Frontal Outflow Tract Research Articles

Growth rate, impact of smoking and management of incidentally found paranasal sinus osteomas

ObjectiveTo build upon existing literature regarding growth rate of asymptomatic, incidentally found paranasal sinus (PNS) osteomas, evaluate potential factors associated with growth rate and present an argument for how to follow up. MethodsAt our institution, EPIC SlicerDicer was used to screen imaging studies using keyword ‘osteoma’ and included patients with at least 2 imaging studies 6 months apart that both demonstrated a PNS osteoma(s). Imaging studies with the largest time interval were selected. Non-PNS osteomas were excluded. Results47 patients that fit this criterion with a median duration of interval imaging of 35.9 months. Growth rate was measured to be 0.39 mm/year in the cephalocaudal direction and 0.45 mm/year in the mediolateral direction, together averaging 0.42 mm/year. Increases in growth rate additionally did not appear to impact the likelihood of developing conditions including nasal polyposis or chronic sinusitis and symptoms such as sinus pressure, headache, postnasal drip, or congestion. Those with interval scans >36 months were found to have a slower growth rate than those with closer interval scans. Furthermore, former smokers and current smokers had significantly greater growth rates than nonsmokers. ConclusionGiven their slow growth rate, we conclude that select lesions likely do not require follow-up. If there is concern that growth could cause an obstructive complication, such as blocking the frontal outflow tract, we argue a single scan at one year is appropriate. If there is additional growth on this scan, surveillance scans up to 3 years could be performed to assess stability. Lastly, while there was a significant growth rate for smokers compared to non-smokers, the slow growth rate is unlikely to influence management.

Prolonged Implantation of Sinus Devices and Implications for Chronic Rhinosinusitis: A Case Report and Review of the Literature.

Implantation of sinus stents and spacers can be used as adjuvant management to maintain patency of sinuses after endoscopic sinus surgery for chronic rhinosinusitis. These implants are typically removed several weeks after surgery. We present two cases of different patients who were initially treated by different physicians and were found to have retained sinus spacers in their paranasal sinuses 6-10 years after implantation. Case 1: a 40-year old male with chronic rhinosinusitis and history of balloon sinuplasty six years prior presented with worsening symptoms of chronic rhinosinusitis refractory to medical management. He underwent revision functional endoscopic sinus surgery and was found to have retained sinus implants in the left and right frontal sinus recesses. Case 2: a 48-year-old female with long-standing chronic rhinosinusitis refractory to medical management presented after two prior sinus surgeries most recently 10 years ago. She underwent revision functional endoscopic surgery and was found to have a retained sinus implant from prior surgery in the right frontal recess outflow tract embedded within scar tissue and reactive hyperostosis. Foreign bodies from both patients were removed without complication and patients were healing appropriately in the post-operative period. While sinus stents and spacers can help with post-operative scarring, leaving then unmonitored and in place will eventually result in them becoming a nidus for scarring and infection. It is critical that patients are aware of any foreign bodies we place, if they need scheduled removal or routine observation, and what symptoms may indicate that they are causing a problem.

Management of Frontal Sinus Fractures.

Fractures of the frontal sinus occur from extreme forces and are often associated with other injuries. Management of frontal sinus fractures is variable and dependent on involvement of the anterior table, posterior table, and frontal outflow tract. Severe complications can developed from poorly managed fractures, such as meningitis, mucocele, mucopyocele, and brain abscess. Surgeons should be aware of appropriate management and surgical techniques for addressing frontal sinus fractures. Herein, we review the presentation and management of frontal sinus fractures, including conservative, endoscopic, and open surgical techniques.

Compartmentalization: An Open Technique for Frontal Sinus Repair and Preservation-Description of Technique and Early Case Series.

Background Cranialization or obliteration is widely accepted intervention for traumatic or intentional breach of the frontal sinus. These techniques, however, result in the loss of frontal sinus function and have a persistent risk of cerebrospinal fluid (CSF) leak and mucocele. Compartmentalization is an open technique for repair of the frontal sinus using allograft onlay and a vascularized periosteal flap that allows for preservation of frontal sinus function. Objective The main objective of this article is to describe the technique for compartmentalization of the frontal sinus and demonstrate its efficacy and complication rate with an early patient series. Methods Our technique includes the following key components: harvesting of a pedicled periosteal flap, frontal sinus repair through a bifrontal craniotomy with minimal mucosa removal, ensuring the patency of the nasal frontal outflow tract, and separation of the brain from the frontal sinus with a dual layer of periosteum and allograft. All cases of frontal sinus repair using the compartmentalization technique at our institution were reviewed. Charts were reviewed for CSF leak, mucocele, and other complications. Results Twenty-three patients underwent the described frontal sinus repair technique 17 for tumor and 6 for trauma. There were no CSF leaks and no mucoceles. One patient experienced postoperative anemia and a "parameningeal reaction" that were managed with a short course of antibiotics. Conclusions Compartmentalization, due to its sinus preservation and low complication rate, represents a meaningful step forward in neurosurgical technique for open frontal sinus repair. However, long-term outcomes are necessary to fully evaluate risk of mucocele.

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.

Transnasal frontal intersinus septum takedown for frontal sinus pyocele

IntroductionThe open frontal intersinus septum takedown (FISST) technique was first described in 1976. We describe our experience with an endoscopic transnasal approach to manage a frontal sinus pyocele arising from an obstructed frontal sinus outflow tract due to anterolateral thigh flap reconstruction of a maxillectomy defect. Case reportA 40-year-old lady experienced upper eyelid swelling and purulent nasal discharge 3 weeks after undergoing a left extended medial maxillectomy with free anterolateral thigh flap reconstruction. A computed tomography (CT) scan revealed total opacification of the left frontal sinus. There was no improvement with intravenous antibiotics and she underwent a surgery, whenshe was found intraoperatively to have a frontal sinus pyocele, which was then drained. She then underwent an endoscopic transnasal FISST to ventilate the left frontal sinus via the contralateral frontal recess with good results. A CT scan performed 3 months postoperatively showed a widely patent interfrontal sinus septal window and right frontal outflow tract with no disease recurrence. DiscussionThe FISST is a useful technique to manage unilateral frontal sinus disease by taking advantage of the contralateral outflow tract when the ipsilateral frontal recess is obstructed.

The Bifurcated Frontal Sinus.

ObjectivesFrontal sinus anatomy is complex, and multiple variations of ethmoid pneumatization have been described that affect the frontal outflow tract. In addition, the lumen proper of the frontal sinus may exist as 2 separate parallel cavities that share an ipsilateral outflow tract. This variant has not been previously described and may have implications for surgical management.Study DesignCase series.SettingTertiary rhinology practice.Subjects and MethodsCases with radiographic and intraoperative findings of separate parallel tracts within a unilateral frontal sinus were identified from a consecutive series of 186 patients who underwent endoscopic sinus surgery between May 2015 and July 2016. Data were recorded including sinusitis phenotype, coexisting frontal cells, and extent of surgery.ResultsTen patients (5.4%) were identified with computed tomography scans demonstrating bifurcation of the frontal sinus into distinct medial and lateral lumens. All cases were treated with Draf 2a or 2b frontal sinusotomy with partial removal of the common wall to create a unified ipsilateral frontal ostium. Eleven sides had a coexisting ipsilateral agger nasi cell, 7 had a supra-agger cell, 8 had a suprabullar cell, and 1 had a frontal septal cell. There were no significant complications.ConclusionThe bifurcated frontal sinus is an anatomic variant that the surgeon should recognize to optimize surgical outcomes. Failure to do so may result in incomplete clearance of the sinus and residual disease. The bifurcated sinus may occur with other types of frontal sinus cells and may be safely treated with endoscopic techniques.

Virtual Mapping of the Frontal Recess: Guiding Safe and Efficient Frontal Sinus Surgery.

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Frontal sinus fractures with suspected outflow tract obstruction: A new approach for sinus preservation

ObjectiveThe description of a new approach for the management of patients with frontal sinus fractures and associated obstruction of the frontal outflow tract to, restore sinus function and avoiding sinus obliteration. Subjects and methodsIn a prospective study, 21 patients with anterior wall frontal sinus fractures associated with potential obstruction of the frontal outflow tract, underwent rigid internal fixation and intraoperative guarded nasal endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. Patients were followed up clinically and radiologically by CT to assess the status of the frontal sinus and to detect any manifestations of frontal sinusitis or any other complications. ResultsSeventeen patients completed the postoperative follow-up while four patients were excluded from the study. Postoperative follow-up ranged from 6 to 34 months with a mean of 20 months. All patients had associated craniofacial fractures. Follow-up CT scans showed complete restoration of frontal sinus ventilation and mucociliary clearance for 13 patients. Four patients showed frontal sinus mild mucosal thickening without signs of chronic sinusitis. ConclusionPatients with anterior wall frontal sinus fractures associated with frontal sinus outflow tract obstruction could be successfully managed with rigid internal fixation and intraoperative guarded endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. This type of management could increase the chance of frontal sinus preservation and decrease the need for frontal sinus obliteration for similar patients.

Modified cranialization and secondary cranioplasty for frontal sinus infection after craniotomy: technical note.

Frontal sinus infection after incorrect treatment of an opened frontal sinus may require extended approaches. This article aims to introduce modified cranialization technique and secondary cranioplasty for frontal sinus infection involving the frontal sinus outflow tract after craniotomy. Eight patients with delayed onset frontal sinus infection involving frontal outflow tract after craniotomy were treated from 2008 to 2012. Debridement and cranialization involving the elimination of the frontal outflow tract was performed. Unilateral sinus cranialization combined with reduction of the non-affected contralateral sinus was carried out for the patients with unilateral sinusitis. A pericranial-frontalis muscle flap was used to separate the intracranial and extracranial spaces. Secondary cranioplasty with hydroxyapatite was performed approximately 3 months after the cranialization. The patients’ original conditions included brain tumors (n = 3), frontal sinus fractures (n = 2), and subarachnoid hemorrhage (n = 3). The mean interval between the initial treatment and the onset of sinus infection was 23 years. The frontal sinus infection was bilateral in six cases and unilateral in two cases. Frontal sinus outflow tract was involved in sinus infection in every case. None of the patients suffered recurrent rhinogenic infections within the follow-up period (mean = 35 months) after the secondary cranioplasty. Aesthetic results were satisfactory in every case. Modified cranialization involving elimination of the frontal outflow tract is an alternative method for the patients with pathology in the frontal outflow tract after frontal craniotomy. Secondary cranioplasty provides an esthetically pleasing appearance in such cases.

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.

Current advances in sinus preservation for the management of frontal sinus fractures

This review summarizes the current advances in sinus preservation techniques with endoscopic sinus surgery for the well tolerated and effective management of frontal sinus fractures. Advances in computed tomography (CT) imaging can now reproduce higher quality reformatted images, creating excellent diagnostic coronal, axial, and sagittal image views that provide a better evaluation of the frontal sinus outflow tracts (FSOTs). The FSOTs are pivotal in determining which technique is used in the management of frontal sinus fractures. Several recent studies have proposed sinus preservation protocols using endoscopic management of the frontal outflow tract as a viable alternative to frontal sinus obliteration. Among those protocols, extended endoscopic sinus frontal surgery with reconstruction of the frontal outflow tracts has been demonstrated to be well tolerated and effective. It can be used in conjunction with frontal sinus trephinations as well as to treat complications. Modified treatment protocols have been developed based on thorough clinical examination and CT imaging in an attempt to provide a practical and safe protocol for the management of frontal sinus injuries. Conservative care and sinus preservation with or without endoscopic surgery can be done in selected cases with good result. The importance of preserving the frontal sinus is gaining acceptance in the evidence-based literature.

Revision frontal sinusotomy using stepwise balloon dilation and powered instrumentation

To report a novel approach toward revision frontal sinusotomy using a technique of balloon dilation followed by the use of powered instrumentation. Case report. The frontal sinus outflow tract location was first confirmed with image guidance and then dilated with a balloon to address the soft tissue stenosis. Subsequently, the drill was introduced to accomplish a Draf 2B frontal sinusotomy. An advantage of initial balloon dilation of the frontal sinus outflow tract was to quickly address the soft tissue stenosis with minimal tissue trauma and therefore less bleeding. This subsequently enabled insertion and clear visualization of the entire drill bit within the inferior aspect of the frontal outflow tract. The increased visualization makes other instrumentation safer as well, and avoids relatively blind removal of scar tissue that could result in inadvertent entry into the orbit or skull base. We describe the utility of the balloon as a tool for revision frontal sinusotomy to efficiently and safely allow subsequent instrumentation of the frontal outflow tract with larger more aggressive instruments, such as the drill. We have found this to be a safe and effective technique provided proper preoperative patient selection and assessment for limiting factors.

Endoscopic Frontal Sinus Drillout for Recurrent Barotrauma: A Procedure to Save a Pilot's Career

Complete sphenoethmoidectomy with a Draf IIA frontal dissection is the standard of care surgical management for medically resistant diffuse recurrent sinus barotrauma. Surgical failures still occur with this technique mainly due to the propensity of the frontal outflow tract to stenose. Endoscopic frontal revisions are notoriously prone to failure and historically represented the only option for aircrew afflicted by this career-ending complication of surgery. The frontal sinus drillout or endoscopic modified Lothrop procedure (EMLP) offers a highly successful salvage surgery for postoperative frontal ostium stenosis and is particularly suited to the physiologic requirements of the aviator. A high-performance aircraft pilot developed frontal stenosis after extensive sinus surgery for recurrent sinus barotrauma. Multiple failed endoscopic attempts to rehabilitate his sinuses finally gave way to success using the EMLP. He was returned permanently to flight duty at 6 wk post-op. This case report represents the first published successful application of the modified endoscopic Lothrop procedure to a pilot with recurrent frontal sinus barotrauma.

Endoscopic frontal outflow tract obliteration for pneumocephalus after frontal sinus cranialization

Otolaryngology–Head and Neck SurgeryVolume 139, Issue 5 p. 735-737 Case Report Endoscopic Frontal Outflow Tract Obliteration for Pneumocephalus after Frontal Sinus Cranialization Raj Sindwani MD, FRCS, Corresponding Author Raj Sindwani MD, FRCS [email protected] Department of Otolaryngology-Head and Neck Surgery, St Louis University School of Medicine, St. Louis, MOCorresponding author: Raj Sindwani, MD, FRCS, Department of Otolaryngology-Head and Neck Surgery, St Louis University Hospital, 3635 Vista Ave, 6th Floor, FDT, St Louis, MO 63110. E-mail address: [email protected].Search for more papers by this author Raj Sindwani MD, FRCS, Corresponding Author Raj Sindwani MD, FRCS [email protected] Department of Otolaryngology-Head and Neck Surgery, St Louis University School of Medicine, St. Louis, MOCorresponding author: Raj Sindwani, MD, FRCS, Department of Otolaryngology-Head and Neck Surgery, St Louis University Hospital, 3635 Vista Ave, 6th Floor, FDT, St Louis, MO 63110. E-mail address: [email protected].Search for more papers by this author First published: 24 July 2018 https://doi.org/10.1016/j.otohns.2008.07.008Citations: 1AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume139, Issue5November 2008Pages 735-737 RelatedInformation

Frontal Sinus Posterior Table Fractures in a Goat

Objective The goal of this study was to investigate how patency of the nasofrontal outflow tract would affect the healing of the frontal sinus in the setting of displaced, posterior table fractures in the adult goat (Capra Hircus). Methods Posterior table fractures were created in 20 adult goats (Capra Hircus). The nasofrontal outflow tract was obstructed in 10 goats and left patent in 10. Gross, radiologic, and histological evaluation was carried out at 6 months post-operatively. Results All posterior table fractures healed without gross or radiological evidence of mucosal ingrowth. Obstruction of the nasofrontal outflow tract resulted in an increased rate of mucocele formation. Histological analysis did not reveal significant mucosal ingrowth in either group. Conclusions An occluded nasal frontal outflow tract leads to an increase rate in mucocele formation at 6 months. There is no gross or radiographic evidence that mucosal ingrowth into the posterior table occurs at 6 months. These findings would suggest that not all significantly displaced posterior table fractures need to be surgically addressed if the nasofrontal outflow tract is patent.

Frontal Sinus Posterior Table Fractures in a Goat

Problem The goal of this study was to investigate how patency of the nasofrontal outflow tract would affect the healing of the frontal sinus in the setting of displaced, posterior table fractures in the adult goat (Capra Hircus). Methods Prospective animal study. Posterior table fractures were created in twenty adult goats (Capra Hircus). The nasofrontal outflow tract was obstructed in 10 goats and left patent in 10. Gross, radiologic, and histological evaluation was carried out at six months post operatively. Results All posterior table fractures healed without gross or radiological evidence of mucosal ingrowth. Obstruction of the nasofrontal outflow tract resulted in an increased rate of mucocele formation. Histological analysis did not reveal significant mucosal ingrowth in either group. Conclusion An occluded nasal frontal outflow tract leads to an increase rate in mucocele formation at 6 months. There is no gross or radiographic evidence that mucosal ingrowth into the posterior table occurs at 6 months. These findings would suggest that not all significantly displaced posterior table fractures need to be surgically addressed if the nasofrontal outflow tract is patent. Significance Posterior frontal sinus table fracture treatment is based on poorly controlled animal studies from 30 years ago and small case series reports. Our aim in this study was to determine changes in the frontal sinus at 6 months after a displaced, comminuted frontal sinus fracture was created. We hope to provide evidence demonstrating that not all posterior table fractures need to be treated, especially if the nasofrontal outflow tract is intact.

Long-Term Results after Endoscopic Sinus Surgery Involving Frontal Recess Dissection

To assess long-term follow-up on a cohort of patients who underwent endoscopic frontal sinus surgery with identification and preservation of the natural frontal outflow tract. Retrospective chart review, telephone interview, and endoscopic evaluation on a previously studied cohort of patients at a university affiliated medical center. Two hundred patients who underwent endoscopic frontal sinus surgery were previously studied and reported after short-term (mean = 12.2 mo) follow-up. One hundred fifty-two (76%) patients were available for long-term (mean 72.3 mo) follow-up and assessment of subjective symptoms. Fifty-seven of 152 (37.5%) patients also had nasal endoscopy for evaluation of objective findings. The percentage of patients responding to telephone interview reporting overall improvement after surgery was 92.4%. Endoscopic assessment revealed patency of the frontal sinus in 67.6% of the patients after initial surgery. Thirteen additional patients had patent sinuses after revision procedures, bringing overall patency rate to 71.1%. We found statistically significant correlation of asthma and smoking and poor subjective and objective outcome. Long-term assessment of subjective and objective findings in our previously reported cohort of patients who underwent frontal sinus surgery indicates that the frontal sinus, similar to any other sinus, can be successfully treated surgically by preserving the natural frontal sinus outflow tract.

Outcomes of Frontal Mucocele Marsupialization: Endonasal and External Approaches

Frontal sinus mucoceles are known to undergo repeated recurrences, and the management of this disease constitutes a challenge regarding the ideal treatment. The aim of this study was to evaluate the postoperative results of the endoscopic ventilation approach in the treatment of frontal mucoceles. We retrospectively reviewed the charts of 24 subjects with mucocele who underwent endoscopic marsupialization. The preoperative characteristics of the frontal sinus on computed tomography scans were compared with the postoperative results. Postoperative endoscopic examination revealed in 15 nasal sides wide patency of the frontal outflow tract. The ostium was patent but had become slightly narrowed in nine nasal sides. Restenosis of the ostium was found in six cases. A membranous type of obstruction in the region of the frontal outflow tract was related to a better outcome.

Frontal sinus stents.

The formation of scar tissue, synechiae, or osteogenesis in the narrow frontal outflow tract after instrumentation of the frontal sinus has led to attempts to enlarge the frontal duct or stenting. Prospective pilot study. Sixty-four Freeman frontal sinus stents were used to maintain patency in 46 patients. Stents were inserted using an endoscopic technique in 26 sinuses containing polyps, 20 with pansinusitis, and 18 cavities with stenosis of the frontal duct. External incisions with frontal sinusotomy were required to remove the stenosis and insert the stent in nine sinuses. Polypoid degeneration, granulation, purulent drainage, and lateralization of the middle turbinate were encountered infrequently. Frontal obliteration was subsequently required in six sinuses. The Freeman frontal sinus stent prevented blockage of the outflow tract in patients who had removal of disease in the sinus or duct or treatment of frontal stenosis.