Endoscopic Frontal Sinusotomy Research Articles

Long‐term results after primary frontal sinus surgery

The objectives of this study were to evaluate the long-term frontal ostium patency rate and symptom improvement in patients undergoing primary endoscopic frontal sinusotomy (Draf 2A) and to assess the impact of patient factors, disease factors, and frontal ostium size on surgical outcomes. Retrospective chart review was used. Endoscopic assessment of frontal ostium patency and patient-reported symptoms were prospectively collected on patients who underwent primary frontal sinusotomy between January 2003 and December 2009. A total of 109 patients underwent primary endoscopic surgery on 210 frontal sinuses over the study period. The overall patency rate was 92%. Complete resolution of symptoms was noted in 85 patients (78%). Stenosis of the frontal sinus ostium correlated significantly with persistence of symptoms, infection, or polyp recurrence (p = 0.0066), and frontal ostium size (p < 0.03). No significant correlation could be found between the presence of eosinophilic mucin, asthma, polyposis, and smoking on patency or resolution of symptoms. To our knowledge, this is the largest study of primary endoscopic frontal sinus surgery in the literature. The technical and subjective measures of success are high. Frontal ostium size correlates with risk of stenosis of the frontal sinus. Patients with a stenosed frontal ostium and residual frontal sinus disease are more likely to be symptomatic or have endoscopic evidence of polyp recurrence or endoscopic evidence of persistent infection. Asthma, eosinophilic mucin chronic rhinosinusitis (EMCRS), allergy, and smoking do not appear to affect outcomes.

The Draf III Mucosal Grafting Technique

The Draf III procedure is an advanced surgical option for frontal sinus disease refractory to endoscopic frontal sinusotomy and is used to expose the anterior limit of resection of the skull base during endoscopic management of anterior skull base tumors. Our objective was to evaluate outcomes of a strategy using mucosal grafts to decrease postoperative closure. Prospective cohort. Tertiary care facility. Patients requiring a Draf III procedure were prospectively enrolled in the study. Demographics, reason for the procedure, percentage graft viability, and complications were recorded. The primary outcome measure was anterior-posterior (AP) diameter at 3 months. Mucosal grafting was performed during 29 Draf III procedures from 2008 to 2011. Twenty-seven patients (average age, 58 years) were available for measurement at 3 months (average postoperative follow-up, 15.4 months; range, 3-30 months). Reasons for the procedure included tumor (n = 14), chronic rhinosinusitis (CRS) with frontal ostium stenosis (n = 12), and trauma (n = 1). Average intraoperative AP diameter was 11.7 mm. All patients met the definition of success (<50% reduction in diameter), maintaining a patent combined frontal sinus ostium for the duration of follow-up (average diameter 10.8 mm at 3 months). Nine patients with CRS and frontal ostium stenosis had openings similar to the entire cohort (>1-year follow-up; average, 19.3 months) with significant symptom reduction (SNOT-22 preop 62.3 ± 20.8 vs 3 months 27.8 ± 14.8 and 1 year 21.4 ± 13.6; P < .0001). Cicatricial stenosis and osteoneogenesis are common following the Draf III procedure. This study indicates that the use of mucosal grafts may assist with postoperative stenosis and should be considered a routine strategy for preventing closure.

Selecting the Best Approach to the Frontal Sinus

The Messerklinger technique is an endoscopic approach to sinus surgery designed to be minimally invasive and preserve mucosa and hence physiological function. More recently there have been advocates for more radical endoscopic approaches to the frontal sinus such as the Modified Lothrop. This review discusses different approaches to frontal sinus surgery including any advantages and disadvantages to each approach. After examining the evidence from the literature, meticulously performed endoscopic frontal sinusotomy with or without computer guidance appears to be the most effective minimally invasive procedure for treating chronic frontal sinusitis secondary to outflow tract obstruction. Properly performed, it is almost always effective in dealing with even the most diseased frontal sinus. It offers clear advantages in reducing complications and recurrence rates in frontal sinus disease, even for revision cases.

Endoscopic frontal sinusotomy—Preventing recurrence or a route to revision?

The Messerklinger technique is an endoscopic approach to sinus surgery designed to be minimally invasive and preserve mucosa and therefore physiological function. More recently there have been advocates for more radical endoscopic approaches to the frontal sinus such as the modified Lothrop procedure. This study aims to determine the effectiveness of endoscopic frontal sinusotomy in preventing recurrent frontal sinus disease and the need for any revision frontal sinus surgery. Retrospective data review. A retrospective review of the chronic rhinosinusitis database at St. Paul's Sinus Centre was performed, randomly selecting 200 patients who had undergone primary bilateral functional endoscopic sinus surgery between 2000 and 2009. Any endoscopic or radiological recurrences listed on the database were counted along with the number of cases returned to theater for revision surgery. The preoperative Lund-Mackay score was also extracted from the database. In the 200 patients who had undergone their primary surgery at St. Paul's Hospital, the recurrence rate of frontal sinus disease was 19%, with less than one half (8%) requiring revision surgery. The Lund-Mackay scores showed no correlation between disease severity and the incidence of recurrence (P = .35), and there was no difference between polyp and nonpolyp forms of chronic rhinosinusitis (P = .14). A comparison with 100 patients in the database who had received their primary surgery at another center showed that the revision patients had a recurrence rate of 34% and a revision rate of 21%. The patients who did not receive surgical revision were treated satisfactorily with topical medications in the outpatient clinic. Meticulously performed endoscopic frontal sinusotomy with computer guidance appears to be an effective minimally invasive procedure to treat chronic frontal sinusitis secondary to outflow tract obstruction. Properly performed, it is effective in dealing with the most diseased frontal sinus. It offers clear advantages in reducing complications and recurrence rates in frontal sinus disease even in revision cases.

Recurrent Pott's puffy tumor – atypical presentation of a rare disorder

We report the case of a 14-year-old girl who presented with an 8-week history of unilateral pansinusitis. In the course of the disease a right-side frontal swelling was observed, which disappeared following antibiotic treatment. Four weeks later, however, the swelling reappeared and was now diagnosed as recurrent Pott's puffy tumor. Interestingly, C-reactive protein levels were in the normal range throughout. Following functional endoscopic frontal sinusotomy, antibiotic treatment with ceftriaxone was administered over 3 weeks and led to complete remission of the lesion. Pott's puffy tumor is a subperiostal abscess of the frontal bone, usually presenting as localized swelling of the soft tissue in the overlying region of the forehead, and is associated with localized osteomyelitis and occasionally with intracranial epidural abscess. The entity has been known since 1768, although recurrent cases with normal inflammation parameters have not been published previously.

Long‐term frontal sinus patency after endoscopic frontal sinusotomy

The frontal recess is the drainage pathway that connects the frontal sinus to the anterior ethmoid sinus. Mechanical obstruction is the primary cause of chronic frontal sinusitis with or without a secondary inflammatory process. Eosinophilic inflammation is one of the underlying causes for chronic rhinosinusitis. OBJECTIVES/HYPHOTHESIS: To evaluate long-term frontal sinus patency after endoscopic frontal sinusotomy in chronic rhinosinusitis patients and to assess the effect of eosinophilic inflammation on frontal sinus patency. Retrospective chart review. Symptom assessment and archived endoscopic photographs were prospectively collected on patients who underwent frontal sinusotomy between 7-1-1999 and 12-31-2000. Subjective symptom improvements were evaluated using the SNOT-20 = 20-item Sino-Nasal Outcome Test. Objective findings of endoscopic frontal sinus patency were documented by archived digital photography. A total of 161 patients with 294 frontal sinuses who underwent endoscopic frontal sinus surgery in the 18 months had an average follow-up of 45.9 months. The patient population was divided into two groups: 58 patients had eosinophilic CRS (ECRS), and 103 patients had CRS without eosinophils (non-ECRS). The mean follow-up for patients with ECRS is 61.6 months and 37.0 months for non-ECRS patients. The non-ECRS patients had a documented endoscopic frontal sinus patency of 90%, and the ECRS patients had an endoscopic frontal sinus patency of 85%. The overall frontal ostium patency rate for all patients was 88.0%. Long-term endoscopic confirmation of frontal ostium patency demonstrates that endoscopic frontal sinusotomy can yield high quality, durable results. There was no significant difference in patency results between ECRS and non-ECRS patients. Laryngoscope, 2009.

Frontal Sinus Inverted Papilloma: Surgical Strategy Based on the Site of Attachment

The surgical management of inverted papilloma (IP) involving the frontal sinus (FS) remains a challenge given the narrow confines of the frontal recess and the close proximity to critical structures. The objective of this study was to elucidate a surgical strategy for management of frontal sinus IP based on the site of attachment. A retrospective chart review was performed on 18 patients with FS IP treated at the Pusan National University Hospital and the Cleveland Clinic Foundation between 1998 and 2008. The mean age was 53.8 years with a male/female ratio of 13:5. The sites of tumor attachment included the medial wall (MW; six cases), posterior wall (PW; five cases), diffuse (all walls involved; five cases), intersinus septal cell (three cases), lateral wall (two cases), and anterior wall (two cases). IP involvement was unifocal in 10 cases and multifocal in 8 cases. Unifocal IP attached to the MW or PW was managed strictly by endoscopic frontal sinusotomy (EFS) in five of six cases (83%). Multifocal IP required endoscopic modified Lothrop (EML) and/or open approaches (endoscopic frontal trephination [EFT], four, osteoplastic flap [OPF], one) in seven of eight cases (88%). One additional patient with bilateral anterior table involvement required OPF. Four (22%) patients developed recurrences. Two were managed by EML, one was managed by EFS, and one was managed by EFT and EFS. Two patients developed cerebrospinal fluid leaks that were managed endoscopically without untoward effects. All patients were free of disease at the time of last evaluation with a mean follow-up of 36.6 months. Frontal sinus IP with MW or PW involvement can generally be managed by standard EFS. Tumors with multifocal involvement often require EML, along with adjunct EFT in selected cases. OPF can be avoided as the primary surgical approach in most patients with sinonasal papilloma of FS.

Comprehensive Management of Failed Frontal Sinus Obliteration

Treatment of patients with failed frontal sinus (FS) obliteration (FSO) remains an important challenge in the endoscopic era. Advances in endoscopic techniques have facilitated the application of minimally invasive approaches for clinical scenarios that previously required open procedures. A retrospective chart review of patients presenting with failed FSO from January 1, 2001 to June 30, 2007 was performed. Seventeen patients (mean age, 52.8 years; 10 men and 7 women) presented at an average of 9.7 years from initial FSO. The most common primary presenting symptoms included headache (41.2%) and forehead swelling (23.5%). Seven patients had prior craniotomies and 10 patients had prior endoscopic sinus surgery. All patients underwent surgical exploration; revision procedures were required in 5 patients. Definitive procedures included endoscopic frontal sinusotomy (EFS; 10 patients), endoscopic frontal drill-out (3 patients), revision osteoplastic frontal sinusotomy with obliteration reversal (2 patients), and repeat FSO (2 patients). One patient required revision EFS twice. Initial intraoperative findings included mucocele (13 cases), bone wax (3 cases), fibrous tissue (2 cases), and polypoid mucosa (1 case). All patients had resolution or improvement of their primary presenting signs/symptoms. All FSO reversal patients achieved functional FS patency documented by endoscopy and/or CT scan with mean follow-up of 9.5 months (range, 1.5-30.8 months). Operative exploration should be considered in all patients with persistent or recurrent symptoms and/or signs of failed FSO. In most instances, repeat FSO can be avoided, and a minimally invasive endoscopic strategy can be used successfully.

Endoscopic management of the inverted papilloma with attachment to the frontal sinus drainage pathway

Conclusion. Extensive inverted papilloma (Krouse T3 lesions) with attachment to the frontal sinus drainage pathway can be treated successfully using an endoscopic approach. Objectives. The endoscopic management of inverted papilloma (IP) has gained in popularity over the last 15 years. However, the appropriate management of lesions involving the frontal sinus and its drainage pathway still has to be determined. Patients and methods. We performed a retrospective review of the results for patients with IP in the Otolaryngology, Head and Neck Surgery Department, Beijing Tongren Hospital from 2004 to 2007 to identify those patients with lesions involving the frontal sinus and its drainage pathway. By their appearance on nasal endoscopic examination and by computed tomography scanning, the tumors were defined using the Krouse staging system. Sinus endoscopy was used to screen for disease after endoscopic resection and the clinical outcomes were analyzed. Results. A total of nine patients (eight males and one female) were identified in which IP involved the frontal sinus and its drainage pathway. Preoperative and postoperative pathological examinations revealed IP as the diagnosis. All tumors were defined as T3 lesions. Four cases with lateral wall of frontal recess tumor attachment underwent an endoscopic Draf IIA frontal sinusotomy. Three cases with either lateral and posterior walls of frontal recess and frontal infundibulum attachment, or medial and posterior walls of frontal recess and frontal infundibulum attachment underwent a Draf IIB procedure. Two cases with posterior wall of frontal recess and frontal infundibulum attachment, or medial, lateral, and posterior walls of frontal recess and frontal infundibulum attachment underwent a Draf III procedure. All patients remain disease-free after an average follow-up period of 15 months.

Management of frontal sinus mucoceles with posterior table erosion in the pretransplant cystic fibrosis population

Background Chronic rhinosinusitis has been described as a universal finding in cystic fibrosis (CF). Much of the literature has focused on pediatric population with a relative paucity of data on adult CF patients. In this report, we review our experience with management of frontal sinus mucoceles with posterior table (PT) erosion diagnosed by imaging in asymptomatic adult CF patients presenting for pretransplant evaluation. Study design Retrospective chart analysis. Materials and methods Adult CF patients presenting with frontal sinus mucoceles from January 2003 to December 2005 comprised the focus of the study. Charts were reviewed for age, sex, clinical presentation, culture results, complications, and outcome. Results Fifty-nine CF patients undergoing lung transplant evaluation were seen in the outpatient rhinology clinic. Among these, 3 patients presented with asymptomatic frontal sinus mucoceles with PT erosion. The average age was 28.7 years (range, 23-38 years) and male-female ratio was 1:2. Two patients were managed with computer-aided endoscopic frontal sinusotomy during the pretransplant period. In the third patient, surgery was performed post transplantation when the patient was clinically stable. Intraoperative cultures grew Pseudomonas aeruginosa in all cases. No intraoperative surgical complications were encountered. One patient required overnight ventilatory support and was extubated successfully after 24 hours. Endoscopic patency of the frontal sinusotomy was confirmed at mean follow-up of 12.7 months (range, 4-22 months). Conclusions This preliminary report describes asymptomatic frontal sinus mucoceles with PT erosion in CF patients presenting for transplant evaluation. A high index suspicion must be maintained to avoid an inordinate delay in diagnosis given the potential risk of intracranial complications with this clinical entity.

Combined Endoscopic Trephination and Endoscopic Frontal Sinusotomy for Management of Complex Frontal Sinus Pathology

The advances in endoscopic sinus surgery have revolutionized the management of frontal sinus disease. Despite the successes, the purely endoscopic approach has its limitations, especially in patients with alterations in anatomy caused by previous surgical intervention or complex frontal sinus pneumatization patterns. The purpose of this study was to evaluate the efficacy of combined endoscopic trephination and endoscopic frontal sinusotomy (the above and below approach) in the management of these difficult cases. Chart review was performed on patients undergoing the combined approach from October 1999 to June 2004. Demographic data, symptomatology, comorbidity, previous surgery, and primary pathology were determined. Outcome was assessed based on subjective symptom relief and objective endoscopic patency. Twenty-two patients with a mean age of 49.2 years underwent the combined approach. The primary pathology included mucoceles (15 patients), frontal sinusitis (2 patients), inverted papilloma (2 patients), osteoma (1 patient), fibrous dysplasia (1 patient), and pneumocephalus (1 patient). A total of 25 above and below procedures (22 primary and 3 revision procedures) were performed to manage the pathology. Postoperatively, headaches resolved in 47%, improved in 35%, and remained unchanged in 18% of the patients. Orbital symptoms resolved in 63%, improved in 25%, and remained unchanged in 12% of the patients. Endoscopic patency of the frontal sinusotomy was confirmed in 19 of 22 cases (86%) at a mean follow-up of 16.2 months. Management of complex frontal sinus pathology may require adjunct approaches in conjunction to the standard endoscopic techniques. In this series, the above and below approach was used successfully in 22 patients. The combined approach may serve as an important adjunct for management of complex frontal sinus disease.

Factors associated with failure of frontal sinusotomy in the early follow-up period

Objectives To understand factors associated with failure of endoscopic frontal sinusotomy. Methods Retrospective review of 130 consecutive frontal sinusotomies. The preoperative extent of disease was graded radiologically in each frontal sinus as total opacification, partial opacification, or mucosal thickening. Records were also reviewed to determine the incidence of comorbid conditions. Results Patency at most recent follow-up was observed in 117/130 (90%). Patency was achieved after our first procedure in 107 sinusotomies. These were considered successes. Ten required revision surgery, and an additional 13 were not patent at last follow-up. These 23 sinusotomies were considered failures. Among those failing our initial surgery, 19/23 (83%) were partially or totally opacified preoperatively. In contrast, only 47/107 (44%) in the success group contained partial or total opacification preoperatively ( P = 0.003), with the majority exhibiting mucosal thickening only. Mean follow-up was 8.3 months for the successes and 10.7 months for the failures ( P = NS). No significant differences were observed between the success and failure groups with respect to the prevalence of asthma, aspirin sensitivity, or allergic fungal disease. Patients in the failure group, however, had a higher mean number of prior surgeries before undergoing frontal sinusotomy at our institution (1.8 vs 0.9, P = 0.033). Conclusions During the early follow-up period, failure of endoscopic frontal sinusotomy is associated with advanced degrees of preoperative disease within the sinus and is also more likely in patients who have failed prior surgical management.

Use of the 70-degree diamond burr in the management of complicated frontal sinus disease.

Management of frontal sinus disease may require drill-out of bone in the frontal recess for access, ventilation, and drainage of the sinus cavity; removal of osteitic foci; or resection of neoplastic tissue. Technological advances, particularly burrs with angles of 70 degrees and stereotactic navigational imaging, offer new opportunities to provide access and minimize trauma. The preliminary study evaluates the safety and efficacy of such minimally invasive approaches. Retrospective review. The authors describe the use of a 70-degree diamond burr in a series of 10 patients with complicated frontal sinus disease who underwent endoscopic frontal sinusotomy under stereotactic imaging guidance. The diagnoses consisted of frontal sinus mucocele (n = 4), chronic frontal sinusitis (n = 1), Pott's puffy tumor after frontoethmoid fracture (n = 1), and recurrent inverting papilloma (n = 4). Partial septectomy was required in 6 of 10 patients. No complications were attributable to the drill-out procedure, despite a pre-existing frontoethmoid bony dehiscence in 6 of 10 patients. One patient had a CSF leak during removal of tumor from the skull base. One patient required revision frontal sinusotomy 10 months after the initial procedure, and another required further surgery for residual inverting papilloma on the medial orbital wall. All frontal sinusotomies were patent at last follow-up (mean period, 9.3 mo). Extended endoscopic frontal sinusotomy may be necessary in the management of complicated frontal sinus inflammatory disease and inverting papilloma. The 70-degree diamond burr is a safe and effective tool for access to the frontal recess. Complication rates appear to be similar to those for other extended frontal sinusotomy approaches.

Revision endoscopic frontal sinus surgery.

Recurrent or persistent frontal sinus disease after endoscopic sinus surgery poses formidable challenges owing to the frontal sinus outflow tract's complex variable anatomy, close proximity to vital structures, and predilection for scarring and stenosis. Frontal sinus obliteration used to be the preferred technique of most sinus surgeons for addressing difficult frontal sinus disease; however, several effective endoscopic techniques exist as excellent alternative procedures for addressing this difficult clinical problem. Several endoscopic techniques have been described for addressing these problems including endoscopic frontal sinusotomy, the frontal sinus rescue procedure, endoscopic transseptal frontal sinusotomy, and the modified Lothrop procedure. Advances in treating recurrent frontal sinus disease have included recent articles reviewing the long-term outcomes of some of these techniques, the prevalence of frontal sinus cells, the optimization of medical management, and the spectrum of postoperative debridement regimens. When used in the appropriate setting, these less invasive revision endoscopic techniques provide excellent results with low morbidity and several advantages. This article reviews recent developments in the treatment of recurrent or persistent frontal sinus disease including incorporation of these techniques.

Endoscopic frontal sinusotomy using the suprainfundibular plate as a key landmark.

Endoscopic frontal sinusotomy using the suprainfundibular plate as a key landmark.

The five year experience with endoscopic trans-septal Frontal Sinusotomy

Endoscopic trans-septal frontal sinusotomy (TSFS) represents a unique surgical approach to the floor of the frontal sinus. Although the final result can have similarities to the modified Lothrop procedure in that the intersinus septum may be drilled out, endoscopic TSFS represents a novel approach that can be valuable in patients with certain anatomic configurations. Endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist to augment treatment of refractory frontal sinus disease. This procedure is best considered for patients with favorable anatomy who have significant frontal sinus disease and cannot be managed adequately through an endoscopic frontal sinusotomy.

Primary endoscopic management of the frontal sinus

Surgical treatment of the frontal sinus continues to be an area of much interest and controversy. The complex anatomy and confined space of this region require the endoscopic surgeon to be knowledgeable and delicate to obtain a positive result. Proper instrumentation is crucial and continues to evolve over time. Postoperative endoscopic care is integral to the success of endoscopic frontal sinusotomy and the availability of proper office equipment to perform this care is critical. In most instances, the intranasal endoscopic approach can be accomplished successfully without the need for an external procedure.

Revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement: The frontal sinus rescue procedure

Frontal sinusitis after middle turbinate resection occurs because of stenosis of the frontal ostium by soft tissue scarring or residual bony fragments (which are pulled to the medial orbital wall by scar contracture). Standard endoscopic techniques cannot address this problem; however, revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement (the frontal sinus rescue procedure) relieves this bony stenosis and incorporates a mucosal flap that minimizes postoperative stenosis.

The frontal sinus rescue procedure: early experience and three-year follow-up.

The frontal sinus rescue (FSR), first described in 1997, has now been performed on 24 patients (32 sides) over a period of three years. It is a functional endoscopic surgical approach to correct an iatrogenically scarred and obstructed frontal recess, which cannot be successfully opened via a normal endoscopic frontal sinusotomy approach. It is utilized primarily for patients whose only remaining option is either a Draf-type drill-out (modified intranasal Lothrop) procedure or frontal sinus obliteration. The FSR is a technically challenging procedure, but faster, less difficult, and less destructive for the patient than a "drill-out" or frontal sinus obliteration. Once learned, it can save the patient from undergoing the more radical drill-out or obliterative procedure. The early experience and three-year follow-up with this new endoscopic procedure is presented in our first 24 patients (32 sides).

Endoscopic trans-septal frontal sinusotomy: the rationale and results of an alternative technique.

Endoscopic transseptal frontal sinusotomy (TSFS) represents an alternate approach to surgical treatment of chronic frontal sinus disease that is refractory to traditional modes of medical and surgical therapy. We retrospectively reviewed our experience with endoscopic TSFS from 1995-1997. Twenty-one procedures were performed through a transseptal approach. One patient was excluded for failure to follow-up, for a total of 20 procedures. Patients were followed with serial endoscopic examinations and a telephone questionnaire with a mean follow-up of 12 months (Range 1-24 months) and 16 months (range 5-31), respectively. The primary indication for surgery was frontal recess stenosis after previous endoscopic frontal sinusotomy in 17/20 (85%). Three patients were considered poor candidates for a primary endoscopic frontal sinusotomy. Patency was maintained in all patients during the follow-up period. A diameter of greater than 3 mm was confirmed by passage of a curved suction in 19/20 (95%). Of the 19 patients that were evaluated via a telephone questionnaire, 17 patients (89.5%) reported some degree of improvement in their nasal/sinus symptoms, and 12/18 patients (67%) felt the frequency of medication requirements was less than that before undergoing endoscopic TSFS. We conclude that endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist, to augment treatment of refractory frontal sinus disease. This procedure seems especially suited for revision surgery in those patients with acquired frontal sinus stenosis. In revision operations with distorted anatomical landmarks, localization of the frontal sinus may be improved with the aid of 3-dimensional computer assisted localization systems. Unlike traditional frontal sinus obliteration, endoscopic TSFS does not preclude radiographic assessment postoperatively, and allows for endoscopic evaluation of the frontal sinus in the office setting.