Posterior Wall Of Frontal Sinus Research Articles

External Frontal Sinostomy to Drain Frontal Lobe Abscess

A case of frontal sinusitis with osteomyelitis of its posterior wall producing frontal lobe brain abscess is presented, whereby the posterior wall dehiscence was exposed by external sinostomy by an ENT surgeon and then, through the dehiscence, the abscess was drained by a neurosurgeon. This is an uncommon technique of draining a frontal lobe brain abscess where no frontal bone craniotomy was required. This approach yields the least damage to the cerebral tissue as the frontal abscess was very close to posterior wall of frontal sinus and drain has to travel through minimal intracerebral distance.

Arachnoid cyst with bony erosion of the posterior frontal sinus wall as cause of a subdural empyema after pansinusitis

Intracranial arachnoid cysts (AC) can lead to a bony thinning of the surrounding skull. We present a young man, in whom a frontal AC has caused a thinning of the frontal calvaria and of the posterior wall of the frontal sinus. This bony vulnerability allowed a frontal sinusitis to spread intracranially and finally led to a subdural empyema with neurological deterioration. The treatment consisted of an emergency craniotomy with evacuation of the empyema and appropriate antibiotic treatment of the causing pathogen (Streptococcus intermedius).

Results of Transcranial Resection of Olfactory Groove Meningiomas in Relation to Imaging-Based Case Selection Criteria for the Endoscopic Approach.

Endoscopic endonasal surgery (EES) is increasingly used for olfactory groove meningiomas (OGMs). The role of EES for large (≥4 cm) or complex OGMs is debated. Specific imaging features have been reported to affect the degree of gross total resection (GTR) and complications following EES for OGMs. The influence of these factors on transcranial resection (TCR) is unknown. To examine the impact of specific imaging features on outcome following TCR to provide a standard for large and endoscopically less favorable OGMs against which endoscopic outcomes can be compared. Retrospective study of patients undergoing TCR for OGMs 2002 to 2016. Fifty patients (mean age 62.1 yr, mean maximum tumor diameter 5.04 cm and average tumor volume of 48.8 cm3) were studied. Simpson grade 1 and 2 resections were achieved in 80% and 12%, respectively. A favorable functional outcome (modified Rankin Scale [mRS] 0-2) was attained in 86%. The degree of resection, mRS, mortality (4%), recurrence (6%), infection (8%), and cerebrospinal fluid leak requiring intervention (12%) were not associated with tumor calcification, absence of cortical cuff, T2 hyperintensity, tumor configuration, tumor extension beyond midpoint of superior orbital roof, or extension to posterior wall of frontal sinus. There was no difference in resection rates but a trend towards greater complications between 3 arbitrarily divided groups of large meningiomas of increasing complexity based on extensive extension or vascular adherence. Favorable outcomes can be achieved with TCR for large and complex OGMs Factors that may preclude endoscopic resection do not negatively affect outcome following TCR.

Endoscopic Endonasal Reconstruction of Anterior Skull Base Defects: What Factors Really Affect the Outcomes?

Endoscopic endonasal surgery has evolved in recent decades, requiring comparable advances in reconstructive techniques. This study aimed to retrospectively review outcomes of endoscopic anterior skull base reconstruction and to analyze factors associated with failures. Data from patients who underwent endoscopic endonasal anterior skull base reconstruction in a single institution between 1998 and 2017 were collected. Patients were stratified according to selected risk factors: sex; age; previous surgery; disease treated (cerebrospinal fluid leaks, benign tumors, malignant tumors); single or multiple defects; defect dimension (<1 cm2, 1-2 cm2, 2-6 cm2, >6 cm2) and site (olfactory cleft, ethmoidal roof, planum sphenoidalis, posterior wall of frontal sinus); reconstruction technique (overlay graft, multilayer grafts, pedicled flap) and materials used; postoperative radiotherapy; and year of surgery. Statistical significance was assessed using Fisher exact test. Univariate logistic regression was implemented to analyze the association between risk factors and failures. Inclusion criteria were met by 513 cases with median follow-up of 96 months (range, 12-257 months). Success rate for initial repair was 95% (487/513), with 100% success rate for secondary closure after revision surgery. Failures were not significantly related to sex (P= 0.54), reconstruction technique (P= 0.28), location of defect (P= 0.65), dimension (P= 0.69), disease (P= 0.83), or postoperative radiotherapy (P= 0.83). Year of surgery, considered as a continuous variable, was associated with a statistically significant reduction of failures (odds ratio=0.89, P= 0.005). Endoscopic surgery is safe and effective for anterior skull base reconstruction. Refinements in surgical technique and increasing experience have contributed to improved success rates.

Endoscopic Repairs of Sinonasal Cerebrospinal Leaks: Outcome and Prognostic Factors.

The aim of this study was to review the management of sinonasal cerebrospinal fluid (CSF) leaks and outcome of endoscopic repairs and to provide experience regarding leaks at the lateral wall of sphenoid sinus and the posterior wall of frontal sinus. Patients who underwent endoscopic repairs of CSF leaks were reviewed. Characteristics of different etiologies were compared, and prognostic factors were analyzed. The study included 144 patients with 150 CSF leaks, in which spontaneous leaks account for 55%. Patients with traumatic leaks were significantly younger than those with spontaneous leaks (P = 0.012), and most traumatic leaks occurred in men (P < 0.001). The computed tomography scan showed an overall accuracy of 86.7%. For 17 leaks at the lateral wall of sphenoid sinus, transnasal (29%), transethmoid (24%), and transpterygoid (47%) approaches were used, with a success rate of 75%. For 11 defects at the posterior wall of the frontal sinus, 2 were managed by draf III surgery, and 3 by trephination-assisted procedure successfully. Success rate for primary repair was 95.6%, reaching 100% after a second repairing. Six leaks failed to be repaired included 4 spontaneous leaks, and 3 occurred at the lateral wall of the sphenoid sinus, 4 occurred in patients with elevated body mass index (BMI), 4 had evidence of raised intracranial pressure (ICP). Repair of leaks at lateral sphenoid sinus and posterior frontal sinus could achieve favorable results via selected endoscopic approaches. The failure of repair was associated with inaccessible leak sites, spontaneous leaks, raised ICP, and elevated BMI.

Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma.

Sinonasal inverting papilloma (IP) is a benign but locally aggressive mucosal neoplasm with a high recurrence rate. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitofrontal approach for managing extensive IP. Case series. Four patients seen between 2012 and 2016 with biopsy-proven IP with lateral frontal sinus extension underwent a combined endonasal and transpalpebral approach for tumor resection. Patient demographic data, preoperative characteristics, imaging, and follow-up data were compiled through retrospective chart review. Patients were selected for this approach when the tumor extended to the posterior frontal sinus wall, lateral frontal sinus recess, and orbit. Tumors were first approached endonasally until the frontal recess was reached. A Draf IIB or Draf III procedure was then performed to gain better exposure. Orbitofrontal exposure was achieved through an upper eyelid incision. Miniorbitofrontal craniotomy window was designed based on tumor location. Resection of the frontal and orbital extension was enhanced by endoscopic-assisted dissection through the orbitofrontal window. The transpalpebral approach provided access to all walls of the ipsilateral frontal sinus, the intersinus septum, and the medial aspect of the contralateral sinus. Complete tumor resection was achieved in all patients. There were no orbital complications, no visible eyelid asymmetry or scarring, and all patients had preserved forehead sensation. There were no recurrences on follow-up. Combining a transpalpebral orbitofrontal craniotomy with the endonasal approach allows complete resection of invasive IP with extension into the frontal sinus. This is achieved with great cosmetic results. 4. Laryngoscope, 128:3-9, 2018.

Purely endoscopic pterional extradural approach: A novel technique for repair of cerebrospinal fluid rhinorrhea.

Study Design:Retrospective descriptive study of an innovative surgical technique.Objective:To assess the feasibility and success of repair of transfrontal sinus cerebrospinal fluid (CSF) rhinorrhea through pterional transcranial extradural approach using endoscope.Summary of Background Data:Repair of CSF rhinorrhea has seen advancement with the evolution of endoscopic transnasal techniques. However, leaks from defect in the posterior wall of frontal sinus still remain a challenge for the skull base surgeons and requires conventional craniotomy more often. We describe a novel technique to repair these leaks by purely endoscopic pterional extradural (PEPE) approach thereby avoiding complications associated with conventional craniotomy and endoscopic transnasal approaches.Materials and Methods:Thirty-five patients with traumatic CSF rhinorrhea from the posterior wall of frontal sinus underwent repair with the present technique. They were followed up for 6–18 months and were evaluated for feasibility of procedure, recurrence of leak, and occurrence of the fresh neurological deficit.Results:Thirty-five patients underwent CSF rhinorrhea repair using the above technique. The procedure was accomplished in all patients without any intraoperative complications. There was no requirement of blood transfusion in any case. All patients had a cessation of CSF leak in the postoperative period, and there was no recurrence. There was no evidence of frontal lobe retraction injury in any of these patients, and no fresh neurological deficit was observed.Conclusion:This PEPE approach to repair CSF leak through the posterior wall of the frontal sinus is a novel technique in which we can avoid disadvantages associated with both conventional craniotomy as well as transnasal endoscopic approaches.

Endoscopic Repair with Above and Below Technique of Recurrent Cerebrospinal Fluid Leak from the Posterior wall of Frontal Sinus: Case Report

Endoscopic Repair with Above and Below Technique of Recurrent Cerebrospinal Fluid Leak from the Posterior wall of Frontal Sinus: Case Report

Draf III Extension in the Endoscopic Endonasal Transethmoidal, Transcribriform Approach Through the Back Wall of the Frontal Sinus: A Cadaveric Study

The Draf III (modified endoscopic Lothrop) procedure has been proposed to extend the endonasal transethmoidal, transfovea ethmoidalis, and transcribriform approach through the back wall of the frontal sinus. The exposure is time-consuming and increases the risk of cerebrospinal fluid leak, and the indications for use are not well described. There are few data quantifying the advantage it conveys over the approach without the Draf III procedure. An endoscopic, endonasal transfovea, transcribriform approach was performed in 5 fresh, injected cadaveric heads. Anatomic boundaries and measurements of the exposure were compared before and after addition of a Draf III procedure. Computed tomography scans were performed before and after dissection, and additional radiographic measurements were made to quantify the additional exposure provided by the Draf III procedure. Also, 2 clinical cases are presented in which a Draf III procedure was used. The mean anterior to posterior boundary from the frontal sinus to the planum sphenoidale before the Draf III procedure was 3.0 cm and after the Draf III procedure was 3.8 cm with an average change of 0.8 cm. After the Draf III procedure, the mean anterior to posterior boundary from the posterior wall of frontal sinus to the planum sphenoidale increased from 3.0 cm to 4.3 cm. There was an average increase of 1.3 cm with an average increased area of view of 1.79 cm(2). This study quantifies the increased field of view provided by the Draf III procedure during anterior skull base dissection. Recommendations for preoperative examination of radiographic evidence are provided to help identify which individuals would benefit from the additional exposure.

Newly designed double-vascularized nasoseptal flap to prevent restenosis after endoscopic modified Lothrop procedure (Draf III): laboratory investigation

Despite advances in endoscopic approaches, instrumentations and imaging guidance systems, the management of frontal sinus is still challenging. Failure of the endoscopic procedure and restenosis of the newly formed ostium have been demonstrated even with large frontal sinusotomy. We describe a newly designed double nasoseptal flap to cover the bare bone after endoscopic modified Lothrop procedure (EMLP). Five fresh, double-injected cadavers were dissected through an endoscopic endonasal approach. Posteriorly based nasoseptal flap on one side and laterally based nasoseptal flap on the other side were harvested before performing wide EMLP. Feasibility of the procedure, versatility of the flap, coverage area and measurements were calculated. Harvesting the mucoperichondrial/mucoperiosteal flap over the septectomy site was straightforward step. Two different designed flaps (one on each side) are more practical to avoid torsion of the flap. The flap measures 2 × 3 cm on average that was able to cover the bare bone of the anterior and posterior wall of frontal sinus. Osteoneogenesis and progressive osteoplastic activity after EMLP plays a major role in restenosis of frontal sinus. Vascularized nasoseptal flap helps in preventing closure of the newly formed ostium. Applying these flaps over the bare bone enhances the healing process and minimizes the crust formation.

Anteriorly Based Inferior Turbinate Flap for Endoscopic Skull Base Reconstruction

In the absence of the nasal septal flap, there is limited ability to reconstruct the anterior skull base because of the paucity of alternative intranasal vascularized flaps. In this article, the authors describe the anteriorly pedicled inferior turbinate flap (AITF) as a method for endoscopic reconstruction of anterior skull base defects. A case series with chart review of the demographic, clinical, surgical, and early follow-up data of patients who underwent endoscopic reconstruction of skull base defects by the AITF. An academic cancer center. The nature of the arterial blood supply of the inferior turbinate from the anterior ethmoidal artery was exploited to design an anteriorly pedicled flap. Flap survival, adequacy of the seal, and rate of complications were assessed. Seven patients were suitable to undergo anterior skull base reconstruction using the AITF with or without combinations with other flaps. Each had a high-flow intraoperative cerebrospinal fluid (CSF) leak. The reconstruction achieved covering of the anterior skull base, including the frontal sinus and cribriform plate, with no postoperative CSF leaks or any other complications. The AITF is well tolerated and is associated with good outcomes. Its length and angle of rotation allow reconstruction of skull base defects in the posterior frontal sinus wall and cribriform plate, especially when traditional reconstruction techniques are not possible.

Recurrent meningitis associated with frontal sinus tuber encephalocele in a patient with tuberous sclerosis

Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder that commonly affects the CNS. The most commonly associated brain tumors include cortical tubers, subependymal nodules, and subependymal giant cell astrocytomas (SEGAs). The authors report an unusual case of recurrent meningitis due to a tuber-containing encephalocele via the posterior wall of the frontal sinus. An 11-year-old girl presented with a history of TSC and previous SEGA resection via interhemispheric approach. She presented twice within 4 months with classic bacterial meningitis. Cerebrospinal fluid cultures revealed Streptococcus pneumoniae. Computed tomography and MR imaging of the brain showed a right frontal sinus encephalocele via a posterior frontal sinus wall defect. Both episodes of meningitis were treated successfully with standard regimens of intravenous antibiotics. The neurosurgical service was consulted to discuss surgical options. Via a bicoronal incision, a right basal frontal craniotomy was performed. A large frontal encephalocele was encountered in the frontal sinus. The encephalocele was herniating through a bony defect of the posterior sinus wall. The encephalocele was ligated and resected followed by removing frontal sinus mucosa and complete cranialization of frontal sinus. Repair of the sinus floor was conducted with fat and pericranial grafts followed by CSF diversion via lumbar drain. Histopathology of the resected encephalocele showed a TSC tuber covered with respiratory (frontal sinus) mucosa. Tuber cells were diffusely positive for GFAP. The patient underwent follow-up for 2 years without evidence of recurrent meningitis or CSF rhinorrhea. This report demonstrates that frontal tubers of TSC can protrude into the frontal sinus as acquired encephaloceles and present with recurrent meningitis. To the authors' knowledge, recurrent meningitis is not known to coincide with TSC. Careful clinical and radiographic follow-up for frontal tubers in patients with TSC is recommended.

Fronto-ethmoidal fractures: A staging system and case series analysis

Background Fractures of fronto-ethmoidal bones (FEFs) are treated by a surgical team. A staging system for classifying FEFs is of paramount importance in order to plan surgery, to define prognosis and to exchange information among trauma centers. Some classifications are available but they are quite complex. Here a simple stage is proposed. Methods Five types of FEFs are possible: in situ FEF (without fragment dislocation, dura laceration or cerebrospinal fluid leak), type I (dislocated fracture involving the outer cortical bone, i.e. anterior frontal sinus wall), type II (dislocated fracture involving the inner cortical bone – i.e. posterior frontal sinus wall – and/or structures comprised in the diploe – i.e. the sinunasal tract), type III (dislocated FEF with dura laceration and cerebrospinal fluid leak), and type IV (i.e. comminuted fronto-ethmoid-orbital fractures). To evaluate the suitability of the proposed classification a retrospective study on a series of 42 patients was performed. Age, gender, stage, clinical diagnosis at admission, type of surgery and outcome were considered. Results A good correlation between the proposed classification and the studied variables was detected. Conclusions The proposed classification (that is a simplification of the Ioannides’ system) is a simple and precise method for staging FEFs. It can be used in daily practice. It is our understanding, however, that a multi-center study should be performed before the effectiveness of the proposed classification can be clearly stated.

Treatment of frontal sinus diseases via combined transfrontal and intranasal endoscopic approaches

To summarize the clinical experience of treatment of frontal sinus diseases via combined transfrontal and intranasal endoscopic approaches, and to explore its indications. A retrospective study of 24 patients was conducted. All patients were underwent combined transfrontal and intranasal double approaches because of different kinds of frontal sinus diseases, including 16 cases with frontal sinus cerebrospinal fluid rhinorrhea caused by traumatic comminuted fractures located in posterior wall of frontal sinus, 5 cases with osteoma, 3 cases with inverted papilloma (cancer was confirmed in one case). All sixteen cases with frontal sinus cerebrospinal fluid rhinorrhea were cured after the first attempt. All cases with osteoma and inverted papilloma (including the patient with canceration) were resected completely after the first attempt. Postoperative follow-up lasted from 3 to 132 months in frontal sinus cerebrospinal fluid rhinorrhea, 8-38 months in osteoma, 7-42 months in inverted papilloma and canceration, the median follow-up period was 36 months. No recurrence was found. Operations were successful in all the patients and frontal sinus outflow tracts were unobstructed. No intraoperative or postoperative complications occurred and no disfigurement was found. The potential indications for the combined transfrontal and intranasal endoscopic approaches are listed as follows, (1) frontal sinus lesions mainly located on the posterior wall, (2) propensity to recur or malignant neoplasms, (3) the lesions of frontal sinus with their lateral boundaries or operative site beyond the plane of the lamina papyracea.

Skull Base Reconstruction after Oncologic Resections

Material and Methods: In 109 patients, 120 anterior skull base resections of tumors (52 malignant [43%], 68 benign [57%]) via the subcranial approach were performed. Limited dural defects were closed primarily or reconstructed using a temporalis fascia. Large anterior skull base defects were reconstructed by a double-layer fascia lata graft. A split calvarial bone graft, posterior frontal sinus wall, or 3D titanium mesh was used when the tumor involved the frontal, nasal, or orbital bones respectively. A temporalis muscle flap was used to cover the orbital socket for cases of eye globe exenteration, and a rectus abdominis free flap was used for subcranial-orbitomaxillary resection. Pericranial flap wrapping of the frontonasal-orbital segment was performed to prevent osteoradionecrosis if perioperative radiotherapy was planned.

A Comprehensive Algorithm for Anterior Skull Base Reconstruction after Oncological Resections

To present our method for anterior skull base reconstruction after oncological resections. One hundred nine patients who had undergone 120 anterior skull base resections of tumors (52 malignant [43%], 68 benign [57%]) via the subcranial approach were studied. Limited dural defects were closed primarily or reconstructed using a temporalis fascia. Large anterior skull base defects were reconstructed by a double-layer fascia lata graft. A split calvarial bone graft, posterior frontal sinus wall, or three-dimensional titanium mesh were used when the tumor involved the frontal, nasal, or orbital bones. A temporalis muscle flap was used to cover the orbital socket for cases of eye globe exenteration, and a rectus abdominis free flap was used for subcranial-orbitomaxillary resection. Pericranial flap wrapping of the frontonaso-orbital segment was performed to prevent osteoradionecrosis if perioperative radiotherapy was planned. The incidence of cerebrospinal fluid (CSF) leak, intracranial infection, and tension pneumocephalus was 5%. Histopathological and immunohistochemical analysis of fascia lata grafts in reoperated patients (n = 7) revealed integration of vascularized fibrous tissue to the graft and local proliferation of a newly formed vascular layer embedding the fascial sheath. A double-layer fascial graft alone was adequate for preventing CSF leak, meningitis, tension pneumocephalus, and brain herniation. We describe a simple and effective method of anterior skull base reconstruction after resections of both malignant and benign tumors.

Volumineuse mucocèle frontale à extension orbito-palpébrale

A mucocele is an unusual benign cystic tumor, frequently seen in the adult and affecting mucous sinuses that expand the orbit by bone destruction. It is caused by a lack of sinus aeration; surgical treatment consists in cyst extirpation and sinus drainage. A 72-year-old man, without a history of sinus disease, presented a voluminous mucocele of the right frontal sinus that had begun 3 years before, with superior eyelid and orbit expansion hiding and pushing the eye to the downside and the outside. The cyst was surgically removed via the external approach without sinus drainage because of a lack of technical means resulting from the total destruction of the anterior and severe thinning of the posterior wall of the right frontal sinus with dura mater exposure. After surgery, the patient recovered visual function without diplopia, and normal eyelid and ocular motility. However, the right eye is abnormally sized a bit downside. A mucocele of the frontal sinuses can show major superior eyelid development with a low risk of trochlea injury during surgery, a possibility particularly if the destruction of the anterior wall of the frontal sinuses is opened ahead of the orbit septum. Sinus drainage was not undertaken for our patient because of the substantial destruction of the posterior wall of the frontal sinus, with a high risk of infection.

Posterior frontal sinus wall: A unique calvarial bone donor site

Cranial bone grafts are the ideal substitute for the reconstruction of defects of the craniofacial skeleton, given the optimal conditions for survival and incorporation. An unusual calvarial bone graft site, the posterior frontal sinus wall was used in 5 patients who underwent the extended subcranial approach for anterior cranial base tumors or trauma. The bone defects comprised the nasal and orbital bones to a varying degree. In all but one patient, reconstruction was successful, and in one case attributable to inadequate soft tissue coverage, part of the bone graft was removed. We recommend the use of this donor site in cases of anterior cranial base, especially when using the extended subcranial approach, thereby minimizing operating time and donor site morbidity.

Cranialization of the frontal sinus: indications, technique and results

The osteoplastic frontal sinus surgery with obliteration of the sinus has been established in the therapy of frontal sinus diseases that can not be drainaged permanently or healed through an endonasal access. The obliteration of the frontal sinus is endangered in cases of multiple fracturing of the posterior frontal sinus wall or if it has been destroyed by an inflammatory process. In these problematic cases obliteration bears the danger of complications and cranialization of the frontal sinus is therefore the method of choice. We review 8 patients who were operated on using the cranialization technique. Indications for surgery were a combined fracture of the anterior and posterior frontal sinus wall (3), a pyocele of the frontal sinus with extensive destruction of the posterior wall (4) and a large osteoma of the posterior frontal sinus wall (1). The frontal sinus was exposed through a coronal incision, the mucosa and the posterior wall were completely removed and the frontal sinus obliterated with fat tissue. The anterior sinus wall was replaced after obliteration of the sinus or reconstructed with calvarian bone transplants. The follow up period was 1.8 years (11 months to 8 years). All patients underwent postoperatively a clinical ENT-examination and radiological assessment by CT-Scan or MRI. The overall functional and esthetic outcome was excellent. There were no serious complications nor any recurrence. The cranialization of the frontal sinus is a reliable and safe variation of the classical osteoplastic frontal sinus surgery with fat obliteration.

鼻性頭蓋内膿よう例

A case of a rhinogenic brain abscess is reported. A 19-year-old male presented with a onemonth history of headache and pyrexia. He also had nausea and vomiting with concomitant progressive decline of initiativity and level of consciousness. CT and MRI scans revealed a huge brain abscess in the left frontal lobe in association with a small amount of pus collection in the epidural space, left frontal-ethmoid-maxillary sinusitis, and a fracture line on the posterior wall of the left frontal sinus. The brain abscess was totally removed with frontal craniotomy following aspiration and external drainage through a burr hole. The left frontal-ethmoid-maxillary sinuses were treated by endoscopic sinus surgery. The patient recovered without neurological deficit. Infection seemed to have spread directly from the frontal sinus to the intracranial space through the bone defect in the posterior wall of the frontal sinus and a tear in the underlying dura mater, both of which were probably the result of a previous head injury.