Osteoplastic Frontal Sinusotomy Research Articles

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.

Intraoperative surgical navigation for endoscopic sinus surgery: rationale and indications

The present review discusses the rationale and indications for image-guided surgery through a critical discussion of registration concepts as well as clinical reports. The surgical navigation accuracy achieved by commercially available image-guided surgery systems is best reported as target registration error. Clinically achievable target registration error is probably in the 1.5-2.0 mm range. Dry lab studies of registration serve to highlight the principles of registration, the process through which image-guided surgery systems calculate the one-to-one mapping relationship between the preoperative imaging data and the intraoperative surgical volume. Reports on image-guided surgery have highlighted its usefulness in primary and revision endoscopic sinus surgery, osteoplastic frontal sinusotomy, transsphenoidal hypophysectomy, endoscopic cerebrospinal fluid leak repair and endoscopic pterygomaxillary fossa biopsy. Both three-dimensional computed tomography angiography and computed tomography-magnetic resonance fusion images have been incorporated into IGS for advanced minimally invasive endoscopic skull base procedures. The American Academy of Otolaryngology-Head and Neck Surgery policy statement accurately summarizes the current consensus for image-guided surgery applications. Image-guided surgery has emerged as an important technology, which both general otolaryngologists and subspecialty rhinologists can employ for a wide variety of procedures.

Analysis of Different Surgical Approaches for the Treatment of Cerebrospinal Fluid Rhinorrhea

The current treatment method for cerebrospinal fluid (CSF) rhinorrhea is surgical repair of the fistula. The aim of this study was to analyse different surgical approaches used for the treatment of CSF rhinorrhea regarding several preoperative and postoperative variables to determine the optimal method in these patients. Patients' charts were retrospectively reviewed to get the required data. Twenty-six patients who underwent different types of surgical approach for the treatment of CSF rhinorrhea were included in the study. Patients who had extensive comminuted fractures of the anterior cranial base and additional brain injury besides CSF rhinorrhea, mostly as a result of gunshot injuries, underwent craniotomy (n = 14). Osteoplastic frontal sinusotomy was used in two patients with a dural defect located at the posterior wall of the frontal sinus. Uncomplicated CSF fistulas in ten patients, located at the anterior and posterior ethmoid roof and in the sphenoid sinus, were closed with an endonasal endoscopic approach. Postoperative success rate was higher (97 % for intracranial approach, 100 % for extracranial external and endonasal endoscopic approach) for all techniques. Anosmia was the most frequent permanent complication (n = 5), seen after craniotomy. In conclusion, endonasal endoscopic approach can be preferred for the closure of uncomplicated CSF fistula, located at the anterior or posterior ethmoid roof and in the sphenoid sinus, due to its minimal postoperative morbidity. Uncomplicated CSF fistula, located at the posterior wall of frontal sinuses can be repaired extradurally with osteoplastic frontal sinusotomy. Intracranial approaches should be reserved for more complicated CSF rhinorrhea which results from extensive comminuted fractures of the anterior cranial base and is accompanied with intracranial complications.

Image-Guided Osteoplastic Frontal Sinusotomy

A 6-ft Caldwell radiograph template and transillumination, typically, are used to elucidate the frontal sinus outline for osteoplastic frontal sinusotomy (OFS). These techniques can be fraught with imprecision. The consequences of imprecise OFS may result in significant complications. Computer-aided surgery may offer a safe and accurate alternative to these techniques in selected cases. Several disadvantages were noted with early computer-aided assistance. Current infrared and electromagnetic systems have eliminated many of these disadvantages. We describe our technique and experience with an infrared image-guidance system (The LandmarX Evolution; Medtronic Xomed, Jacksonville, FL) to create a precise OFS that maximizes exposure while minimizing morbidity. We describe the use of an infrared image guidance system, the LandmarX Evolution for OFS in three cases. The LandmarX Evolution allowed for accurate placement of the OFS in each of the three cases and successful treatment of two symptomatic frontal sinus osteomas and a recurrent inverted papilloma. No complications were encountered. Image-guided OFS results in a confident and accurate entry into the frontal sinus. Image-guided OFS creation should be considered for select cases (i.e., complete opacification and altered anatomy) where performing an OFS by standard techniques may increase the complication rate. More experience with the technique and increased accessibility to image-guided equipment must be made possible before establishing this technique as a standard.

Frontal Sinus Obliteration

Osteoplastic frontal sinusotomy with obliteration was popularized by Goodale and Montgomery in the 1950s and has been considered the gold standard procedure for the surgical management of frontal sinus disease for many years. However, with advancements in functional endoscopic sinus surgery since the mid 1980s, the role of this operation has been questioned. Goodale and Montgomery in 1958 and Hardy and Montgomery in their subsequent review article describe the results of osteoplastic frontal sinusotomy with fat obliteration in 250 patients. Abnormalities included chronic frontal rhinosinusitis, frontal sinus mucocele, frontal sinus fractures, and complicated acute frontal rhinosinusitis. Patients were evaluated clinically using plain radiography and early-generation computed tomography. In the last 20 years numerous articles have been written about the endoscopic management of frontal sinus disease. Technology and instrumentation have advanced to the point that the frontal sinus can be accessed successfully and with minimal morbidity via transnasal endoscopic approaches. The purpose of this article is to examine the role of osteoplastic frontal sinusotomy with obliteration as the treatment of frontal sinus abnormality in an age of minimally invasive functional endoscopic sinus surgery. The pros and cons of this procedure will be presented, and reasonable indications will be outlined. A comprehensive description of anatomy is beyond the scope of this article. However, a brief review of frontal sinus anatomy is useful to understand the anatomic effects of inflammatory disease processes and the importance of appropriate choice of surgical approach to the frontal sinus. Unfortunately, the term nasofrontal duct continues to appear in the literature when in fact no such duct exists anatomically. Early anatomists recognized this long before the endoscopic era. The drainage from the frontal sinus is variable and at times difficult to ascertain, even with mutliplanar imaging, but most simplistically can be thought of in terms of the “frontal sinus outflow tract” (FSOT). The FSOT resembles an hourglass on sagittal view and includes the frontal sinus infundibulum, frontal sinus ostium, and frontal recess. Each of these areas can be affected by the varied pneumatization patterns of the ethmoid sinus, and each, if compromised, can lead to obstruction of outflow from the frontal sinus and secondary inflammatory disease. For example, an osteoma in the frontal sinus infundibulum may eventually obstruct outflow from the frontal sinus. The patient may develop a mucocele, mucopyocele, acute frontal rhinosinusitis with osteomyelitis (Pott puffy tumor), or chronic frontal rhinosinusitis. A large obstructing agger nasi cell or type I/II frontal cell can lead to the same scenarios by obstructing the frontal recess. In each of these clinical situations, however, the problem is not with the frontal sinus primarily but with obstruction of drainage within the FSOT.

Modern concepts of frontal sinus surgery.

To validate the endonasal surgical approach to frontal sinus in inflammatory sinus disease, trauma, and selective tumor surgery, and to define the role of external approaches to the frontal sinus. Endonasal frontal sinusotomy can range from endoscopic removal of obstructing frontal recess cells or uncinate process to the more complex unilateral or bilateral removal of the frontal sinus floor as described in the Draf II-III drainage procedures. In contrast, the osteoplastic frontal sinusotomy remains the "gold standard" for external approaches to frontal sinus disease. A retrospective review of 1286 patients undergoing either endonasal or external frontal sinusotomy by the authors at four university teaching programs from 1977. Prior author reports were updated and previously unreported patient series were combined. Six hundred thirty-five patients underwent type I frontal sinusotomy, 312 type II sinusotomy, and 156 type III sinusotomy. A successful result was seen in these groups, 85.2% to 99.3%, 79% to 93.3%, and 91.5% to 95%, respectively. External frontal sinusotomy or osteoplastic frontal sinusotomy was successfully performed in 187 of 194 patients. Clinical symptoms, endoscopic findings, computed tomography, and magnetic resonance image scanning, and reoperation rate measured postoperative success. A stepwise approach to the surgical treatment of frontal sinusitis, trauma, and selective benign tumors yields successful results as defined by specific criteria which vary from 79% to 97.8%. The details of specific techniques are discussed, essential points emphasized, and author variations noted.

Functional and esthetic results of osteoplastic frontal sinus operations and profile reconstruction with bitemporal coronal incision

The majority of inflammatory frontal sinus diseases requiring operative intervention can now be managed successfully by endonasal surgery. In problematic cases, however, optimal exposure of the entire frontal sinus and possibly complete mucous membrane removal combined with sinus obliteration must be achieved. In these cases, external frontal sinus surgery is indicated. The operative approach and findings of 35 osteoplastic sinusotomy operations and 5 forehead reconstruction operations with porous polyethylene are reviewed. Median follow-up was 3.7 years, ranging from 1 to 7 years. Indications for surgery were trauma (12), infections (8), tumors (11), muco- or pyoceles (4), and frontal deformities (5). The overall functional and esthetic result was excellent. No recurrent infection was noted. None of the patients have required revision surgery so far, and no serious complications occurred. Abnormal forehead sensation was reported by 12 patients (30%). Temporary double vision was described in 3 cases (7.5%). Due to optimal sinus exposure and advantageous incision, osteoplastic frontal sinusotomy leads to excellent functional and esthetic results. Porous polyethylene demonstrates superior material properties and seems to be, in comparison with other implants, the current material of choice in frontal reconstruction.

Extracranial Repair of Cerebrospinal Fluid Fistulas: Technique and Results in 37 Patients

Although neurosurgeons have traditionally preferred intracranial repair for the management of cerebrospinal fluid (CSF) fistulas, this approach is associated with the complications of a craniotomy, anosmia, and a high incidence of recurrent fistulas. Extracranial repair, on the other hand, produces no central nervous system morbidity, preserves olfaction, and is associated with a low incidence of recurrence. Although there have been several reports of extracranial repair of CSF fistulas by otorhinolaryngologists, this approach has received scant mention in the neurosurgical literature. We report here our experience with 37 patients with CSF rhinorrhea or otorrhea who underwent extracranial repair. The etiology of the fistula was postoperative in 22, traumatic in 6, and spontaneous in 9. The fistulas were repaired using one of four techniques: external ethmoid-sphenoid in 18 patients, transmastoid in 9, transseptosphenoid in 7, and osteoplastic frontal sinusotomy in 3. In 32 of the 37 patients (86%) the fistulas were successfully repaired with the initial procedure. Of the 5 patients requiring a second operation, the fistula was successfully closed in 4 for an overall success rate of 97%. Complications were few and consisted of a transient facial paresis in a patient undergoing transmastoid repair and one death from meningitis. The authors conclude that because of low morbidity and mortality and a high success rate in closing fistulas, extracranial repair is the preferred technique for the operative management of CSF rhinorrhea and otorrhea.

Transillumination during osteoplastic frontal sinusotomy.

Transillumination during osteoplastic frontal sinusotomy.

The use of synthetic implant material in osteoplastic frontal sinusotomy.

The use of homologous fat in obliterating frontal sinus operations has proved to be a satisfactory technique. It does entail, however, a separate procedure to obtain the graft. Furthermore, the implanted fat has a tendency to shrink or absorb in varying degrees. Proplast has been used in a series of osteoplastic frontal sinus operations. The implant block is a highly porous preparation of Teflon fluorocarbon polymer and vitrous carbon fibers. It can be easily carved into desired shapes or it may be implanted in peices. The porosity of the substance permits in-growth of connective tissue. Eight obliterating frontal sinus procedures using the osteoplastic flap technique and implanting the synthetic material are reported. There have been no failures to date after 1 to 5 years follow-up.

Anterior table frontal sinus fractures.

Frontal sinus fractures cover a spectrum of injury. A series of 52 primarily treated patients from the University of Cincinnati Medical Center is presented. Initial systematic management was applied to these patients and consisted of complete radiographic evaluation supplemented by wound care and cosmetic restoration when needed. All patients were followed on a long-term basis; both clinically and radiographically. Results to date are that 49 patients have had an uneventful post-traumatic course with re-establishment of normal sinus aeration. From the cosmetic standpoint no contour revisions have been needed and only two patients required elective scar revision. Three patients developed chronic suppurative sinus disease within the first post-traumatic year which was readily diagnosed and managed without complication by osteoplastic frontal sinusotomy and adipose obliteration.

Osteoplastic frontal sinusotomy: an analysis of 250 operations.

The operative approach and findings of 250 osteoplastic frontal sinusotomy operations performed from 1956 through 1972 at the Massachusetts Eye and Ear Infirmary are reviewed. Indications for surgery were symptomatic and/or complicated disease of the frontal sinus, including primary chronic sinusitis and osteoma or trauma with or without associated infection. Immediate postoperative complications were minor. Follow-up of at least three years was obtained in 83% of the patients, and 93% of these have no significant symptoms to date. A distressing problem of persistent postoperative frontal pain is discussed in detail. Revision surgery has been performed in 6% of patients due to recurrent frontal sinus infection. The reasons for failure are anlyzed, and recommendations are made to minimize the possibility of recurrence.

Osteoplastic frontal sinusotomy for the removal of osteomata of the frontal sinuses.

Osteoplastic frontal sinusotomy for the removal of osteomata of the frontal sinuses.