50,000/QALY, ESS without EFS was more cost-effective than ESS with EFS with 52.1% certainty. These results were robust to one-way analysis and probabilistic sensitivity analysis. ESS remains a cost-effective intervention compared to medical therapy alone for patients with CRSwNP. In this study, the addition of frontal sinusotomy during ESS for patients with CRSwNP was not found to be cost-effective at a WTP threshold of $50,000/QALY, but may be cost effective at a higher threshold of $100,000/QALY. 2c. Laryngoscope, 128:43-51, 2018.

Novel use of an ultrasonic bone aspirator for extended endoscopic frontal sinusotomy: A feasibility study.

Extended endoscopic frontal sinusotomy is often required for surgical management of anterior skull base pathology. Such approaches are necessary for access to pathology and maintenance of postoperative frontal sinus outflow tract drainage. Cold steel instrumentation and endoscopic high-speed microdrills are typically used for bony removal during extended frontal sinus approaches but are associated with certain drawbacks, such as thermal injury and obscuration of the surgical field with bone dust. We investigated the ultrasonic bone aspirator (UBA) as an adjunctive tool for extended endoscopic frontal sinusotomy in the setting of skull base surgery. Medical records of patients who underwent either Draf IIB or Draf III sinusotomies from 2011 to 2014 were reviewed. The patients were split into two cohorts based on instrumentation: those who received sinusotomy primarily with the UBA, and those who had sinusotomy performed with conventional instrumentation only. The patients were followed up after surgery with routine endoscopic examinations and imaging when indicated. Patient demographics, surgical approach, operative complications, and postoperative outcomes were evaluated. A total of 18 patients underwent endoscopic extended frontal sinusotomy for a variety of skull base pathologies with the UBA and the conventional instrumentation cohorts, which contained nine patients each. Five of the nine patients in the UBA cohort received Draf III sinusotomies compared with three of nine in the conventional cohort. Three patients in the UBA cohort experienced postoperative transient pressure hyperemia of the lip; this was seen in a single patient in the conventional cohort. All patients with postoperative endoscopic examinations maintained frontal sinus ostial patency to varying degrees, irrespective of cohort. Lund-Mackay scores and the need for operative revision of the frontal sinus were similar for both groups and seemed to be related to the use of postoperative radiation. The UBA was a safe, effective tool for extended endoscopic frontal sinusotomy in endoscopic skull base surgery.

Endoscopic Sinus Surgery in Acute and Chronic Pediatric Rhinosinusitis

Submit Manuscript | http://medcraveonline.com their quality of life [3]. Hence, the fact remains that some children, who do not respond to medical treatment, will be referred to the Otorhinolaryngologist, who, in turn, faces the problem of what to recommend. Part of the problem is lying upon the discrepancy in opinions between Otorhinolaryngologist and Pediatricians, regarding the indications for sinus surgery, especially in chronic cases, which can be frequently, summarized in the quote “in chronic sinusitis every effort should be made to avoid operative procedures” [4]. This discrepancy necessitates the least possible variance in the proposed treatment plan by the Otolaryngologist, and his/her adherence to the principles of evidence-based medicine in this domain also, disregarding any dogmatic views. With regard to acute rhinosinusitis, endoscopic sinus surgery is usually reserved for the management of pending or existing complications. Osteomyelitis of the anterior frontal plate (Pott’s puffy tumour) represents such a condition, and should be managed in the majority of cases with an endoscopic frontal sinusotomy (Draf 2a). The procedure should include uncinectomy and middle meatal antrostomy, and complete anterior and posterior ethmoidectomy using the lamina papyracea and skull base as landmarks. The agger nasi as well as any frontal sinus cells obstructing the frontal recess should also be removed [5]. Neurosurgical intervention for the drainage of a co-existing intracranial abscess should be performed in the same session as the endoscopic nasal drainage, when possible [5]. Orbital complications represent the most frequently encountered complications of acute rhinosinusitis, appearing approximately twice as often as the intracranial ones, and followed by osseous involvement (osteomyelitis) [6]. Surgical intervention, preferably endoscopic, is advocated in cases of documented subperiosteal or intraorbital abscess, reduced visual acuity or color vision, affected afferent pupillary reflex or inability to assess the child’s vision. In addition, progressing or not improving orbital signs (diplopia, ophthalmoplegia, proptosis, swelling and chemosis) after 48 hours of intravenous antibiotics, or even progressing or not improving general condition of the child during the same time period also represent indications for prompt surgical exploration and drainage [6]. The procedure usually includes uncinectomy and middle meatal antrostomy, and anterior ethmoidectomy. Skeletonization of the lamina papyracea following probing, and drainage of the subperiosteal or intraorbital pus collection are also required in case of respective abscess formation. By contrast, surgical drainage could be withheld in children aged between 2-4 years old or less with small (< 0.5-1 ml in volume) medially located subperiosteal abscess, demonstrating clear clinical improvement within 24-48 hours of intravenous antibiotics, no decrease in visual acuity, and no significant systemic involvement [7]. As far as chronic rhinosinusitis is concerned, it has become clear in the modern era of endoscopy and imaging that rhinitis and adenoid hypertrophy are not the only reasons of a runny nose in children, as in the majority of cases the sinuses are involved as well. Hence, chronic rhinosinusitis may often be overlooked. Irrespective of difficulties in diagnosis associated with the variability in the clinical presentation of chronic pediatric rhinosinusitis, and/or the frequent inability of children to reliably describe their exact symptoms, chronic rhinosinusitis may have a serious impact on children’s quality of life, and their respective health status.

Endoscopic Management of Chronic Frontal Sinusitis: Prospective Quality of Life Analysis.

Previous studies of endoscopic frontal sinus surgery have been primarily retrospective and focused on symptom relief only. To prospectively assess the impact of endoscopic frontal sinus surgery on frontal sinus ostium patency and disease-specific quality of life as measured by the Rhinosinusitis Disability Index (RSDI). A 60-patient cohort with chronic frontal sinusitis (100 diseased frontal sinuses) was prospectively evaluated using the RSDI, computed tomography (CT) imaging, and endoscopic examination. Image-guided endoscopic frontal sinusotomy (Draf 2a) was performed in each case. Patients were assessed with RSDI and endoscopic assessment at least 6 months postoperatively. At a mean follow-up of 10 months, endoscopic assessment revealed patent frontal recesses in 90 of 100 frontal sinuses (90%), with significant improvement in the total RSDI score (41.98 ± 26.48 preoperatively to 17.15 ± 15.66 postoperatively) as well as each of its physical, emotional, and functional subscales from 16.3 ± 9.03, 12.23 ± 10.55, 13.45 ± 9.59 preoperatively to 5.95 ± 5.71, 5.55 ± 5.66, 5.65 ± 5.72 postoperatively, respectively. Similar improvement was seen in patients with asthma, polyps, and those undergoing revision sinus surgeries. With frontal recess mucosal preservation and meticulous postoperative endoscopic surveillance, endoscopic frontal sinusotomy results in high rates of frontal sinus ostium patency with significant improvement in quality of life.

Endoscopic Frontal Sinus Exploration in Children with Cystic Fibrosis

Objectives: Frontal sinus exploration is uncommon in children. Delayed pneumatization of the frontal sinus, technical difficulties, and concerns for postoperative scarring and mucocele formation impact the incidence of this operation in the pediatric population. The objective of this study is to review outcomes after endoscopic frontal sinus exploration in children with cystic fibrosis (CF). Methods: Retrospective case series of children with CF undergoing endoscopic frontal sinus exploration at a tertiary children’s hospital from 2004 to 2012. Pre- and postoperative pulmonary function tests (PFT), surgical complications, and the rate of revision operations were evaluated. Outcomes were compared to a cohort of children without CF that underwent endoscopic frontal sinusotomy for chronic sinusitis. Results: Twenty-three children (12 with CF, 11 without CF) underwent endoscopic frontal sinusotomy. The average age was 11.3 years (range 7-14) in the CF group compared to 13.5 years (range 6-18) in the non-CF population. Four of the 12 CF patients (33%) required at least 1 revision operation, compared to 1 of 11 control patients without CF (not statistically significant). No significant improvement in PFT was noted after surgery (mean FEV1% predicted pre-operative: 97.3 ± 19.9, post-operative: 96.7 ± 27.6). The average time from initial surgery to revision operation was 20.3 months (range 8-30 months). No major surgical complications related to the procedure were identified. Conclusions: The revision rate for frontal sinus exploration in this series is similar to revision rates described in the literature for other sinuses in CF patients. PFT results did not change after the operation.

Allergic Fungal Rhinosinusitis Involving Frontal Sinus: A Prospective Study comparing Surgical Modalities

ABSTRACTAllergic fungal rhinosinusitis (AFRS) represents a hypersensitivity response to extramucosal fungi within the sinus cavity without evidence of tissue invasion. AFRS is characterized by fungal element with allergic mucin, Charcot-Leyden crystals, type I hypersensitivity, bony erosion with sinus infection on computed tomographic (CT) scan. Surgery remains the treatment of choice for AFRS followed by prolonged steroid therapy. Surgical approaches for frontal sinus disease can be either endonasal endoscopic or external. This is a nonrandomized prospective study, where the postoperative results of endoscopic frontal sinusotomy were compared with external frontoethmoidectomy approach. This is a nonrandomized prospective study, where the postoperative results of endoscopic frontal sinusotomy were compared with external frontoethmoidectomy approach. The comparison between external frontoethmoidectomy and endoscopic approach was done by using Chi-square test. There was no statistical significant difference found, when postoperatively clinical symptoms, radiology and investigations in patients of both the groups were compared. The success rate was 95.5% in group I and 91.1% after 6 months of follow-up. The world literature lacks prospective studies where attempts are made to compare the long-term results of both the surgical modalities for AFRS patients. Endoscopic endonasal approach has a distinct advantage over the external frontoethmoidectomy approach as it minimizes external scars over the face with almost equal or better long-term results.How to cite this articleVerma H, Rijuneeta, Gupta AK, Chakrabarti A. Allergic Fungal Rhinosinusitis Involving Frontal Sinus: A Prospective Study comparing Surgical Modalities. Clin Rhinol An Int J 2013;6(1):10-15.

Double J stent of frontal sinus outflow tract in revision frontal sinus surgery

Frontal sinus surgery continues to challenge even the most experienced endoscopic sinus surgeon. Revision frontal sinus surgery is even more challenging. The use of stents in frontal sinus surgery has long been described, as an attempt to decrease the incidence of synechiae and stenosis. This study included five patients who had previously undergone functional endoscopic sinus surgery but suffered recurrence of frontal sinusitis. Two had bilateral disease. Double J stents were used after endoscopic frontal sinusotomy. The stents were left in place for six months. Four of the 5 patients (6 out of 7 sinuses) had a patent frontal outflow tract after 10 to 36 months' follow up. Double J stents can be used as frontal sinus stents. They are well tolerated by patients, easily applied, and self-retaining with no need for sutures. The length of the stent can be altered according to the patient's anatomy and pathology.

Risk factors and outcomes for primary, revision, and modified Lothrop (Draf III) frontal sinus surgery

The purpose of this level 4, retrospective cohort study was to detail the outcomes of primary, revision, and endoscopic modified Lothrop procedure (EMLP) (Draf III) frontal sinus surgery and evaluate whether risk factors would help determine which patients would benefit from which procedures. The study used a retrospective chart review. Endoscopic assessment of frontal ostium patency and patient reported symptoms were prospectively collected on patients who underwent frontal sinusotomy between January 2003 and December 2009. High-risk cohorts were studied to assess their response to standard endoscopic sinus surgery (ESS) compared with EMLP. A total of 339 patients who met the inclusion and exclusion criteria underwent either primary or revision endoscopic frontal sinus surgery. The average ± standard deviation (SD) length of follow-up was 20.8 ± 18.7 (95% confidence interval [CI], 18.0-22.9) months. Postsurgical recurrence of disease with persistence of symptoms requiring an EMLP occurred in 9 patients in the primary group and 38 in the revision group. The highest risk groups for failure of standard frontal sinusotomy were patients with nasal polyps, asthma, Lund-Mackay score >16, and frontal ostium size <4 mm (relative risk = 9.9, p < 0.0001). Patients with underlying asthma and polyposis as well as narrow frontal ostia and extensive radiological disease have a high failure rate from standard endoscopic frontal sinusotomy. In this patient group consideration should be given to offering the patient a primary EMLP procedure, which has excellent success rates with low risks and low morbidity.

Surgical management of frontal sinus inverted papilloma: A systematic review

Surgical management of frontal sinus (FS) inverted papilloma (IP) remains a significant challenge. This study systematically reviews the FS IP literature to delineate outcomes based on surgical strategy. Systematic review. Cases for inclusion were identified by literature query for the terms frontal sinus and inverted papilloma between 1995 and 2010. Cases reported with sufficient outcomes data, defined as specific surgical approach and disease-free follow-up, were included. Statistical analysis was performed to identify significant risk factors for recurrence. The reported length of follow-up for each surgical approach was analyzed as an indicator of the strength of the reported literature for each approach. Fifty-seven cases were identified in 13 studies, with 49 cases deemed adequate for additional analysis. Twenty-four cases (49%) were primary, and 25 (51%) were secondary (residual or recurrent disease) IP. Bilateral FS involvement was reported in eight cases (16.3%). Surgical approaches employed included endoscopic frontal sinusotomy (EFS) in 21 (42.9%), endoscopic modified Lothrop (EML) in 10 (20.4%), osteoplastic flap in 13 (26.5%), and endoscopic trephination and EFS in five (10.2%) patients. The overall rate of recurrence was 22.4%. Mean follow-up time was 27 months. The recent reported literature of FS IP demonstrates high prevalence of recurrent and bilateral cases. Although statistical analysis of this accrued data is unable to delineate the best surgical approach for FS IP, more aggressive approaches frequently employed for secondary or bilateral disease may facilitate better disease control.