Sinus Outflow Tract Research Articles

Radiological Analysis of Frontal Cells and its Association with Frontal Sinus Mucosal Disease: A Tertiary Care Hospital Based Study

Introduction
 The frontal sinus and frontal recess both have complex anatomy causing difficulty during endoscopic sinus surgeries. The term frontal cells is currently used to describe a group of anterior ethmoidal cells classified by Kuhn et al into 4 types. Though there are precise descriptions, the frequency of frontal sinus cells (FSCs) varies widely in the literature. The presence of FSCs is responsible for a narrowing of the frontal sinus outflow tract which subsequently causes a partial obstruction of drainage and aeration of the frontal sinus. Our main aim is to the see the distribution of different frontal cells in Nepali population and relation with frontal sinus mucosal disease.
 
 Materials and Methods
 This prospective, longitudinal study performed in 110 consecutive patients who underwent CT scan of nose and paranasal sinuses. The frontal cells and agger nasi cells were identified and association between the frontal cells and agger nasi cells with frontal sinus mucosal disease was analyzed with chi square test.
 
 Results
 The agger nasi was present in 83.63% CT scans whereas frontal cells were distributed in 61.82% CT (computed tomogram) scans. There was not statistical significance and any association between the frontal cells and agger nasi cells with frontal sinus mucosal disease.
 
 Conclusion
 The frontal cells and agger nasi cells distribution in Nepalese population, even though in small sample size, is similar with other studies in the literature. There is also non association of either frontal cells or agger nasi cells with frontal sinus mucosal disease.

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 endoscopic modified lothrop procedure: Review of single institution experience and long-term outcomes.

BackgroundEndoscopic Modified Lothrop Procedure (EMLP) has become a fundamental practice in rhinology. Improvements in symptom burden, ostial patency, morbidity, and costs have surpassed that of an open approach to the frontal sinus. Long‐term efficacy has not been well established.ObjectiveThis study details the long‐term outcomes of EMLP and risk factors for subsequent surgical revision at a single institution.MethodsThis study utilized a retrospective review of patients who underwent EMLP from September 2006 to February 2017 by a single surgeon at an academic tertiary referral center. Patient demographics, indications, symptom burden, and endoscopic assessment of frontal ostium patency were analyzed for their effect on surgical outcome. Risk factors for failures were identified.ResultsSeventy‐six consecutive patients with an average age of 58.1 years met the inclusion and exclusion criteria and underwent EMLP for chronic rhinosinusitis (CRS, 59%), neoplasm (26%), and mucoceles (15%). The average number of standard endoscopic sinus surgeries prior to EMLP was 2.9. The mean follow‐up of the cohort was 34.8 months, at the end of which, EMLP was successful in 78% of all patients, requiring no further surgery. Ninety percent of patients reported significant clinical improvement at the most recent follow‐up. Subgroup analysis of CRS patients revealed an equally high success rate but a higher likelihood of ostial closure. Recurrent disease necessitated revision endoscopic surgery in 17 patients, the majority of whom suffered CRS. Only tissue eosinophilia was identified to significantly increase the risk of revision surgery.ConclusionsThe majority of the patients who undergo EMLP achieve sustained patency of the frontal sinus outflow tract and adequate symptom improvement. Prominent tissue eosinophilia identifies patients at risk of requiring additional frontal sinus surgery.Level of Evidence4.

The role of frontal sinus drillouts in nasal polyposis.

Historically, the common frontal sinusotomy has been reserved only for salvage frontal sinus surgery in patients with severely recalcitrant inflammatory sinus disease. By understanding the pathophysiology of inflammatory sinus disease and the long-term role of topical medication in their treatment, the indications for Draf3 have expanded. A major therapeutic impact from endoscopic sinus surgery for inflammatory sinus disease is imparted by allowing sinus access to topical therapies to work. Although traditionally, the Draf3 frontal sinus procedure has been reserved for revision surgery in severe cases, advancements in technology, instrumentation, and techniques has allowed the Draf3 to evolve to efficient and safe procedure, often applied primarily in select patients. There is evidence to support the indication for Draf3 in primary surgery for severe cases. In inflammatory sinus disease, the goal of endoscopic sinus surgery is to convert the complex and limited frontal sinus outflow tracts into a simple common cavity. This allows for local, topical anti-inflammatory treatments to control the disease. When patients have broader inflammatory airway disease and asthma, the Draf3, as part of a neo-sinus cavity, is commonly applied early in surgical care.

Frontal sinus outflow tract: Multi-detector CT assessment

IntroductionKnowledge of the normal anatomical variants is critical for safe endoscopic navigation during FESS. The frontal sinus outflow tract FSOT includes the frontal infundibulum, ostium and recess respectively in the direction of the drained secretions. The original classification of Bent and Kuhn (B&K) divided the frontal infundibulum cells into four categories. Lund and Mackay scoring system (LMS) is a radiological score that offer effective evaluation of sinusitis. The aim of this work was to revise the radiological classification of frontal air cells by B&K and to correlate it with the clinic-radiological LMS scoring system. Methods and resultsThis study was carried out on 200 sides divided into two equal groups. Three types were added to the original B&K description; Type 0 (Not identified frontal cells), Combined type and Couldn't be assessed type. The percentages of each type were calculated according to modified B&K classification and correlated to LMS. ConclusionsThe main limitation of the original B&K classification system is to accurately classify frontal air cells in cases with extensive opacification of the frontal sinus (LMS 2) as well as in cases of complicating sino-nasal polyposis. Three new types are suggested to be added to the original B&K classification system.

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis

ObjectiveTo determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management. MethodsLongitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed. ResultsThe frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement. ConclusionsOur long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions.

Does the frontal sinus need to be obliterated following fracture with frontal sinus outflow tract injury?

Does the frontal sinus need to be obliterated following fracture with frontal sinus outflow tract injury?

Survey of Current Practice Patterns in the Management of Frontal Sinus Fractures.

The management of frontal sinus fractures has evolved in the endoscopic era. The development of functional endoscopic sinus surgery (FESS) has been incorporated into management algorithms proposed by otolaryngologists, but the extent of its influence on plastic surgeons and oral and maxillofacial surgeons is heretofore unknown. A cross-sectional survey was performed to assess the practice pattern variations in frontal sinus fracture management across multiple surgical disciplines. A total of 298 surveys were reviewed. 33.5% were facial plastic surgeons with otolaryngology training, 25.8% general otolaryngologists, 25.5% plastic surgeons, and 15.1% oral and maxillofacial surgeons. 74.8% of respondents practiced in an academic setting. 61.7% felt endoscopic sinus surgery changed their management of frontal sinus fractures. 91.8% of respondents favored observation for uncomplicated, nondisplaced frontal sinus outflow tract fractures. 36.4% favored observation and 35.9% favored endoscopic sinus surgery for uncomplicated, displaced frontal sinus outflow tract fractures. For complicated, displaced frontal sinus outflow tract fractures, obliteration was more frequently favored by plastic surgeons and oral and maxillofacial surgeons than those with otolaryngology training. The utility of FESS in managing frontal sinus fractures appears to be recognized across multiple surgical disciplines.

Anatomical variations in superior attachment of uncinate process and localization of frontal sinus outflow tract

<p class="abstract"><strong>Background:</strong> Uncinate process (UP) is a part of ethmoid bone, which is a thin sickle shaped projection on the lateral wall of nose. UP extends from the frontal recess superiorly and inferiorly to the ethmoid process of inferior turbinate. Various studies have shown that superior attachment of uncinate process (SAUP) is the key to frontal recess region in endoscopic sinus surgeries (ESS). But these studies have yielded conflicting results, showing multiple patterns and classifications of superior attachment of uncinate process. Knowing the anatomic variations of SAUP will help the surgeon to plan the endoscopic sinus surgery and to avoid the unwanted complications. Hence this study was conducted to observe and classify the superior attachment of uncinate process and to localize the frontal sinus outflow tract<span lang="EN-IN">. </span></p><p class="abstract"><strong>Methods:</strong> We did a retrospective cross sectional study, consisting of 100 patients including both sexes, above the age of 10 years. We excluded pregnant ladies, patients with prior sinus surgeries, sinonasal tumours, nasal polyposis, and craniofacial trauma<span lang="EN-IN">. </span></p><p class="abstract"><strong>Results:</strong> We observed Type I SAUP, in 67.5% (n=135) cases, Type II SAUP in 18.5% (n=37), Type III attachment in 9.5% (n =19) and Type IV in 4.5% (n=9). Bilaterally similar attachments observed in 96% cases. Rest of the cases (4%), the attachment patterns was varying between sides<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> The site of SAUP is highly variable. The most common type of SAUP is Type I (67.5%) followed by Type II (18.5%), Type III (9.5%) and Type IV (4.5%)<span lang="EN-IN">.</span></p>

Approach to Frontal Sinus Outflow Tract Injury

Frontal sinus outflow tract (FSOT) injury may occur in cases of frontal sinus fractures and nasoethmoid orbital fractures. Since the FSOT is lined with mucosa that is responsible for the path from the frontal sinus to the nasal cavity, an untreated injury may lead to complications such as mucocele formation or chronic frontal sinusitis. Therefore, evaluation of FSOT is of clinical significance, with FSOT being diagnosed mostly by computed tomography or intraoperative dye. Several options are available to surgeons when treating FSOT injury, and they need to be familiar with these options to take the proper treatment measures in order to follow the treatment principle for FSOT, which is a safe sinus, and to reduce complications. This paper aimed to examine the surrounding anatomy, diagnosis, and treatment of FSOT.

A six-month analysis of frontal sinus drainage pathway in patients with frontal sinusitis after balloon sinuplasty

Background: The balloon catheter has been used for a decade to dilate paranasal sinus outflow tracts. The question is: how wide and how durable is the dilation of drainage pathways in patients in long-term observations after this procedure?Objective: The objective of our study was to observe the changes occurring in the frontal sinus drainage pathway (FSDP) in patients with frontal sinusitis at least 6 months after surgery using balloon catheters in an isolated procedure.Materials and methods: We analyzed and measured the FSDP width on computed tomography (CT) of 23 images before and after the use of balloon catheters. We also assessed mucosal changes using Zinreich’s scale, and symptom improvements with the Sino-Nasal Outcome Test (SNOT-20).Results: A statistically significant difference in the width of the FSDP was found before and after sinuplasty in the study group (p ≤ .0016). On average, the FSDP increased by 24.1%. Clinically meaningful and statistically significant (p ≤ .0002) symptom improvement as indicated by the mean SNOT-20 score was observed. Mucosal changes were also statistically significant (p ≤ .0018) after surgery.Conclusion: The findings at least 6 months after follow-up indicated that the use of balloon catheters in an isolated procedure allowed durable modeling of FSDP and was associated with radiological and clinical improvements.

Novel use of an ultrasonic bone aspirator for extended endoscopic frontal sinusotomy: A feasibility study.

Extended endoscopic frontal sinusotomy is often required for surgical management of anterior skull base pathology. Such approaches are necessary for access to pathology and maintenance of postoperative frontal sinus outflow tract drainage. Cold steel instrumentation and endoscopic high-speed microdrills are typically used for bony removal during extended frontal sinus approaches but are associated with certain drawbacks, such as thermal injury and obscuration of the surgical field with bone dust. We investigated the ultrasonic bone aspirator (UBA) as an adjunctive tool for extended endoscopic frontal sinusotomy in the setting of skull base surgery. Medical records of patients who underwent either Draf IIB or Draf III sinusotomies from 2011 to 2014 were reviewed. The patients were split into two cohorts based on instrumentation: those who received sinusotomy primarily with the UBA, and those who had sinusotomy performed with conventional instrumentation only. The patients were followed up after surgery with routine endoscopic examinations and imaging when indicated. Patient demographics, surgical approach, operative complications, and postoperative outcomes were evaluated. A total of 18 patients underwent endoscopic extended frontal sinusotomy for a variety of skull base pathologies with the UBA and the conventional instrumentation cohorts, which contained nine patients each. Five of the nine patients in the UBA cohort received Draf III sinusotomies compared with three of nine in the conventional cohort. Three patients in the UBA cohort experienced postoperative transient pressure hyperemia of the lip; this was seen in a single patient in the conventional cohort. All patients with postoperative endoscopic examinations maintained frontal sinus ostial patency to varying degrees, irrespective of cohort. Lund-Mackay scores and the need for operative revision of the frontal sinus were similar for both groups and seemed to be related to the use of postoperative radiation. The UBA was a safe, effective tool for extended endoscopic frontal sinusotomy in endoscopic skull base surgery.

Computed tomographic analysis of frontal sinus drainage pathway variations and frontal rhinosinusitis.

The objective of this study was to radiologically determine frontal sinus drainage pathway variations with respect to superior attachment of uncinate process (SAUP) and their effect on prevalence of frontal rhinosinusitis. This was a retrospective cohort study. Computed tomography scans of the 919 frontal sinus sides of 460 patients (252 female, 208 male; mean age, 35.1 ± 10.5 years) who were candidates for endoscopic sinus surgery were evaluated retrospectively between August 2012 and January 2013 by 3 radiologists to determine the SAUP types and the presence of frontal rhinosinusitis. The frontal sinus outflow tract was localized medial to the SAUP in 651 frontal sinus sides and lateral to the SAUP in 268 sides. We determined 3 types (types 7, 8, and 9) of SAUP in addition to 6 types defined in literature. The most common type of SAUP was type 3 (n = 332, 36.1%) followed by type 2 (n = 256, 27.8%) and type 7 (n = 160, 17.4%). Of the evaluated sides, 316 (34.3%) had frontal rhinosinusitis. Frontal rhinosinusitis was more common in the sides where the frontal sinus outflow tract was localized medial to the SAUP than those localized lateral (37.2% vs 27.6%, P = 0.006). Endoscopic approach to frontal recess usually requires uncinectomy, and it is necessary to know SAUP to prevent postoperative retained superior portion of the uncinate process. The location of frontal sinus outflow tract on the SAUP affects the prevalence of frontal rhinosinusitis as well. Frontal rhinosinusitis is significantly more common when the frontal sinus outflow tract was localized medial rather than lateral to the SAUP. 2b.

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

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

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

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

Frontal sinus drillout (modified Lothrop procedure): Long‐term results in 204 patients

To determine the long-term results of frontal sinus drillout (also known as modified Lothrop procedure) for the treatment of advanced frontal sinus disease. Retrospective review. The records of patients who underwent frontal sinus drillout by a single surgeon at an academic medical center from June 1995 through November 2011 were reviewed. Patient demographics and perioperative clinical findings were analyzed for their impact on surgical outcome. Failure was defined as restenosis of the frontal drainage pathways, necessitating additional frontal sinus surgery. A total of 204 patients underwent frontal drillout surgery (143 bilateral procedures) over the 16-year period. Mean follow-up was 10.2 years (range 0.9-17 years). Symptomatic re-obstruction of the frontal sinus requiring revision surgery occurred in 61 (29.9%) patients. Drillouts performed for a diagnosis of mucocele or tumor had significantly higher failure rate (38.9%, odds ratio [OR] = 2.9, P = 0.022 and 58.3%, OR = 5.3, P = 0.020, respectively). The majority of surgical failures (61%) occurred within 2 years of surgery, but delayed failures were observed up to 12 years after drillout. Clinical outcome did not correlate with a history of smoking, asthma, nasal allergy, aspirin sensitivity, prior sinus surgery, nasal polyposis, or the presence of eosinophilic mucin. For the majority of patients who undergo frontal sinus drillout, patency of the frontal sinus outflow tract appears to be maintained for more than a decade; nevertheless, almost one-third of patients who undergo this procedure will ultimately require additional frontal sinus surgery.

Maxillary Mucocele With Proptosis and Visual Impairment

Maxillary mucoceles are a relatively rare entity especially following surgical procedures involving osteotomies of the maxilla. The etiology of maxillary mucoceles has been ascribed to facial trauma (fractures), sinus surgery, and chronic inflammatory diseases or infections. Mucoceles can follow injury to the sinus mucosa and/or sinus outflow tract with a resulting expansile cystic mass. The clinical presentation ranges from swelling, pain, a palpable mass, proptosis, enophthalmos, and diplopia. The treatment involves either open or endoscopic incision and drainage of the cyst, mucosal resection, and an antrostomy for drainage.We report the case of a patient with Pfeiffer syndrome who underwent Le Fort III distraction osteogenesis and developed a symptomatic mucocele 15 years postoperatively.

Cranialization in a Cohort of 154 Consecutive Patients With Frontal Sinus Fractures (1987–2007) Review and Update of a Compelling Procedure in the Selected Patient

Retrospective review of charts of 180 consecutive patients with frontal sinus fractures managed by plastic surgeons at the University of Kentucky between 1987 and 2007 was performed with institutional review board approval. Twenty-six charts did not meet the criteria. The remaining 154 records provided 1-to-20-year follow-up. The study included 34 patients who underwent cranialization and 120 patients who did not. A low-complication rate of 6% after cranialization is ascribed by the authors to meticulous sinus mucosal debridement; thorough obliteration of the frontal sinus outflow tract (with sterile gelatin sponge pledgets and bone chips from the outer cortex of the temporoparietal skull); and avoidance of avascular barriers, such as abdominal fat. As high-resolution computerized tomography with parasaggital views was introduced, an increasing ability to preoperatively define the extent of injury of the medial and lateral sinus floor was observed. The authors conclude selective use of cranialization is indicated.

Frontal sinus outflow tract evaluation by sagittal computed tomography in frontal sinus fracture

The status of the frontal sinus outflow tract is important in the management of frontal sinus fractures. Anatomic and mucosal obstruction of the FSOT leads to mucociliary stasis with consequent infectious complications. This has been evaluated by routine CT scan. ObjectivesThe aim of this study was to determine the ability of MPR mainly the sagittal CT images assessing the patency of FSOT in frontal sinus fractures. Patients and methodsA prospective study was carried out from December 2008 to May 2012 on 19 patients with frontal sinus fractures. Reformatted sagittal views were done besides the routine axial, coronal CT scan views as part of facial trauma workup. These views were assessed to determine the status of the nasofrontal ducts (NFD) and compared with the operative findings. ResultsThe patency of FSOT by sagittal CT reformatted images was the same as that of the operative finding in all cases (specificity and PPV were 100%) even in patients in whom FSOT in the axial and/orcoronal views were doubtful. ConclusionSagittal reformatted CT images are helpful in evaluating FSOT in frontal sinus fractures due to their ability to evaluate the frontal sinus in anteroposterior and superoinferior dimensions, thus aiding the surgical approach.

In-office functional endoscopic sinus surgery for chronic rhinosinusitis utilizing balloon catheter dilation technology

Balloon catheter dilation (BCD) technology was introduced in 2005 as a device employed to dilate maxillary, sphenoid, and frontal sinus outflow tracts in patients with chronic sinus disease. With the evolution of the technology, BCD has been utilized in the office setting. The purpose of this review is to discuss the safety, tolerability, and technical success of this change of venue and to consider the possible significant cost savings in the current healthcare environment. Recent studies have shown that BCD technology can be safely and successfully used in the office setting with high patient satisfaction and symptom improvement similar to that achieved in the operating room. In select patients with chronic sinus disease, BCD can be safely and effectively utilized to open compromised outflow tracts from the peripheral sinuses including the maxillary, sphenoid, and frontal sinuses. This has the potential to reduce the overall costs related to the surgical treatment of medically refractory sinus disease.