Frontal sinus procedures

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FRONTAL SINUS PROCEDURESDR. AJAY MANICKAMMS ENT PGTRG KAR MEDICAL COLLEGE

Comprehensive AnatomyVaries remarkably in size, degree of septation, drainage configurationDrainage is downwards acute sinusitis heals fast, chronic is less frequentWidth and course of fronto nasal recess depends on size & number of ant etmoidal cells

The Frontal sinusUpper dome attachment of Uncinate process within frontal recess described by Stammberger as Egg shell in an inverted cupHour Glass Configuration Frontal infundibulum, Frontal ostium, Frontal Recess

Endoscopic viewThe upper border of attachment of uncinate process is removedBulla removed systematically

Frontal CellsAnterior ethmoidal air cell can migrate to frontal recess area Frontal CellsType 1 single above agger nasi cellType 2 multiple cell above agger nasiType 3 a cell into frontal sinusType 4 isolated loner cell within frontal sinus

Type 1 and Type 2 cell

Type 3 and Type 4 cell

Clinical DiagnosisHistoryClinical Examination 1. Inspection2. Palpation 3. Percussion 4. Ant Rhinoscopy & EndoscopyImagingPlain X rayCT & MRIScintigraphy

PathologyFronto Basal malformationsTrauma of the Frontal sinusInflamatory diseasesFrontal Pneumosinus dilatansTumours

Frontobasal malformationsClassification Site of herniationContents of the sac

Frontobasal malformationsFronto basal occult or manifest?CT & MRI ESSENTIALWhole skull base Multi locular defects

Operative principleNasal fistulas and cyst short ones endoscopically, larger via external approachMeningo and encephalocele endonasal approachVery large meningo encephalocele preferably external via coronal approach

Trauma of Frontal sinusCT imaging & MRIComminuted fracture post wall dural lacerations has to be ruled outPrinciplesNo wait & seePNS is not sterile ascending intracranialEarlier Riedels operation

3 Individual situationsFracture of anterior and/or posterior wall but intact KILLIANS infundibulumSeverely comminuted fractureFractures of the orbital roof

Dural LesionUnderlay technique between brain & duraUnderlay technique between dura & boneOnlay technique onto the posterior wall of the frontal sinus

Inflammatory DiseasesFrontal sinus trephenation and endoscopyExternal fronto ethmoidectomyEndonasal surgery of the frontal sinusRhinofrontal sinuseptomyOsteoplastic bone flap procedureCranialization of the frontal sinus

Frontal sinus trephanation

External frontoethmoidectomy

Endonasal surgeryType 1 simple drainageType 2 extended drainageType 3 endonasal median drainage

Type 1Simple drainage established by ethmoidectomy. Inferior part is untouched.Minor pathology

Type 2Resecting floor of frontal sinus between lamina papyracea and the middle turbinate (2a) or the nasal septum (2b)

Type 32b is enlarged by resecting nasal septum. The diameter is about 1.5 cm.Starting on oneside crossing midline contralateral lamina papyracea is reached.

Rhinofrontal sinuseptotomyExternal approach jansen-ritter approachResection of frontal sinus pathologyTotal resection of frontal intersinus septumPartial endonasal rection of the nasal septumBilateral endoscopic ethmoidectomyComplete epithelization with free mucosal grafts.

Osteoplastic bone flap procedure

Cranialization of the frontal sinusInitial part similar to osteoplastic frontal sinus procedureAfter careful mobilization of the dura eventual duraplasty, post wall of frontal sinus completely removed.Dead space between ant wall and dura obliterated abdominal fat.

Frontal pneumosinus dilatansPneumatization varies between individualsPneumatization may extend beyond the confines of the frontal bone.May be associated with arachnoid cysts, meningioma, fibrous dysplasiaCranio cerebral hemiatrophy (Dyke Davidoff-Masson syndrome)

Tumours EndonasalMidfacial deglovingSubcranial Lateral rhinotomy justified only if orbital exenteration is necessary

Benign frontal sinus neoplasmNot extending more laterally than a vertical plane through the lamina endonasalPoint of origin posterior lower third endonasal & if there is fixation at ant wall of frontal sinus contraindicatedIntracranial extension degree & experience of surgeon

Endoscopic surgery of Osteoma

Open approach

Fibrous dysplasiaTumour like lesion self limiting non encapsulated3 typesMonostoticPolyostoticmcCune Albright syndrome

Communited fracture

Conclusion Bony borders outlet intact and preserving mucosa as much as possible offer less morbidity. If endo nasal procedure is not leading to success then osteoplastic frontal sinus operation results in 90% solution.

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