Acute Frontal Sinusitis Surgery

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Complications and Causes

Acute frontal sinusitis is considered a more serious type of acute sinus infection because of its complications, with the frontal sinus being the one that is most commonly associated with intracranial infection. Frontal sinus surgery is performed to prevent potentially life-threatening complications when the infection is unresponsive to maximal medical treatment. The images below demonstrate the anatomy of the frontal sinus, as well as frontal sinus surgery.


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(A) Frontal sinus, (B) middle turbinate, (C) ethmoid bulla, (D) hiatus semilunaris, (E) uncinate process, and (F) superior turbinate.


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(A) Incision under brow extending about 1 cm below the medial palpebral (canthal) ligament, (B) medial orbital wall entered with removal of posterior ....


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(A) Incision (above or below eyebrows), (B) superiorly based skin flap, with use of template of frontal sinus and a cut through periosteum along the s....


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(A) After obliteration, the flap is returned, and the periosteum reapproximated with absorbable suture, (B) outline of extension of brow incision in b....

Causes of acute frontal sinusitis

Because of the close anatomic relationship of the ethmoid and frontal sinuses, obstruction of the ethmoid air cells often leads to frontal sinusitis. This obstruction may be caused by nasal polyps, tumor, septal deviation, trauma, mucosal swelling, or acute infection. Obstruction impedes the drainage of the frontal and ethmoid sinuses via the frontal recess and hinders the sinuses' mucociliary function.

Mucociliary clearance in the frontal sinus travels in a counterclockwise direction in the right sinus and in a clockwise direction in the left, transporting secretions along the septal wall to the sinus roof and from there, laterally along the roof to medially along the floor to reach the ostium. Secretions that are retained because of obstruction serve as a nidus and as growth media for infections.

Particular anatomic variants that can lead to obstruction of nasofrontal outflow include a massive concha bullosa, a laterally rotated uncinate process that contacts the middle turbinate, and, conversely, a medially convex middle turbinate that contacts the lateral nasal wall. Previous middle turbinate resection can also lead to stenosis of the frontal sinus ostium because of soft-tissue scarring or residual bony fragments.

Complications of acute frontal sinusitis

The complications of frontal sinusitis are divided into intracranial and ocular types. Intracranial complications include meningitis, brain abscess, epidural empyema, subdural empyema, and cerebral empyema.

Ocular complications are preseptal or orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis. A Pott puffy tumor is a subperiosteal abscess with soft-tissue swelling that causes pitting edema over the frontal bone. Acute infection of the diploic vein resulting in thrombophlebitis causes a Pott puffy tumor. A sinocutaneous fistula can also develop from osteomyelitis of the frontal bone. A few of these complications are relative contraindications to endoscopic sinus surgery.[1, 2, 3]

History of frontal sinus surgery

Trephination of the frontal sinus was performed as early as prehistoric times, by scraping or incision. Two Peruvian skulls at the Museum of Man, in San Diego, show trephines with evidence of the patients’ survival. Early surgeries also described removing part of the anterior frontal sinus wall, leaving the patient with a significant cosmetic deformity. More refined surgery of the frontal sinus was first described in the 19th century, and options for treatment have expanded since the advent of endoscopic sinus surgery.

Despite its long history, much remains to be elucidated about long-term outcomes for acute frontal sinusitis surgery, as well as about postoperative care and follow-up.

Frontal Sinus Anatomy

The frontal sinus develops from small grooves in the cartilage of the lateral nasal wall near the middle meatus during the third and fourth fetal month. It forms an outgrowth from the area of the nasofrontal recess. The frontal recess itself is a space within the anterior ethmoid sinuses, bordered by the agger nasi (the most anterior ethmoid cell) anteriorly and the ethmoidal bulla cells posteriorly between the middle turbinate and lamina papyracea. It may be indistinguishable from the anterior ethmoid cells. The images below show the frontal sinus in relation to other structures.


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(A) Frontal sinus, (B) middle turbinate, (C) ethmoid bulla, (D) hiatus semilunaris, (E) uncinate process, and (F) superior turbinate.


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Axial section through right nasal cavity depicts the following: (A) middle turbinate (or concha); (B) ethmoid bulla; (C) drainage sites for frontal si....


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(A) Frontal sinus, (B) sphenoid sinus, (C) cut surface of the middle turbinate, (D) ethmoid bulla, and (E) hiatus semilunaris.

The frontal sinus opens into the anterior part of the middle meatus, the frontal recess, or directly into the anterior end of the infundibulum. This relationship to the infundibulum and middle meatus serves to protect the frontal sinus from the spread of disease in the ostiomeatal complex.

Inspection of the frontal sinus reveals its natural ostium in the posteromedial aspect of the sinus floor. The agger nasi is also intimately involved, either adjoining or abutting the floor of the frontal sinus. The posterior wall of the agger nasi forms the anterior border of the frontal recess, which then passes posteromedially to the agger nasi and supraorbital cells. This recess is present in 77% of patients. In the other 23%, drainage occurs via a frontal sinus ostium.[4]

The frontal recess relates medially to the lateral lamella of the cribriform and the cribriform plate. This is a potential area for a cerebrospinal fluid (CSF) leak during surgery.

There are also 2 patterns to the frontal sinus outflow tract: those that drain medial to the uncinate process and those that drain lateral to the uncinate process. Those that drain medially are more common and are significantly related to the presence of frontal sinusitis.

The frontal sinus drainage pathway marks itself laterally with the orbit and posteriorly with the skull base and bulla ethmoidalis. The mucociliary clearance of the frontal sinus is an active process that involves the inward transport of mucus, which starts laterally and forms a whorl-like pattern.

The frontal sinus is incompletely developed at birth and is first visible radiographically in patients aged 6 years. The sinus enlarges vertically in older adolescents to reach its adult volume of 4-7 cm3. Pneumatization of the frontal sinus extends into the squamous part of the frontal bone and posteriorly into the orbital part of the frontal bone to form a supraorbital cell. The inner plate of the frontal sinus is compact bone, while the outer plate is cancellous bone.

Pneumatization in the agger nasi region is variable; the following 4 variations have been described:

The ethmoid sinus itself can pneumatize into the orbital plate of the frontal bone posterior to the frontal sinus. This supraorbital cell usually opens more posteriorly and laterally, as compared with the frontal sinus.

The supraorbital and supratrochlear arteries, which branch off the ophthalmic artery, form the arterial supply of the frontal sinus. The superior ophthalmic vein provides venous drainage, and the supraorbital and supratrochlear branches of the trigeminal nerve supply innervation.

The layers encountered between the air cell of the sinus and the frontal lobe of the brain are, in order, as follows:

The dura mater actually provides the venous drainage for the inner table, the periorbita for the orbital plate, and the cranial periosteum for the outer table. This is in addition to the diploic veins and all venous structures that communicate in the venous plexuses of the inner table, periorbita, and cranial periosteum.

Surgical Indications

As mentioned, surgical treatment for acute frontal sinusitis is undertaken when the infection fails to respond to conservative therapy (defined as the use of intravenous antibiotics and mucolytic agents along with topical and systemic decongestants for 3-5 days) or when dangerous complications arise. An additional indication is recurrent acute sinusitis, defined as 3-4 infections per year.

Indications for operative intervention in acute frontal sinusitis in children are similar to those in adults, but surgery is uncommon. Clinicians reserve surgical treatment for situations involving serious complications of frontal sinusitis, such as intracranial, bony, or orbital infection, and for failure of acute infection to respond to 24-48 hours of maximal medical therapy.

Surgical Contraindications

Contraindications to the various surgical treatments depend on the procedure used. The primary contraindication to trephination is the presence of an aplastic frontal sinus. The main contraindications to external approaches are a history of keloid development and previous failure of an external approach. The presence of hypoplastic frontal sinuses obviates the use of osteoplastic flap procedures with frontal sinus obliteration.

Contraindications to functional endoscopic sinus surgery (FESS) for the treatment of acute frontal sinusitis are as follows:

Relative contraindications to the procedure include small frontal sinus ostia (< 4 mm) and hypertrophic mucosa that obstructs the sinus.

The possibility of too much bleeding and granulation tissue is a concern with FESS, because bleeding and granulation tissue interfere with the postoperative results and healing. Any bony dehiscence or defect in the anterior lateral lamella of the cribriform plate, as well as a prior CSF leak, is also a relative contraindication to FESS.

Preoperative Imaging

CT scanning is the imaging study of choice in acute frontal sinusitis, because it depicts optimal bony, soft-tissue, and air detail in the setting of sinus disease. Coronal and axial paranasal CT images can be diagnostic and aid in preoperative preparation. Intravenous contrast enhancement should be considered if abscess formation is suspected.

Three-millimeter, nonenhanced, coronal sections are recommended because they best correlate with surgical approaches, they demonstrate the ostiomeatal complex and channels, and they accurately depict the relationship of the brain to the fovea ethmoidalis and ethmoid sinus, as well as the relationship of the orbits to the sinuses.

External Procedures

Many techniques are used to perform an external frontoethmoidectomy. External frontoethmoidectomy can be used for the treatment of acute sinus disease with frontal extension, as in the case of mucoceles, pyoceles, and sinocutaneous fistulae, and for the treatment of various intracranial complications of frontal sinusitis. Primary contraindications to the external approaches are a history of keloid development and previous failure of an external approach.

Trephination

Trephination, an ancient procedure now modified, is used in the treatment of acute purulent frontal sinusitis, sinusitis refractory to conservative management, and intracranial and orbital complications of frontal sinusitis. In children, loss of the afferent pupillary reflex is an important sign of orbital complications.

Under local anesthesia, a small incision (usually 1 cm long) is made below the medial eyebrow and supraorbital rim down through the periosteum. The periosteum is then elevated. A drill or chisel helps in gaining access to the anterior table of the sinus. Purulent drainage is then evacuated, and catheters are inserted for future irrigation or drainage. The image below depicts the surgical procedure.


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(A) Curved incision under eyebrow to periosteum, (B) underlying bone exposed by periosteal elevator, with burr holes created with small drill, (C) two....

Four-millimeter 0° and 30° scopes are used upon entering the sinus to identify the nasofrontal duct. This procedure can be performed in combination with endoscopic sinus surgery.

The intersinus septum is removed when the frontal sinusitis is unilateral, to provide drainage through the contralateral frontal sinus recess. Irrigating solution is allowed to drain through the recess. This procedure is performed for 7-10 days (no longer than 14 d) to help restore the function of the outflow tract. Adequate imaging of the frontal sinus by means of axial and coronal CT scanning is paramount. (Formerly, Caldwell or lateral plain radiographs were used.)

Trephination does not guarantee healing of the ostiomeatal complex and anterior ethmoids. The main contraindication to the trephination procedure is the presence of an aplastic frontal sinus.

Lynch procedure

The Lynch approach involves a curvilinear or gull-wing incision above the caudal margin of the lateral nasal bone halfway between the nasal dorsum and medial canthus. The trochlea and medial canthal ligament must be avoided. The incision is made through the periosteum, and the periosteum is then elevated off the lacrimal fossa, lamina papyracea, and floor of the frontal sinus. The anterior ethmoidal artery, seen in the frontoethmoidal suture line, can be clipped or cauterized. The frontal sinus is then opened medially with a burr or chisel, and the medial floor is removed until the area of acute infection is identified.

The modified Lynch procedure preserves as much of the normal mucosa as possible, as well as the middle turbinate and frontal process of the superior maxilla. Mucosa should be preserved, especially in the frontal recess to prevent stenosis. The frontal recess may be opened with a stent and rolled silicone for several weeks to further impede stenosis.

The advantage of the Lynch approach is that it is technically simple, and as such, it can be performed rapidly, especially in elderly patients or in those with high medical risks. This procedure causes some disfigurement, most notably when the supraorbital rim is removed. The risks of recurrence and of mucocele and mucopyocele formation are higher than in other procedures. The Lynch approach is also not the optimal procedure if the sinus is widely pneumatized, because removing the mucosa (and eradicating all disease) is difficult with this technique.

Killian procedure

The Killian method is used in very tall frontal sinuses. In the first step, an anterior ethmoidectomy and middle turbinectomy help to remove the floor and much of the anterior wall of the frontal sinus. Only a 10-mm strut of bone at the supraorbital rim remains to support the brow and prevent deformity. This operation is technically difficult and has no notable advantages.

Reidel procedure

In the Reidel method, the entire anterior wall and floor of the sinus, including the mucosa, is removed. This procedure is reserved for disease of the entire anterior wall. A modification of the Reidel approach involves removing the posterior wall. The advantage of the Reidel method is that the sinus can be completely obliterated if its anteroposterior diameter is narrow. However, obliteration can be difficult and produces significant frontal depression if the diameter is large. Cranioplasty is sometimes required later to protect the frontal lobes.

Lothrop procedure

The Lothrop or Chaput-Meyer technique is used mainly for chronic, bilateral frontal sinusitis, but modifications are used in the treatment of acute infection. The external technique involves resection of the intersinus septum, superior nasal septum, and medial frontal sinus floor, connecting the 2 outflow tracts and thereby creating a large frontonasal communication. Drainage via the healthy side of the sinus can be used to treat unilateral frontal sinus disease.

This operation is more effective than others in eradicating persistent frontal sinus disease, although it can be used in treating acute frontal sinusitis. One of the disadvantages of this procedure is that it causes medial collapse of the orbital soft tissues, which may result in stenosis of the nasofrontal communication. Also, the procedure is technically difficult, and the cribriform plate is directly posterior to the dissection, increasing the risk of intracranial injury.

Osteoplastic flap with obliteration of the frontal sinus

The osteoplastic flap is typically reserved for chronic cases of refractory frontal sinusitis or for those accompanied by intracranial complications. Conservative medical management and/or surgical drainage procedures must be performed prior to the consideration of obliteration. The presence of hypoplastic frontal sinuses is a contraindication to the obliteration procedure.

The particular advantages of the osteoplastic flap procedure are the excellent visualization of the sinus, an ability to correct problems of the posterior table and dura, the elimination of the need to establish a frontonasal communication, and an overall low failure rate.

A drawback of the osteoplastic flap procedure is difficulty in postoperative follow-up, because the sinus is obliterated.

Nonetheless, the osteoplastic flap procedure remains the criterion standard in chronic refractory or recurrent acute frontal sinusitis. Current modifications include the use of a pericranial flap and cancellous bone grafts.

In osteoplastic frontal sinus obliteration, the following 3 approaches are possible:

The coronal incision is useful and cosmetically acceptable if the patient is not balding, but it involves more blood loss. The midline forehead incision is incorporated into a patient's forehead wrinkles, if present. The brow incision is the least cosmetically acceptable and may cause postoperative pain, anesthesia, or paresthesias. A Caldwell-Luc image obtained preoperatively at a distance of 6 feet provides a template for the frontal sinus, which is used intraoperatively after it is sterilized. Ipsilateral tarsorrhaphy also should be performed to protect the globe.

After one of the 3 approaches is used, the frontal periosteum is cleaned of subcutaneous tissues. The template aids in outlining the frontal sinus. The periosteum is then incised 5 mm above the outline of the sinus and elevated to just below the sinus outline. A power saw is used to cut into the sinus by beveling the saw blade downward and inward. The template helps to ensure that the bone cuts are in the frontal sinus and do not enter the anterior cranial fossa inadvertently.

Small cuts above the glabella may be necessary to weaken the frontonasal suture. The osteoplastic flap is then fractured forward from above, exposing the contents of the frontal sinus and allowing meticulous removal of all sinus mucosa and/or the removal of the intersinus septum.

The sinus is commonly drilled out with a polishing burr to ensure adequate bone exposure and complete removal of mucosa in preparation for the fat graft. If the posterior table of the frontal sinus is involved with osteomyelitis or is absent because of an expanding frontal sinus mucocele, it can be removed, allowing the dura to move forward to occupy the frontal sinus space (ie, cranialization of the frontal sinus).

Generally, the posterior frontal sinus is intact, and after complete removal of mucosa, it can be packed with fat or other materials before replacing the ostiomeatal flap and suturing the periosteum and the incision in layers. A variety of substances can be used, including Gelfoam, Teflon, fat, paraffin, silastic sponge, and cartilage.

Autogenous fat, typically harvested from subcutaneous abdominal adipose tissue, is currently the preferred substance for obliteration, because it is thought to prevent osteoneogenesis and impede regrowth of the mucoperiosteum. In addition, the fat revascularizes and, thus, is theoretically more resistant to postoperative infection than other substances. The drawbacks to autogenous fat use include donor site morbidity.

Adequate obliteration can also be achieved with osteoneogenesis, allowing the sinus to obliterate itself after the inner bony cortex and mucosa is removed and a transfrontal ethmoidectomy is performed. This technique obviously avoids donor site morbidity.

A study demonstrated the value of magnetic resonance imaging (MRI) in the follow-up of patients after obliteration, in that MRI results can be used to differentiate the distribution of fatty and fibrous tissue. The review, of patients undergoing frontal sinus obliteration with adipose tissue, had a 12-year follow-up period. In the study, a 10.2% incidence of persistent changes in frontal contouring and a 9.8% incidence of mucocele were documented with MRI results. The images also showed a significant decrease in the amount of adipose tissue with time, as revealed by a median half-life of 15.4 months.

Endoscopic Procedures

Although endoscopic procedures for acute frontal sinus disease are more technically difficult than open/external procedures are, the endoscopic method provides some important advantages. Endoscopic frontal sinus procedures are used to treat sinusitis that is unresponsive to intravenous antibiotics and local vasoconstrictor therapy.

Endoscopic procedures are cosmetically preferable to open procedures, because they leave no external scar. In addition, lateral bony support for the sinus is preserved, so medial soft-tissue collapse does not occur and ethmoid disease can be eradicated.

Opening the lower anterior ethmoid and agger nasi region may relieve any frontal sinus outflow obstruction, obviating entrance into the frontal sinus. The purpose of FESS is to provide a wide and patent frontonasal communication, prevent recurrent obstruction, and create conditions conducive to reepithelialization.

A procedure known as endoscopic frontal sinuplasty has been described. It can be considered the least invasive of all techniques; however, it requires the surgeon to be as familiar with the anatomy as would be necessary when performing a standard endoscopic frontal sinusotomy.

Endoscopic frontal sinuplasty can be used in conjunction with standard endoscopic frontal sinusotomy or as a stand-alone procedure by dilating the drainage of the frontal sinus without damaging mucociliary clearance. The medial agger nasi cell wall is pushed laterally and the ethmoid bulla lamella is pushed posteriorly. It is best used in isolated frontal sinus disease but can be used with sinuplasty of other sinuses in chronic cases. There is minimal long-term data at this time.

Intraoperative Endoscopic Details

Endoscopic surgery for acute frontal sinusitis is performed under general anesthesia. Local anesthetic is injected in a usual manner for field blocks, and vasoconstrictor-soaked pledgets (Neo-Synephrine) are packed intranasally for approximately 10 minutes. The patient is also appropriately positioned with elevation and extension of the head. Nasal endoscopy is performed by using 0°, 30°, 45°, and 70° telescopes. An area between the superior attachment of the middle turbinate and the superior end of the uncinate process or infundibulum houses the frontal outflow tract (FOT).

Uncinectomy, anterior ethmoidectomy, agger nasi removal, and resection of the anterosuperior attachment of the middle turbinate may all be necessary to create a widely patent FOT. An ostium probe or ball-tip seeker may be used to locate the outflow tract. To remove the anterior nasofrontal beak, which is the shelflike bony process anterior to the FOT, a variety of instruments can be used, including a Kerrison rongeur, a drill, and bony curettes.

Further drainage may require removal of the superior aspect of the nasal septum, especially for a bilateral frontal sinus drill-out procedure. To allow reepithelialization, the surgeon must not remove the posterior table mucosa. Mucosal preservation is of utmost importance in routine, uncomplicated frontal sinus surgery.

A stent is used in more complicated cases where mucosal preservation may be difficult and typically when the neo-ostium is less than 5 mm in diameter. The stent is placed in the tract by using a 3- to 4-mm endotracheal tube with additional holes created near the tip of the tube.

Stents are inserted until the roof of the frontal sinus is reached. Then, they are pulled out 2-3 mm and sutured to the membranous nasal septum and cut to lay flush with the external limit of the nares. The patient must irrigate the stents frequently (2-3 times a day) for 5-7 weeks. Presence of a dehiscent posterior table contraindicates this irrigation. Foreign body reactions to the stent material are a concern with stent use.

FESS can also be used with trephination in the presence of thick septations, high frontal cells within the sinus, and lateralized frontal sinus disease. Extended drainage of the sinus can be achieved by means of resection of the frontal sinus floor.

Modified Lothrop procedure

The modified Lothrop procedure, described by Gross et al, helps to prevent nasofrontal duct stenosis due to medial collapse of orbital soft tissue by preserving the lateral bony wall, and it is entirely intranasal/endoscopic and bilateral.[6] The frontal recess is cannulated on 1 side. A soft-tissue shaver can then be used to remove the perpendicular plate mucosa anterior to the frontal recess and the anterior aspect of the frontal recess bordered by the anterosuperior attachment of the middle turbinate.

A wire probe is placed through the nasofrontal isthmus into the frontal sinus to assist in orientation. A bone-cutting drill is used to cut the bone of the anterior face of the frontal recess unilaterally. This area is the nasofrontal beak. The perpendicular plate is removed as far as the nasal floor of the sinus, while the surgeon stays well anterior to the wire probe. The drill then enters the floor anterior to the nasofrontal isthmus in the nasal crest, which is then removed. The contralateral frontal recess and isthmus are opened to communicate with the frontonasal opening. Bone is removed until a thin rim of bone exists around the frontonasal opening in the glabellar region.

Frontal sinuplasty

In frontal sinuplasty, an endoscope is used to place a 70° or 90° guiding cannula into the upper middle meatus, and the guide wire is passed through it into the frontal sinus. Image guidance can be used to identify the entrance to the frontal recess, which is medial against the middle turbinate and more posterior than expected. Fluoroscopy is also used to confirm position of the guide wire, and the cannula is repositioned as needed.

A balloon catheter is passed over the cannula into the frontal sinus and then inflated to dilate the frontal sinus ostium completely. The balloon serves to fracture the surrounding bone, and as little as 6 atmospheres of pressure may be enough. It is important to keep pressure to the minimum necessary because of subsequent mucosal edema.

Transblepharoplasty

In the transblepharoplasty approach, standard endoscopic techniques are used to perform ethmoidectomy and remove agger nasi and frontal recess cells while exposing the ethmoid skull base.[7] The upper eyelid crease on the affected side is injected; an incision is placed in the skin fold above the tarsal plate at least 8 mm above the lid margin with care to prevent webbing by not extending too far medially. The lateral limit is rarely beyond the bony orbital rim. The orbital portion of the orbicularis oculi is located and the muscle is incised. Then a plane is developed between this muscle and the levator aponeurosis toward the orbital rim while keeping the orbital septum intact.

The preseptal plane must be maintained to keep the levator intact, and then a periosteal incision is made anterior to the orbital septum at the superior orbital rim. A subperiosteal dissection is completed in all directions, with the medial limit defined by the supraorbital notch and neurovascular bundle and the lateral and posterior limits defined by the extent of frontal sinus pneumatization. The frontal sinus floor is directly accessible and the area of dehiscence (in case of mucocele) is easily identified and treated. The flap is redraped in place once the patency of the outflow tract is determined endoscopically.

Postoperative Endoscopic Considerations

Postoperative care is similar to that following any endoscopic procedure. Removal of crust, clots, granulation tissue, and polyps may be necessary.

The advantages of this procedure are less pain and edema, less blood loss, and better cosmesis than those achieved with the use of an osteoplastic flap. Surgeons can address disease of the anterior ethmoids at the same time. The use of a second donor site and its attendant morbidity are completely avoided.

The difficulty involved in postoperative evaluation after obliteration is also avoided because patients can be followed up endoscopically and radiographically; this ability is especially helpful in evaluating frontal pain.

The disadvantages of FESS include an inability to access disease in any supraorbital frontal sinus cell. Also, this procedure is technically difficult, and much effort is required in postoperative care.

Confirming the patency of the nasofrontal communication is difficult in the initial postoperative period, and close follow-up and possible debridement are important. Stent use may decrease the need for debridement.

Surgical Complications

Trephination

The trephination procedure has notable complications, including the following:

Injury to the posterior table may cause a dural tear, meningitis, intracranial abscess, hemorrhage, or even frontal lobe trauma. Long-term complications include mucocele and pyocele.

External approaches

Complications with the external approaches occur less often than with endoscopic techniques. Injuring the periosteal attachment of the trochlea may cause diplopia, but the diplopia may spontaneously resolve if the periosteum is reapproximated well.

Neuralgias can occur with injury to the supraorbital and supratrochlear nerves, which can result from an incision that extends too far superiorly and laterally. Damage to the optic nerve, artery, vein, or extraocular muscles can occur, but these happen less often with the external approach because of generous exposure. Other complications include deformity or concavity, synechiae to the septum, stenosis of the sphenoid os, recurrence, anosmia, CSF leak, and meningitis.

A septal mucosal flap that is rotated posteriorly and supported by packing for 5-7 days with antibiotics helps in the management of CSF leaks. Long-term complications include mucocele and pyocele.

Osteoplastic flap

The complications of an osteoplastic flap procedure with frontal sinus obliteration include cerebral contusion, CSF leak, forehead neuralgia and/or numbness, recurrence or need for revision, and poor cosmetic appearance. Operating on a patient with a previous osteoplastic obliteration is difficult, because the frontal sinuses are difficult to view after the first operation.

One group of investigators reported a total complication rate of 19%, including a 2.8% incidence of CSF leak, a 9% revision rate, and a 6% frontal headache rate.

Failure or recurrence (usually marked by frontal pain) with this procedure may be due to incomplete occlusion of the frontonasal opening, incomplete removal of the sinus mucosa, or infection of the fat or obliterative substance. Persistent disease or mucosa in the frontal recess may lead to a mucocele. Intraoperative blood loss is high. Other disadvantages or complications include anesthesia or paresthesia in the distribution of the supraorbital and supratrochlear nerve. Long-term complications include mucocele and pyocele.

Endoscopic approaches

Complications of endoscopic sinus procedures are stratified into major and minor categories. Minor complications are epistaxis, orbital/periorbital ecchymoses and emphysema, dental pain, adhesions, and stenosis.

Stenosis in the frontal recess occurs for 3 reasons: (1) overly aggressive dissection with stripping of the mucosa, (2) incomplete removal of the agger nasi and frontal cells causing adhesions and scarring, and (3) excessive removal of the middle turbinate. Hyposmia and asthma are also included in the category of minor complications.

Some major complications are similar to the complications of untreated or aggressive frontal sinusitis. These include meningitis and brain abscess. Others are a direct result of intraoperative trauma: CSF leaks, intraorbital hemorrhage, diplopia, blindness, epiphora, intracranial injury, cerebrovascular trauma, tension pneumocephalus, significant epistaxis, and anosmia.

Ophthalmoplegia, proptosis, and changes in pupil size may result from intraorbital hemorrhage, which is a surgical emergency. Postoperative bedside measures to treat this complication include the removal of nasal packing, administration of intravenous steroids and mannitol, and lateral canthotomy and cantholysis of the lower lid. Any other ophthalmologic complications warrant at least an urgent consultation with an ophthalmologist.

Mucosal grafts (with or without muscle or fascia, depending on the size of the dural defect) may be used to patch defects and repair CSF leaks; intermittent clear rhinorrhea is an indication for their use. Composite septal cartilage-mucosal grafts or conchal cartilage may be used to repair larger bony defects.

Further Surgical Considerations

Stent placement

A debate exists regarding the role and duration of frontal recess stent placement in the surgical treatment of acute and chronic frontal sinus disease. Many authors advocate the use of stents any time the frontal sinus ostium is surgically enlarged. Varieties of stents and sheeting have been studied for this purpose. These include silicone drainage catheters, rolled silicone sheeting, Foley catheters, and Dacron prostheses.

Freeman and Blom reported the successful use of a double-ended, flanged silicone stent.[8] The shape of the stent allowed controlled retention, making it easier for the surgeon to determine the duration of the stent placement.

Typically, preventative stents are left in place for 1-8 weeks, and stents placed after correction of frontal outflow tract stenosis are left in place for 6-12 months. Experienced endoscopists have presented arguments for each of these time frames. No long-term data are available on stent placement in the setting of surgically treated acute frontal sinusitis.

Mitomycin C

An additional subject of debate is the use of mitomycin C (MMC), an antifibrotic agent used to help prevent scarring in the frontal recess or in the frontal sinus outflow tract.

One study looked at 1-time intraoperative topical application of MMC at 0.5mg/mL for 4 minutes; however, no difference was found in the degree of stenosis at 1, 3, and 6 months when compared with a control group.[9]

A different study demonstrated an 86% patency rate with follow-up of up to 32 months, but the investigators used multiple applications of the drug.[10] Clearly, no standard protocol for application has been developed, so the efficacy of MMC is still in question.

Pediatric surgery

In pediatric patients, surgery should be minimal and focused, because sinus surgery in the pediatric population can alter facial growth. Other concerns regarding these patients include the proximity of vital structures, bone fragility, and smaller anatomy, which makes avoiding stenosis of the nasofrontal duct more difficult.

For recurrent disease, endoscopic approaches to the frontal sinus are preferred. External approaches are typically reserved for recurrent serious acute frontal sinusitis.

Postsurgical Prognosis

Many aspects of the surgical treatment of acute frontal sinusitis have yet to be studied thoroughly. One aspect is the long-term outcomes of the various surgical treatments.[11]

Concerning trephination, a study from Finland reported that patients undergoing trephination had a 22% rate of a delayed healing process or recurrences in the first year after trephination.[12]

Another study investigated a method for prediction of the clinical outcome of acute frontal sinusitis after trephination and found it to be highly effective. The technique used measurements of the nasofrontal duct. Rhinomanometry of the frontal recess was measured by means of a trephination drain. The patient breathed through a flow mask, and concurrent pressure changes inside the frontal sinus were recorded via the drain with a pressure channel that was connected to the drain by a short plastic tube.

The ventilation test proved to be highly predictable if the ventilation was considered open (pressure changes during breathing and forced breathing >50% compared with the nasal airflow) or if it was totally obstructed (no pressure changes obtainable). This finding underlines the importance of the pathology of the frontal recess/infundibulum in causing acute and recurrent frontal sinusitis.

Osteoplastic flap obliteration procedures have varying rates of complications (as high as 18%), depending on the substance used for obliteration and if a donor site is needed. A 30% recurrence rate has been noted for some external approaches.

Analysis of short-term outcomes for endoscopic frontal sinus drill-out procedures in one study revealed a success rate of higher than 80%, along with a 12.5% failure rate. However, these results were tabulated for patients with a history of chronic sinusitis. Long-term outcome data for acute frontal sinus disease managed with endoscopic sinus surgery are minimal.

Postoperative results in one study indicated a 5% surgical revision rate with FESS for frontal sinusitis, with 40% of the frontal sinuses visualized at endoscopy.[13]

Another study indicated that endoscopic surgery for frontal sinusitis was associated with a 25% improvement in the number of medications used and in overall improved general health.

Increased risk of recurrence of acute frontal sinusitis occurs in patients with chronic rhinitis, polyps, and previous sinus surgery. A history of atopic disease appears to have an impact on overall duration of infection.[14]

Author

Priya Krishna, MD, FACS, Assistant Professor, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Dennis Lee, MD, MPH, Director, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Southern Illinois University School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Disclosure: Axis Three Corporation Ownership interest Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting

Additional Contributors

Erik Kass, MD Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern Virginia

Erik Kass, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American Medical Association, and American Rhinologic Society

Disclosure: Nothing to disclose.

Eric J Moore, MD, FACS Residency Director, Associate Professor, Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Graduate School of Medicine

Eric J Moore, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, and American Head and Neck Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References

  1. Hakim HE, Malik AC, Aronyk K, Ledi E, Bhargava R. The prevalence of intracranial complications in pediatric frontal sinusitis. Int J Pediatr Otorhinolaryngol. Aug 2006;70(8):1383-7. [View Abstract]
  2. Lang EE, Curran AJ, Patil N, Walsh RM, Rawluk D, Walsh MA. Intracranial complications of acute frontal sinusitis. Clin Otolaryngol Allied Sci. Dec 2001;26(6):452-7. [View Abstract]
  3. Parida PK, Surianarayanan G, Ganeshan S, Saxena SK. Pott's puffy tumor in pediatric age group: a retrospective study. Int J Pediatr Otorhinolaryngol. Sep 2012;76(9):1274-7. [View Abstract]
  4. Metson R. Endoscopic treatment of frontal sinusitis. Laryngoscope. Jun 1992;102(6):712-6. [View Abstract]
  5. Tabaee A, Kamat A, Shrivastava R, Buchbinder D. Surgical management of pneumosinus dilatans frontalis in the setting of chronic rhinosinusitis and type III frontal Cell. J Craniofac Surg. Jan 2012;23(1):158-60. [View Abstract]
  6. Gross WE, Gross CW, Becker D, Moore D, Phillips D. Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg. Oct 1995;113(4):427-34. [View Abstract]
  7. Knipe TA, Gandhi PD, Fleming JC, Chandra RK. Transblepharoplasty approach to sequestered disease of the lateral frontal sinus with ophthalmologic manifestations. Am J Rhinol. Jan-Feb 2007;21(1):100-4. [View Abstract]
  8. Freeman SB, Blom ED. Frontal sinus stents. Laryngoscope. Jul 2000;110(7):1179-82. [View Abstract]
  9. Chan KO, Gervais M, Tsaparas Y, Genoway KA, Manarey C, Javer AR. Effectiveness of intraoperative mitomycin C in maintaining the patency of a frontal sinusotomy: a preliminary report of a double-blind randomized placebo-controlled trial. Am J Rhinol. May-Jun 2006;20(3):295-9. [View Abstract]
  10. Amonoo-Kuofi K, Lund VJ, Andrews P, Howard DJ. The role of mitomycin C in surgery of the frontonasal recess: a prospective open pilot study. Am J Rhinol. Nov-Dec 2006;20(6):591-4. [View Abstract]
  11. Wide K, Antila J, Sipilä J, Suonpää J, Parkkola R. Healing results of prolonged acute frontal sinusitis treated with endoscopic sinus surgery. Rhinology. Dec 2002;40(4):189-94. [View Abstract]
  12. Sipilä J, Suonpää J, Wide K, Silvoniemi P. Prediction of the clinical outcome of acute frontal sinusitis with ventilation measurement of the nasofrontal duct after trephination: a long-term follow-up study. Laryngoscope. Mar 1996;106(3 Pt 1):292-5. [View Abstract]
  13. Wigand ME, Hosemann W. Am J Rhinol. Endoscopic surgery for frontal sinusitis and its complications. 1991;5:85-9.
  14. Wide K, Suonpaa J, Laippala P. Clin Otolaryngol. Recurrent and prolonged frontal sinusitis. 2004;29:59-65.

(A) Frontal sinus, (B) middle turbinate, (C) ethmoid bulla, (D) hiatus semilunaris, (E) uncinate process, and (F) superior turbinate.

(A) Incision under brow extending about 1 cm below the medial palpebral (canthal) ligament, (B) medial orbital wall entered with removal of posterior edge of nasal process of maxilla and lacrimal and anterior portions of lamina papyracea, (C) removal of posterior ethmoid cells, (D) superiorly based mucoperiosteal flaps lining of new frontal nasal communication, intranasal tube into frontal sinus.

(A) Incision (above or below eyebrows), (B) superiorly based skin flap, with use of template of frontal sinus and a cut through periosteum along the superior, medial, and lateral edges, (C) saw blade of sagittal plane saw used to make a beveled cut through bone with inferior hinge of intact periosteum, with a line of fracture of bone-periosteum flap, (D) osteotome used along cut edges to elevate bone-periosteum flap, (E) flap reflected downward to expose sinus (in this case, osteoma is seen in the sinus; otherwise, in frontal sinus disease, all mucosa of sinus must be removed).

(A) After obliteration, the flap is returned, and the periosteum reapproximated with absorbable suture, (B) outline of extension of brow incision in bilateral frontal sinus disease, (C) coronal incision in female patient to obviate brow incision.

(A) Frontal sinus, (B) middle turbinate, (C) ethmoid bulla, (D) hiatus semilunaris, (E) uncinate process, and (F) superior turbinate.

Axial section through right nasal cavity depicts the following: (A) middle turbinate (or concha); (B) ethmoid bulla; (C) drainage sites for frontal sinus (3 shaded areas); (D) uncinate process; (E) nasolacrimal duct; (F) hiatus semilunaris; (G) basal lamella; (H) septal cartilage.

(A) Frontal sinus, (B) sphenoid sinus, (C) cut surface of the middle turbinate, (D) ethmoid bulla, and (E) hiatus semilunaris.

(A) Curved incision under eyebrow to periosteum, (B) underlying bone exposed by periosteal elevator, with burr holes created with small drill, (C) two small plastic tubes inserted for daily irrigation of the frontal sinus.

(A) Frontal sinus, (B) middle turbinate, (C) ethmoid bulla, (D) hiatus semilunaris, (E) uncinate process, and (F) superior turbinate.

Axial section through right nasal cavity depicts the following: (A) middle turbinate (or concha); (B) ethmoid bulla; (C) drainage sites for frontal sinus (3 shaded areas); (D) uncinate process; (E) nasolacrimal duct; (F) hiatus semilunaris; (G) basal lamella; (H) septal cartilage.

(A) Frontal sinus, (B) sphenoid sinus, (C) cut surface of the middle turbinate, (D) ethmoid bulla, and (E) hiatus semilunaris.

(A) Curved incision under eyebrow to periosteum, (B) underlying bone exposed by periosteal elevator, with burr holes created with small drill, (C) two small plastic tubes inserted for daily irrigation of the frontal sinus.

(A) Incision under brow extending about 1 cm below the medial palpebral (canthal) ligament, (B) medial orbital wall entered with removal of posterior edge of nasal process of maxilla and lacrimal and anterior portions of lamina papyracea, (C) removal of posterior ethmoid cells, (D) superiorly based mucoperiosteal flaps lining of new frontal nasal communication, intranasal tube into frontal sinus.

(A) Incision (above or below eyebrows), (B) superiorly based skin flap, with use of template of frontal sinus and a cut through periosteum along the superior, medial, and lateral edges, (C) saw blade of sagittal plane saw used to make a beveled cut through bone with inferior hinge of intact periosteum, with a line of fracture of bone-periosteum flap, (D) osteotome used along cut edges to elevate bone-periosteum flap, (E) flap reflected downward to expose sinus (in this case, osteoma is seen in the sinus; otherwise, in frontal sinus disease, all mucosa of sinus must be removed).

(A) After obliteration, the flap is returned, and the periosteum reapproximated with absorbable suture, (B) outline of extension of brow incision in bilateral frontal sinus disease, (C) coronal incision in female patient to obviate brow incision.