Interfrontal Sinus Research Articles

Silent sinus syndrome with interfrontal sinus retraction: A 3-case series using CARE methodology

IntroductionSilent sinus syndrome (SSS) is a rare entity, almost exclusively involving the maxillary sinus, frontal location being very rarely reported. The aim of the present study was to describe clinical and radiological characteristics and surgical treatment using the CARE methodology. ResultsOne woman and 2 men were referred for chronic unilateral frontal pain with imagery showing silent sinus syndrome. All showed partial or complete liquid opacification of the affected sinus associated with a thin interfrontal sinus (IFS) retracted toward the affected sinus. Functional endoscopic sinus surgery was performed in all cases, with good functional results. DiscussionWe describe 3 cases of SSS with IFS involvement. The frontal sinus wall seemed most vulnerable, probably most liable to be weakened by atelectasis. The study suggests that frontal SSS can be an etiology in chronic frontal sinusitis. Preoperative findings of IFS retraction are useful for surgical restoration of frontal sinus ventilation, relieving chronic pain and preventing complications.

History of frontal sinus surgery and current view of the problem. Part 1

Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.

3D CT stereoscopic imaging: observations of the frontal and anterior ethmoid sinuses development from birth to early adulthood

Objective: Our objective is to provide observations demonstrated with 3Dimensional Computed x-ray Stereoscopic Imaging (3DCTSI) in the evaluation of the anterior ethmoid and frontal sinus development from birth to age 18. Methods: This is a retrospective evaluation of patient’s CT studies performed over a fifteen-year period, reported as normal studies, and included 53 patients (142 sides) from birth to age 18. Results: At birth, there are two spaces covered by folds, the uncinate and bulla lamellae. The spaces communicate with the Middle Meatus (MM) through the emerging ethmoid infundibulum (EI) and the retrobulbar recess space (RBRS). In the first month after birth, an expansile and breakdown developmental phase blend and continue throughout the growth into the teenage years. The 3D images reveal dark lamellar structures, on the surface of the medial lamina papyracea as well as bridging the broken spatial outlines. The dark lamellae represent the mucosal lamina propria, in unossified lamellae and are the origin of permanent spatial walls. From ages 4 to 18 years, initially, the frontal recess (FR) and later the MM penetrate into the cancellous frontal bone creating the frontal Sinus (FS), the frontal septum (FS), Inter-Frontal Sinus Septal Cell (IFSSC), as well as the Fronto-Ethmoidal and Frontal Bulla Spaces. Conclusion: 3DCTSI is the first intuitive imaging modality to reveal the microanatomical development of the anterior ethmoid and frontal sinus anatomy.

Two Cases of Isolated Frontal Septal Cell Inflammation Treated with the Draf IIb Procedure

The frontal septal cell (FSC) is a medially based air cavity of the anterior ethmoid or the inferior frontal sinus, located in the interfrontal sinus septum. FSC pathologies are extremely rare although they are common frontal recess cells. We report on two patients with isolated FSC sinusitis presenting with frontal headache who were treated with Draf IIb endoscopic sinus surgery (ESS). Paranasal sinus computed tomography of the patients revealed a clear frontal sinus and FSC soft tissue density. The patients underwent a Draf IIb procedure through left-sided approach to treat FSC inflammation. After surgery, the patients no longer complained of headache, and the widened outflow tract was maintained without narrowing in endoscopic views during 2 years of follow-up. When a patient presents with continuous frontal headache, FSC inflammation should be considered. It can be successfully treated by Draf IIb ESS. (J Clinical Otolaryngol 2021;32:85-89)

Frontal Sinus Variations and Prevalence of Frontal Recess Cells among Adult Egyptians: Computerized Tomography Study

Abstract Background: The frontal sinus is often considered as the most challenging area to approach in Functional Endoscopic Sinus Surgery (FESS). Considerable variations in the shape, capacity and symmetry of frontal sinus have been reported. Aim of Study: To provide better understanding of frontal sinus morphometry and anatomical variations of specific frontal recess cells and their prevalence among adult Egyptians. Material and Methods: Coronal and sagittal CT scans of sixty adult persons of the Egyptian population (30 males and 30 females, assigned into Group 1; from 20 to 30 years, group 2; from 31 to 50 years and group 3; more than 50 years) were done to demonstrate the anatomy of the frontal sinus. Results: A statistically significant difference in the width of the right sinus between group 2 and group 3 was revealed. Eighty percent of frontal sinuses were asymmetrical. Agger nasi cell was the most common encountered frontal recess cell and mostly bilateraly presented. The second common was Interfrontal sinus septal cell (IFSC). Statistically significant association was found between Fronta Bullar Cell (FBC) and frontal cell type 4 (FC4) but no statistically significant differ-ence was found between males and females except for frontal cell type 3 (FC3) which was higher among females than males. Statistically significant positive correlation between A-P length of left FR and AP length of right FR was revealed, while no significant correlation was found between AP length and volume of ANC. Conclusion: Awareness of frontal sinus dimensions frontal recess cells variations among Egyptians should be taken in consideration in safe frontal endoscopic surgery.

Three-dimensional computed tomography analysis of frontoethmoidal cells: A critical evaluation of the International Frontal Sinus Anatomy Classification (IFAC).

Two major classifications of frontoethmoidal cells, Lee and Kuhn and the IFAC (International Frontal Sinus Anatomy Classification), distinguish anterior, posterior and medial cells. The European anatomical position paper includes also lateral cells. According to the IFAC, anterior cells push the frontal sinus drainage pathway (FSDP) medially, posteriorly or posteromedially. Posterior cells push the FSDP anteriorly. The only medial cell, pushing the FSDP laterally is the frontal septal cell, which is attached to or located in the interfrontal sinus septum. The aim of this study was to verify the IFAC and characterise cells, which are inconsistent with this classification. A radioanatomic analysis. Tertiary university hospital. One hundred and three Caucasian adult patients with no inflammatory changes in paranasal sinuses CT. Results of assessment of multiplanar reconstruction of thin slice CT. Two types of cells that cannot be classified using the IFAC were found: (a) Lateral cells extending between the skull base and the anterior buttress, pushing the FSDP anteromedially or medially, present in 34 (16.5%) of the sides, (b) Paramedian cells: medially based, not adjacent to the interfrontal septum, pushing the FSDP laterally and posteriorly, present in 33 (16%) of sides. Suprabulla cells and suprabulla frontal cells were found to push the FSDP in directions other than anterior 28% and 31% of the time respectively. Neglecting lateral and paramedian cells may lead to inconsistent results between radioanatomical studies and impede communication between surgeons. They should be included in existing classifications of frontoethmoidal cells.

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

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

A computed tomographic analysis of frontal recess cells in association with the development of frontal sinusitis

ObjectiveThis study was done to determine frontal recess anatomy cell variations and its association with frontal sinusitis. The incidence of frontal recess cells in the population, the presence of frontal recess cell variations in chronic rhinosinusitis and non-chronic rhinosinusitis and the association of frontal recess cell variation in the development of frontal sinusitis were also assessed. MethodsThis was an observational, retrospective cross-sectional study of computed tomography (CT) scan of paranasal sinus that had been performed on patients in Hospital Universiti Sains Malaysia and Hospital Sultanah Bahiyah done from January 2009 until December 2016. The presence of frontal recess cells variation was compared with other populations. ResultsA total of 312 sides from 156 patients’ CT scan images were analyzed. Left and right sinuses were considered individually. A total of 63 sides showed evidence of frontal sinusitis, 37 were male and 26 were female, whereas 249 sides were clear from frontal sinus disease. It was not much difference in mean age for frontal sinusitis patient (46.51±14.00) and patients without frontal sinusitis (48.73±16.44). The percentage was almost equal for CRS and non-CRS groups regardless of side and gender. In our study, the frontal recess cell such as agger nasi cell was found in almost all patients 98.1%, frontal ethmoidal cell type 1, type 2, type 3 and type 4 comprised of 28.8%, 31.1%, 14.4% and 0% respectively. Whereas, suprabullar cell can be seen in 40.3%, supraorbital ethmoid cells 16.7%, frontal bullar cell 33.0% and inter-frontal sinus septal cells 10.8%. There was a statistically significant association between the presence of frontal bullar cell and the development of frontal sinusitis (p value<0.001). ConclusionThe frontal recess cells variation in Malaysian subjects were almost similar to those reported in other Asian populations such as Japanese, Taiwanese, Chinese and Korean. Our study found that frontal bullar cells had a significant association with the development of frontal sinusitis than other frontal recess cells. The understanding of the frontal recess anatomical structures was very important as this would lead to a successful treatment of CRS and at the same time it helped the surgeon to have a better plan of endoscopic sinus surgery to prevent the disease recurrence and surgical complication.

Evaluation of the frontal recess cells with image-guided system

Objective:To investigate the value of image-guided system in identifying the frontal recess cells.Method:We collected 30 cases that underwent image-guided frontal sinus surgery from November 2014 to December 2015. These frontal recess cells were devided into 2 groups based upon their locations in the frontal sinus ostium. Group A consists of the agger nasi cells, type Ⅰfrontal cells, type Ⅱ frontal cells and suprabullar cells; group B consist of type Ⅲ frontal cells, type Ⅳ frontal cells, frontal bullar cells, interfrontal sinus septal cells and supraorbital ethmoid cells. Visual analogue scale (VAS) was used to evaluate the degree of demand of image guide system on the location of frontal recess cells, and then analyzed the value of image guided system on the frontal recess cells.Result:In all 30 patients the imageguided frontal sinus surgery was successfully completed.The demand degree of image-guided system on frontal recess cells by VAS was slight for the agger nasi cells, type Ⅰfrontal cells, type Ⅱ frontal cells and suprabullar cells; the demand degree was general for the frontal bullar cells and interfrontal sinus septal cells; the demand degree was obvious for type Ⅲ frontal cells, type Ⅳ frontal cells and supraorbital ethmoid cells. Frontal recess cells of group B were more depended on image guided system than those of group A, and the difference was signicant(P <0.01).Conclusion:Imageguided system is valuable in distinguishing for type Ⅲ frontal cells,type Ⅳ frontal cells supraorbital ethmoid cells and interfrontal sinus septal cells.Furthermore,it is significantly helpful for accurate removal of these frontal recess cells in endoscopic frontal sinus surgery.

Radiological Assessment of the Anatomy of Frontal Recess Cells and the Anterior Ethmoidal Artery.

It is necessary for the surgeon to be familiar with frontal recess anatomy during an endoscopic approach to the frontal sinuses. The aim of this study was to evaluate the prevalence of frontal recess cells in Japanese adults as well as the association between the frontal recess and the location of the anterior ethmoidal artery (AEA). The frontal recess cells and the AEAs were retrospectively evaluated in CT scans of the nasal and paranasal sinuses for 89 patients. The prevalence of agger nasi cells was 90.7%. The frequency of frontal cell types 1, 2, 3 and 4 was 28.8, 0.6, 2.6 and 0%, respectively. Suprabullar cells (SBCs) and frontal bullar cells (FBCs) were identified in 78/96 sides (81.3%) and 24/96 sides (24%), respectively. The prevalence of the medial group of frontal recess cells (interfrontal sinus septal cells) was 12.4%. In 42/61 sides (68.9%), the AEAs were located within the posterior margin of the SBCs or the FBCs. Therefore, SBCs, FBCs and the vertical portion of the middle turbinate are reliable landmarks for the identification of AEAs.

Frontal recess anatomy in Japanese subjects and its effect on the development of frontal sinusitis: Computed tomography analysis

BackgroundComprehensive understanding of frontal recess anatomy is essential for the successful treatment of patients with frontal sinus disease. This study was designed to determine the prevalence of specific frontal recess cells in Japanese subjects and the association of these cells with the development of frontal sinusitis.MethodsFrontal recess anatomy was analyzed using high-resolution spiral computed tomography images of paranasal sinuses from December 2008 through September 2011. The distribution of various frontal recess cells in patients with and without frontal sinusitis was compared by logistic regression analysis.ResultsA total of 150 patients met the criteria, and 300 sides were analyzed. Agger nasi cells were present in 88.0 % of sides; frontal cell types 1 (FC1), 2 (FC2), 3 (FC3), and 4 (FC4) were present in 37.0 %, 6.3 %, 4.3 %, and 1.3 %, respectively; supraorbital ethmoid cells in 6.0 %, suprabullar cells in 37.0 %, frontal bullar cells (FBC) in 7.0 %, and interfrontal sinus septal cells in 8.6 %. Multiple logistic regression analysis showed that the presence of FBCs was significantly associated with the development of frontal sinusitis (p = 0.043).ConclusionsThe frequencies of frontal recess cells in Japanese adult patients were similar to those reported for other East Asian adult populations, including Chinese, Korean, and Taiwanese. Anatomically, FBCs may show a greater association with the development of frontal sinusitis than other frontal recess cells.

Unilateral Transnasal Endoscopic approach to Frontal Sinuses: Draf IIc

For chronic sinusitis surgery, the Draf III approach provides a common median drainage pathway for bilateral frontal sinuses from orbit to orbit. The Draf IIb provides unilateral drainage from orbit to septum. In several cases, inclusion of the nasal and frontal sinus septum in a Draf IIb was advantageous without extension to the opposite frontal recess. The proposed nomenclature is Draf IIc. This study was designed to (1) develop a surgical option for chronic frontal sinusitis where access to one frontal recess is limited or unnecessary and (2) minimize unnecessary surgical manipulation of uninvolved areas. Revision endoscopic frontal sinus surgery was performed on two patients with persistent frontal sinus opacification. Surgery crossed midline including one frontal recess with resection of the superior nasal septum. The surgical result was assessed on endoscopy and computed tomography (CT). The postoperative course was unremarkable with relief of frontal pressure. Postoperative CT scan showed well-aerated frontal sinuses with a widely patent common drainage pathway. Postoperative nasal endoscopy revealed normal mucosa with no exposed bone or edema. The Draf IIc extends the Draf IIb across the midline, without including the opposite frontal recess. This can be accomplished most easily using an interfrontal sinus septal cell or an eccentric interfrontal sinus septum. The Draf IIc is a surgical option in cases of chronic or recalcitrant frontal sinus diseases, including unilateral or bilateral obstruction, where access to the ipsilateral frontal recess is limited or favorable anatomy allows drainage with reduced manipulation of an uninvolved side.

Pneumatization Pattern of the Frontal Recess: Relationship of the Anterior-to-Posterior Length of Frontal Isthmus and/or Frontal Recess with the Volume of Agger Nasi Cell

ObjectivesWe analyzed the pneumatization pattern of the frontal recess (FR) in a Korean population. We also determined the correlation between the volume of the agger nasi cell (ANC) and the anterior-to-posterior (A-P) length of the frontal isthmus (FI) and FR.MethodsMultiplanar paranasal sinus computed tomography (CT) images from 105 patients who underwent endoscopic sinus surgery were reviewed. The prevalence of frontal recess cells (FRCs), thickness of the frontal beak (FB), volume of the ANC, A-P length of the FI, and FR were evaluated.ResultsThe ANC was identified in 96% of the patients and frontal cells (FCs) in 32% (FC type 1, 24.2%; type 2, 4.2%; type 3, 3.1%; and type 4, 0%). The prevalences of frontal bullar, suprabullar, supraorbital ethmoidal, and interfrontal sinus septal cells were 10%, 7.8%, 3.6%, and 6.8%, respectively. The A-P lengths of the FR and FI were 10.1±3.1 and 8.4±2.9 mm, respectively. The thickness of the FB was 7.8±1.8 mm and the volume of the ANC averaged 394.1±240.5 mm3. The thickness of the FB did not correlate with the volume of the ANC. In contrast, the A-P length of the FI and FR were positively correlated with the volume of the ANC.ConclusionANCs and FCs were found in 96% and 32% of the cases in this series. FC type 4 was not seen. What appeared to be FC4 on conventional CT was identified as FBC from reconstructed parasagittal images. A large ANC increased the A-P length of the FI and FR, regardless of the thickness of the FB.

Initial Surgical Treatment for Chronic Frontal Sinusitis: A Pilot Study

The initial surgical treatment for chronic frontal sinusitis is not well defined. Our objective was to determine the effectiveness of anterior ethmoidectomy for chronic frontal sinusitis. Patients with chronic frontal sinusitis who underwent anterior ethmoidectomy as initial surgical treatment were reviewed. Data were collected from computed tomography scans with use of the Lund-Mackay scale. Data on demographics, comorbidities, management, postoperative recovery, and follow-up were collected. Seventy-seven patients representing 121 diseased frontal sinuses met the inclusion criteria. The respiratory comorbidities were asthma alone (8.3%), asthma and polyps (6.6%), aspirin triad (5.8%), and cystic fibrosis (0.8%). Nineteen of 121 frontal sinuses (15.7%) belonged to smokers. Fourteen of 121 frontal sinuses (11.5%) exhibited postoperative evidence of disease. Of these 14 frontal sinuses, 10 (8.3%) underwent revision surgery. Frontal sinuses of patients with aspirin triad, with both nasal polyposis and asthma, or with inter-frontal sinus septal cells were more likely to fail Draf I surgery (p < .05). Anterior ethmoidectomy for drainage of frontal sinuses appears to be effective initial surgical treatment for chronic frontal sinusitis. Patients with aspirin triad, both asthma and polyposis, or inter-frontal sinus septal cells are more likely to fail this procedure.

Resection of the interfrontal sinus septum in chronic or recurrent frontal sinusitis. Pre- and post-operative evaluation of the naso-frontal duct.

In 9 patients with recurrent attacks of acute or chronic frontal sinusitis, interfrontal sinus septum resection was performed. In 5 patients there was unilateral disease and in 4 bilateral. As all patients had previously had their frontal sinus trephined, pre- and post-operative naso-frontal duct function tests were performed. Pre-operatively, of 11 naso-frontal ducts tested (2 patients bilaterally) not one showed air flow on spontaneous respiration. Passage of air was obtained at forced inspiration and expiration in one patient and by Valsalva's manoeuvre in 6. No flow of air whatsoever was obtained in 4 of the ducts, whatever the method used. At follow-up performed 1-8 years post-operatively 7 out of the 9 patients had no frontal sinus problems. The remaining 2 patients, who both had nasal allergy, were improved. Post-operative testing of the 9 patients showed flow of air on spontaneous respiration in 4 patients, whereas 4 needed forced inspiration or expiration and only one patient Valsalva's manoeuvre. The sinus septum resection, which is very simple to perform, is a good alternative to more extensive frontal sinus surgery but may be of less value in patients with nasal allergy.

Diagrams (Lantern Slides) of Patients in Whom the Inter-Frontal Sinus Septum Has Been Deliberately Broken down by the Nasal Route so as to Ensure More Complete Lavage for Double Frontal Sinus Suppuration

Diagrams (Lantern Slides) of Patients in Whom the Inter-Frontal Sinus Septum Has Been Deliberately Broken down by the Nasal Route so as to Ensure More Complete Lavage for Double Frontal Sinus Suppuration