Virtual Mapping of the Frontal Recess: Guiding Safe and Efficient Frontal Sinus Surgery

Objective To define relationships between the frontal sinus opening, ostia of other frontal recess cells, and endoscopic landmarks and to develop a clinically useful framework to guide frontal sinus surgery. Study Design Retrospective review. Setting Tertiary care academic referral center. Methods Adult patients with computed tomography (CT) without sinonasal pathology were included. Virtual endoscopy (using OsiriX) and corresponding CT reconstructions were used to identify all visible ostia in the frontal recess and characterize their positions in spaces between the uncinate/agger nasi (U), bulla ethmoidalis (EB), and middle turbinate (MT). Results Two hundred sides in 100 patients (median age 51 years, 62% female) were analyzed. The “center” of each map was defined as the intersection of spaces between U, EB, and MT. The frontal sinus opening was in the “center” in 53% of frontal recesses, lateral to this position in 29%, and anterior in 11%. When the frontal sinus opening was at the “center,” anterior ostia drained frontal Kuhn T cells in 51% and intersinus septal cells in 23%. The skull base attachment of the apical strut of the uncinate process demarcated medial and lateral within the space between U and EB, with the opening to the frontal sinus medial in 68% and lateral in 31%. Left-right asymmetry in frontal sinus openings was noted in 46% of patients. Conclusion Combining preoperative imaging and knowledge of these anatomic relationships may facilitate more efficient frontal outflow tract identification and instrumentation. This represents the first and largest description of ostial configurations relative to endoscopic structural landmarks. Level of Evidence: 4

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Endoscopic Anatomic Characterization of the Frontal Recess and Its Implications in Frontal Sinus Surgery

ORL ◽

10.1159/000114530 ◽

2008 ◽

Vol 70 (2) ◽

pp. 84-90 ◽

Cited By ~ 1

Author(s):

Zhou Bing ◽

Han Demin ◽

Liu Huachao ◽

Huang Qian ◽

Zhang Luo ◽

...

Keyword(s):

Frontal Sinus ◽

Sinus Surgery ◽

Frontal Recess ◽

Frontal Sinus Surgery

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Indications for External Frontal Sinus Procedures for Inflammatory Sinus Disease

American Journal of Rhinology and Allergy ◽

10.2500/ajra.2009.23.3327 ◽

2009 ◽

Vol 23 (3) ◽

pp. 342-347 ◽

Cited By ~ 47

Author(s):

Samuel Hahn ◽

James N. Palmer ◽

Michael T. Purkey ◽

David W. Kennedy ◽

Alexander G. Chiu

Keyword(s):

Inflammatory Disease ◽

Frontal Sinus ◽

Sinus Surgery ◽

External Approach ◽

Previous Surgery ◽

Frontal Recess ◽

Frontal Sinus Surgery ◽

Previous Trauma ◽

History Of ◽

Type 3

Background In the modern age of endoscopic sinus surgery (ESS), there is an undefined role for external approaches in the treatment of inflammatory disease. This study examines the frontal sinus surgery practices of three experienced rhinologists with a focus on those who underwent an external approach. Our goal was to characterize these patients and propose indications for the use of an external approach alone or in combination with functional ESS (FESS) for frontal sinus inflammatory disease. Methods A retrospective review was performed of frontal sinus procedures performed for inflammatory disease at one institution from 2004 to 2007. Results Seven hundred seventeen procedures were performed, 38 (5.3%) of which were external alone (14 procedures) or in combination with FESS (24 procedures). Osteoplastic flap with obliteration (12/14) made up the majority of external alone procedures and the most common indication was neo-osteogenesis of the frontal recess. Trephination was the most common external adjunct to FESS (12/24), and often was performed for type 3 frontal recess cells or in the initial management of acute frontal bone osteomyelitis (FOM). Twenty-eight of 38 (74%) patients had a history of previous surgery. Of the 10 patients with no history of previous surgery, 6 (60%) had an external adjunct for frontal recess neo-osteogenesis. There were no major complications but 9/38 (23.7%) patients required revision surgery for persistent/recurrent symptoms. Conclusion External approaches alone and in combination with FESS are predominantly secondary to neo-osteogenesis of the frontal recess. Factors associated with neo-osteogenesis include previous trauma, endoscopic surgery, and FOM. External frontal sinus surgery provides adequate management of inflammatory disease but has a high revision rate.

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The Effect of Middle Turbinate Resection upon the Frontal Sinus

American Journal of Rhinology ◽

10.2500/105065895781873737 ◽

1995 ◽

Vol 9 (4) ◽

pp. 191-196 ◽

Cited By ~ 53

Author(s):

Paul B. Swanson ◽

Donald C. Lanza ◽

Eugenia M. Vining ◽

David W. Kennedy

Keyword(s):

Frontal Sinus ◽

Statistical Difference ◽

Severe Disease ◽

Middle Turbinate ◽

Sinus Surgery ◽

Ct Scans ◽

Control Group ◽

Case Group ◽

Frontal Sinusitis ◽

Frontal Recess

Diversity of opinion exists among otolaryngologists regarding the importance of preserving the middle turbinate during sinus surgery. The purpose of this study is to determine whether or not middle turbinate resection has a bearing upon postoperative disease within the frontal sinus. In this retrospective analysis of 110 consecutive patients with chronic or recurrent acute sinusitis, 69 (case group) had previous middle turbinectomy and 41 patients (control group) had intact middle turbinate after prior sinus surgery. In 42 patients, CT scans were scored and defined as having either mild-moderate or severe disease. Frontal sinusitis seen on CT scan was present in 75% (30 of 40) of case sides and 45% (9 of 20) of control sides, and this difference was significant (P < 0.05). The height of middle turbinate resection was measured, and there was no statistical difference in frontal sinusitis between patients with high and low resection. Therefore, this work does not support the concept that middle turbinate resection results in a lower incidence of frontal recess disease.

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Frontal Sinus Surgery Anterior to the Ethmoid Bulla

International Surgery ◽

10.9738/cc37 ◽

2013 ◽

Vol 98 (2) ◽

pp. 149-155 ◽

Cited By ~ 2

Author(s):

Junfeng Ji ◽

Mei Zhou ◽

Zeqing Li ◽

Tianyou Wang ◽

You Cheng ◽

...

Keyword(s):

Frontal Sinus ◽

Middle Turbinate ◽

Sinus Surgery ◽

Frontal Sinus Surgery ◽

Relative Constant ◽

Anterior Ethmoid Artery

Abstract The frontal sinus surgery is difficult to perform but the ethmoid bulla is a relative, constant landmark in the middle turbinate that can improve the surgery. The purpose of this study was to evaluate the validity, security, and predominance of approaches to the frontal sinus via the route anterior to the ethmoid bulla. The data from 370 endoscopic frontal sinus surgery cases from our center were integrated and retrospectively analyzed. Three hundred twenty-nine patients underwent frontal sinus surgery via the route anterior to the ethmoid bulla. An additional 27 patients underwent frontal sinus surgery with mini-trephination, 13 patients with the Draf II procedure, and 1 patient had applied MELP (modified endoscopic Lothrop procedure). No serious complications occurred; however, there were 3 cases of eyelid ecchymosis and 1 case of anterior ethmoid artery bleeding. In all, 319 patients (86.2%) were cured, an improvement was noted in 36 of the patients (9.7%), and there was no improvement in 15 patients (4.1%). Frontal sinus surgery via the route anterior to the ethmoid bulla is valid, relatively safe, and can be applied in most cases involving frontal disease.

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Anatomical Variants in Frontal Recess Region and their Impact on Frontal Sinus Surgery in Chronic Sinusitis

American Journal of Health Research ◽

10.11648/j.ajhr.20150303.15 ◽

2015 ◽

Vol 3 (3) ◽

pp. 140

Author(s):

Omer Abd El-Moneim El-Banhawy

Keyword(s):

Frontal Sinus ◽

Chronic Sinusitis ◽

Sinus Surgery ◽

Anatomical Variants ◽

Frontal Recess ◽

Frontal Sinus Surgery

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Use of a New Mucoperiosteal Flap from the Upper Lateral Nasal Wall in Frontal Sinus Surgery

Otolaryngology ◽

10.1177/019459988108900607 ◽

1981 ◽

Vol 89 (6) ◽

pp. 912-916 ◽

Cited By ~ 3

Author(s):

George S. Dokianakis ◽

Emmanuel Helidonis ◽

Dimitris Karamitsos ◽

George Papazoglou

Keyword(s):

Nasal Cavity ◽

Frontal Sinus ◽

Middle Turbinate ◽

Sinus Surgery ◽

Lateral Nasal Wall ◽

Frontal Sinus Surgery ◽

Mucoperiosteal Flap

Various mucoperiosteal flaps from the nose (nasal walls) are in use today in frontal sinus surgery in cases where a wide opening between the frontal sinus and the nasal cavity is created. These flaps are transferred to cover denuded bone in the area of opening and thus prevent the opening from narrowing or closing, which would result in the reappearance of frontal sinus problems. In this paper, a new mucoperiosteal flap taken from the upper extension of middle turbinate is described.

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Pre- and Postoperative Imaging Analysis for Frontal Sinus Disease following Conservative Partial Middle Turbinate Resection

Ear Nose & Throat Journal ◽

10.1177/014556139807700415 ◽

1998 ◽

Vol 77 (4) ◽

pp. 326-334 ◽

Cited By ~ 9

Author(s):

Iyad S. Saidi ◽

John F. Biedlingmaier ◽

Michael I. Rothman

Keyword(s):

Frontal Sinus ◽

Middle Turbinate ◽

Sinus Surgery ◽

Mr Images ◽

Sinus Disease ◽

Frontal Recess ◽

Postoperative Mri ◽

Preoperative Ct ◽

Magnetic Resonance Imaging Mri ◽

Mucosal Thickening

The prudence of partial or complete middle turbinate resection during endoscopic sinus surgery (ESS) is controversial. The greatest concern regarding partial resection relates to the effect on the frontal recess and the development of frontal sinus disease. The purpose of this study was to radiographically evaluate the frontal sinus in patients who had undergone ESS with partial conservative middle turbinate resection. We reviewed the charts and operative records from 195 consecutive cases of ESS performed by a single surgeon (JFB) over a two-year period. Thirty-three of 117 patients who had undergone ESS with conservative partial middle turbinate resection without frontal recess exploration agreed to return for magnetic resonance imaging (MRI) of their sinuses. The preoperative computed tomography (CT) scans and postoperative MR images were reviewed and graded (1–3) by a single neuroradiologist. Significant frontal sinus disease (grades 2 and 3) was seen in 15 of 52 sides preoperatively (29%), and in 14 sides postoperatively (27%). During the postoperative MRI studies, only six frontal sinus sides demonstrated minimal mucosal thickening (grade 1) which had not been apparent on preoperative CT. This radiographic analysis suggests that conservative partial middle turbinate resection during ESS does not adversely affect the frontal sinus. We believe that the surgical technique employed when resecting the middle turbinate, and the avoidance of unnecessary dissection in the recess are both important factors in preventing the development of frontal sinus disease following ESS.

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The Role of Frontal Sinus Obliteration in the Era of FESS

Otolaryngology ◽

10.1016/j.otohns.2008.05.261 ◽

2008 ◽

Vol 139 (2_suppl) ◽

pp. P81-P81

Author(s):

Nicolas BuSaba ◽

Stacey T. Gray

Keyword(s):

Frontal Sinus ◽

Tertiary Care ◽

Case Series ◽

Care Facility ◽

Sinus Surgery ◽

Salvage Procedure ◽

Frontal Sinusitis ◽

First Line ◽

Frontal Sinus Surgery ◽

Sinus Obliteration

Objective To determine the current indications for osteoplastic frontal sinus obliteration (OFSO) for the treatment of inflammatory frontal sinus disease. Methods Retrospective case series from a single tertiary care facility. The medical records of 35 patients who underwent OFSO for chronic frontal sinusitis (n=26) and frontal sinus mucocele (n=9) between 1995 and 2007 were reviewed. Data regarding age, gender, date and nature of previous frontal sinus operation(s), pre-operative imaging, pre-operative diagnosis, and operative complications were culled. Results There were 19 males and 16 females with an age range of 19 to 76 years. All patients had pre-operative sinus CT, while 6 patients had additional MRI. Among the 9 patients diagnosed with frontal sinus mucocele, OFSO was first-line treatment in 8 and salvage for 2 failed endoscopic masupialization procedures in 1. Among the 26 patients with chronic frontal sinusitis, OFSO was first-line in 9 and salvage for failed frontal sinus surgery in 17. The failed surgeries were OFSO (n=7), Lynch procedure (n=2), and endoscopic frontal sinus surgery including drill-out (n=10). Five patients failed multiple previous operations. The failed operations dated from 1 to 33 years prior to the present illness in the case of OFSO, 1 to 4 years in the case of Lynch procedure, and 1 to 7 years in the case of endoscopic frontal sinus surgery. There was one reported complication (orbital hematoma). Conclusions OFSO remains a key surgical treatment for frontal sinus mucocele, but is used more commonly as a salvage procedure for chronic frontal sinusitis.

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Incidence of sinonasal anatomical variations associated with chronic sinusitis by CT scan in Karaikal, South India

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20172291 ◽

2017 ◽

Vol 3 (3) ◽

pp. 576 ◽

Cited By ~ 1

Author(s):

Kranti Gouripur ◽

Udaya Kumar M. ◽

Anand B. Janagond ◽

S. Elangovan ◽

V. Srinivasa

Keyword(s):

Ct Scan ◽

Endoscopic Sinus Surgery ◽

Frontal Sinus ◽

Chronic Sinusitis ◽

Middle Turbinate ◽

Anatomical Variations ◽

Uncinate Process ◽

Sinus Surgery ◽

Nasal Endoscopy ◽

Deviated Nasal Septum

Background: Variations in sinonasal anatomy of adults are common and vary among different populations. Their role in development of pathological conditions such as sinusitis, epistaxis, etc is debated. Having clear picture of sinonasal anatomy of a person is essential in avoidance of complications during surgery. This study was done to analyze sinonasal anatomy in adults from Karaikal region having chronic sinusitis by nasal endoscopy and CT scan imaging.Methods: A total of 50 patients undergoing endoscopic sinus surgery were studied by preoperative nasal endoscopy, CT scanning and endoscopy at the time of definitive surgery and variations recorded and analyzed. Results: The incidence of the sinonasal anatomical variations in CT scan study were – discharge in the frontal sinus (100%), agger nasi cells (96%), deviated nasal septum (70%), anterior ethmoidal cells (86%), posterior ethmoidal cells (58%), sinus lateralis (52%), frontal cells (50%), discharge in sphenoid sinus (50%), pneumatised superior turbinate (46%), INSA (34%), prominent bulla ethmoidalis (30%), supra orbital cells (26%), pneumatised septum(16%), medialised uncinate process (16%), paradoxical middle turbinate (16%), Haller cells (14%), supreme turbinate (14%), pneumatised inferior turbinate (12%), frontal recess obliteration (12%), absent pneumatisation of frontal sinus (12%), pneumatised middle turbinate (10%), Onodi cells (6%), pneumatised uncinate process (2%), maxillary sinus septation (2%).Conclusions: The high incidence of variations emphasises the need for proper preoperative assessment for safe and effective endoscopic sinus surgery.

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

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20160077 ◽

2017 ◽

Vol 3 (2) ◽

pp. 176

Author(s):

Arun G. ◽

Sanu P. Moideen ◽

Mohan M. ◽

Khizer Hussain Afroze M. ◽

Aparna S. Thampy

Keyword(s):

Frontal Sinus ◽

Uncinate Process ◽

Outflow Tract ◽

Sinus Surgery ◽

Type I ◽

Type Ii ◽

Cross Sectional ◽

Type Iii ◽

Frontal Recess ◽

Type Iv

Background: 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. Methods: 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. Results: 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. Conclusions: 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%).

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