frontal sinus surgery
TRANSCRIPT
Frontal Sinus Surgery
Jacques Peltier, MD Faculty Advisor: Matthew Ryan, MD
Department of Otolaryngology University of Texas Medical Branch
Grand Rounds Presentation October 11, 2006
Anatomy • Uncinate process
• Agger Nasi
Anatomy
• Hiatus Semilunaris
• Ethmoid infundibulum
• Frontal Sinus Drainage Pathway
• Frontal Sinus Ostium
Anatomy
Anatomy
• Cribriform Plate
• Lamina papyracea
• Fovea ethmoidalis
Anatomic Variations
Anatomy
• Anterior Terminal Recess
• Posterior Terminal Recess
Finding The Frontal Recess
Finding The Frontal Recess
Frontal Cells
• Type I - Single cell above the agger nasi
• Type II - Two or more cells above the agger cell
• Type III - Single cell extending from the agger cell into the frontal sinus
• Type IV - Isolated cell within the frontal sinus
Frontal Cells
Frontal Cells
Frontal Cells
Anatomic Variations
Surgical Indications
• Chronic sinusitis unresolved with maximal medical therapy;
• Polyps and allergic fungal sinusitis
• Intracranial complications of sinusitis
• Mucoceles or mucopyoceles
• Benign neoplasms such as osteomas, inverting papillomas, or fibrous dysplasia.
Draf Procedures
Draf I
• Anterior ethmoid cells
• Uncinate process
• Obstructing frontal cells
Draf II
• Floor of the frontal sinus
• Lamina papyracea to Septum
• Anterior face of Frontal
Draf III
• Modified Lothrop
• Interfrontal septum
• Nasal septum
• Frontal sinus floor
Frontal Sinus Trephination
• Finding the frontal recess
• Mucoceles
• Isolated Type IV frontal cells
• With endoscopic techniques to assist with Draf II and III
Frontal Sinus Trephination
Frontal Sinus Trephination
Frontal Sinus Trephination
Frontal Sinus Trephination
Combined Approaches
Combined Approaches
Combined Approaches
Modified Lothrop
Modified Lothrop
Take down the septum first
Osteoplastic Flap Vs. Draf III
• Narrow Nasal Airway
• Small Frontal Sinus
• Deep Nasion
• Floor of sinus < 1.5 cm
• Heavy thick nasofrontal beak
• Proliferative osteitis, complicated chronic infection
• Favor Draf III for mucoceles
Osteoplastic Flap Vs. Draf III
Osteoplastic Flap
• May be modified to
fit the patient
Osteoplastic Flap
• Small bony flap
• Care to preserve
supratrochlear
bundle
Osteoplastic Flap
• 6 foot Caldwell
• Image guidance
• Wire probe
Osteoplastic Flaps
Osteoplastic Flaps
Osteoplastic Flap
Osteoplastic Flap
Osteoplastic Flap
Pearls to Operating in the frontal recess
• Taken from a lecture by David Kennedy MD at the academy meeting this year
• Pearl – look for lectures at academy that will assist your grand rounds
Pearl #1 Carefully Examine the Anatomy in more than one CT plane
• Size of the frontal recess
• Size of the frontal sinus
• Bony thickening or neo-osteogenesis
• Identify the frontal sinus drainage pathway
• Note the position of the anterior ethmoidal artery
Pearl # 2 Identify the Anterior Ethmoidal Artery
• Superior extension of anterior wall of bulla
• Nipple on the medial orbital wall
• 1-4 mm’s below skull base
• Typically posterior to supraorbital ethmoid cells
Pearl #3: Plan the least invasive approach possible
• Ethmoidectomy with Middle Meatal Antrostomy without frontal recess surgery
• Frontal recess surgery
• Endoscopic frontal sinusotomy
• Frontal sinus trephination
• Unilateral extend frontal sinus surgery (Draf II)
• Endoscopic Modified Lothrop (Draf III)
• Osteoplastic flap with or without obliteration
Pearl #4 Positively Identify the Skull Base Posteriorly
• Skeletonize from posterior to anterior
• Open cells immediately posterior to the middle turbinate
• Identify the sinus with a seeker
Pearl #5 Positively identify the frontal sinus with a probe
• Need a relatively dry field
• 45 degree telescopes are helpful
• Identify medial orbital wall and stay close to it dissecting superiorly
• Opening to frontal sinus typically medial
• Identify opening with a probe
Pearl # 6 Preserve the Mucosa
• Consider leaving polyps if sinus is open
• Remove osteitic intersinus septae carefully
• Do not traumatize unless sinus can be opened widely
• Standard frontal sinusotomy – Draf Type II
– Works well if you can: • Preserve mucosa
• Remove bony partitions
• Create an ostium >4-5 mm
Pearl #7 Keep the Sinus Open Postoperatively
• Remove fibrin and blood from frontal recess and frontal sinus
• Remove residual bone
• Antibiotics, topical steroids?
• Oral Steroids?
Pearl #8 Avoid obliteration in tumors and allergic fungal sinusitis
• Combine osteoplastic approach with
Draf 3 if possible in these situations
• Avoids imaging difficulties after surgery
Pearl #9 Always avoid complications in FESS. Most
operations are for benign disease
Conclusion
• Very little evidence based medicine
• Do the least invasive procedures first
• Be aware of various surgical options
• Image guidance a valuable tool
• First do no harm