Frontal Sinus Stents Research Articles

Outcomes of Frontal Sinus Stenting With Steroid Impregnated Microsponge Versus Steroid-Eluting Implant.

Mometasone-eluting poly-L-lactide-coglycolide (MPLG) is available commercially for frontal sinus ostium (FSO) stenting. An alternative chitosan polymer-based drug delivery microsponge is also available at a lower cost per unit. To compare the outcomes of MPLG stents versus triamcinolone-impregnated chitosan polymer (TICP) microsponge in frontal sinus surgery. Patients who underwent endoscopic sinus surgery from December 2018 to February 2022 were reviewed to identify those with the intraoperative placement of TICP microsponge or MPLG stent in the FSO. FSO patency was evaluated by endoscopy at follow-up. Twenty-two-item sinonasal outcome test (SNOT-22) was also recorded, and complications were noted. A total of 68 subjects and 96 FSOs were treated. TICP was first used in August 2021 and MPLG in December 2018. MPLG placement in a Draf 3 cavity was excluded since TICP had not been used during Draf 3 procedure. Both cohorts (TICP 20 subjects, 35 FSOs; MPLG 26 subjects, 39 FSOs) had similar clinical characteristics. At a mean total follow-up of 249.2 days for TICP and 490.4 days for MPLG, FSO patency was 82.9% and 87.1%, respectively (P = .265). At an equivalent follow-up of 130.6 days in TICP and 154.0 days in MPLG, patency was 94.3% and 89.7%, respectively (P = .475). Both groups showed significant reductions in SNOT-22 (P < .001). MPLG demonstrated crusting within the FSO at 1 month (none in TICP). FSO patency for both stents was similar, although TICP had significantly lower costs per unit. Additional comparative trials may be helpful for guiding clinicians on the appropriate clinical situations for the use of these devices.

Frontal sinus stenting in endoscopic sinus surgery: the 10-year Oxford experience.

Frontal sinus stents have been introduced to reduce frontal sinus re-stenosis after surgery and to improve outcomes. This study was a retrospective analysis of 19 patients who had endoscopic sinus surgery with approach to the frontal sinus and insertion of a soft sinus stent. The frontal recess was patent in 78.9 per cent and stenosed in 21.1 per cent of patients; no completely closed recesses were observed. Mean follow up was 20.7 months, and time period of stenting was 9.8 months on average; complications were observed in 47.4 per cent of the patients, with post-operative sinonasal infection being the most common. In the authors' experience, indications for frontal sinus stenting include recalcitrant chronic rhinosinusitis after multiple functional endoscopic sinus surgeries (especially in chronic rhinosinusitis with nasal polyps), patients with history of important craniofacial surgery or trauma, and recurrent mucoceles. The stent was overall well tolerated as only minor complications were observed. Close clinical follow up is mandatory.

Balloon Sinuplasty and Stenting in the Management of Complex Frontal Sinus Outflow Tract Fractures.

Classical management of complex fractures involving the frontal sinus outflow tract (FSOT) favors obliteration or cranialization to avoid delayed complications. We aim to exhibit success with a novel application of balloon sinuplasty and frontal stenting in the management of complex injuries disrupting the FSOT, which might have otherwise required more invasive interventions. Retrospective review. Single institution, level 1 trauma center. Retrospective review of patients presenting to a level 1 trauma center with fractures involving the FSOT. Outcomes include patency of the FSOT on imaging and endoscopy, rate of complications, degree of residual tabular displacement, and need for revision surgery. Twenty-five patients met inclusion criteria, with complete FSOT obstruction seen in all cases on computed tomography. All patients underwent balloon sinuplasty with frontal sinus stenting; 48% underwent concurrent anterior table repair, and 36% open repair of nasoorbitoethmoidcomplexfractures. The mean follow-up length was 13.9 months, at which time 91.3% of patients demonstrated radiographic and endoscopic FSOT patency. No residual sinus opacification or pneumocephalus was observed. Balloon sinuplasty with frontal sinus stenting is a straightforward and minimally invasive technique that can create a safe sinus in complex fractures disrupting the FSOT while avoiding the need for more invasive procedures.

The use of modified Montgomery T-tubes as frontal sinus stents: how I do it.

Frontal sinus surgery is challenging as the frontal recess is prone to re-stenosis and there is subsequent occlusion of the frontal sinus outflow tract. In an attempt to maintain the frontal recess calibre and reduce frontal sinus re-stenosis, frontal sinus stents have been used with different materials and varying results. This paper presents the technique of using a modified Montgomery T-tube as a frontal sinus stent. The use of a soft, self-retaining and non-absorbable stent that can be used for stenting of the frontal sinus is described. Our technique is safe, effective, inexpensive and well tolerated.

The use of modified Silastic nasal splints as frontal sinus stents: a technical note

Endoscopic frontal sinus surgery is frequently complicated by post-operative stenosis and obstruction of the frontal sinus outflow tract, resulting in recurrent disease. Frontal sinus stents may help prevent re-occlusion of the frontal neo-ostia. This paper presents a simple and cost-effective approach to frontal sinus stenting using modified Silastic nasal splints. The current technique provides an effective, reliable and inexpensive method for achieving post-operative frontal sinus outflow tract patency.

Biodegradable nasal stents (MgF2 -coated Mg-2 wt %Nd alloy)-A long-term in vivo study.

Despite innovative surgical techniques and use of current frontal sinus stents from different materials, the problem of treatment failure with consecutive reoperation remains present. The aim of our study is to investigate biocompatibility, degradation kinetics, and functionality of a newly developed fluoride-coated magnesium-based nasal stent. A minipig anatomy of frontal sinus adapted design and an external surgical approach were developed and established. The functionality of the stents was evaluated endoscopically. The stent-tissue blocks were analysed after 90 and 180 days using microcomputed tomography (µ-CT), histology, scanning electron microscopy (SEM), and energy-dispersive X-ray spectroscopy (EDS). Functional evaluation revealed an unobstructed stent lumen in all cases. Histological analysis showed moderate mucosal hyperplasia with a mild, nonspecific inflammatory response, and nonosteoconductive effect. Rejection reactions or necrosis did not occur. The volumetric analysis of the stents showed 51% volume loss after 180 days. The EDS analysis did not detect any neodymium (Nd) in the mucosa or bone. The Mg-2 wt % Nd stents are a promising option when treating the narrow passages following paranasal sinus surgery. In particular, its good biocompatibility and good functionality facilitate the re-epithelization of these constricted passages. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 350-365, 2017.

A novel biodegradable frontal sinus stent (MgNd2): a long-term animal study.

The frontal sinus recess consists of anatomically narrow passages that are prone to stenosis in endonasal frontal sinus surgery for chronic sinus disease. Over the past 100years, diverse frontal sinus stents have been developed and evaluated in clinical and animal studies. However, superinfection, formation of granulations tissue, stent dislocation and late stenosis of the duct have remained challenges and subject of debate in the literature. Currently developed biodegradable materials, including rare earth-containing magnesium alloys are promising candidates for application as temporary implant materials. The Mg 2% wt Nd alloy (MgNd2) was used to design a nasal stent that fit the porcine anatomy. In the current study, we evaluate biocompatibility, biodegradation and functionality of a frontal sinus stent in 16 minipigs over 6months. Intraoperative endoscopy revealed free stent lumen in all cases. Blood examination and clinical examinations indicated no systematic or local inflammation signs. The histopathology and elements analysis showed a very good biocompatibility. The μ-computed tomography-based volumetric analysis showed substantial stent degradation within 6 months. Our MgNd2 based stent appears to be a promising, solid basis for the development of a frontal sinus stent for clinical use.

Safety and Efficacy of Frontal Sinus Stents: A Systematic Review

Objectives: Postsurgical stenosis of frontal sinus can be a challenging problem for the endoscopic sinus surgeon. Frontal sinus stents are often used in an attempt to maintain frontal outflow patency. The current study systematically reviews the literature to determine the safety and efficacy of frontal stents. Methods: The Pubmed, Google Scholar, and Cochrane databases were reviewed and studies evaluating the usage and reliability of frontal sinus stents were extracted based on defined inclusion criteria. Results: Eleven studies comprising a total of 192 patients met inclusion criteria and were evaluated for stent material, stenting duration, surgical techniques, patient outcomes, and complication. All studies were classified as level 4 evidence provided by the Oxford Center for Evidence Based Medicine. Multiple stent materials were used with varying duration. Complications were generally minor and included stent migration, pain, epistaxis, and infection. Frontal sinus patency following stent replacement varied from 71.4% to 100%, however, the efficacy of stent placement in maintaining frontal sinus patency could not be evaluated due to a lack of controlled studies. Conclusions: Current literature evaluating the use of frontal sinus stents is limited and comprised entirely of level 4 studies. The efficacy of frontal sinus stenting could not be accurately evaluated because of the small number of studies and variable outcome measures. Larger, high-quality studies are needed to support the use of stents in endoscopic surgery of frontal sinus.

A Modified Lacrimal Sac Implant for High-Risk Dacryocystorhinostomy

The reported 5% of patients with nasolacrimal duct obstruction who fail dacryocystorhinostomy likely include patients with severe mucosal disease or anatomical anomalies. The technique described herein avoids mucosal anastomosis and minimizes mucosal manipulation by inserting a permanent silicone conduit from the lacrimal sac into the nasal cavity. This retrospective review of 9 surgical cases was performed with institutional review board approval. Six patients underwent 9 surgeries (3 sequentially bilateral) for dacryocystitis. Two patients had Wegener granulomatosis, 1 had pemphigoid, 1 sarcoidosis, 1 Rosai-Dorfman disease, and 1 congenital choanal atresia with chronic neonatal dacryocystitis. In each case, a modified Rains sinus stent was inserted through an external lacrimal sac incision with the draining end positioned in the nasal cavity. Two patients underwent concurrent canalicular intubation with Guibor silicone stents to prevent internal punctum obstruction by the lacrimal sac implant. Recurrence of symptoms, patient comfort, and modified Rains stent stability and patency were evaluated. Mean follow up was 30 months (range 7-59 months). The modified Rains stent remained stable and patent in 7 of 9 cases, and symptoms resolved in 8 of 9 cases. In 1 patient with sarcoidosis, the modified Rains stent became repeatedly obstructed with nasal secretions and ultimately dislodged after intranasal manipulation by a physician unfamiliar with the surgery. In no other case did the patient experience recurrent infection, and in those cases, epiphora resolved entirely. In the patient with pemphigoid, one of the modified Rains stents extruded 6 months postoperatively, but his symptoms remained controlled. No adverse reaction to the implant material was seen. A Rains silicone frontal sinus stent can be modified for implantation into the lacrimal sac and can safely and effectively drain the lacrimal sac into the nose in patients with severe mucosal disease or anatomical anomalies. Additional study and a stent specifically designed for this application will likely improve outcomes.

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.

Frontal sinus stenting techniques

Postoperative reocclusion or obstruction of the frontal sinus outflow tract are key factors in the failure of surgical efforts to treat frontal sinus disease. Stenting of the frontal sinus is a useful adjunctive measure for select patients, including those who have failed previous surgical treatment or who are deemed to be at high risk of failure due to unfavorable anatomy or mucosal disease. Multiple approaches to stenting of the frontal sinus are available, including purely endonasal techniques, a combined approach using both endonasal access to the frontal sinus and external trephination, and an external approach via modified Lynch (Neel-Lake) frontoethmoidectomy. Herein, we describe the surgical techniques for frontal sinus stent placement, review the options for choice of stenting material, and discuss key factors in postoperative management and stent maintenance.

Long-term stenting for chronic frontal sinus disease: case series and literature review

The frontal sinus outflow tract consists anatomically of narrow channels prone to stenosis. Following both endonasal and external approach surgery, up to 30 per cent of patients suffer post-operative re-stenosis of the frontal sinus outflow tract, with recurrent frontal sinus disease. This paper proposes the surgical placement of a long-term frontal sinus stent to maintain fronto-nasal patency, as an alternative to more aggressive surgical procedures such as frontal sinus obliteration and modified Lothrop procedures. We present a series of three patients with frontal sinus disease and significant co-morbidity, the latter making extensive surgery a significant health risk. We also review the relevant literature and discuss the use of long-term frontal sinus stenting. These three cases were successfully treated with long-term frontal sinus stenting. Stents remained in situ for a period ranging from 48 to over 60 months. Due to the relatively high failure rates for both endonasal and external frontal sinus surgery, with a high post-operative incidence of frontal sinus outflow tract re-stenosis, long-term stenting is a useful option in carefully selected patients.

Prolonged stenting of the frontal sinus

Stenting of the frontal sinus outflow tract is occasionally used following surgery to prevent stenosis. The optimal length of stent retention has not been defined and some experts advocate up to 6 months prior to removal. The tolerance of even longer periods of stenting is unknown. Retrospective review. We identified adult patients in a tertiary rhinology practice with frontal sinus stents placed between July 2000 and December 2006 and in place at least 6 months. Length of stenting and condition at last follow-up were determined. : During the 6-year study period, 10 frontal sinus stents were placed out of over 450 endoscopic frontal sinus surgery procedures. Each patient had only one stent placed. Of these 10 patients, one was excluded because the stent was electively removed at eight weeks. None of the remaining nine has been lost to follow-up. The mean length of stenting was 32.6 months (median 17, range 11 to 73). One patient had the stent removed at 61 months because of infection. Another had the stent removed at 11 months because of pain and edema. The remaining seven patients remain asymptomatic with patent stents and no granulation tissue seen on nasal endoscopy. In this group, long-term frontal stenting was rarely used but relatively well tolerated with only two of nine patients requiring removal up to 6 years after placement. With the optimal length for frontal stenting unknown, risks and benefits of removal at each evaluation point must be weighed.

Pilot study using doxycycline‐releasing stents to ameliorate postoperative healing quality after sinus surgery

Poor postoperative healing after sinus surgery is associated with high concentrations of matrix metalloproteinase-9 (MMP-9). The frontal recess is especially vulnerable to restenosis, and frontal sinus stents have been used to overcome this problem. However, the long-term success rate is still controversial and may be poor. In this perspective, we developed doxycycline (DC)-releasing stents, delivering the MMP-9 synthesis-suppressing agent locally to the frontal recess area. We evaluated postoperative MMP-9 levels, bacterial colonization, healing quality, and symptom scores in patients suffering from chronic rhinosinusitis with (CRSwNP) and without nasal polyposis (CRSsNP) (n=10) who underwent functional endoscopic sinus surgery during which the DC-releasing and placebo stents were placed. We found that MMP-9 concentrations were significantly lower at the side of the DC-releasing stent (3,414+/-582 ng/mL) compared with the contralateral placebo stent (9,172+/-2,564 ng/mL) (p<0.05) at month 3 postsurgery. DC stents adequately suppressed bacterial growth compared with placebo stents. Furthermore, the visual analog scale (VAS) for the frontal region was significantly better (mean value 75.1 vs. 52.8, p<0.001) compared with its placebo counterpart. We conclude that compared with placebo stents, DC-releasing stents significantly lowered MMP-9 concentrations and bacterial colonization locally, and improved postoperative healing quality after functional endoscopic sinus surgery, as demonstrated by visual analog scale and ostial closure.

Effectiveness of Intraoperative Mitomycin C in Maintaining the Patency of a Frontal Sinusotomy: A Preliminary Report of a Double-Blind Randomized Placebo-Controlled Trial

Postoperative scarring in the frontal recess is the most common cause of iatrogenic frontal sinusitis. Topical mitomycin-C (MMC) is an antifibroblastic agent that has been shown to reduce clinical scarring. This is a preliminary report of a double-blind, randomized, placebo-controlled trial using MMC to determine its effectiveness in reducing frontal recess stenosis after frontal sinusotomy. All patients with chronic rhinosinusitis undergoing primary or revision bilateral image-guided endoscopic sinus surgery were enrolled. Patients requiring frontal sinus stents and those with allergic fungal sinusitis were excluded. After completion of the frontal sinusotomy, dimensions of the frontal recess were measured using curved Frazer suction diameters. A neuropattie soaked in 0.5 mg/mL of MMC was then placed into one frontal recess for 4 minutes in a randomized manner. A saline control was used for the other side. The primary surgeon was blinded to the medicated side intraoperatively and throughout the follow-up period. Measurements of the frontal recess were repeated at 1, 3, and 6 months. There was no difference in the degree of frontal recess stenosis between the MMC and control sides at 1, 3, and 6 months postoperatively for both primary and revision cases. One-time intraoperative topical MMC is not effective in reducing postoperative frontal recess stenosis in both primary and revision cases.

Evidence of Bacterial Biofilms on Frontal Recess Stents in Patients with Chronic Rhinosinusitis

Bacterial biofilms have been documented on middle ear mucosa, tonsils, and cholesteatoma. We hypothesize that bacterial biofilms are present in mucosa of patients with chronic sinusitis. We believe that frontal sinus stents may serve as a reservoir for biofilms. We studied silicone frontal sinus stents removed from six patients 1 to 4 weeks after FESS with scanning electron microscopy (SEM). We identified evidence of bacterial biofilms on the frontal recess stents in six of six patients under SEM. Five of these patients had sinus cultures positive for Staphylococcus aureus. Bacterial biofilms were identified by evidence of glycocalyx, water channels, and three-dimensional structure. These images were similar to other images of known biofilms. This is evidence of the possible presence of bacterial biofilms on frontal sinus stents in patients with chronic sinusitis. Further study into the role of bacterial biofilms in perpetuating chronic sinusitis is warranted.

A Preliminary Report on the Effects of Paclitaxel-Impregnated Stents on Sheep Nasal Mucosa

Traditional frontal sinus stents serve only as mechanical devices. It has been proposed that stents also may serve as drug-delivery systems for the topical application of drugs that minimize postoperative scarring. Paclitaxel (Taxol), which has recognized antiscarring effects, may be incorporated via a polymeric formulation into standard rubber stents. The impact of topically applied paclitaxel on the morphology of the nasal mucosa is unknown. An adult sheep model was used for this study. A modified rubber T-tube stent (incorporating paclitaxel at varying dosages) was secured to each side of the septum in four animals (eight sides). An unmodified T-tube was placed on each side of one animal, a T-tube with the drug carrier (but no paclitaxel) was placed on each side of the second animal, and T-tubes with varying paclitaxel were placed on each side of the final two animals. After 4 weeks, animals were killed and the nasal mucosa was harvested. The nasal mucosa was sectioned and stained with hematoxylin and eosin. A pathologist then assessed the nasal mucosa for vascular congestion, glandular atrophy, chronic inflammation, mucosal metaplasia, and mucosal ulceration. No consistent histopathological differences were noted in the specimens. All specimens showed varying degrees of vascular congestion, glandular atrophy, chronic inflammation, and mucosal metaplasia; the paclitaxel-impregnated stents were not consistently associated with more severe mucosal injury. Finally, mucosal ulceration was noted to be very rare in all specimens. This preliminary report describes the impact of paclitaxel-impregnated stents on sheep nasal mucosa, which tolerated these stents very well. Because paclitaxel minimizes scarring reactions at very low concentrations, paclitaxel-impregnated stents may prove useful in clinical situations in which frontal sinus stenting is deemed necessary. Additional investigations with animal models, as well as clinical trials, may be warranted.

Toxic shock syndrome associated with frontal sinus stents

Toxic shock syndrome associated with frontal sinus stents

Frontal sinus stenting

Recurrence of frontal sinusitis following external and endoscopic intranasal drainage procedures has been and is presently a challenge to rhinologic surgeons. The complexity of the anatomy, especially with regard to size of the newly created frontal neo-ostium, directly influences long-term success. Frontal sinus stenting is indicated if the neo-ostium is less than 5 mm. Other important factors include excessive denuded bone, remnants of osteitic bone in the frontal recess, and severe mucosal disease as seen in allergic fungal sinusitis and nonallergic eosinophilic rhinitis. Lateralization of the middle turbinate and excessive removal of the middle turbinate have also been associated with recurrent frontal sinus disease. This article reviews previous frontal sinus stenting techniques and introduces a new soft self-retaining frontal sinus stent designed for endoscopic insertion.

A simple and effective frontal sinus stent.

We describe a frontal sinus stent which is cheap, easily produced and effective.